A meta-analysis and investigation for the source of bias of left ventricular volumes and function by three-dimensional echocardiography in comparison with magnetic resonance imaging

Imaging Advances in Heart Failure

This paper delves into the significance of imaging in the diagnosis, aetiology and therapeutic guidance of heart failure, aiming to facilitate early referral and improve patient outcomes. Imaging plays a crucial role not only in assessing left ventricular ejection fraction, but also in characterising the underlying cardiac abnormalities and reaching a specific diagnosis. By providing valuable data on cardiac structure, function and haemodynamics, imaging helps diagnose the condition, evaluate haemodynamic status and, consequently, identify the underlying pathophysiological phenotype, as well as stratifying the risk for outcomes. In this article, we provide a comprehensive exploration of these aspects.

Validating real-time three-dimensional echocardiography against cardiac magnetic resonance, for the determination of ventricular mass, volume and ejection fraction: a meta-analysis

INTRODUCTION

Real-time three-dimensional echocardiography (RT3DE) is currently being developed to overcome the challenges of two-dimensional echocardiography, as it is a much cheaper alternative to the gold standard imaging method, cardiac magnetic resonance (CMR). The aim of this meta-analysis is to validate RT3DE by comparing it to CMR, to ascertain whether it is a practical imaging method for routine clinical use.

METHODS

A systematic review and meta-analysis method was used to synthesise the evidence and studies published between 2000 and 2021 were searched using a PRISMA approach. Study outcomes included left ventricular end-systolic volume (LVESV), left ventricular end-diastolic volume (LVEDV), left ventricular ejection fraction (LVEF), left ventricular mass (LVM), right ventricular end-systolic volume (RVESV), right ventricular end-diastolic volume (RVEDV) and right ventricular ejection fraction (RVEF). Subgroup analysis included study quality (high, moderate), disease outcomes (disease, healthy and disease), age group (50 years old and under, over 50 years), imaging plane (biplane, multiplane) and publication year (2010 and earlier, after 2010) to determine whether they explained the heterogeneity and significant difference results generated on RT3DE compared to CMR.

RESULTS

The pooled mean differences for were - 5.064 (95% CI - 10.132, 0.004, p > 0.05), 4.654 (95% CI - 4.947, 14.255, p > 0.05), - 0.783 (95% CI - 5.630, 4.065, p > 0.05, - 0.200 (95% CI - 1.215, 0.815, p > 0.05) for LVEF, LVM, RVESV and RVEF, respectively. We found no significant difference between RT3DE and CMR for these variables. Although, there was a significant difference between RT3DE and CMR for LVESV, LVEDV and RVEDV where RT3DE reports a lower value. Subgroup analysis indicated a significant difference between RT3DE and CMR for studies with participants with an average age of over 50 years but no significant difference for those under 50. In addition, a significant difference between RT3DE and CMR was found in studies using only participants with cardiovascular diseases but not in those using a combination of diseased and healthy participants. Furthermore, for the variables LVESV and LVEDV, the multiplane method shows no significant difference between RT3DE and CMR, as opposed to the biplane showing a significant difference. This potentially indicates that increased age, the presence of cardiovascular disease and the biplane analysis method decrease its concordance with CMR.

CONCLUSION

This meta-analysis indicates promising results for the use of RT3DE, with limited difference to CMR. Although in some cases, RT3DE appears to underestimate volume, ejection fraction and mass when compared to CMR. Further research is required in terms of imaging method and technology to validate RT3DE for routine clinical use.

Evaluation of left ventricular function and volume by two-dimensional echocardiography in a pediatric population: Correlation with cardiac magnetic resonance imaging

Background

Echocardiographic quantification of left ventricular (LV) volume and ejection fraction (EF) is widely used in the pediatric population. However, there is no consensus on the most accurate method of quantifying ventricular volumes and systolic function.

Purpose

The purpose of this study is to compare two commonly used echocardiographic methods for the evaluation of LV volume and quantification of EF, the five-sixth area-length (5/6 AL) and the modified biplane Simpson (BS), to cardiac magnetic resonance (CMR) imaging in children.

Methods

CMR studies were paired with echocardiograms and retrospectively analyzed in children 18 years of age and younger. Studies performed more than 3 months between modalities, patients with congenital heart disease, and patients who had changes in medication regimen between corresponding CMR and echocardiograms were excluded. LV volumes and EF were calculated using the 5/6 AL and BS methods and compared to volumes and EF measured on corresponding CMR studies. Subgroup analyses were conducted based on LV function, pathology, and weight.

Results

We retrospectively analyzed 53 CMR and corresponding echocardiogram studies (23 studies for myocarditis and 30 studies for cardiomyopathy) in 46 patients. LVEF derived by both echocardiographic methods showed a good correlation to CMR (5/6 AL r = 0.85 and BS r = 0.82). However, both echocardiographic methods overestimated LVEF and underestimated LV volumes when compared to CMR.

Conclusion

Left ventricular volumes and EF, as measured by echocardiography, correlate well with CMR measurements. Echocardiography underestimates LV systolic and diastolic volumes and overestimates LVEF. While echocardiography is a good surrogate for estimating LVEF, CMR should be considered in patients for whom accurate measurements are needed for critical clinical decision-making.

Heart Failure With Preserved Ejection Fraction: An Evolving Understanding

Heart failure (HF) with preserved ejection fraction (HFpEF) is a clinical syndrome in which patients have signs and symptoms of HF due to high left ventricular (LV) filling pressure despite normal or near normal LV ejection fraction. It is more common than HF with reduced ejection fraction (HFrEF), and its diagnosis and treatment are more challenging than HFrEF. Although hypertension is the primary risk factor, coronary artery disease and other comorbidities, such as atrial fibrillation (AF), diabetes, chronic kidney disease (CKD), and obesity, also play an essential role in its formation. This review summarizes current knowledge about HFpEF, its pathophysiology, clinical presentation, diagnostic challenges, current treatments, and promising novel treatments. It is essential to continue to be updated on the latest treatments for HFpEF so that patients always receive the most therapeutic treatments. The use of GnRH agonists in the management of HFpEF, infusion of Apo a-I nanoparticle, low-level transcutaneous vagal stimulation (LLTS), and estrogen only in post-menopausal women are promising strategies to prevent diastolic dysfunction and HFpEF; however, there is still no proven curative treatment for HFpEF yet.

