Variables Influencing the Accuracy of Right Ventricular Volume Assessment by Real-time 3-Dimensional Echocardiography: An In Vitro Validation Study

Right ventricular dysfunction in patients with diffuse large B-cell lymphoma undergoing anthracycline-based chemotherapy: a 2D strain and 3D echocardiography study

To investigate whether 2D strain and 3D echocardiography could early identify the impaired right ventricular (RV) function after anthracycline exposure. Sixty-one patients with diffuse large B-cell lymphoma treated with anthracycline were studied. Echocardiography was conducted at baseline, after the third cycle of the chemotherapy, after the completion of the chemotherapy, and follow-up at 10 months after the initiation of chemotherapy. RV global longitudinal strain (RV GLS) and RV free wall longitudinal strain (RV FWLS) were calculated using speckle tracking echocardiography. RV ejection fraction (RVEF) was analyzed by 3D echocardiography. RV systolic dysfunction was defined by ≥ 2 RV parameters below the threshold value, and cardiotoxicity was defined as a reduction in left ventricular EF > 10 to < 53%. After the third cycle of chemotherapy, only RV GLS was significantly decreased, while after the completion of the chemotherapy, RV GLS, RV FWLS, and RVEF were all significantly decreased compared with baseline measurements. At the end of follow-up, 9 patients (14.8%) were diagnosed with RV systolic dysfunction, and 16 patients (26.2%) had at least 1 abnormal RV function parameter. The proportion of RV systolic dysfunction was significantly higher in patients with cardiotoxicity than in patients without cardiotoxicity, yielding an odds ratio of 5.143. A percentage decrease in RV FWLS and RVEF were independent predictors of RV systolic dysfunction. Two-dimensional strain and 3D echocardiography are valuable methods for evaluating anthracycline-related impairment of RV function in DLBCL patients receiving chemotherapy. RV FWLS and RVEF are reliable predictors of RV systolic dysfunction.

A closer look at right ventricular 3D volume quantification by transthoracic echocardiography and cardiac MRI

AIM

To compare right ventricular (RV) volumetry using state-of-the-art three-dimensional (3D) transthoracic echocardiography (3DE) and cardiac magnetic resonance imaging (CMR) near-simultaneously in a clinical setting.

MATERIALS AND METHODS

Forty-seven consecutive patients received comprehensive echocardiography including 3DE within 30 minutes of CMR. RV volumetry was performed offline with semi-automated 3D endocardial border tracing as well as manual delineation of the compacted myocardium in short-axis views by CMR.

RESULTS

Forty-two examinations (89%) could be analysed offline by 3D RV reconstruction. Mean RV volumes assessed by CMR and 3DE were 215±63 and 127±42 ml for end-diastole (RV-EDV), as well as 110±43 and 62±27 ml for end-systole (RV-ESV). RV-EDV, RV-ESV, and RV stroke volume measured by 3DE were significantly lower than RV volumetry by CMR. Mean bias were -88, -48, and -41 ml, respectively. Mean RV ejection fraction (-EF) showed a non-significant deviation of +2% between 3DE and CMR and the correlation coefficient was r=0.58 for RV-EF.

CONCLUSION

RV-EF can be assessed reliably using transthoracic 3DE in patients with good image quality; however, absolute RV volumes measured by 3DE show a systematic deviation to CMR volumetry that has been previously neglected and requires careful interpretation regarding anatomical cardiac imaging.

