Accuracy of Left Ventricular Volumes and Ejection Fraction Measurements by Contemporary Three-Dimensional Echocardiography with Semi- and Fully Automated Software: Systematic Review and Meta-Analysis of 1,881 Subjects

Echocardiographic assessment of left ventricular volumes: a comparison of different methods in athletes

BACKGROUND

Cardiac magnetic resonance imaging (cMRI) is considered the gold standard for the assessment of left ventricular (LV) systolic function. However, discrepancies have been reported in the literature between LV volumes assessed by transthoracic echocardiography (TTE) and cMRI. The objective of this study was to analyze the differences in LV volumes between different echocardiographic techniques and cMRI.

METHODS AND RESULTS

In 64 male athletes (21.1 ± 4.9 years), LV volumes were measured by TTE using the following methods: Doppler echocardiography, anatomical M-Mode, biplane/triplane planimetry and 3D volumetry. In addition, LV end-diastolic (LVEDV), end-systolic (LVESV), and stroke volumes (LVSV) were assessed in 11 athletes by both TTE and cMRI. There was no significant difference between LVEDV and LVESV determined by biplane/triplane planimetry and 3D volumetry. LVEDV and LVESV measured by M-Mode were significantly lower compared to 3D volumetry. LVSV determined by Doppler with 3D planimetry of LV outflow tract was significantly higher than 2D planimetry and 3D volumetry, whereas none of the planimetric or volumetric methods for determining LVSV differed significantly. There were no significant differences for LVEDV, LVESV, LVSV and LVEF between cMRI and TTE determined by biplane planimetry in the subgroup of 11 athletes.

CONCLUSION

The choice of echocardiographic method used has an impact on LVSV in athletes, so the LVSV should always be checked for plausibility. The same echocardiographic method should be used to assess LVSV at follow-ups to ensure good comparability. The data suggest that biplane LV planimetry by TTE is not inferior to cMRI.

Examining temporal changes in model-optimized parameters using longitudinal hemodynamic measurements

BACKGROUND

We previously applied hemodynamic data to personalize a mathematical model of the circulation expressed as physically interpretable parameters. The aim of this study was to identify patterns in the data that could potentially explain the estimated parameter changes. This included investigating whether the parameters could be used to track the effect of physical activity on high blood pressure. Clinical trials have repeatedly detected beneficial changes in blood pressure after physical activity and uncovered changes in lower level phenotypes (such as stiffened or high-resistance blood vessels). These phenotypes can be characterized by parameters describing the mechanical properties of the circulatory system. These parameters can be incorporated in and contextualized by physics-based cardiovascular models of the circulation, which in combination can become tools for monitoring cardiovascular disease progression and management in the future.

METHODS

Closed-loop and open-loop models of the left ventricle and systemic circulation were previously optimized to data from a pilot study with a 12-week exercise intervention period. Basal characteristics and hemodynamic data such as blood pressure in the carotid, brachial and finger arteries, as well as left-ventricular outflow tract flow traces were collected in the trial. Model parameters estimated for measurements made on separate days during the trial were used to compute parameter changes for total peripheral resistance, systemic arterial compliance, and maximal left-ventricular elastance. We compared the changes in these cardiovascular model-based estimates to changes from more conventional estimates made without the use of physics-based models by correlation analysis. Additionally, ordinary linear regression and linear mixed-effects models were applied to determine the most informative measurements for the selected parameters. We applied maximal aerobic capacity (measured as VO2max ) data to examine if exercise had any impact on parameters through regression analysis and case studies.

RESULTS AND CONCLUSIONS

Parameter changes in arterial parameters estimated using the cardiovascular models correlated moderately well with conventional estimates. Estimates based on carotid pressure waveforms gave higher correlations (0.59 and above when p < 0.05 ) than those for finger arterial pressure. Parameter changes over the 12-week study duration were of similar magnitude when compared to short-term changes after a bout of intensive exercise in the same parameters. The short-term changes were computed from measurements made immediately before and 24 h after a cardiopulmonary exercise test used to measure VO2max . Regression analysis indicated that changes in VO2max did not account for any substantial amount of variability in total peripheral resistance, systemic arterial compliance, or maximal left-ventricular elastance. On the contrary, changes in stroke volume contributed to far more explained variability. The results suggest that more research is required to be able to accurately track exercise-induced changes in the vasculature for people with pre-hypertension and hypertension using lumped-parameter models.

Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment

Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment-especially in patients with combined aortic and mitral regurgitation-are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation.

