- Email: [email protected]
Three-dimensional echocardiographic measurement of left ventricular volumes and election fraction using a multiplane transesophageal probe in patients
Three-Dimensional Echocardiographic Measurement of Left Ventricular Volumes and Ejection Fraction Using a Multiplane Transesophageal Probe in Patients Takeshi
Hozumi,
MD, Junichi
Yoshikawa, MD, Kiyoshi Yoshida, MD, Takashi Tsutomu Takagi, MD, and Atsushi Yamamuro, MD
t has been reported that 2-dimensional echocardiography underestimates left ventricular (LV) Ivolumes compared with cineventriculography.1-5 Several 3-dimensional methods6-lo from the transthoracic approach have provided accurate measurement of LV volumes, because 3-dimensional methods have the advantage of eliminating the need for geometric assumptions about LV shape. Multiplane transesophageal echocardiography (TEE) enables 3dimensional image sets of the left ventricle from multiple cross-sectional images by rotation of the transducer without changing its position.“-‘5 Threedimensional echocardiography using a multiplane TEE probe may be expected to provide accurate LV volumes. To date, there are few reports of 3-dimensional measurement of LV volumes by TEE, especially in the clinical setting.16.17This study compares LV volumes and ejection fraction by 3-dimensional echocardiography with a multiplane TEE probe with those by cineventriculography. ... The study group consisted of 18 consecutive patients (14 men and 4 women; age range 45 to 74 years) who underwent elective cardiac catheterization to evaluate chest pain or known cardiac disease as follows: 11 patients with ischemic heart disease (8 with regional wall motion abnormalities, 3 without wall motion abnormalities), 6 with valvular disease, and 1 with dilated cardiomyopathy. Multiplane TEE was performed within 24 hours before angiography in the echocardiography laboratory. The system consisted of a 64-element, ~-MHZ, multiplane TEE probe, and a SONOS 1500 imaging system (Hewlett-Packard, Andover, Massachusetts), linked to 3-dimensional reconstruction system with a 486 CPU (Echoscan, Tomtec Imaging System, Boulder, Colorado). The multiplane TEE probe was introduced into the esophagus with the patient in the left decubitus position after local anesthetic (lidocaine) spray to the hypopharynx. After diagnostic study, the probe was positioned at the midesophageal portion for image data acquisition for 3-dimensional reconstruction and was kept stationary during data acquisition. The scanning plane of the heart was obtained by rotating the transducer at 3” angular increments around a 180” arc starting from From the Division of Cardiology, Kobe General Hospital, Kobe; and First Department of Internal Medicine, Osaka City University School of Medicine. Osaka. laoon. Dr. Hozumi’s address is: Division of Cardialog Kobe Gen&l’Hospital, 4-6 Minatojima-nakamachi, Chuoku, Ko t e 650, Japan. Manuscript received March 12, 1996; revised manuscript received and accepted May 24, 1996.
0 1996 by Excerpta Medica, All rights reserved.
Inc.
