Original Articles
Assessment of left ventricular function by real-time 3-dimensional echocardiography compared with conventional noninvasive methods*,**

https://doi.org/10.1067/mje.2001.111158Get rights and content

Abstract

Quantitative assessment of left ventricular ejection fraction is an essential component of cardiac evaluation. We performed real-time 3-dimensional echocardiography in 56 consecutive patients who underwent multigated radionuclide angiography. Thirteen patients were excluded for the following reasons: 5 for large size of left ventricle required for image acquisition, 5 for suboptimal image quality in real-time 3-dimensional echocardiography, and 3 for atrial fibrillation. Finally, we compared left ventricular ejection fraction assessed by real-time 3-dimensional echocardiography and conventional 2-dimensional echocardiography with that obtained by multigated radionuclide angiography in 43 patients. Left ventricular ejection fraction was determined by real-time 3-dimensional echocardiography with the use of parallel plane-disks and sector plane-disks summation methods. A good correlation was obtained between both real-time 3-dimensional echocardiography methods and multigated radionuclide angiography (r = 0.87 and 0.90, standard error of estimate = 3.7% and 4.2%), whereas the relation between the 2-dimensional echocardiography method and radionuclide angiography demonstrated a significant departure from the line of identity (P <.001). In addition, interobserver variability was significantly lower (P <.05) for the real-time 3-dimensional echocardiography methods than that by the 2-dimensional echocardiography method. Real-time 3-dimensional echocardiography may be used for quantification of left ventricular function as an alternative to conventional methods in patients with adequate image quality. (J Am Soc Echocardiogr 2001;14:275-84.)

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).

. Volumetric scanning and images of the left ventricle. Demonstrated are 2 adjustable orthogonal B-scan images perpendicular to the transducer and 3 adjustable C-scan images parallel to the face of

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.

. Comparison of values obtained by RT3D with true volume

GroupTrue volume (mL) (range)MethodEcho volume (mL) (range)rSEE (mL)Regression equationP value (F test)Bias (mL)Limits of agreement (mL)
Group 1139.1 ± 67.0RT3D-S137.4 ± 65.8 (41-255)0.9981.81y = 0.98x + 0.92NS−1.72−10.3, 6.9
(n = 29)(39-252)RT3D-P139.9 ± 67.0 (42-248)0.9981.89y = 0.99x + 1.00NS0.75−7.8,

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

References (42)

  • I Schnittger et al.

    Standardized intracardiac measurements of two-dimensional echocardiography

    J Am Coll Cardiol

    (1983)
  • C Gaudio et al.

    Comparison of left ventricular ejection fraction by magnetic resonance imaging and radionuclide ventriculography in idiopathic dilated cardiomyopathy

    Am J Cardiol

    (1991)
  • The Multicenter Postinfarction Research Group

    Risk stratification and survival after infarction

    N Eng J Med

    (1983)
  • EL Alderman et al.

    Results of coronary artery surgery in patients with poor left ventricular function (CASS)

    Circulation

    (1983)
  • LC Becker et al.

    Comparison of early thallium-201 scintigraphy and gated blood pool imaging for predicting mortality in patients with acute myocardial infarction

    Circulation

    (1983)
  • MA Pfeffer et al.

    Effect of captoril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction

    N Eng J Med

    (1992)
  • FJT Wackers et al.

    Multiple gated cardiac blood pool imaging for left ventricular ejection fraction: validation of the technique and assessment of variability

    Am J Cardiol

    (1976)
  • N Honda et al.

    Factor analysis of multigated cardiac blood pool centigram for the measurement of left ventricular ejection fraction

    Ann Nucl Med

    (1989)
  • RD Burow et al.

    Analysis of left ventricular function from multiple gated acquisition cardiac blood pool imaging. Comparison to contrast angiography

    Circulation

    (1977)
  • ED Folland et al.

    Assessment of left ventricular ejection fraction and volumes by real time, two-dimensional echocardiography

    Circulation

    (1979)
  • NB Schiller et al.

    Recommendations for quantitation of the left ventricle by two-dimensional echocardiography

    J Am Soc Echocardiogr

    (1989)
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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]).

    **

    J Am Soc Echocardiogr 2001;14:275-84

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