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.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Interaction between the left ventricular ejection fraction and left ventricular strain and its relationship with coronary stenosis

BACKGROUND

Coronary artery stenosis (CAS) is the most common type of heart disease and the leading cause of death in both men and women globally. CAS occurs when the arteries that supply blood to the heart muscle harden and become narrower due to plaque buildup - cholesterol and other material - on their inner walls. As a result, the heart muscle cannot receive the blood or oxygen it needs. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage.

AIM

To analyze the relationship between the left ventricular ejection fraction (LVEF), left ventricular strain (LVS), and coronary stenosis.

METHODS

A total of 190 participants were enrolled in this trail. The control group comprised 93 healthy individuals, and observation group comprised 97 patients with coronary heart disease who were hospitalized between July 2020 and September 2021. Coronary lesions were assessed using the Gensini score, and the LVEF and LVS were measured using magnetic resonance imaging (MRI). The interaction between the LVEF and LVS was examined using a linear regression model. The relationship between LVEF and coronary stenosis was examined using Spearman’s correlation.

RESULTS

The LVEF of the observation group was lower than that of the control group. The left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) of the observation group were significantly higher than those of the control group (P < 0.05). The longitudinal and circumferential strains (LS, CS) of the observation group were significantly higher than those of the control group; however, the radial strain (RS) of the observation group was significantly lower than that of the control group (P < 0.05). LVS, LS, and CS were significantly negatively correlated with the LVEF, and RS was positively correlated with the LVEF. There were significant differences in the LVEF, LVESV, and LVEDV of patients with different Gensini scores; the LVEF significantly decreased and the LVESV and LVEDV increased with increasing Gensini scores (P < 0.05). In the observation group, the LVEF was negatively correlated and the LVESV and LVEDV were positively correlated with coronary stenosis (P < 0.05).

CONCLUSION

The LVEF measured using MRI is significantly linearly correlated with LVS and negatively correlated with coronary stenosis.

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.

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.

Three-dimensional echocardiographic assessment of left ventricular volume in different heart diseases using a fully automated quantification software

BACKGROUND

HeartModel (HM) is a fully automated adaptive quantification software that can quickly quantify left heart volume and left ventricular function. This study used HM to quantify the left ventricular end-diastolic (LVEDV) and end-systolic volumes (LVESV) of patients with dilated cardiomyopathy (DCM), coronary artery heart disease with segmental wall motion abnormality, and hypertrophic cardiomyopathy (HCM) to determine whether there were differences in the feasibility, accuracy, and repeatability of measuring the LVEDV, LVESV, LV ejection fraction (LVEF) and left atrial end-systolic volume (LAESV) and to compare these measurements with those obtained with traditional two-dimensional (2D) and three-dimensional (3D) methods.

AIM

To evaluate the application value of HM in quantifying left heart chamber volume and LVEF in clinical patients.

METHODS

A total of 150 subjects who underwent 2D and 3D echocardiography were divided into 4 groups: (1) 42 patients with normal heart shape and function (control group, Group A); (2) 35 patients with DCM (Group B); (3) 41 patients with LV remodeling after acute myocardial infarction (Group C); and (4) 32 patients with HCM (Group D). The LVEDV, LVESV, LVEF and LAESV obtained by HM with (HM-RE) and without regional endocardial border editing (HM-NE) were compared with those measured by traditional 2D/3D echocardiographic methods to assess the correlation, consistency, and repeatability of all methods.

RESULTS

(1) The parameters measured by HM were significantly different among the groups (P < 0.05 for all). Compared with Groups A, C, and D, Group B had higher LVEDV and LVESV (P < 0.05 for all) and lower LVEF (P < 0.05 for all); (2) HM-NE overestimated LVEDV, LVESV, and LAESV with wide biases and underestimated LVEF with a small bias; contour adjustment reduced the biases and limits of agreement (bias: LVEDV, 28.17 mL, LVESV, 14.92 mL, LAESV, 8.18 mL, LVEF, -0.04%). The correlations between HM-RE and advanced cardiac 3D quantification (3DQA) (r_s = 0.91-0.95, P < 0.05 for all) were higher than those between HM-NE (r_s = 0.85-0.93, P < 0.05 for all) and the traditional 2D methods. The correlations between HM-RE and 3DQA were good for Groups A, B, and C but remained weak for Group D (LVEDV and LVESV, r_s = 0.48-0.54, P < 0.05 for all); and (3) The intraobserver and interobserver variability for the HM-RE measurements were low.

CONCLUSION

HM can be used to quantify the LV volume and LVEF in patients with common heart diseases and sufficient image quality. HM with contour editing is highly reproducible and accurate and may be recommended for clinical practice.