Akasaka,
MD,
a 4-chamber view. Cardiac intervals within which cardiac cycles will be recorded were predefined by the investigator before the scan, according to the electrocardiographic RR intervals. When the predefined ranges for cardiac cycle were met at expiratory phase, the cross-sectional image were recorded through the entire cardiac cycle in a given plane at 20 to 25 frames/s, digitized, and stored in the imageprocessing computer. Transducer rotation occurs at the end of each acquired cardiac cycle. Finally, a total of 60 sequential cross-sections during a complete cardiac cycle were acquired from each of the transducer orientations which were varied at 3” increments from 0” to 180”. Once the scanning sequence was completed, the digital images were stored into the memory and formatted in a cubic data set of the entire cardiac anatomy over 1 cardiac cycle. For the measurement of LV volumes, multiple short-axis cross-sectional views were reconstructed in 2-mm increments from the apex to the mitral annular level from the cubic data set (Figure 1). End-diastolic images were defined as the visually estimated largest intracavity area from the dynamic reconstructed short-axis views, and end-systole as the smallest intracavity area. With the use of a software program incorporated into the 3-dimensional reconstruction system, we traced the innermost edge of the endocardial echoes in multiple short-axis views with the trackball and measured the traced area of each cross section. The papillary muscles were not included within the endocardial border delineations. LV volume was computed from each traced endocardial boundary of each cross section using summation of disks algorithm as follows: LV volume = h X A, where A is the cross-sectional area of the left ventricle, and h is the 2-mm height of each disk. Volume measurement was performed by 1 observer who did not know the result of left cineventriculography. All patients underwent diagnostic catheterization. A 5Fr pigtail catheter was inserted into the body of the left ventricle. Biplane 30” right anterior oblique and 60” left anterior oblique cineventriculograms were used for volume calculation. Cineventriculograms were obtained with a 8-inch field of view and recorded on tine film at 60 frames/s during the power injection of 32 to 36 ml of contrast medium at 10 to 12 ml/s. The magnification factor in each projection was determined by a metal sphere of known dimensions at the level of the midventricle. Cine films were viewed on a projector and the LV cavity outlined using a digitizing pad and the ana0002.9149/96/$15.00 PII 50002.9149(96)00591-7
1077
LV end-diastolic and end-systolic volumes and ejection fraction calculated by 3-dimensional echocardiography were compared with those by cineventriculography by linear regression analysis. The mean difference between echocardiographic and angiographic values was calculated, and expressed as mean ?2 SD.*’ Observer variability was assessed for echocardiographic measurements of end-diastolic and end-systolic volumes in 8 randomly selected patients. Interobserver variability was calculated as the standard deviation of the differences between the measurements of 2 independent observers who had knowledge of the result of angiography, and expressed as a percentage of the average value. Intraobserver variability was calculated as the FIGURE 1. Calculation of left ventricular volume from 3-dimensional transstandard deviation of the differences beesopha eal echocardiogmms. A, in the Ion -axis cross-sectional views recontween the first and second determination from the cubic data set, the level o Bthe short-axis cmss section was StllJJ for a single observer and expressed as a determined by the line shown. B, et&cordial border was traced in each repercentage of the average value. constructed short-axis cross-sectional view at end-diastole or end-systole. C, wire frame model of the left ventricle at end-diastole or end-systole was finally Average image acquisition time was 3 demonstrated after summation of the tracing of endocardial border in every to 5 minutes. The time required for 3-dishort-axis cross section. mensional reconstruction and data analysis ranged from 40 to 50 minutes. LV lyzer (CAMAC 300, Goodman, Nagoya, Japan). volumes from 3-dimensional echocardiograms demEnd-diastole was defined as the visually estimated onstrated excellent correlations with those from largest silhouette area, and end-systole as the small- cineventriculograms at end-diastole (r = 0.97, y = est silhouette area. LV volumes were calculated us- 0.83x + 9.0) (Figure 2) and at end-systole (r = 0.97, ing the biplane summation-of-disks method.1s,‘9 y = 0.77x + 6.6) (Figure 3)) with a small degree of Ejection fraction was calculated from the formula: underestimation: the mean differences between angiographic and echocardiographic measurements (end-diastolic volume - end-systolic volume)/ (end-diastolic volume) X 100. Volume measure- were 13.2 ? 28.2 and 5.2 + 16.0 ml at end-diastole ment was performed by 1 observer who did not know and end-systole, respectively (Figures 2 and 3). Ejection fraction by the 3-dimensional method corthe result of echocardiography.
End-diastolic volume 300 0-N 200
y= 0.83 x + 9.0 - k0.97 SEE= 11.7 ml *[email protected].
E
. . _..“...”
“...! .._...F.. mean
,......................................................