Valid and Reproducible Quantitative Assessment of Cardiac Volumes by Echocardiography in Patients with Valvular Heart Diseases-Possible or Wishful Thinking?

The analysis of left ventricular function is predominantly based on left ventricular volume assessment. Especially in valvular heart diseases, the quantitative assessment of total and effective stroke volumes as well as regurgitant volumes is necessary for a quantitative approach to determine regurgitant volumes and regurgitant fraction. In the literature, there is an ongoing discussion about differences between cardiac volumes estimated by echocardiography and cardiac magnetic resonance tomography. This viewpoint focuses on the feasibility to assess comparable cardiac volumes with both modalities. The former underestimation of cardiac volumes determined by 2D and 3D echocardiography is presumably explained by methodological and technical limitations. Thus, this viewpoint aims to stimulate an urgent and critical rethinking of the echocardiographic assessment of patients with valvular heart diseases, especially valvular regurgitations, because the actual integrative approach might be too error prone to be continued in this form. It should be replaced or supplemented by a definitive quantitative approach. Valid quantitative assessment by echocardiography is feasible once echocardiography and data analysis are performed with methodological and technical considerations in mind. Unfortunately, implementation of this approach cannot generally be considered for real-world conditions.

Functional and Metabolic Imaging in Heart Failure with Preserved Ejection Fraction: Promises, Challenges, and Clinical Utility

Heart failure with preserved ejection fraction (HFpEF) is recognised as an increasingly prevalent, morbid and burdensome condition with a poor outlook. Recent advances in both the understanding of HFpEF and the technological ability to image cardiac function and metabolism in humans have simultaneously shone a light on the molecular basis of this complex condition of diastolic dysfunction, and the inflammatory and metabolic changes that are associated with it, typically in the context of a complex patient. This review both makes the case for an integrated assessment of the condition, and highlights that metabolic alteration may be a measurable outcome for novel targeted forms of medical therapy. It furthermore highlights how recent technological advancements and advanced medical imaging techniques have enabled the characterisation of the metabolism and function of HFpEF within patients, at rest and during exercise.

Three-dimensional echocardiography of the athlete's heart: a comparison with cardiac magnetic resonance imaging

Three-dimensional echocardiography (3DE) is the most accurate cardiac ultrasound technique to assess cardiac structure. 3DE has shown close correlation with cardiac magnetic resonance imaging (CMR) in various populations. There is limited data on the accuracy of 3DE in athletes and its value in detecting alterations during follow-up. Indexed left and right ventricular end-diastolic volume (LVEDVi, RVEDVi), end-systolic volume, ejection fraction (LVEF, RVEF) and left ventricular mass (LVMi) were assessed by 3DE and CMR in two-hundred and one competitive endurance athletes (79% male) from the Pro@Heart trial. Sixty-four athletes were assessed at 2 year follow-up. Linear regression and Bland-Altman analyses compared 3DE and CMR at baseline and follow-up. Interquartile analysis evaluated the agreement as cardiac volumes and mass increase. 3DE showed strong correlation with CMR (LVEDVi r = 0.91, LVEF r = 0.85, LVMi r = 0.84, RVEDVi r = 0.84, RVEF r = 0.86 p < 0.001). At follow up, the percentage change by 3DE and CMR were similar (∆LVEDVi r = 0.96 bias - 0.3%, ∆LVEF r = 0.94, bias 0.7%, ∆LVMi r = 0.94 bias 0.8%, ∆RVESVi r = 0.93, bias 1.2%, ∆RVEF r = 0.87 bias 0.4%). 3DE underestimated volumes (LVEDVi bias - 18.5 mL/m², RVEDVi bias - 25.5 mL/m²) and the degree of underestimation increased with larger dimensions (Q1vsQ4 LVEDVi relative bias - 14.5 versus - 17.4%, p = 0.016; Q1vsQ4 RVEDVi relative bias - 17 versus - 21.9%, p = 0.005). Measurements of cardiac volumes, mass and function by 3DE correlate well with CMR and 3DE accurately detects changes over time. 3DE underestimates volumes and the relative bias increases with larger cardiac size.

Left ventricular volume and ejection fraction measurements by fully automated 3D echocardiography left chamber quantification software versus CMR: A systematic review and meta-analysis

BACKGROUND

Although transthoracic three-dimensional echocardiography (3DE) is now recommended by guidelines for left ventricular (LV) volumetric measurements, widespread implementation has been limited due to time constraints and required expertise. We hypothesized that fully automated 3DE left chamber quantification software might provide accurate measurements, and that its application could eliminate these obstacles.

METHODS

To address this hypothesis, we conducted a systematic review and meta-analysis following a search for studies that compared LV volumes and ejection fraction (EF) using fully automated 3DE software (HeartModel or Dynamic HeartModel, Philips Healthcare, Andover, MA, USA) with cardiac magnetic resonance (CMR), from 2015 to 2021. A random effects model was used to determine biases, correlations, and 95 % confidence intervals (CI) of LV end-diastolic volume (EDV), end-systolic volume (ESV), and EF. Subgroup and meta-regression analyses were performed to determine effects of moderators on the outcome.

RESULTS

Of 12 studies (616 subjects), mean differences and 95 % CIs in EDV, ESV, and EF between fully automated 3DE software and CMR were -19.6 mL (95 % CI; -27.6 to -11.5 mL), -11.4 mL (-16.7 to -6.2 mL), and 0.4 % (-1.1 to 2.0 %), respectively. Corresponding correlation values between the two methods were 0.91 (0.86-0.94), 0.89 (0.82-0.93), and 0.85 (0.81-0.88), respectively. Meta-regression analysis revealed that there were no effects of either publication year, type of software, or type of analysis on the outcome of LV volumetric and functional parameters except for publication year on LVESV correlation values.

CONCLUSIONS

Although 3DE still underestimates LV volumes, the observed differences were no >20 mL. EF showed similar values to CMR. Excellent correlations between the two techniques make fully automated 3DE left chamber quantification software useful for routine clinical practice in adult population.

Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies

Objectives

We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies.

Methods

We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study.

Results

LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ² = 98.3 vs. χ² = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ² = 15.9, p < 0.001 vs. χ² = 10.8, p = 0.001; 3DE LVESV: χ² = 24.4, p < 0.001 vs. χ² = 17.4, p = 0.001).

Conclusion

In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.

