Abnormal vascular thickness and stiffness in young adults with type 1 diabetes: new insights from cutting-edge ultrasound modalities.

BACKGROUND: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with Type 1 Diabetes (T1D). Early markers of CVD include increased carotid intima-media thickness (CIMT) and pulse wave velocity (PWV), but these existing ultrasound technologies show limited spatial and temporal resolution in young adults. The purpose of this study is to evaluate the utility of high-resolution ultrasound modalities, including high frequency ultrasound CIMT (hfCIMT) and ultrafast ultrasound PWV (ufPWV), in young adults with Type 1 Diabetes. METHODS: This is a prospective single-center observational cohort study including 39 participants with T1D and 25 age and sex matched controls. All participants underwent hfCIMT and ufPWV measurements. hfCIMT and ufPWV measures of T1D were compared with controls and associations with age, sex, BMI, A1c, blood pressure, and lipids were studied. RESULTS: Mean age was 24.1 years old in both groups. T1D had a greater body mass index (27.7 [5.7] vs 23.1 [3.2] kg/m2), LDL Cholesterol, and estimated GFR, and had a mean A1c of 7.4 [1.0] % (57 mmol/mol) and diabetes duration of 16.1 [3.7] years with 56% using insulin pumps. In T1D, hfCIMT was significantly increased as compared to controls (0.435 ± 0.06 mm vs 0.379 ± 0.06 mm respectively, p < 0.01). ufPWV measures were significantly increased in T1D (systolic foot PWV: 5.29 ± 0.23 m/s vs 5.50 ± 0.37 m/s, p < 0.01; dicrotic notch PWV = 7.54 ± 0.46 m/s vs 7.92 ± 0.41 m/s, p < 0.01). Further, there was an impact of A1c-measured glycemia on hfCIMT, but this relationship was not seen with ufPWV. No significant statistical correlations between hfCIMT and ufPWV measures in either T1D or healthy controls were observed. CONCLUSION: Young adults with T1D present with differences in arterial thickness and stiffness when compared with controls. Use of novel high-resolution ultrasound measures describe important relationships between early structural and vascular pathophysiologic changes and are promising tools to evaluate pre-clinical CVD risk in youth with T1D. TRIAL REGISTRATION: ISRCTN91419926.

Impact of cardiopulmonary bypass on cerebrovascular autoregulation assessed by ultrafast ultrasound imaging.

Newborns with congenital heart disease undergoing cardiac surgery are at risk of neurodevelopmental impairment with limited understanding of the impact of intra-operative cardiopulmonary bypass (CPB), deep hypothermia and selective cerebral perfusion on the brain. We hypothesized that a novel ultrasound technique, ultrafast power Doppler (UPD), can assess variations of cerebral blood volume (CBV) in neonates undergoing cardiac surgery requiring CPB. UPD was performed before, during and after surgery in newborns with hypoplastic left heart syndrome undergoing a Norwood operation. We found that global CBV was not significantly different between patients and controls (P = 0.98) and between pre- and post-surgery (P = 0.62). UPD was able to monitor changes in CBV throughout surgery, revealing regional differences in CBV during hypothermia during which CBV correlated with CPB flow rate (R2  = 0.52, P = 0.021). Brain injury on post-operative magnetic resonance imaging was observed in patients with higher maximum variation in CBV. Our findings suggest that UPD can quantify global and regional brain perfusion variation during neonatal cardiac surgery with this first intra-operative application demonstrating an association between CBV and CPB flow rate, suggesting loss of autoregulation. Therefore, the measurement of CBV by UPD could enable optimization of cerebral perfusion during cardiac surgery in neonates. KEY POINTS: The impact of cardiopulmonary bypass (CPB) on the neonatal brain undergoing cardiac surgery is poorly understood. Ultrafast power Doppler (UPD) quantifies cerebral blood volume (CBV), a surrogate of brain perfusion. CBV varies throughout CPB surgery and is associated with variation of the bypass pump flow rate during deep hypothermia. Association between CBV and bypass pump flow rate suggests loss of cerebrovascular autoregulatory processes. Quantitative monitoring of cerebral perfusion by UPD could provide a direct parameter to optimize CPB flow rate.

Ultrafast Doppler for neonatal brain imaging.

