Rapid freehand scanning three-dimensional echocardiography: Accurate measurement of left ventricular volumes and ejection fraction compared with quantitative gated scintigraphy

doi:10.1067/mje.2003.4

Journal of the American Society of Echocardiography

Volume 16, Issue 2, February 2003, Pages 110-115

https://doi.org/10.1067/mje.2003.4 Get rights and content

Abstract

This study was performed to assess clinical feasibility of rapid freehand scanning 3-dimensional echocardiography (3DE) for measuring left ventricular (LV) end-diastolic and -systolic volumes and ejection fraction using quantitative gated myocardial perfusion single photon emission computed tomography as the reference standard. We performed transthoracic 2-dimensional echocardiography and magnetic freehand 3DE using a harmonic imaging system in 15 patients. Data sets (3DE) were collected by slowly tilting the probe (fan-like scanning) in the apical position. The 3DE data were recorded in 10 to 20 seconds, and the analysis was performed within 2 minutes after transferring the raw digital ultrasound data from the scanner. For LV end-diastolic and -systolic volume measurements, there was a high correlation and good agreement (LV end-diastolic volume, r = 0.94, P <.0001, standard error of the estimates = 21.6 mL, bias = 6.7 mL; LV end-systolic volume, r = 0.96, P <.0001, standard error of the estimates = 14.8 mL, bias = 3.9 mL) between gated single photon emission computed tomography and 3DE. There was an overall underestimation of volumes with greater limits of agreement by 2-dimensional echocardiography. For LV ejection fraction, regression and agreement analysis also demonstrated high precision and accuracy (y = 0.82x + 5.1, r = 0.93, P <.001, standard error of the estimates = 7.6%, bias = 4.0%) by 3DE compared with 2-dimensional echocardiography. Rapid 3DE using a magnetic-field system provides precise and accurate measurements of LV volumes and ejection fraction in human beings (J Am Soc Echocardiogr 2003;16:110-5.)

Section snippets

Study participants

We performed a freehand 3DE scanning in patients for whom a standard transthoracic echocardiographic examination and rest technetium-99m methoxy isobutyl isonitile SPECT were clinically indicated. Patients with a variety of LV shapes were considered in an attempt to cover a large range of LV volumes. Exclusion criteria were cardiac arrhythmias, including patients with pacemaker and implantable cardioverter defibrillators. A total of 15 patients (8 men; mean age, 65.2 years [range: 39 to 78

Results

LV volumes and EF determined with gated SPECT were as follows: EDV ranged from 35.8 to 279.0 mL (135.1 ± 69.8 mL), ESV ranged from 3.8 to 236.0 mL (80.1 ± 67.6 mL), and EF ranged from 15.4 to 89.4% (49.5 ± 22.1%).

The 3D data were recorded in 10 to 20 seconds, and the analysis was performed within 2 minutes after transferring the raw digital ultrasound data from the scanner. In the estimation of the LVEDV and LVESV values by 3D method, interobserver variability was 7.4% and 5.6%, respectively.

Discussion

Three-dimensional reconstructions of LV volumes with the use of either freehand scanning techniques10, 11 or rotational data acquisition12, 13, 14 have previously been reported. More recently, real-time acquisition of LV volume data has been introduced.¹⁵ However, the clinical application of these techniques is not widespread because of compromised image quality, challenging technical design, and prolonged acquisition or processing times. We demonstrated that, with a magnetic position sensor

Conclusions

Rapidly acquired 3D data sets of apical tomograms using a magnetic-field system provide precise and accurate measurements of LV volumes and EF in human beings. Because of the short duration of acquisition and processing time, this technique is clinically feasible, and it allows repeated collection of 3D data during the course of a routine clinical examination, further enhancing the results.