Right ventricular function in transcatheter mitral and tricuspid valve edge-to-edge repair

Since transcatheter edge-to-edge repair (TEER) has become a valuable therapy in the treatment of both, mitral (MR) and tricuspid regurgitation (TR), the question of optimized patient selection has gained growing importance. After years of attributing rather little attention to the right ventricle (RV) and its function in the setting of valvular heart failure, this neglect has recently changed. The present review sought to summarize anatomy and function of the RV in a clinical context and aimed at presenting the current knowledge on how the RV influences outcomes after TEER for atrioventricular regurgitation. The anatomy of the RV is determined by its unique shape, which necessitates to use three-dimensional imaging methods for detailed and comprehensive characterization. Complex parameters such as RV to pulmonary artery coupling (RVPAc) have been developed to combine information of RV function and afterload which is primary determined by the pulmonary vasculature and LV filling pressure. Beyond that, TR, which is closely related to RV function also plays an important role in the setting of TEER. While mitral valve transcatheter edge-to-edge repair (M-TEER) leads to reduction of concomitant TR in some patients, the prognostic value of TR in the setting of M-TEER remains unclear. Overall, this review summarizes the current state of knowledge of the outstanding role of RV function and associated TR in the setting of TEER and outlines the unsolved questions associated with right-sided heart failure.

Impact of correcting the 2D PISA method on the quantification of functional tricuspid regurgitation severity

AIMS

In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity.

METHODS AND RESULTS

In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21 cm2; P < 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25 mL; P < 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = -0.04 cm2, limits of agreement (LOA) ± 0.02 cm2 vs. bias = -0.15 cm2, LOA ± 0.31 cm2] and RegVol (bias = -3.29 mL, LOA ± 2.19 mL vs. bias = -10.9 mL, LOA ± 13.5 mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P < 0.001).

CONCLUSION

Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.

Correlation between Volumes Determined by Echocardiography and Cardiac MRI in Controls and Atrial Fibrillation Patients

Aims: We aimed to compare cardiac volumes measured with echocardiography (echo) and cardiac magnetic resonance imaging (MRI) in a mixed cohort of healthy controls (controls) and patients with atrial fibrillation (AF). Materials and methods: In total, 123 subjects were included in our study; 99 full datasets were analyzed. All the participants underwent clinical evaluation, EKG, echo, and cardiac MRI acquisition. Participants with full clinical data were grouped into 63 AF patients and 36 controls for calculation of left atrial volume (LA Vol) and 51 AF patients and 30 controls for calculation of left ventricular end-diastolic volume (LV EDV), end-systolic volume (ESV), and LV ejection fraction (LV EF). Results: No significant differences in LA Vol were observed (p > 0.05) when measured by either echo or MRI. However, echo provided significantly lower values for left ventricular volume (p < 0.0001). The echo LA Vol of all the subjects correlated well with that measured by MRI (Spearmen correlation coefficient r = 0.83, p < 0.0001). When comparing the two methods, significant positive correlations of EDV (all subjects: r = 0.55; Controls: r = 0.71; and AF patients: r = 0.51) and ESV (all subjects: r = 0.62; Controls: r = 0.47; and AF patients: r = 0.66) were found, with a negative bias for values determined using echo. For a subgroup of participants with ventricular volumes smaller than 49.50 mL, this bias was missing, thus in this case echocardiography could be used as an alternative for MRI. Conclusion: Good correlation and reduced bias were observed for LA Vol and EF determined by echo as compared to cardiac MRI in a mixed cohort of patients with AF and healthy volunteers. For the determination of volume values below 49.50 mL, an excellent correlation was observed between values obtained using echo and MRI, with comparatively reduced bias for the volumes determined by echo. Therefore, in certain cases, echocardiography could be used as a less expensive, less time-consuming, and contraindication free alternative to MRI for cardiac volume determination.

Measurement of Left Ventricular Dimensions and Ejection Fraction in Neonates by Three-Dimensional Echocardiography: A Comparative Study Between Philips QLAB and TOMTEC Software-Are the Values Interchangeable?

Three-dimensional echocardiography is being used to evaluate left ventricular dimensions and ejection fraction in clinical practice. The validity and normal values have been established in a large group of normal adults, children and neonates. The aim of this study was to compare left ventricular dimensions and ejection fraction obtained from the same 3-dimensional echocardiography datasets using 2 commercially available applications: Philips QLAB and Tomtec 4D LEFT VENTRICLE-ANALYSIS. Fifty consecutive newborns or neonates coming to their first newborn visit within the first 3 weeks of live, were recruited. 38 babies underwent full Echocardiographic evaluation, including the acquisition of several 3-dimensional datasets, while naturally sleeping. Left ventricular dimensions, volumes and ejection fraction were measured using Philips QLAB version 9.0 and results were compared to results of the same datasets, analysed using TomTec 4D LV software. Mean left ventricular diastolic, and systolic volumes indexed to body surface area and ejection fraction were: 24.7 ± 3.6 ml/m², 9.2 ± 1.3 ml/m² and 62 ± 3.8% using TomTec and 26.6 ± 3.8 ml/m², 10.4 ± 2 ml/m² and 63 ± 3.1% using QLAB, respectively. Mean indexed left ventricular diastolic, and systolic volumes measured with QLAB were significantly higher as compared to TomTec with insignificant difference in the ejection fraction. Normal left ventricular indices obtained from 3-dimensional echocardiography datasets were established, using Philips QLAB and TomTec 4D LV ANALYSIS software. Measurements obtained were significantly different between those venders, and hence, may not be used interchangeably.

Normal reference values of left ventricular volumetric parameters in healthy adults-real-life single-center experience from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Background

The left ventricle (LV) is the pump of the peripheral circulation, therefore its non-invasive accurate volumetric and functional assessment is essential. Three-dimensional (3D) speckle-tracking echocardiography (STE) is a new tool with capability of quantification of LV volumes and ejection fraction (EF). In the present study, age- and gender-dependency of 3DSTE-derived LV volumetric parameters were aimed to be quantified in healthy adults.

Methods

The present study involved 298 healthy adults. Data acquisition took place over a 6 year period (2011-2017), during which 123 adults had to be excluded due to inferior image quality. The study population was further divided into 4 groups based on age decades. In every case, a complete two-dimensional echocardiography was performed followed by 3DSTE examination.