Quantification of right ventricular volume measured by use of real-time three-dimensional echocardiography and electrocardiography-gated 64-slice multidetector computed tomography in healthy dogs

OBJECTIVE To evaluate accuracy of quantification of right ventricle volume (RVV) by use of 3-D echocardiography (3DE) and ECG-gated multidetector CT (MDCT). ANIMALS 6 healthy hound-cross dogs. PROCEDURES ECG-gated MDCT and complete 3DE examinations were performed on each dog. Right ventricular end-diastolic volumes (EDVs), end-systolic volumes (ESVs), stroke volume (SV), and ejection fraction (EF) were measured for 3DE and MDCT data sets by use of software specific for RVV quantification. Correlation and level of agreement between methods were determined. Intraobserver and interobserver variability were assessed for 3DE. RESULTS No significant differences were detected between SV and EF obtained with MDCT and 3DE. Significant differences were detected between right ventricular EDV and ESV obtained with MDCT and 3DE. No significant difference in heart rate was detected between methods. The correlation between MDCT and 3DE was very good (r = 0.87) for EDV and ESV, moderate (r = 0.60) for EF, and poor (r = 0.31) for SV. Bland-Altman analysis revealed a systematic underestimation of RVV derived by use of 3DE, compared with the RVV derived by use of MDCT (mean bias, 15 and 10.3 mL for EDV and ESV, respectively). Intraobserver (EDV, 12%; ESV, 18%) and interobserver (EDV, 14%; ESV, 11%) variability were acceptable for 3DE. CONCLUSIONS AND CLINICAL RELEVANCE There was substantial variance for RVV measured by use of 3DE in healthy dogs and a significant underestimation of volumes, compared with results for MDCT, despite the fact there were no significant differences in SV and EF.

Real-Time Three-Dimensional Echocardiography: Characterization of Cardiac Anatomy and Function-Current Clinical Applications and Literature Review Update

Our review of real-time three-dimensional echocardiography (RT3DE) discusses the diagnostic utility of RT3DE and provides a comparison with two-dimensional echocardiography (2DE) in clinical cardiology. A Pubmed literature search on RT3DE was performed using the following key words: transthoracic, two-dimensional, three-dimensional, real-time, and left ventricular (LV) function. Articles included perspective clinical studies and meta-analyses in the English language, and focused on the role of RT3DE in human subjects. Application of RT3DE includes analysis of the pericardium, right ventricular (RV) and LV cavities, wall motion, valvular disease, great vessels, congenital anomalies, and traumatic injury, such as myocardial contusion. RT3DE, through a transthoracic echocardiography (TTE), allows for increasingly accurate volume and valve motion assessment, estimated LV ejection fraction, and volume measurements. Chamber motion and LV mass approximation have been more accurately evaluated by RT3DE by improved inclusion of the third dimension and quantification of volumetric movement. Moreover, RT3DE was shown to have no statistical significance when comparing the ejection fractions of RT3DE to cardiac magnetic resonance (CMR). Analysis of RT3DE data sets of the LV endocardial exterior allows for the volume to be directly quantified for specific phases of the cardiac cycle, ranging from end systole to end diastole, eliminating error from wall motion abnormalities and asymmetrical left ventricles. RT3DE through TTE measures cardiac function with superior diagnostic accuracy in predicting LV mass, systolic function, along with LV and RV volume when compared with 2DE with comparable results to CMR.

Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.

Pediatric Pulmonary Hypertension: Guidelines From the American Heart Association and American Thoracic Society

Pulmonary hypertension is associated with diverse cardiac, pulmonary, and systemic diseases in neonates, infants, and older children and contributes to significant morbidity and mortality. However, current approaches to caring for pediatric patients with pulmonary hypertension have been limited by the lack of consensus guidelines from experts in the field. In a joint effort from the American Heart Association and American Thoracic Society, a panel of experienced clinicians and clinician-scientists was assembled to review the current literature and to make recommendations on the diagnosis, evaluation, and treatment of pediatric pulmonary hypertension. This publication presents the results of extensive literature reviews, discussions, and formal scoring of recommendations for the care of children with pulmonary hypertension.

Right Ventricular Dimensions and Function: Why do we Need a More Accurate and Quantitative Imaging?

The right ventricle plays an important role in the morbidity and mortality of patients presenting with symptoms and signs of cardiopulmonary disease. This cardiac chamber has a unique crescent shape, which adds complexity to the quantification of its size and function. Until recently, little uniformity in echocardiographic imaging of the right heart existed because of a lack of familiarity with various techniques, and the enormous attention directed towards left heart quantification. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the quantitative evaluations of right ventricle because of its independence from any geometrical assumption. In this review, we focus on the contribution of this new modality to the evaluation of right ventricle.