Quantification of chronic aortic regurgitation using left and right ventricular stroke volumes obtained from two new automated three-dimensional transthoracic echocardiographic software: feasibility and accuracy

The present study aimed to evaluate the feasibility and accuracy of chronic aortic regurgitation (CAR) quantification using left and right ventricular stroke volumes (LVSV and RVSV, respectively) obtained from two new automated three-dimensional transthoracic echocardiographic software-Dynamic HeartModel (DHM) and 3D Auto RV. Patients (n=116) with more than mild isolated CAR were included and divided into two groups: central (n=53) and eccentric CAR (n=63) groups. LVSV and RVSV were automatically measured by DHM and 3D Auto RV. Next, aortic regurgitant volume (ARVol) was calculated three ways: as the difference between LVSV and RVSV, by the two-dimensional proximal isovelocity surface area (PISA) method, and using effective regurgitant orifice area derived from real-time three-dimensional echocardiography (RT3DE) multiplied by CAR velocity time integral (the reference standard). DHM plus 3D Auto RV correlated well with RT3DE in ARVol measurement in both groups (central, r = 0.90; eccentric, r = 0.96), with no significant difference based on consistency analysis. In the eccentric group, PISA led to an obvious underestimation (mean difference= - 4.20 ml, P < 0.05). The kappa agreement between DHM plus 3D Auto RV and RT3DE in grading CAR severity in both groups was good (central, k = 0.89; eccentric, k = 0.86), but that between PISA and RT3DE in the eccentric CAR group was suboptimal (k = 0.74). This study indicates that ARVol quantification using DHM plus 3D Auto RV is feasible and reproducible in patients with more than mild isolated CAR. This new method has great correlation and agreement with RT3DE in ARVol measurement, with evident advantages over PISA in eccentric CAR.

Standardization of normal values for cardiac chamber size in echocardiography

Echocardiography is used worldwide to evaluate cardiac size and function. To determine what values are abnormal, it is essential to establish normal reference values for echocardiography. The current guidelines for chamber quantification specify normative values for cardiac chambers and recommend that gender and body size be taken into account. However, these normative data were established using databases for which a variety of measurement methods were used and the majority of subjects consisted of Whites in Europe and the United States. However, several regional studies from other countries suggest that cardiac size varies globally. To overcome these limitations, the Normal Reference Ranges for Echocardiography study and the World Alliance of Societies of Echocardiography Normal Values study have recently been conducted to examine similarities and differences in cardiac chamber size and to establish normal reference values while taking worldwide diversity into account. The results from these studies have demonstrated that standardization of normal reference values for cardiac size is important. This review article aims to summarize the current status of normative echocardiographic values for cardiac chamber size.

Advanced Cardiovascular Imaging in Clinical Heart Failure

Cardiovascular imaging is the cornerstone of the assessment of patients with heart failure. Although noninvasive volumetric estimation of the cardiac function is an essential and indisputably useful clinical tool, cardiac imaging has evolved and matured to offer detailed functional, hemodynamic, and tissue characterization. The adoption of a new framework to diagnose and phenotype heart failure that incorporates comprehensive imaging assessment has been lacking in clinical trials. The present review offers a general overview of available imaging strategies for patients with heart failure.

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study

OBJECTIVES

The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods.

DESIGN

A prospective observational study.

SETTING

A tertiary referral center and a university level teaching hospital.

PARTICIPANTS

The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions.

MEASUREMENTS AND MAIN RESULTS

Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71).

CONCLUSIONS

Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular-Focused Views versus Apical Four-Chamber Views

BACKGROUND

Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined.

METHODS

One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia.

RESULTS

The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r = 0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r = 0.83, bias = 1.7%, n = 78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5 months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P = .009, n = 44]; 4CV: hazard ratio, 0.90 [P = .009, n = 68]).

CONCLUSIONS

RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

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.

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.

The left ventricular ejection fraction: new insights into an old parameter

Accurate evaluation of cardiac function has become increasingly important as the treatment of cardiac disease has become more complex. At the same time, technological advances allow greater accuracy and precision in cardiac measurements. Measurement of left ventricular ejection fraction (LVEF) has been a pillar of cardiac evaluation. Several noninvasive modalities are available to assess LVEF; each has advantages and limitations. This review examines various modalities used to measure LVEF and focuses on the relative strengths and weaknesses of each modality. In some clinical settings, however, LVEF may be too insensitive to convey subtle changes in LV contractility. In certain clinical situations, use of LVEF may be an insufficient measure of left ventricular systolic function. Global longitudinal strain is one such parameter that has shown promise for detecting subtle reductions in left ventricular contractility in subjects with chemotherapy-induced cardiotoxicity.