The emergence of functional neuroimaging has dramatically accelerated our understanding of the human mind. The advent of functional Magnetic Resonance Imaging paved the way for the next decades' major discoveries in neuroscience and today remains the "gold standard" for deep brain imaging. Recent improvements in imaging technology have been somewhat limited to incremental innovations of mature techniques instead of breakthroughs. Recently, the use of ultrasonic plane waves transmitted at ultrafast frame rates was shown to highly increase Doppler ultrasound sensitivity to blood flows in small vessels in rodents. By identifying regions of brain activation through neurovascular coupling, Ultrafast Doppler was entering into the world of preclinical neuroimaging. The combination of many advantages, including high spatio-temporal resolution, deep penetration, high sensitivity and portability provided unique information about brain function. Recently, Ultrafast Doppler imaging was found able to non-invasively image the spatial and temporal dynamics of microvascular changes during seizures and interictal periods with an unprecedented resolution at bedside. This review summarizes the technical basis, the added value and the clinical perspectives provided by this new brain imaging modality that could create a breakthrough in the knowledge of brain hemodynamics, brain insult, and neuroprotection.

The brain of fetuses with congenital diaphragmatic hernia shows signs of hypoxic injury with loss of progenitor cells, neurons, and oligodendrocytes.

Congenital diaphragmatic hernia (CDH) is a birth defect characterized by incomplete closure of the diaphragm, herniation of abdominal organs into the chest, and compression of the lungs and the heart. Besides complications related to pulmonary hypoplasia, 1 in 4 survivors develop neurodevelopmental impairment, whose etiology remains unclear. Using a fetal rat model of CDH, we demonstrated that the compression exerted by herniated organs on the mediastinal structures results in decreased brain perfusion on ultrafast ultrasound, cerebral hypoxia with compensatory angiogenesis, mature neuron and oligodendrocyte loss, and activated microglia. In CDH fetuses, apoptosis was prominent in the subventricular and subgranular zones, areas that are key for neurogenesis. We validated these findings in the autopsy samples of four human fetuses with CDH compared to age- and sex-matched controls. This study reveals the molecular mechanisms and cellular changes that occur in the brain of fetuses with CDH and creates opportunities for therapeutic targets.

Quantification of brain-wide vascular resistivity via ultrafast Doppler in human neonates helps early detection of white matter injury.

Preterm birth is associated with cerebrovascular development disruption and can induce white matter injuries (WMI). Transfontanellar ultrasound Doppler is the most widely used clinical imaging technique to monitor neonatal cerebral vascularisation and haemodynamics based on vascular indexes such as the resistivity index (RI); however, it has poor predictive value for brain damage. Indeed, these RI measurements are currently limited to large vessels, leading to a very limited probing of the brain's vascularisation, which may hinder prognosis. Here we show that ultrafast Doppler imaging (UfD) enables simultaneous quantification, in the whole field of view, of the local RI and vessel diameter, even in small vessels. Combining both pieces of information, we defined two new comprehensive resistivity parameters of the vascular trees. First, we showed that our technique is more sensitive in the early characterisation of the RI modifications between term and preterm neonates and for the first time we could show that the RI depends both on the vessel diameter and vascular territory. We then showed that our parameters can be used for early prediction of WMI. Our results demonstrate the potential of UfD to provide new biomarkers and pave the way for continuous monitoring of neonatal brain resistivity.

Impact of Right Ventricular Pressure Overload on Myocardial Stiffness Assessed by Natural Wave Imaging.