Results

No significant differences were detected between the different age groups regarding 3D end-diastolic volume (EDV) and 3D end-systolic volume (ESV) and their body surface area (BSA)-indexed counterpart. 3DEF differed significantly between the 30-39-year-old males and 40-49-year-old males (P=0.04). Between the youngest and oldest patient group, only 3D left ventricular mass (LVM) was significantly different (P=0.02). The 18-29-year-old females had a significantly different 3DLVM (P<0.001) compared to that of the 50+ year-old females. Between the 40-49-year-old and 50+ year-old females 3DLVM (P=0.02) and BSA-indexed 3DLVM (P=0.05) proved to be significantly different.

Conclusions

3DSTE seems to be a reasonably viable tool for the quantification of LV volumetric parameters.

A multicenter study of three-dimensional echocardiographic evaluation of normal pediatric left ventricular volumes and function

BACKGROUND

Three-dimensional echocardiography (3DE) evaluation of left ventricular (LV) volume and function in pediatrics compares favorably with cardiac magnetic resonance imaging. The aim of this study was to establish from a multicenter, normal pediatric z-score values of 3DE left ventricular volumes and function.

METHODS

Six hundred and ninety-eight healthy children (ages 0-18 years) were recruited from five centers. LV 3DE was acquired from the 4-chamber view. A vendor-independent software analyzed end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) using semi-automated quantification. Body surface area (BSA)-based z-scores were generated. Intraobserver and interobserver variability were calculated using intraclass correlation (ICC) and repeatability coefficient (RC).

RESULTS

Z-scores were generated for ESV, EDV, and SV. The ICC for intraobserver variability for EDV, ESV, and SV was 0.99, 0.99, and 0.99, respectively. The ICC for interobserver variability for EDV, ESV, and SV was 0.98, 0.94, and 0.98, respectively. The RC for intraobserver and interobserver variability for LV EF was 4.39% (95% CI: 3.01, 5.59) and interobserver was 7.08% (95%CI: 5.51, 8.42).

CONCLUSIONS

We report pediatric z-scores for normal LV volumes using the semi-automated method from five centers, enhancing its generalizability. 3DE evaluation of LV volumes and EF in pediatric patients is highly reproducible.

Usefulness of three-dimensional echocardiography for assessment of left and right ventricular volumes in children, verified by cardiac magnetic resonance. Can we overcome the discrepancy?

INTRODUCTION

The role of three-dimensional echocardiography (3D-ECHO) chamber quantification in children is still underestimated.

MATERIAL AND METHODS

In 43 children 3D-ECHO measurements of end-diastolic (EDV) and end-systolic ventricular volumes (ESV) were compared to cardiac magnetic resonance (CMR) using Bland-Altman analysis and linear regression. The values of left and right ventricular volumes calculated in 3D-ECHO were compared with each other and verified by CMR.

RESULTS

The values of LV-EDV and LV-ESV measured in 3D-ECHO showed highly significant correlations with CMR (for LV-EDV r = 0.892, p < 0.00001; for LV-ESV r = 0.896, p < 0.00001). In the case of the right ventricle the correlation of 3D-ECHO results with CMR was still high (RV-EDV r = 0.848, p < 0.00001, RV-ESV r = 0.914, p < 0.00001), although mean RV-EDV and RV-ESV in 3D-ECHO were underestimated compared to CMR (by 38% for RV-EDV and 45% for RV-ESV). Correction of 3D-ECHO results using the coefficient of 1.38 and 1.45 for RV-EDV and RV-ESV, respectively, significantly improved the consistency of the results with CMR. 3D-ECHO offered lower mean values of right ventricular volumes compared to the left ventricle. The discrepancy was again reduced by the calculated coefficients.

CONCLUSIONS

3D-ECHO is a valuable tool for assessment of left ventricular volume, which strongly correlates and agrees with CMR. The right ventricular volumes calculated in 3D-ECHO tend to be significantly underestimated in comparison to CMR and corresponding left ventricular volumes obtained from 3D-ECHO. The use of coefficients developed by the study improves the consistency of right ventricular volumes measured by 3D-ECHO with results obtained by CMR and reduces the volumetric discrepancy between ventricles in 3D-ECHO.

Three-dimensional echocardiographic acquisition and validity of left ventricular volumes and ejection fraction

Transthoracic (TTE) and transesophageal (TEE) three-dimensional echocardiography (3DE) is now used in daily clinical practice. Advancements in technology have improved image acquisition with higher frame rates and increased resolution. Different 3DE acquisition techniques can be used depending upon the structure of interest and if volumetric analysis is required. Measurements of left ventricular (LV) volumes are the most common use of 3DE clinically but are highly dependent upon image quality. Three-dimensional LV function analysis has been made easier with the development of automated software, which has been found to be highly reproducible. However, further research is needed to develop normal reference range values of LV function for both 3D TTE and TEE.

Conversion of prior univentricular repairs to septated circulation: Case selection, challenges, and outcomes

Objectives

Complex congenital heart defects that present earlier in life are sometimes channelled in the single ventricle pathway, because of anatomical or logistic challenges involved in biventricular correction. Given the long-term functional and survival advantage, and with the surgeons' improved understanding of the cardiac anatomy, we have consciously explored the feasibility of a biventricular repair in these patients when they presented later for Fontan completion. We present a single institution's 10-year experience in achieving biventricular septation of prior univentricular repairs, the technical and physiological challenges and the surgical outcomes.

Methods

Between June 2010 and December 2019, 246 patients were channelized in the single ventricle pathway, of which 32 patients were identified as potential biventricular candidates at the time of evaluation for Fontan palliation, considering their anatomic feasibility. The surgical technique involves routing of the left ventricle to the aorta across the ventricular septal defect, ensuring an adequate sized right ventricular cavity, establishing right ventricle-pulmonary artery continuity and taking down the Glenn shunt with rerouting of the superior vena cava to the right atrium. This is a retrospective study where we reviewed the unique physiological and surgical characteristics of this subset of patients and analysed their surgical outcomes and complications.

Results

Biventricular conversion was achieved in all cases except in 3 patients, who had the Glenn shunt retained leading to a one and a half ventricle repair. The average age of the patients was 4.9 years of whom 18 were male. The average cardiopulmonary bypass time was 371 min with an average cross clamp time of 162 min. There was one mortality in a patient with corrected transposition of great arteries (c-TGA) with extensive arterio-venous malformations (AVMs). At a median follow-up of 60 months, all patients remained symptom free except two with NYHA II symptoms, one being treated for branch pulmonary artery stenosis with balloon dilatation and the other with multiple AVMs who needed coil closure. One patient with branch pulmonary artery (PA) stenosis required balloon dilatation and stent placement.