0
200
100 LVG
300 (ml)
50
100
150
-SD
200
250 (ml) Mean ( [3D TEE + LVG] / 2 )
FIGURE 2. Left, scatterplots showing correlations between 3-dimensional (3D) echacardiogmphic and cineventriculogra hit end-diaraphic and cineventriculogmphic end-diasto PIC volumes. The stolic volumes. Rig/tt, agreement plots between 3-dimensional echocardi line between the 2 lines of +2 SD is the line of mean difference. LVG = I3 cineventriculogmphy; 3D TEE = 3-dimensional transesophageal echocardiogmphy. 1078
THE AMERICAN JOURNAL OF CARDIOLOGY@
VOL. 78
NOVEMBER 1, 1996
End-systolic volume 150(ml)
100 y= 0.77 x + 6.6 r= 0.97 SEE= 5.1 ml
100.
Pm’) c.& 5Of
5
o _
e. +2SD “” ..-.............-....... “I.. ma” .,............................ m2SD
. -r*+d.-...
8
0, 0
50
100
150 (ml)
LVG
k -5oE n -100 0
I 25
I 50
I 75
I 100
125 ml) Mean ( [3D TEE + LVG] / 2 \
FIGURE 3. Left, scatterplots showing correlations between I-dimensional echocardiographic and cineventriculographic end-systolic volumes. Right, agreement plots between 3-dimensional echocardiographic and cineventriculogmphic end-systolic volumes. The line between the 2 lines of k2 SD is the line of mean difference. Abbreviations OS in Figure 2.
Ejection fraction 100% (%) y= 0.93 x + 4.3 SEE= 4.3 %
o0
20
40
60 LVG
80
100 @)
20
30
40
50
60
70
80 (“4 Mean ( [3D TEE + LVG] I2 )
FIGURE 4. Left, scatterplots showing correlations between 3-dimensional echocardiogmphic and cineventriculographic ejection fractions. Right, agreement lots between 3-dimensional echocardiographic and cineventriculographic ejection fractions. The line between the 2 lines of ~2 SD is t/t e line of mean difference. Abbreviations as in Figures 2 and 3.
related well with that by cineventriculography (r = 0.94, y = 0.93~ + 4.3) (Figure 4). The mean difference between angiographic and echocardiographic measurements was 0.2 & 8.5% (Figure 4). The average interobserver variability for measurements of end-diastolic and end-systolic volumes were 9.2% and 9.0% in 3-dimensional echocardiography. The corresponding intraobserver variability was 8.5% and 7.6%. ... This study is the first to compare LV volumes and ejection fraction by 3-dimensional echocardiography using a multiplane TEE probe with those by cineventriculography in a clinical setting. We demonstrated that LV volumes from the 3-dimensional
approach correlated highly with those by cineventriculography. In addition, ejection fraction by the 3dimensional approach correlated well with that by cineventriculography. Previous studies have demonstrated significant underestimation of angiographic LV volumes by 2dimensional echocardiography, and several reasons have been reported to account for the underestimation.lm5 In TEE, underestimation of LV length from base to apex seems to be a major factor contributing to smaller LV volumes.4s5 Several studies have shown that 3-dimensional echocardiography provides accurate measurements of the volume of excised left heart or phantom model, because these methods make no assumptions about chamber BRIEFREPORTS 1079
shape.6-10In phantom models, it was demonstrated that 3-dimensional echocardiography is superior to 2-dimensional echocardiography in volume measurement.6 In vitro study comparing 3- and 2-dimensional echocardiography and cineventriculography with the volume of excised hearts documented that 3-dimensional echocardiography has significantly smaller variation than 2-dimensional echocardiography.’ Recent studies have demonstrated that 3-dimensional echocardiography is superior to 2-dimensional echocardiography in measuring LV volumes in normal subjects or patients.‘,” Furthermore, it has been shown that measurement variation of the 3-dimensional approach is significantly lower than that of the 2-dimensional approach in patients.” Introduction of multiplane TEE enables 3-dimensional image sets of the left ventricle from multiple cross sections by rotation of the transducer without changing its position. ‘l-L5 Three-dimensional echocardiography using a multiplane TEE probe may be expected to provide accurate LV volumes. To date, there are few reports of 3-dimensional measurement of LV volumes by TEE, especially in the clinical setting. 