BACKGROUND: Right ventricular (RV) hemodynamic performance determines the prognosis of patients with RV pressure overload. Using ultrafast ultrasound, natural wave velocity (NWV) induced by cardiac valve closure was proposed as a new surrogate to quantify myocardial stiffness. OBJECTIVES: This study aimed to assess RV NWV in rodent models and children with RV pressure overload vs control subjects and to correlate NWV with RV hemodynamic parameters. METHODS: Six-week-old rats were randomized to pulmonary artery banding (n = 6), Sugen hypoxia-induced pulmonary arterial hypertension (n = 7), or sham (n = 6) groups. They underwent natural wave imaging, echocardiography, and hemodynamic assessment at baseline and 6 weeks postoperatively. The authors analyzed NWV after tricuspid and after pulmonary valve closure (TVC and PVC, respectively). Conductance catheters were used to generate pressure-volume loops. In parallel, the authors prospectively recruited 14 children (7 RV pressure overload; 7 age-matched control subjects) and compared RV NWV with echocardiographic and invasive hemodynamic parameters. RESULTS: NWV significantly increased in RV pressure overload rat models (4.99 ± 0.27 m/s after TVC and 5.03 ± 0.32 m/s after PVC in pulmonary artery banding at 6 weeks; 4.89 ± 0.26 m/s after TVC and 4.84 ± 0.30 m/s after PVC in Sugen hypoxia at 6 weeks) compared with control subjects (2.83 ± 0.15 m/s after TVC and 2.72 ± 0.34 m/s after PVC). NWV after TVC correlated with both systolic and diastolic parameters including RV dP/dtmax (r = 0.75; P < 0.005) and RV Ees (r = 0.81; P < 0.005). NWV after PVC correlated with both diastolic and systolic parameters and notably with RV end-diastolic pressure (r = 0.65; P < 0.01). In children, NWV after both right valves closure in RV pressure overload were higher than in healthy volunteers (P < 0.01). NWV after PVC correlated with RV E/E' (r = 0.81; P = 0.008) and with RV chamber stiffness (r = 0.97; P = 0.03). CONCLUSIONS: Both RV early-systolic and early-diastolic myocardial stiffness show significant increase in response to pressure overload. Based on physiology and our observations, early-systolic myocardial stiffness may reflect contractility, whereas early-diastolic myocardial stiffness might be indicative of diastolic function.

Fast Thresholding of SVD Clutter Filter Using the Spatial Similarity Matrix and a Sum-Table Algorithm.

Singular value decomposition (SVD) has become a standard for clutter filtering of ultrafast ultrasound datasets. Its implementation requires the choice of appropriate thresholds to discriminate the singular value subspaces associated with tissue, blood, and noise signals. Comparing the similarity of the spatial singular vectors was shown to be a robust and efficient method to estimate the SVD thresholds. The correlation of the spatial singular vector envelopes gives the spatial similarity matrix (SSM), which usually exhibits two square-like domains juxtaposed along the diagonal of the SSM, representing the tissue and the blood subspaces. Up to now, the proposed methods to automatically segment these two subspaces on the SSM were of high computational complexity and had a long processing time. Here, we propose an optimized algorithm using a sum-table approach that decreases the complexity by two orders of magnitude: O(n4) to O(n2) . The proposed method resulted in processing times lower than 0.08 s for datasets of 2000 frames, whereas previous algorithms took more than 26 h, so an improvement by a factor of 106. We illustrated this adaptive square-fitting on the SSM in the in vivo case of human neonate brain imaging and carotid imaging with various conditions of clutter. This optimization of SVD thresholding is essential to develop the use of adaptive clutter filtering, especially for real-time applications or block-wise processing.

Assessing engineered tissues and biomaterials using ultrasound imaging: In vitro and in vivo applications.

Quantitative assessment of the structural, functional, and mechanical properties of engineered tissues and biomaterials is fundamental to their development for regenerative medicine applications. Ultrasound (US) imaging is a non-invasive, non-destructive, and cost-effective technique capable of longitudinal and quantitative monitoring of tissue structure and function across centimeter to sub-micron length scales. Here we present the fundamentals of US to contextualize its application for the assessment of biomaterials and engineered tissues, both in vivo and in vitro. We review key studies that demonstrate the versatility and broad capabilities of US for clinical and pre-clinical biomaterials research. Finally, we highlight emerging techniques that further extend the applications of US, including for ultrafast imaging of biomaterials and engineered tissues in vivo and functional monitoring of stem cells, organoids, and organ-on-a-chip systems in vitro.

The fundamental mechanisms of the Korotkoff sounds generation.

Blood pressure measurement is the most widely performed clinical exam to predict mortality risk. The gold standard for its noninvasive assessment is the auscultatory method, which relies on listening to the so-called "Korotkoff sounds" in a stethoscope placed at the outlet of a pneumatic arm cuff. However, more than a century after their discovery, the origin of these sounds is still debated, which implies a number of clinical limitations. We imaged the Korotkoff sound generation in vivo at thousands of images per second using ultrafast ultrasound. We showed with both experience and theory that Korotkoff sounds are paradoxically not sound waves emerging from the brachial artery but rather shear vibrations conveyed in surrounding tissues by the nonlinear pulse wave propagation. When these shear vibrations reached the stethoscope, they were synchronous, correlated, and comparable in intensity with the Korotkoff sounds. Understanding this mechanism could ultimately improve blood pressure measurement and provide additional understanding of arterial mechanical properties.

