Original ArticlesAssessment of left ventricular function by real-time 3-dimensional echocardiography compared with conventional noninvasive methods*,**
Introduction
Accurate determination of left ventricular (LV) volume and function provides important pathophysiologic and prognostic information in patients with a variety of cardiac disorders.1, 2, 3 Serial noninvasive monitoring would also be desirable for determination of the appropriate time for medical or surgical interventions. Multigated radionuclide angiography (MUGA) has been used for determining LV ejection fraction (LVEF) because it is noninvasive and does not rely on assumptions of LV geometry.4, 5, 6 However, because it requires the exposure of the patient to radiation, it is not optimal for serial assessment. In addition, it requires time-consuming computer processing and operator involvement for data acquisition.7, 8
Two-dimensional echocardiography (2DE) is also a widely used technique for the evaluation of LVEF. It has an advantage of no radiation exposure, the immediate provision of clinically interpretable images, and the superior ability to assess regional wall motion as well as to provide information regarding valvular function and cardiac hemodynamics.9, 10, 11, 12 However, assessment of LVEF by 2DE is based on geometric assumptions and thus involves considerable measurement errors.13, 14, 15, 16
Recently, to reduce the limitations of 2DE and to improve quantitative accuracy and reliability, various 3-dimensional echocardiography (3DE) systems have been developed.17, 18, 19, 20, 21, 22, 23, 24, 25, 26 In these systems, a positional locator device17, 18, 19, 20, 21 and rotational transducer are coupled with electrocardiographic and respiratory gating methods.22, 23, 24, 25, 26 Because the spatial data of these 3DE systems are acquired with a standard 2-dimensional (2D) imaging transducer, the transducer's linear phased array can only scan a single-sector plane at any given time. Thus, with the use of a conventional transducer, different planes of 2D acquisition must be obtained at different times and reconstructed according to their location and time. Moreover, in addition to the data acquisition process, off-line 3-dimensional (3D) reconstruction from multiple 2D images is necessary. In a sense, these 3D systems are a modification of conventional 2DE: the additional installations enable 2D images to be reconstructed for display in a 3D format. As such, these 3DE systems are fundamentally unable to obtain 3D data in real-time. Therefore, although these 3DE systems allow accurate LV volume and EF calculation by eliminating geometric assumptions, intricate data acquisition and time-consuming processes for reconstruction make them impractical for daily clinical use.
To reduce data acquisition time and increase the practicality of 3DE, real-time 3D echocardiography (RT3D) has been developed.27, 28, 29, 30, 31, 32 RT3D uses matrix arrays instead of the linear phased arrays of conventional 2DE. The matrix array, which consists of 2D phased arrays, allows real-time 3D data acquisition and real-time data display.
In the present study, we determined in vitro the maximum volume that could be imaged by RT3D and validated the accuracy of RT3D for volume measurement by using two different volume calculation methods. In the clinical setting, we compared LVEF calculated by RT3D with values obtained by MUGA. In addition, the accuracy of RT3D in patients with low LVEF was evaluated. The estimation of LVEF by RT3D was also compared with that of the 2D quantitative apical biplane-disks summation method. Reproducibility of 3D and 2D echocardiography techniques was also compared in terms of intraobserver and interobserver variabilities.
Section snippets
Real-time 3-dimensional echocardiography
The system was developed at Duke University, Department of Biomedical Engineering and Department of Cardiology.31 The Model 1 of RT3D (Volumetrics Medical Imaging Inc, Durham, NC) was used for the present study. This real-time 3D imaging device is unique in its volumetric scanning abilities (Figure 1).
In vitro comparison for volume measurement by RT3D
The mean ± SD values and range of phantoms as well as the comparison of the values obtained from RT3D with phantoms are presented in Table 1.Group True volume (mL) (range) Method Echo volume (mL) (range) r SEE (mL) Regression equation P value (F test) Bias (mL) Limits of agreement (mL) Group 1 139.1 ± 67.0 RT3D-S 137.4 ± 65.8 (41-255) 0.998 1.81 y = 0.98x + 0.92 NS −1.72 −10.3, 6.9 (n = 29) (39-252) RT3D-P 139.9 ± 67.0 (42-248) 0.998 1.89 y = 0.99x + 1.00 NS 0.75 −7.8,
Comparison with previous studies
Since the recognition of MUGA as an accurate technique in LVEF measurement, several studies have been performed to compare 2DE and MUGA. In 1979, Folland et al9 reported in 35 patients that their r value was 0.75 with limits of agreement of −17.4% to 20.2%. Later, two studies11, 12 also compared 2DE and MUGA in the determination of LVEF. The results for the 2D method were similar to those obtained in our study and demonstrate the unsatisfactory nature of 2DE because of its geometric assumptions
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Reprint requests: Dr Shunichi Homma, Division of Cardiology, Columbia-Presbyterian Hospital, PH 3-342, 630 West 168th Street, New York, New York 10032 (E-mail:[email protected]).
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J Am Soc Echocardiogr 2001;14:275-84