16,17In the present study, with a multiplane TEE probe, each image for 3-dimensional reconstruction had high-image quality. Furthermore, it was not difficult to obtain 60 cross-sectional images continuously by rotation of the array without changing the position of the transducer. Thus, a multiplane TEE probe is suitable for data acquisition for 3-dimensional reconstruction. Although LV volumes from 3-dimensional echocardiograms demonstrated an excellent correlation with those from angiograms, the 3-dimensional method slightly underestimated volumes compared with angiograms. In our present study, echocardiographic boundaries were traced inside the endocardial echoes in the 3-dimensional method so that boundaries stay visible during tracing. The trabeculations and papillary muscles were not included in the LV cavity in tracing echocardiograms. On the other hand, angiographic boundaries were traced outside the contrast silhouette so that boundaries remain visible during tracing. The trabeculations and papillary muscles were included in the LV cavity in tracing angiograms. The difference in tracing in each method seems to be a reason why the 3-dimensional approach slightly underestimated LV volumes compared with angiography in the present clinical study. Thus, LV volumes and ejection fraction obtained from S-dimensional echocardiography using a multiplane TEE probe. correlates highly with left ventriculography for estimation of LV volumes and ejection fraction. This suggests that this technique may be useful in the evaluation of LV function in the clinical setting.
1080
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Acknowledgment: We gratefully acknowledge the assistance of Natesa G. Pandian, MD, in the preparation of the manuscript and the technical assistance of Toshikazu Yagi, the sonographer, for performing 3-dimensional echocardiography in this study. 1. Schiller N, Acquatella H, Ports TA, Drew D, Goerke J, Ringertz H, Silverman NH, Brundage B, Botvinick EH, Boswell R, Carlsson E, Parmley W. Left ventricular volume from paired biplane two-dimensional echocardiography. Circulation 1979;60547-555. 2. Folland ED, Parisi AF, Moynihan PF, Jones DR. Feldman CL, Tow DE. Assessment of left ventricular ejection fraction and volumes by real-time, twodimensional echocardiography. Circulation 1979;60:760-766. 3. Starling MR, Crawford MH, Sorensen SG, Levi B, Richards KL, O’Rourke RA. Comparative accuracy of apical biplane cross-sectional echocardiography and gated equilibrium radionuclide angiography for estimating left ventricular size and performance. Circulation 1981;63:1075-1084. 4. Smith MD, MacPhail B, Harrison MR, Lenhoff SJ, DeMaria AN. Value and limitations of tramesophageal echocardiography in determination of left ventricular volumes and ejection fraction. JAm Coil Car&l 1992;19:1213-1222. 5. Hozumi T, Shakudo M, Shah PM. Quantitation of left ventricular volumes and ejection fraction by biplane transesophageal echocardiography. Am J Cardial 1993;72:356-359. 6. Schroder KM, Sapin PM, King DL, Smith MD, DeMaria AN. Three-dimensional echocardiographic volume computation: in vitro comparison to standard two-dimensional echocardiography. Echocardiography 1993x%467-475. 7. Sapin PM, Schroeder KD, Smith MD, Demaria AN, King DL. Three-dimensional echocardiographic measurement of left ventricular volume in vitro: comparison with two-dimensional echocardiography and cineventiculography. J Am Co11 Cardiol 1993;22:1530-1537, 8. Handschumacher MD, Lethor JP, Siu SC, Mele D, Rivera JM, F’icard MH, Weyman AE, Levine RA. A new integrated system for three-dimensional echocardiograpbic reconstruction: development and validation for venhicular volume with application in human subjects. JAm Coil Cardiol 1993;21:743-753. 