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To assess the feasibility, accuracy, and reproducibility of real-time full-volume 3-dimensional transthoracic echocardiography (3D RT-VTTE) to measure left ventricular (LV) volumes and ejection fraction (EF) using a fully automated endocardial contouring algorithm and to identify and automatically correct the contours to obtain accurate LV volumes in sinus rhythm and atrial fibrillation (AF).
3D transthoracic echocardiography is not used routinely to quantify LV volumes and EF. A fully automated workflow using RT-VTTE may improve clinical adoption.
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Ninety-one patients (67 in normal sinus rhythm [NSR], 24 in AF) were included. Among all NSR patients, there was excellent correlation between RT-VTTE and CMR for end-diastolic volume (EDV), end-systolic volume (ESV), and EF (r = 0.90, 0.96, and 0.98, respectively; p < 0.001). In patients with EF ≥50% (n = 36), EDV and ESV were underestimated by 10.7 ± 17.5 ml (p = 0.001) and by 4.1 ± 6.1 ml (p < 0.001), respectively. In those with EF <50% (n = 31), EDV and ESV were underestimated by 25.7 ± 32.7 ml (p < 0.001) and by 16.2 ± 24.0 ml (p = 0.001). Automated contour correction to track the compacted myocardium eliminated mean volume differences between RT-VTTE and CMR. In patients with AF, LV volumes and EF were accurate by RT-VTTE (r = 0.94, 0.94, and 0.91 for EDV, ESV, and EF, respectively; p < 0.001). Automated 3D LV volumes and EF were highly reproducible.
Rapid, accurate, and reproducible EF can be obtained by RT-VTTE in NSR and AF patients by using an automated trabecular edge contouring algorithm. Furthermore, automated contour correction to detect the compacted myocardium yields accurate and reproducible 3D LV volumes.
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The 3DECHO has been compared with CMR in heterogeneous patients using various approaches, broad inclusion criteria, wide EF range, and few patients with MI or CHF.11,12,24,26-33 FH3DECHO using apical fanlike scanning yielded higher SEE values for EDV and ESV (21.6 and 14.8 mL) than found in our study when compared with gated scintigraphy.33 RT3DECHO using matrix-array transducers enable rapid image acquistion from a fixed position.
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The accuracy, reproducibility, and test-retest reliability of 3-dimensional (3D) echocardiography (3DE) with 3D reconstruction (3DR) and real-time (RT) imaging (RT 3DE) exceed that of 2-dimensional echocardiography (2DE). However, image quality with RT 3DE is inferior to 2DE and we sought to determine whether this justified ongoing use of 3DR.
Unselected patients (n = 30, 22 men, age 66 ± 7 years) presenting to the echocardiography laboratory for left ventricular (LV) evaluation were studied with 2DE and RT 3DE; 3DR images were obtained using external localization. The 3D measurements and reconstructions were obtained offline. Magnetic resonance images (MRI) were obtained using true free induction, steady state precession during breath hold and 3D volumes and ejection fraction (EF) were measured using 3D software. A separate cohort of 20 patients (13 men, age 60 ± 12 years) was measured for test-retest variation.
All echocardiographic measures underestimated LV volumes and EF compared with MRI, but this was least with RT 3DE. End-diastolic volume by MRI (168 ± 54 mL) was underestimated by RT 3DE (−15 ± 31, P = .02), 3DR (−26 ± 33, P < .01), and 2DE (−57 ± 40, P < .01). Similarly, end-systolic volume by MRI (86 ± 50 mL) was underestimated by RT 3DE (−15 ± 31, P = .02), 3DR (−26 ± 33, P < .01), and 2DE (−57 ± 40, P < .01). However, EF measurements were similar with each method. Test-retest variation was less and interobserver and intraobserver correlations were better with RT 3DE for volumes and EF, compared with 3DR and 2DE.
Despite limitations of image quality, RT 3DE is the most feasible and accurate approach for LV volume and EF measurements and follow-up LV assessment in daily practice.
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LV chamber and mass quantification have been studied extensively using 3D echocardiography (Tables 2 and 3).20-38 Initial 3D methods to measure LV volumes used reconstruction techniques that, although more accurate and reproducible than 2D methods, required long acquisition and postprocessing times.20,21,30,35,39-41 Moreover, the accuracy of the volume calculations was highly dependent on image quality.

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^*: Reprint requests: Kazuaki Tanabe, MD, PhD, Division of Cardiology, Kobe General Hospital, 4-6 Minatojima-nakamachi, Chuo-ku, Kobe 650-0046, Japan (E-mail: [email protected]).

^**: 0894-7317/2002/$30.00 + 0

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Original ArticlesRapid freehand scanning three-dimensional echocardiography: Accurate measurement of left ventricular volumes and ejection fraction compared with quantitative gated scintigraphy*,**

Abstract

Section snippets

Study participants

Results

Discussion

Conclusions

J Am Coll Cardiol

Am Heart J

Ultrasound Med Biol

J Nucl Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

Mayo Clin Proc

J Am Soc Echocardiogr

Original Articles
Rapid freehand scanning three-dimensional echocardiography: Accurate measurement of left ventricular volumes and ejection fraction compared with quantitative gated scintigraphy*,**