Local arterial stiffness measured by ultrafast ultrasound imaging in childhood cancer survivors treated with anthracyclines.

Background: There is conflicting literature regarding the long-term effect of anthracycline treatment on arterial stiffness. This study assessed local arterial stiffness using ultrafast ultrasound imaging (UUI) in anthracycline treated childhood cancer survivors, at rest and during exercise. Methods: 20 childhood cancer survivors (mean age 21.02 ± 9.45 years) treated with anthracyclines (mean cumulative dose 200.7 ± 126.80 mg/m2) and 21 healthy controls (mean age 26.00 ± 8.91 years) were included. Participants completed a demographic survey, fasting bloodwork for cardiovascular biomarkers, and performed a submaximal exercise test on a semi-supine bicycle. Pulse wave velocity (PWV) was measured in the left common carotid artery by direct pulse wave imaging using UUI at rest and submaximal exercise. Both PWV at the systolic foot (PWV-SF) and dicrotic notch (PWV-DN) were measured. Central (carotid-femoral) PWV was obtained by applanation tonometry. Carotid measurements were taken by conventional ultrasound. Measures were compared using two-tailed Students t-test or Chi-squared test, as appropriate. Results: There was no statistically significant difference (p > 0.05) between childhood cancer survivors and healthy controls in demographic parameters (age, sex, weight, height, BMI), blood biomarkers (total cholesterol, triglycerides, LDL-c, HDL-c, hs-CRP, fasting glucose, insulin, Hb A1c), cardiovascular parameters (intima media thickness, systolic and diastolic blood pressure, heart rate, carotid diameters, distensibility) or PWV measured by UUI at rest or at exercise. There was also no difference in the cardiovascular adaptation between rest and exercise in the two groups (p > 0.05). Multivariate analysis revealed age (p = 0.024) and LDL-c (p = 0.019) to be significant correlates of PWV-SF in childhood cancer survivors, in line with previously published data. Conclusion: We did not identify a significant impact of anthracycline treatment in young survivors of childhood cancer on local arterial stiffness in the left common carotid artery as measured by UUI.

Impact of Ventricular Geometric Characteristics on Myocardial Stiffness Assessment Using Shear-Wave Velocity in Healthy Children and Young Adults.

BACKGROUND: Diastolic myocardial stiffness (MS) can serve as a key diagnostic parameter for congenital or acquired heart diseases. Using shear modulus and shear-wave velocity (SWV), shear-wave elastography (SWE) is an emerging ultrasound-based technique that can allow noninvasive assessment of MS. However, MS extrinsic parameters such as left ventricular geometric characteristics could affect shear-wave propagation. The aims of this study were to determine a range of normal values of MS using SWE in age groups of healthy children and young adults and to explore the impact of left ventricular geometric characteristics on SWE. METHODS: Sixty healthy volunteers were recruited in the study and divided into 2 groups: neonates (0-1 months old, n = 15) and >1 month old (1 month to 45 years of age, n = 45). SWE was performed using the Verasonics Vantage systems with a phased-array ultrasound probe. The anteroseptal basal segment was assessed in two views. SWE was electrocardiographically triggered during the end-diastolic phase. Conventional echocardiography was performed to assess ventricular function and anatomy. Results are presented as stiffness values along with mean velocity measurements and SDs. Simple and multivariate linear regression analyses were performed. RESULTS: For neonates, mean MS was 1.87 ± 0.79 kPa (range, 0.59-2.91 kPa; mean SWV, 1.37 ± 0.57 m/sec), with high variability and no correlation with age (P = .239). For this age group, no statistically significant correlation was found between MS and any demographic or echocardiographic parameters (P > .05). For the >1 month old group, a mean MS value of 1.67 ± 0.53 kPa was observed (range, 0.6-3 kPa; mean SWV, 1.29 ± 0.49 m/sec) for healthy volunteers. When paired for age, no sex-related difference was observed (P = .55). In univariate linear regression analysis, age (r = 0.83, P < .01), diastolic interventricular septal thickness (r = 0.72, P < .01), and left ventricular end-diastolic diameter (r = 0.67, P < .01) were the parameters with the highest correlation coefficients with MS. In a multiple linear regression analysis incorporating these three parameters as cofounding factors, age was the only statistically significant parameters (r = 0.81, P = .02). CONCLUSION: Diastolic MS increases linearly in children and young adults. Diastolic MS correlates more robustly with age than with myocardial and left ventricular geometric characteristics. However, the geometry affects SWV, implying the need to determine well-established boundaries in future studies for the clinical application of SWE.