9. Gopal AS, Keller AM, Rigling R, King DLJr, King DL. Left ventricular volume and endocardial surface area by three-dimensional echocardiography: comparison with two-dimensional echocardiography and nuclear magnetic resonance imaging in normal subjects. JAm CON Cardiol 1993;22:258-270. IO. Sapin PM, Schroder KM, Gopal AS, Smith MD, Demaria AN, King DL. Comparison of two- and three-dimensional echocardiography with cineventriculography for measurement of left ventricular volume in patients. J Am Coil Cardiol 1994;24:1054-1063. 11. Pandian NG, Hsu TL, Schwartz SL, Weintmub A, Cao QL, Schneider AT, Gordon G, England M, Simonetti J. Multiplane tramesophageal echocardiography: imaging planes, echocardiographic anatomy, and clinical experience with a proto-type phased array omniplane probe. Echocardiography 1992;9:361367. 12. Roelandt JRTC, Thomson IR, Vletter WB, Brommersma P, Born M, Linker DT. Multiplane transesophageal echocardiography: latest evolution in an imaging revolution. J Am Sot Echocardiogr 1992;5:361-367. 13. Roelandt J, ten Cate FJ, Vletter WB, Taams MA, Bekkering L, Glastra H, Djoa KK, Weber F. Ultrasonic dynamic three-dimensional visualization of the heart with a multiplane tramesophageal imaging transducer. J Am Sot Echocardiogr 1994;7:217-229. 14. Belohlavek M, Foley DA, Gerber TC, Kinter TM, Greenleaf JF, Seward JB. Three- and four-dimensional cardiovascular ultrasound imaging: a new era for echocardiography. Mayo Clin Proc 1993;68:221-240. 15. Pandian NG, Roelandt J, Nanda NC, Sugeng L, Cao QL, Azevedo J, Schwartz S, Vannan MA, Ludomirski A, Marx G, Vogel M. Dynamic threedimensional echocardiography: methods and clinical potential. Echocardiography 1994;11:237-259. 16. Martin RW, Graham MM, Kao R, Bashein G. Measurement of left ventricular ejection fraction and volumes with three-dimensional reconstructed tramesophageal ultrasound scans: comparison to radionuclide and thermal dilution measurements. J Cardiothorac Anesth 1989;3:26t-268. 17. Kuroda T, Kinter TM, Seward JB, Yanagi H, Greenleaf JF. Accuracy of three-dimensional volume measurement using biplane transesophageal echocatdiographic probe: in vitro experiment. JAm Sot Echocardiogr 1991;4:475484. 18. Chapman CB, Baker 0, Reynolds J, Bonte FJ. Use of biplane cinefluorography for measurement of ventricular volume. Circulation 1958;18: 1105. 19. Wahl DW, Wang YS, Schiller NB. Left ventricular volumes determined by two-dimensional echocardiography in a normal adult population. J Am Coil Cardiol 1983;1:863-868. 20. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;1:307-310.
NOVEMBER 1, 1996
Hozumi,
MD, Junichi
Yoshikawa, MD, Kiyoshi Yoshida, MD, Takashi Tsutomu Takagi, MD, and Atsushi Yamamuro, MD
t has been reported that 2-dimensional echocardiography underestimates left ventricular (LV) Ivolumes compared with cineventriculography.1-5 Several 3-dimensional methods6-lo from the transthoracic approach have provided accurate measurement of LV volumes, because 3-dimensional methods have the advantage of eliminating the need for geometric assumptions about LV shape. Multiplane transesophageal echocardiography (TEE) enables 3dimensional image sets of the left ventricle from multiple cross-sectional images by rotation of the transducer without changing its position.“-‘5 Threedimensional echocardiography using a multiplane TEE probe may be expected to provide accurate LV volumes. To date, there are few reports of 3-dimensional measurement of LV volumes by TEE, especially in the clinical setting.16.17This study compares LV volumes and ejection fraction by 3-dimensional echocardiography with a multiplane TEE probe with those by cineventriculography. ... The study group consisted of 18 consecutive patients (14 men and 4 women; age range 45 to 74 years) who underwent elective cardiac catheterization to evaluate chest pain or known cardiac disease as follows: 11 patients with ischemic heart disease (8 with regional wall motion