Conclusion

The possibility of achieving the surgical goal in this unique subset of patients evolves with the progressive experience of the congenital heart surgeon. Case selection is a crucial aspect in achieving the desired outcome, and this 'borderline' substrate is often recognized at the time of evaluation for the Fontan completion. A comprehensive preoperative imaging and planning helps in achieving the surgical septation and reconnection to achieve the desired physiological circulation. Though technically challenging, the surgery has excellent short- and mid-term outcomes as evidenced by our 10-year experience.

Three-dimensional echocardiography to assess left ventricular geometry and function

Introduction: Quantification of left ventricular (LV) size and function represents the most frequent indication for an echocardiographic study. New echocardiographic techniques have been developed over the last decades in an attempt to provide a more comprehensive, accurate, and reproducible assessment of LV function.Areas covered: Although two-dimensional echocardiography (2DE) is the recommended imaging modality to evaluate the LV, three-dimensional echocardiography (3DE) has proven to be more accurate, by avoiding geometric assumptions about LV geometry, and to have incremental value for outcome prediction in comparison to conventional 2DE. LV shape (sphericity) and mass are actually measured with 3DE. Myocardial deformation analysis using 3DE can early detect subclinical LV dysfunction, before any detectable change in LV ejection fraction.Expert opinion: 3DE eliminates the errors associated with foreshortening and geometric assumptions inherent to 2DE and 3DE measurements approach very closely those obtained by CMR (the current reference modality), while maintaining the unique clinical advantage of a safe, highly cost/effective, portable imaging technique, available to the cardiologist at bedside to translate immediately the echocardiography findings into the clinical decision-making process.

Usefulness of three-dimensional echocardiography for the assessment of ventricular function in children: Comparison with cardiac magnetic resonance, with a focus on patients with arrhythmia

BACKGROUND

Focusing on patients with arrhythmia, the aims of this study was to assess ventricular function in children using three-dimensional echocardiography (3D-ECHO) and to compare the results to those obtained with cardiac magnetic resonance (CMR).

METHODS

The study group consisted of 43 children in whom 3D-ECHO and CMR were performed. Twenty-five patients had a ventricular arrhythmia, 7 left ventricular cardiomyopathies, 9 proved to be healthy. In all children, 3D-ECHO (offline analysis) was used to assess ventricular ejection fraction (EF). The results were compared to CMR using the Bland-Altman analysis and linear regression. The Student paired T-test was used to compare of means between both modalities.

RESULTS

The relation between the results derived from both methods is linear (for left ventricle: estimated slope = 1.031, p < 0.0001, R-squared = 0.998; for right ventricle: estimated slope = 0.993, p < 0.0001, R-squared = 0.998). In spite of minimal mean differences between results for both ventricles and narrow 95% confidence intervals, the paired t-test proved those differences not to be significant (p > 0.05) for the right ventricle but statistically significant (p < 0.05) for the left ventricle, for which the left ventricular EF calculated in 3D-ECHO was systematically underestimated with a mean difference of -1.8% ± 2.6% (p < 0.0001).

CONCLUSIONS

Three-dimensional echocardiography assessment of both left and right ventricular EF in children showed high significant correlation and agreement with CMR. 3D-ECHO could be a valuable tool in follow-up of children with arrhythmic disorders requiring regular assessment of ventricular function.

Velocity vector imaging for the assessment of segmental ventricular function in children with a single right ventricle after cavopulmonary anastomosis

OBJECTIVE

Ventricular function assessment is very important for the treatment and prognostic classification of children with a single right ventricle (SRV) after cavopulmonary anastomosis (CPA). However, unusual ventricular shapes can result in inaccurate measurements. The aim of this study was to evaluate velocity vector imaging (VVI) for assessing segmental ventricular function in children with SRV after CPA.

METHODS

Twenty-one children with SRV after CPA and 21 age- and sex-matched children with normal biventricular anatomy and function were included. The longitudinal velocity, displacement, strain and strain rate were measured in the two groups in six segments by VVI. The velocity, displacement, strain and strain rate of the SRVs were compared with max(dp/dt) measured during simultaneous cardiac catheterization in the SRV subjects.

RESULTS

The control group consisted of 13 males and 8 females (69% males) with a mean age of 6.7 ± 3.5 years and mean weight of 20.5 ± 6.5 kg, and the study group consisted of 13 males and 8 females with a mean age 6.7 ± 3.7 years and mean weight of 20.6 ± 6.8 kg. Age, weight and sex distribution were similar between the groups (all, p > .05). Strain and strain rate values in all six segments were significantly lower in the study group than in the control group (all, p < .05). The max(dp/dt) of the SRV was 522.84 ± 158.32 mmHg/s, and the strain rate of the basal segment at the rudimentary chamber correlated best with max(dp/dt) (r = 0.74, p < .01).

CONCLUSIONS

Segmental ventricular dysfunction was present in children with SRV after CPA, and it could be assessed using VVI.

Recent Advances in Imaging of Hypertensive Heart Disease

PURPOSE OF REVIEW

To review recent advances in the imaging of hypertensive heart disease (HHD) with an emphasis on developments in the imaging of diffuse myocardial fibrosis using cardiac magnetic resonance (CMR).

RECENT FINDINGS

HHD results from long-standing hypertension and is characterized by the development of left ventricular hypertrophy and diffuse interstitial fibrosis. Diffuse fibrosis traditionally required endomyocardial biopsy to diagnose, but recent developments using T1 mapping in CMR allow for noninvasive assessment. Studies using T1 mapping have shown an increase in extracellular volume fraction (ECV) in patients with HHD compared to normal controls, suggesting ECV can be used as a noninvasive marker for fibrosis in HHD. In addition to T1 mapping, other recent advances in HHD imaging include improvements in three-dimensional echocardiography, allowing for accurate real-time volumetric measurements, and the use of speckle tracking echocardiography to detect subclinical systolic dysfunction. Measurement of ECV using T1 mapping in CMR can be used as a noninvasive marker of diffuse myocardial fibrosis in HHD. While further studies are needed to validate this approach with larger patient cohorts, ECV can potentially be used to both monitor disease progression and assess therapeutic interventions in HHD.

Innovation in 3D Echocardiographic Imaging

PURPOSE OF REVIEW

The purpose of this review is to detail three-dimensional echocardiographic (3DE) innovations in pre-surgical planning of congenital heart disease, guidance of catheter interventions such as fusion imaging, and functional assessment of patients with congenital heart disease.