In Vivo Ultrafast Doppler Imaging Combined with Confocal Microscopy and Behavioral Approaches to Gain Insight into the Central Expression of Peripheral Neuropathy in Trembler-J Mice.

The main human hereditary peripheral neuropathy (Charcot-Marie-Tooth, CMT), manifests in progressive sensory and motor deficits. Mutations in the compact myelin protein gene pmp22 cause more than 50% of all CMTs. CMT1E is a subtype of CMT1 myelinopathy carrying micro-mutations in pmp22. The Trembler-J mice have a spontaneous mutation in pmp22 identical to that present in CMT1E human patients. PMP22 is mainly (but not exclusively) expressed in Schwann cells. Some studies have found the presence of pmp22 together with some anomalies in the CNS of CMT patients. Recently, we identified the presence of higher hippocampal pmp22 expression and elevated levels of anxious behavior in TrJ/+ compared to those observed in wt. In the present paper, we delve deeper into the central expression of the neuropathy modeled in Trembler-J analyzing in vivo the cerebrovascular component by Ultrafast Doppler, exploring the vascular structure by scanning laser confocal microscopy, and analyzing the behavioral profile by anxiety and motor difficulty tests. We have found that TrJ/+ hippocampi have increased blood flow and a higher vessel volume compared with the wild type. Together with this, we found an anxiety-like profile in TrJ/+ and the motor difficulties described earlier. We demonstrate that there are specific cerebrovascular hemodynamics associated with a vascular structure and anxious behavior associated with the TrJ/+ clinical phenotype, a model of the human CMT1E disease.

Nuclear Imaging in Pediatric Cardiology: Principles and Applications.

Nuclear imaging plays a unique role within diagnostic imaging since it focuses on cellular and molecular processes. Using different radiotracers and detection techniques such as the single photon emission scintigraphy or the positron emission tomography, specific parameters can be assessed: myocardial perfusion and viability, pulmonary perfusion, ventricular function, flow and shunt quantification, and detection of inflammatory processes. In pediatric and congenital cardiology, nuclear imaging can add complementary information compared to other imaging modalities such as echocardiography or magnetic resonance imaging. In this state-of-the-art paper, we appraise the different techniques in pediatric nuclear imaging, evaluate their advantages and disadvantages, and discuss the current clinical applications.

Intensity distribution segmentation in ultrafast Doppler combined with scanning laser confocal microscopy for assessing vascular changes associated with ageing in murine hippocampi.

The hippocampus plays an important role in learning and memory, requiring high-neuronal oxygenation. Understanding the relationship between blood flow and vascular structure-and how it changes with ageing-is physiologically and anatomically relevant. Ultrafast Doppler ([Formula: see text]Doppler) and scanning laser confocal microscopy (SLCM) are powerful imaging modalities that can measure in vivo cerebral blood volume (CBV) and post mortem vascular structure, respectively. Here, we apply both imaging modalities to a cross-sectional and longitudinal study of hippocampi vasculature in wild-type mice brains. We introduce a segmentation of CBV distribution obtained from [Formula: see text]Doppler and show that this mice-independent and mesoscopic measurement is correlated with vessel volume fraction (VVF) distribution obtained from SLCM-e.g., high CBV relates to specific vessel locations with large VVF. Moreover, we find significant changes in CBV distribution and vasculature due to ageing (5 vs. 21 month-old mice), highlighting the sensitivity of our approach. Overall, we are able to associate CBV with vascular structure-and track its longitudinal changes-at the artery-vein, venules, arteriole, and capillary levels. We believe that this combined approach can be a powerful tool for studying other acute (e.g., brain injuries), progressive (e.g., neurodegeneration) or induced pathological changes.

A guide for assessment of myocardial stiffness in health and disease.

Myocardial stiffness is an intrinsic property of the myocardium that influences both diastolic and systolic cardiac function. Myocardial stiffness represents the resistance of this tissue to being deformed and depends on intracellular components of the cardiomyocyte, particularly the cytoskeleton, and on extracellular components, such as collagen fibers. Myocardial disease is associated with changes in myocardial stiffness, and its assessment is a key diagnostic marker of acute or chronic pathological myocardial disease with the potential to guide therapeutic decision-making. In this Review, we appraise the different techniques that can be used to estimate myocardial stiffness, evaluate their advantages and disadvantages, and discuss potential clinical applications.