abnormalities, 3 without wall motion abnormalities), 6 with valvular disease, and 1 with dilated cardiomyopathy. Multiplane TEE was performed within 24 hours before angiography in the echocardiography laboratory. The system consisted of a 64-element, ~-MHZ, multiplane TEE probe, and a SONOS 1500 imaging system (Hewlett-Packard, Andover, Massachusetts), linked to 3-dimensional reconstruction system with a 486 CPU (Echoscan, Tomtec Imaging System, Boulder, Colorado). The multiplane TEE probe was introduced into the esophagus with the patient in the left decubitus position after local anesthetic (lidocaine) spray to the hypopharynx. After diagnostic study, the probe was positioned at the midesophageal portion for image data acquisition for 3-dimensional reconstruction and was kept stationary during data acquisition. The scanning plane of the heart was obtained by rotating the transducer at 3” angular increments around a 180” arc starting from From the Division of Cardiology, Kobe General Hospital, Kobe; and First Department of Internal Medicine, Osaka City University School of Medicine. Osaka. laoon. Dr. Hozumi’s address is: Division of Cardialog Kobe Gen&l’Hospital, 4-6 Minatojima-nakamachi, Chuoku, Ko t e 650, Japan. Manuscript received March 12, 1996; revised manuscript received and accepted May 24, 1996.
0 1996 by Excerpta Medica, All rights reserved.
Inc.
Akasaka,
MD,
a 4-chamber view. Cardiac intervals within which cardiac cycles will be recorded were predefined by the investigator before the scan, according to the electrocardiographic RR intervals. When the predefined ranges for cardiac cycle were met at expiratory phase, the cross-sectional image were recorded through the entire cardiac cycle in a given plane at 20 to 25 frames/s, digitized, and stored in the imageprocessing computer. Transducer rotation occurs at the end of each acquired cardiac cycle. Finally, a total of 60 sequential cross-sections during a complete cardiac cycle were acquired from each of the transducer orientations which were varied at 3” increments from 0” to 180”. Once the scanning sequence was completed, the digital images were stored into the memory and formatted in a cubic data set of the entire cardiac anatomy over 1 cardiac cycle. For the measurement of LV volumes, multiple short-axis cross-sectional views were reconstructed in 2-mm increments from the apex to the mitral annular level from the cubic data set (Figure 1). End-diastolic images were defined as the visually estimated largest intracavity area from the dynamic reconstructed short-axis views, and end-systole as the smallest intracavity area. With the use of a software program incorporated into the 3-dimensional reconstruction system, we traced the innermost edge of the endocardial echoes in multiple short-axis views with the trackball and measured the traced area of each cross section. The papillary muscles were not included within the endocardial border delineations. LV volume was computed from each traced endocardial boundary of each cross section using summation of disks algorithm as follows: LV volume = h X A, where A is the cross-sectional area of the left ventricle, and h is the 2-mm height of each disk. Volume measurement was performed by 1 observer who did not know the result of left cineventriculography. All patients underwent diagnostic catheterization. A 5Fr pigtail catheter was inserted into the body of the left ventricle. Biplane 30” right anterior oblique and 60” left anterior oblique cineventriculograms were used for volume calculation. Cineventriculograms were obtained with a 8-inch field of view and recorded on tine film at 60 frames/s during the power injection of 32 to 36 ml of contrast medium at 10 to 12 ml/s. The magnification factor in each projection was determined by a metal sphere of known dimensions at the level of the midventricle. Cine films were viewed on a projector and the LV cavity outlined using a digitizing pad and the ana0002.9149/96/$15.00 PII 50002.9149(96)00591-7