RECENT FINDINGS

Innovations in 3DE have helped us delineate the details of atrioventricular valve function and understand the mechanism of atrioventricular valve failure in patients with atrioventricular septal defect and single ventricle post repair. Advancement in holographic display of 3D datasets allows for better manipulation of 3D images in three dimensions and better understanding of anatomic relationships. 3DE with fusion imaging reduces radiation in catheter interventions and provides presentations of 3DE images in the similar fashion as the fluoroscopic images to improve communication between cardiologists. Lastly, 3DE allows for quantitative ventricular volumetric and functional assessment. Recent innovations in 3DE allow for pre-surgical planning for congenital heart disease, reduce radiation using fusion imaging in catheter interventions, and enable accurate assessment of ventricular volume and function without geometric assumptions.

Effects of adenosine and regadenoson on hemodynamics measured using cardiovascular magnetic resonance imaging

BACKGROUND

Adenosine or regadenoson vasodilator stress cardiovascular magnetic resonance (CMR) is an effective non-invasive strategy for evaluating symptomatic coronary artery disease. Vasodilator injection typically precedes ventricular functional sequences to efficiently reduce overall scanning times, though the effects of vasodilators on CMR-derived ventricular volumes and function are unknown.

METHODS

We prospectively enrolled 25 healthy subjects to undergo consecutive adenosine and regadenoson administration. Short axis CINE datasets were obtained on a 1.5 T scanner following adenosine (140mcg/kg/min IV for 6 min) and regadenoson (0.4 mg IV over 10 s) at baseline, immediately following administration, at 5 min intervals up to 15 min. Hemodynamic response, bi-ventricular volumes and ejection fractions were determined at each time point.

RESULTS

Peak heart rate was observed early following administration of both adenosine and regadenoson. Heart rate returned to baseline by 10 min post-adenosine while remaining elevated at 15 min post-regadenoson (p = 0.0015). Left ventricular (LV) ejection fraction (LVEF) increased immediately following both vasodilators (p < 0.0001 for both) and returned to baseline following adenosine by 10 min (p = 0.8397). Conversely, LVEF following regadenoson remained increased at 10 min (p = 0.003) and 15 min (p = 0.0015) with a mean LVEF increase at 15 min of 4.2 ± 1.3%. Regadenoson resulted in a similar magnitude reduction in both LV end-diastolic volume index (LVEDVi) and LV end-systolic volume index (LVESVi) at 15 min whereas LVESVi resolved at 15 min following adenosine and LVEDVi remained below baseline values (p = 0.52).

CONCLUSIONS

Regadenoson and adenosine have significant and prolonged impact on ventricular volumes and LVEF. In patients undergoing vasodilator stress CMR where ventricular volumes and LVEF are critical components to patient care, ventricular functional sequences should be performed prior to vasodilator use or consider the use of aminophylline in the setting of regadenoson. Additionally, heart rate resolution itself is not an effective surrogate for return of ventricular volumes and LVEF to baseline.

Current Clinical Applications of Three-Dimensional Echocardiography: When the Technique Makes the Difference

Advances in ultrasound, computer, and electronics technology have permitted three-dimensional echocardiography (3DE) to become a clinically viable imaging modality, with significant impact on patient diagnosis, management, and outcome. Thanks to the inception of a fully sampled matrix transducer for transthoracic and transesophageal probes, 3DE now offers much faster and easier data acquisition, immediate display of anatomy, and the possibility of online quantitative analysis of cardiac chambers and heart valves. The clinical use of transthoracic 3DE has been primarily focused, albeit not exclusively, on the assessment of cardiac chamber volumes and function. Transesophageal 3DE has been applied mostly for assessing heart valve anatomy and function. The advantages of using 3DE to measure cardiac chamber volumes derive from the lack of geometric assumptions about their shape and the avoidance of the apical view foreshortening, which are the main shortcomings of volume calculations from two-dimensional echocardiographic views. Moreover, 3DE offers a unique realistic en face display of heart valves, congenital defects, and surrounding structures allowing a better appreciation of the dynamic functional anatomy of cardiac abnormalities in vivo. Offline quantitation of 3DE data sets has made significant contributions to our mechanistic understanding of normal and diseased heart valves, as well as of their alterations induced by surgical or interventional procedures. As reparative cardiac surgery and transcatheter procedures become more and more popular for treating structural heart disease, transesophageal 3DE has expanded its role as the premier technique for procedure planning, intra-procedural guidance, as well as for checking device function and potential complications after the procedure.

Parametrization of an in-silico circulatory simulation by clinical datasets - towards prediction of ventricular function following assist device implantation

BACKGROUND

Left ventricular assist device (LVAD) therapy has revolutionized the way end stage heart failure is treated today. Analysis of LVAD interaction with the whole cardiovascular system and its biological feedback loops is often conducted by means of computer models. Generating real time pressure volume loops (PV-loops) in patients, not using conductance catheters but routine diagnostics to feed an in-silico model could help to predict postoperative complications.

METHODS

Routinely obtained hemodynamic measurements to evaluate myocardial function prior to LVAD implantation like pressure readings in the aorta, the left atrium and the left ventricle and simultaneous three-dimensional (3D) echocardiography recordings were assessed to parametrize a reduced computational model of the cardiovascular system. An automatic parameter identification procedure has been developed.

RESULTS

The results constitute a patient-individual computational simulation model. An exemplary in-silico study focusing on the effect of different ventricular assist device (VAD) speeds has been conducted. Results allow for estimation of the resulting hemodynamic parameters and changes of the PV-loops.

CONCLUSION

The model improves understanding and prediction of the interaction between pump and ventricles. Future modifications in exporting and merging routinely assessed real time hemodynamic patient data are necessary to investigate various clinical and pathological conditions of LVAD recipients.

Quantification of ventricular unloading by 3D echocardiography in single ventricle of left ventricular morphology following superior cavo-pulmonary anastomosis and Fontan completion - a feasibility study

BACKGROUND

Three-dimensional echocardiography. (3DE) is comparable to cardiac magnetic resonance imaging for estimating ventricular volume in congenital heart diseases. However, there are limited data on estimation of ventricular volumes by 3DE in univentricular heart and change in ventricular volumes after surgical creation of cavopulmonary connection. We sought to quantify the unloading of the single ventricle of left ventricular. (LV) morphology by 3DE after superior cavopulmonary anastomosis. (SCPA) or Fontan operation over a period of 3 months and thereby derive a preliminary 3DE data set on this patient subset.