Brain perfusion imaging in neonates.

Abnormal variations of the neonatal brain perfusion can result in long-term neurodevelopmental consequences and cerebral perfusion imaging can play an important role in diagnostic and therapeutic decision-making. To identify at-risk situations, perfusion imaging of the neonatal brain must accurately evaluate both regional and global perfusion. To date, neonatal cerebral perfusion assessment remains challenging. The available modalities such as magnetic resonance imaging (MRI), ultrasound imaging, computed tomography (CT), near-infrared spectroscopy or nuclear imaging have multiple compromises and limitations. Several promising methods are being developed to achieve better diagnostic accuracy and higher robustness, in particular using advanced MRI and ultrasound techniques. The objective of this state-of-the-art review is to analyze the methodology and challenges of neonatal brain perfusion imaging, to describe the currently available modalities, and to outline future perspectives.

Bedside functional monitoring of the dynamic brain connectivity in human neonates.

Clinicians have long been interested in functional brain monitoring, as reversible functional losses often precedes observable irreversible structural insults. By characterizing neonatal functional cerebral networks, resting-state functional connectivity is envisioned to provide early markers of cognitive impairments. Here we present a pioneering bedside deep brain resting-state functional connectivity imaging at 250-µm resolution on human neonates using functional ultrasound. Signal correlations between cerebral regions unveil interhemispheric connectivity in very preterm newborns. Furthermore, fine-grain correlations between homologous pixels are consistent with white/grey matter organization. Finally, dynamic resting-state connectivity reveals a significant occurrence decrease of thalamo-cortical networks for very preterm neonates as compared to control term newborns. The same method also shows abnormal patterns in a congenital seizure disorder case compared with the control group. These results pave the way to infants' brain continuous monitoring and may enable the identification of abnormal brain development at the bedside.

Blood Flow Imaging with Ultrafast Doppler.

The pulsed-Doppler effect is the main technique used in clinical echography to assess blood flow. Applied with conventional focused ultrasound Doppler modes, it has several limits. Firstly, a finely tuned signal filtering operation is needed to distinguish blood flows from surrounding moving tissues. Secondly, the operator must choose between localizing the blood flows or quantifying them. In the last two decades, ultrasound imaging has undergone a paradigm shift with the emergence of ultrafast ultrasound using unfocused waves. In addition to a hundredfold increase in framerate (up to 10000 Hz), this new technique also breaks the conventional quantification/localization trade-off, offering a complete blood flow mapping of the field of view and a simultaneous access to fine velocities measurements at the single-pixel level (down to 50 µm). This data continuity in both spatial and temporal dimensions strongly improves the tissue/blood filtering process, which results in an increase sensitivity to small blood flow velocities (down to 1 mm/s). In this method paper, we aim to introduce the concept of ultrafast Doppler as well as its main parameters. Firstly, we summarize the physical principles of unfocused wave imaging. Then, we present the Doppler signal processing main steps. Particularly, we explain the practical implementation of the critical tissue/blood flow separation algorithms and on the extraction of velocities from these filtered data. This theoretical description is supplemented by in vitro experiences. A tissue phantom embedding a canal with flowing blood-mimicking fluid is imaged with a research programmable ultrasound system. A blood flow image is obtained and the flow characteristics are displayed for several pixels in the canal. Finally, a review of in vivo applications is proposed, showing examples in several organs such as carotids, kidney, thyroid, brain and heart.

Ultrafast Ultrasound Imaging in Pediatric and Adult Cardiology: Techniques, Applications, and Perspectives.

Ultrasound techniques currently used in echocardiography are limited by conventional frame rates. Ultrafast ultrasound imaging is able to capture images at frame rates up to 100 times faster compared with conventional imaging. Specific applications of this technology have been developed and tested for clinical use in pediatric and adult cardiac imaging. These include ultrafast Doppler or vector flow imaging, shear wave imaging, electromechanical wave imaging, and backscatter tensor imaging. The principles of these applications are explained in this manuscript with illustrations on how these methods could be applied in clinical practice. Ultrafast ultrasound has great clinical potential in the assessment of cardiac function, in noninvasive hemodynamic analysis, while providing novel techniques for imaging coronary perfusion and evaluating rhythm disorders.