1077
LV end-diastolic and end-systolic volumes and ejection fraction calculated by 3-dimensional echocardiography were compared with those by cineventriculography by linear regression analysis. The mean difference between echocardiographic and angiographic values was calculated, and expressed as mean ?2 SD.*’ Observer variability was assessed for echocardiographic measurements of end-diastolic and end-systolic volumes in 8 randomly selected patients. Interobserver variability was calculated as the standard deviation of the differences between the measurements of 2 independent observers who had knowledge of the result of angiography, and expressed as a percentage of the average value. Intraobserver variability was calculated as the FIGURE 1. Calculation of left ventricular volume from 3-dimensional transstandard deviation of the differences beesopha eal echocardiogmms. A, in the Ion -axis cross-sectional views recontween the first and second determination from the cubic data set, the level o Bthe short-axis cmss section was StllJJ for a single observer and expressed as a determined by the line shown. B, et&cordial border was traced in each repercentage of the average value. constructed short-axis cross-sectional view at end-diastole or end-systole. C, wire frame model of the left ventricle at end-diastole or end-systole was finally Average image acquisition time was 3 demonstrated after summation of the tracing of endocardial border in every to 5 minutes. The time required for 3-dishort-axis cross section. mensional reconstruction and data analysis ranged from 40 to 50 minutes. LV lyzer (CAMAC 300, Goodman, Nagoya, Japan). volumes from 3-dimensional echocardiograms demEnd-diastole was defined as the visually estimated onstrated excellent correlations with those from largest silhouette area, and end-systole as the small- cineventriculograms at end-diastole (r = 0.97, y = est silhouette area. LV volumes were calculated us- 0.83x + 9.0) (Figure 2) and at end-systole (r = 0.97, ing the biplane summation-of-disks method.1s,‘9 y = 0.77x + 6.6) (Figure 3)) with a small degree of Ejection fraction was calculated from the formula: underestimation: the mean differences between angiographic and echocardiographic measurements (end-diastolic volume - end-systolic volume)/ (end-diastolic volume) X 100. Volume measure- were 13.2 ? 28.2 and 5.2 + 16.0 ml at end-diastole ment was performed by 1 observer who did not know and end-systole, respectively (Figures 2 and 3). Ejection fraction by the 3-dimensional method corthe result of echocardiography.
End-diastolic volume 300 0-N 200
y= 0.83 x + 9.0 - k0.97 SEE= 11.7 ml *[email protected].
E
. . _..“...”
“...! .._...F.. mean
,......................................................
0
200
100 LVG
300 (ml)
50
100
150
-SD
200
250 (ml) Mean ( [3D TEE + LVG] / 2 )
FIGURE 2. Left, scatterplots showing correlations between 3-dimensional (3D) echacardiogmphic and cineventriculogra hit end-diaraphic and cineventriculogmphic end-diasto PIC volumes. The stolic volumes. Rig/tt, agreement plots between 3-dimensional echocardi line between the 2 lines of +2 SD is the line of mean difference. LVG = I3 cineventriculogmphy; 3D TEE = 3-dimensional transesophageal echocardiogmphy. 1078
THE AMERICAN JOURNAL OF CARDIOLOGY@
VOL. 78
NOVEMBER 1, 1996
End-systolic volume 150(ml)
100 y= 0.77 x + 6.6 r= 0.97 SEE= 5.1 ml
100.
Pm’) c.& 5Of
5
o _
e. +2SD “” ..-.............-....... “I.. ma” .,............................ m2SD
. -r*+d.-...
8
0, 0
50
100
150 (ml)
LVG
k -5oE n -100 0
I 25
I 50
I 75
I 100
125 ml) Mean ( [3D TEE + LVG] / 2 \
FIGURE 3. Left, scatterplots showing correlations between I-dimensional echocardiographic and cineventriculographic end-systolic volumes. Right, agreement plots between 3-dimensional echocardiographic and cineventriculogmphic end-systolic volumes. The line between the 2 lines of k2 SD is the line of mean difference. Abbreviations OS in Figure 2.