PATIENTS AND METHODS

Eighteen patients with functional single ventricle of LV morphology, who underwent SCPA or completion of Fontan circulation, were included in the study. Volume of the ventricle was estimated by 3DE before surgery and after surgery. (in the early postoperative phase and 3 months after surgery), and indexed end-diastolic volume. (EDV), end-systolic volume. (ESV), and ejection fraction. (EF) were derived.

RESULTS

Twelve patients underwent SCPA and six patients underwent staged completion of Fontan circulation. Before surgery, EDV was similar in both groups. There was a significant fall in EDV immediately after SCPA (from 48.3 ± 14.9 ml/m² to 39.5 ± 12.3 ml/m²). However, EDV increased at 3 months' follow-up to 41.3 ± 10.5 ml/m². There was no significant fall in EDV immediately after Fontan operation (47.2 ± 10.1 ml/m²-46.6 ± 14.2 ml/m²), but EDV continued to fall at 3 months of follow-up (44.7 ± 10. ml/m²). There was no significant change in ESV in either group, but EF fell significantly after SCPA.

CONCLUSIONS

We provide preliminary information on 3DE volume data of single ventricle of LV morphology and the pattern of unloading after SCPA and Fontan operation. Immediate significant volume unloading occurred after SCPA which tended to catch-up after 3 months, whereas continued fall in ventricular volume with time was noted after Fontan.

Three-dimensional echocardiographic measurements using automated quantification software for big data processing

OBJECTIVE

To compare a full-automated software to quantify 3D transthoracic echocardiography namely, 3DE-HM (three-dimensional echocardiography HeartModel, Philips Healthcare) with the traditional manual quantitative method (3DE-manual) for assessing volumes of left atrial and ventricular volumes, and left ventricular ejection fraction (LVEF).

METHODS

3D full volume images acquired from 156 subjects were collected and divided into 3 groups, which include 70 normal control cases (Group A), 17 patients with left ventricular remodeling after acute myocardial infarction (AMI) (Group B), and 69 patients with left atrial remodeling secondary to hypertension (Group C). The 3DE-HM method was used to quantify left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left atrial end-systolic volume (LAESV), and left ventricular ejection fraction (LVEF), respectively. The results were compared with those obtained with the 3DE-manual method for correlation and consistency analyses. The reproducibility of the 3DE-HM method was also evaluated.

RESULTS

There was a high correlation between LVEDV, LVESV, LAESV and LVEF values obtained with the 3DE-HM method and those obtained using the 3DE-manual method (r = 0.72 to 0.97). The correlation was strongest for Group B, patients with left ventricular remodeling post-AMI also demonstrated the greatest degree of morphologic changes. There was a significant difference in all parameters measured with the 3DE-HM method in different groups (P < 0.05). The difference in the measurements of LVEDV and LVESV between the two methods was greatest in patients in Group B compared with patients with hypertension-induced left ventricular remodeling (Group C) and in normal controls (Group A) (P < 0.05). Lastly, the difference in the measurement of LAESV between the two methods was greater in patients with hypertension-induced left ventricular remodeling (Group C) than that in the control group (Group A) (P < 0.05). The post-processing time of the 3DE-HM data was significantly shorter than that using the 3DE-manual method (P < 0.05). There was no significant variability in repeated measurements at different time points using the 3DE-HM method either between subjects in different groups or within the same subject.

CONCLUSION

3DE-HM is a quick and feasible method for left ventricular quantification and is clinically applicable for evaluating patients with left atrial and left ventricular remodeling.

Cardiac Imaging in Heart Failure with Comorbidities

Imaging modalities stand at the frontiers for progress in congestive heart failure (CHF) screening, risk stratification and monitoring. Advancements in echocardiography (ECHO) and Magnetic Resonance Imaging (MRI) have allowed for improved tissue characterizations, cardiac motion analysis, and cardiac performance analysis under stress. Common cardiac comorbidities such as hypertension, metabolic syndromes and chronic renal failure contribute to cardiac remodeling, sharing similar pathophysiological mechanisms starting with interstitial changes, structural changes and finally clinical CHF. These imaging techniques can potentially detect changes earlier. Such information could have clinical benefits for screening, planning preventive therapies and risk stratifying patients. Imaging reports have often focused on traditional measures without factoring these novel parameters. This review is aimed at providing a synopsis on how we can use this information to assess and monitor improvements for CHF with comorbidities.

The Role of Automated 3D Echocardiography for Left Ventricular Ejection Fraction Assessment

Ejection fraction is one of the most powerful determinants of prognosis and is a crucial parameter for the determination of cardiovascular therapies in conditions such as heart failure, valvular conditions and ischaemic heart disease. Among echocardiographic methods, 3D echocardiography has been attributed as the preferred one for its assessment, given an increased accuracy and reproducibility. Full-volume multi-beat acquisitions are prone to stitching artefacts due to arrhythmias and require prolonged breath holds. Single-beat acquisitions exhibit a lower temporal resolution, but address the limitations of multi-beat acquisitions. If not fully automated, 3D echocardiography remains time-consuming and resource-intensive, with suboptimal observer variability, preventing its implementation in routine practice. Further developments in hardware and software, including fully automated knowledge-based algorithms for left ventricular quantification, may bring 3D echocardiography to a definite turning point.

Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

Left ventricular diastolic function is strongly correlated with active emptying of the left atrium: a novel analysis using three-dimensional echocardiography

Background

Increased left atrial (LA) dimensions are known to be a risk factor in predicting cardiovascular events and mortality and to be one key diagnostic tool to assess diastolic dysfunction. Currently, LA measurements are usually conducted using 2D-echocardiography, although there are well-known limitations. Real-time 3D-echocardiography is able to overcome these limitations, furthermore being a valid measurement tool compared to reference standards (e.g. cardiac magnetic resonance imaging).

We investigated LA function and volume and their association to left ventricular (LV) diastolic function, using newly designed and validated software for 3D-echocardiographic analysis. This software is the first to allow for a sophisticated analysis of both passive and active LA emptying.

Methods

We analyzed 2D- and 3D-echocardiographic measurements of LA volume and function in 56 subjects and compared the results between patients with normal LV diastolic function (NDF) (n = 30, 52 ± 15 years, BMI 24.7 ± 2.6 kg/m²) and patients in which diastolic dysfunction (DDF) was suspected (n = 26, 65 ± 9 years, BMI 26.7 ± 3.7 kg/m²).

Results

Volumes during LA active emptying were significantly smaller in DDF compared to NDF (active atrial stroke volume (ASV): 3.0 (0.1–4.5) vs. 5.5 (2.7–7.8) ml, p = 0.005; True-EF: 7.3(0.1–11.5) vs. 16.2 (8.1–25.4) %, p = 0.002). Furthermore, ASV showed a stronger association to E/e’_mean than all other measured LA volumes (β = − 0.35, p = 0.008). Neither total stroke LA volume, nor maximum or minimum LA volume differed significantly between the groups.

Conclusions

Diastolic LV dysfunction results in a reduction in active LA emptying, which is more strongly associated with LV filling pressure than other previously investigated LA parameters.

Association Between Myocardial Mechanics and Ischemic LV Remodeling

The outcomes associated with heart failure after myocardial infarction are still poor. Both global and regional left ventricular (LV) remodeling are associated with the progression of the post-infarct patient to heart failure, but although global remodeling can be accurately measured, regional LV remodeling has been more difficult to investigate. Preliminary evidence suggests that post-MI assessment of LV mechanics using stress and strain may predict global (and possibly regional) LV remodeling. A method of predicting both global and regional LV remodeling might facilitate earlier, targeted, and more extensive clinical intervention in those most likely to benefit from novel interventions such as cell therapy.

Left Atrial Volumes and Function by Three-Dimensional Echocardiography

Background—

Our study sought to (1) identify reference values for left atrial (LA) volumes and phasic function indices by 3-dimensional echocardiography (3DE) and compare them with those measured by 2-dimensional echocardiography (2DE) and (2) analyze their relationship with age, sex, body size, and left ventricular function. Accuracy and reproducibility of 3DE and 2DE have been also tested to evaluate the robustness of our data.

Methods and Results—

We obtained maximal, minimal, and preA LA volumes by 3DE and 2DE in 276 healthy volunteers (18–79 years; 57% women). Limits of normality for LA volumes and total LA emptying fraction were larger with 3DE than with 2DE (maximal LA volume: 43 versus 35 mL/m 2 ; preA LA volume: 31 versus 25 mL/m 2 ; minimal LA volume: 18 versus 14 mL/m 2 ; 53 versus 48%, respectively; P <0.001). 3DE LA volumes indexed by body surface area were similar in men and women and increased with age. On multivariable analysis, age, weight, and left ventricular systolic and diastolic function indices resulted as correlates of LA 3DE indices. LA volumes were tightly correlated with cardiac magnetic resonance measurements, yet more underestimated by 2DE versus 3DE (bias±SD: −17±16 versus −7±15 mL, respectively). Among all LA parameters, maximal LA volume and total emptying fraction were the most reproducible, including at test-retest and at expert versus trainee comparisons.

Conclusions—

This study provides reference values for LA 3DE volumes and function from a relatively large cohort of healthy subjects with a wide age range. Our data may help clinicians to identify LA remodeling and dysfunction.

Bias associated with left ventricular quantification by multimodality imaging: a systematic review and meta-analysis

Purpose

Cardiac MR (CMR) is the gold standard for left ventricular (LV) quantification. However, two-dimensional echocardiography (2DE) is the most common approach, and both three-dimensional echocardiography (3DE) and multidetector CT (MDCT) are increasingly available. The clinical significance and interchangeability of these modalities remains under-investigated. Therefore, we undertook a systemic review to evaluate the accuracy and absolute bias in LV quantification of all the commonly available non-invasive imaging modalities (2DE, CE-2DE, 3DE, MDCT) compared to cardiac MR (CMR).

Methods

Studies were included that reported LV echocardiographic (2DE, CE-2DE, 3DE) and/or MDCT measurements compared to CMR. Only modern CMR (SSFP sequences) was considered. Studies involving small sample size (<10 patients) and unusual cardiac geometry (ie, congenital heart diseases) were excluded. We evaluated LV end-diastolic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF).

Results

1604 articles were initially considered: 65 studies were included (total of 4032 scans (echo, CT, MRI) performed in 2888 patients). Compared to CMR, significant biased underestimation of LV volumes with 2DE was seen (LVEDV—33.30 mL, LVESV −16.20 mL, p<0.0001). This difference was reduced but remained significant with CE-2DE (LVEDV −18.05, p<0.0001) and 3DE (LVEDV −14.41, p<0.001), while MDCT values were similar to CMR (LVEDV −1.20, p=0.43; LVESV −0.13, p=0.91). However, excellent agreement for echocardiographic LVEF evaluation (2DE LVEF 0.78–1.01%, p=0.37) was observed, especially with 3DE (LVEF 0.14%, p=0.88).

Conclusions

Comparing imaging modalities to CMR as reference standard, 3DE had the highest accuracy in LVEF estimation: 2DE and 3DE-derived LV volumes were significantly underestimated. Newer generation CT showed excellent accuracy for LV volumes.

Advanced functional echocardiographic imaging of the failing heart in children

Over the past decade, new echocardiographic techniques such as three-dimensional echocardiography and the imaging of myocardial deformation (strain) have been developed, and are increasingly used in clinical practice. In this article, we describe the rationale and methodology, review available guidelines for practice, and discuss the advantages and limitations of each of these modalities. When available, we have also summarised the scientific evidence for the clinical application of these techniques to detect heart failure in children.

[Hypertrophic and restrictive cardiomyopathy. Differentiation by imaging]

The differentiation between hypertrophic and restrictive cardiomyopathies is often challenging in the routine clinical setting. Advances in the field of multimodal imaging have improved the diagnostics of these diseases and understanding of the underlying pathophysiology. Each imaging method, such as echocardiography, cardiac magnetic resonance imaging (CMR), cardiac computed tomography (CT) and coronary angiography including cardiac catheterization for pressure measurements, is of significant value in clinical diagnostics and also regarding therapeutic approaches and prognostic implications. This review gives an overview of developments of the past few years, describes recent insights and puts these findings into a scientific context. Particularly CMR has added valuable information to current knowledge by its unique potential of contrast-enhanced tissue characterization. Another promising CMR tool, parametric mapping has appeared on the horizon and may further deepen our understanding of cardiac pathophysiology as well as offer new therapeutic options to patients.