Ejection fraction 100% (%) y= 0.93 x + 4.3 SEE= 4.3 %
o0
20
40
60 LVG
80
100 @)
20
30
40
50
60
70
80 (“4 Mean ( [3D TEE + LVG] I2 )
FIGURE 4. Left, scatterplots showing correlations between 3-dimensional echocardiogmphic and cineventriculographic ejection fractions. Right, agreement lots between 3-dimensional echocardiographic and cineventriculographic ejection fractions. The line between the 2 lines of ~2 SD is t/t e line of mean difference. Abbreviations as in Figures 2 and 3.
related well with that by cineventriculography (r = 0.94, y = 0.93~ + 4.3) (Figure 4). The mean difference between angiographic and echocardiographic measurements was 0.2 & 8.5% (Figure 4). The average interobserver variability for measurements of end-diastolic and end-systolic volumes were 9.2% and 9.0% in 3-dimensional echocardiography. The corresponding intraobserver variability was 8.5% and 7.6%. ... This study is the first to compare LV volumes and ejection fraction by 3-dimensional echocardiography using a multiplane TEE probe with those by cineventriculography in a clinical setting. We demonstrated that LV volumes from the 3-dimensional
approach correlated highly with those by cineventriculography. In addition, ejection fraction by the 3dimensional approach correlated well with that by cineventriculography. Previous studies have demonstrated significant underestimation of angiographic LV volumes by 2dimensional echocardiography, and several reasons have been reported to account for the underestimation.lm5 In TEE, underestimation of LV length from base to apex seems to be a major factor contributing to smaller LV volumes.4s5 Several studies have shown that 3-dimensional echocardiography provides accurate measurements of the volume of excised left heart or phantom model, because these methods make no assumptions about chamber BRIEFREPORTS 1079
shape.6-10In phantom models, it was demonstrated that 3-dimensional echocardiography is superior to 2-dimensional echocardiography in volume measurement.6 In vitro study comparing 3- and 2-dimensional echocardiography and cineventriculography with the volume of excised hearts documented that 3-dimensional echocardiography has significantly smaller variation than 2-dimensional echocardiography.’ Recent studies have demonstrated that 3-dimensional echocardiography is superior to 2-dimensional echocardiography in measuring LV volumes in normal subjects or patients.‘,” Furthermore, it has been shown that measurement variation of the 3-dimensional approach is significantly lower than that of the 2-dimensional approach in patients.” Introduction of multiplane TEE enables 3-dimensional image sets of the left ventricle from multiple cross sections by rotation of the transducer without changing its position. ‘l-L5 Three-dimensional echocardiography using a multiplane TEE probe may be expected to provide accurate LV volumes. To date, there are few reports of 3-dimensional measurement of LV volumes by TEE, especially in the clinical setting. 16,17In the present study, with a multiplane TEE probe, each image for 3-dimensional reconstruction had high-image quality. Furthermore, it was not difficult to obtain 60 cross-sectional images continuously by rotation of the array without changing the position of the transducer. Thus, a multiplane TEE probe is suitable for data acquisition for 3-dimensional reconstruction. Although LV volumes from 3-dimensional echocardiograms demonstrated an excellent correlation with those from angiograms, the 3-dimensional method slightly underestimated volumes compared with angiograms. In our present study, echocardiographic boundaries were traced inside the endocardial echoes in the 3-dimensional method so that boundaries stay visible during tracing. The trabeculations and papillary muscles were not included in the LV cavity in tracing echocardiograms. On the other hand, angiographic boundaries were traced outside the contrast silhouette so that boundaries remain visible during tracing. The trabeculations and papillary muscles were included in the LV cavity in tracing angiograms. The difference in tracing in each method seems to be a reason why the 3-dimensional approach slightly underestimated LV volumes compared with angiography in the present clinical study. Thus, LV volumes and ejection fraction obtained from S-dimensional echocardiography using a multiplane TEE probe. correlates highly with left ventriculography for estimation of LV volumes and ejection fraction. This suggests that this technique may be useful in the evaluation of LV function in the clinical setting.
1080
THE AMERICAN JOURNAL OF CARDIOLOGY”
VOL. 78
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