Multicenter study comparing shunt type in the norwood procedure for single-ventricle lesions: three-dimensional echocardiographic analysis

BACKGROUND

The Pediatric Heart Network's Single Ventricle Reconstruction (SVR) trial randomized infants with single right ventricles (RVs) undergoing a Norwood procedure to a modified Blalock-Taussig or RV-to-pulmonary artery shunt. This report compares RV parameters in the 2 groups using 3-dimensional echocardiography.

METHODS AND RESULTS

Three-dimensional echocardiography studies were obtained at 10 of 15 SVR centers. Of the 549 subjects, 314 underwent 3-dimensional echocardiography studies at 1 to 4 time points (pre-Norwood, post-Norwood, pre-stage II, and 14 months) for a total of 757 3-dimensional echocardiography studies. Of these, 565 (75%) were acceptable for analysis. RV volume, mass, mass:volume ratio, ejection fraction, and severity of tricuspid regurgitation did not differ by shunt type. RV volumes and mass did not change after the Norwood, but increased from pre-Norwood to pre-stage II (end-diastolic volume [milliliters]/body surface area [BSA](1.3), end-systolic volume [milliliters]/BSA(1.3), and mass [grams]/BSA(1.3) mean difference [95% confidence interval]=25.0 [8.7-41.3], 19.3 [8.3-30.4], and 17.9 [7.3-28.5], then decreased by 14 months (end-diastolic volume/BSA(1.3), end-systolic volume/BSA(1.3), and mass/BSA(1.3) mean difference [95% confidence interval]=-24.4 [-35.0 to -13.7], -9.8 [-17.9 to -1.7], and -15.3 [-22.0 to -8.6]. Ejection fraction decreased from pre-Norwood to pre-stage II (mean difference [95% confidence interval]=-3.7 [-6.9 to -0.5]), but did not decrease further by 14 months.

CONCLUSIONS

We found no statistically significant differences between study groups in 3-dimensional echocardiography measures of RV size and function, or magnitude of tricuspid regurgitation. Volume unloading was seen after stage II, as expected, but ejection fraction did not improve. This study provides insights into the remodeling of the operated univentricular RV in infancy.

Validity of the surface electrocardiogram criteria for right ventricular hypertrophy: the MESA-RV Study (Multi-Ethnic Study of Atherosclerosis-Right Ventricle)

OBJECTIVES

The study aimed to assess the diagnostic properties of electrocardiographic (ECG) criteria for right ventricular hypertrophy (RVH) measured by cardiac magnetic resonance imaging (cMRI) in adults without clinical cardiovascular disease.

BACKGROUND

Current ECG criteria for RVH were based on cadaveric dissection in small studies.

METHODS

MESA (Multi-Ethnic Study of Atherosclerosis) performed cMRIs with complete right ventricle (RV) interpretation on 4,062 participants without clinical cardiovascular disease. Endocardial margins of the RV were manually contoured on diastolic and systolic images. The ECG screening criteria for RVH from the 2009 American Heart Association Recommendations for Standardization and Interpretation of the ECG were examined in participants with and without left ventricular (LV) hypertrophy or reduced ejection fraction. RVH was defined using sex-specific normative equations based on age, height, and weight.

RESULTS

The study sample with normal LV morphology and function (n = 3,719) was age 61.3 ± 10.0 years, 53.5% female, 39.6% Caucasian, 25.5% African American, 21.9% Hispanic, and 13.0% Asian. The mean body mass index was 27.9 ± 5.0 kg/m(2). A total of 6% had RVH, which was generally mild. Traditional ECG criteria were specific (many >95%) but had low sensitivity for RVH by cMRI. The positive predictive values were not sufficiently high as to be clinically useful (maximum 12%). The results did not differ based on age, sex, race, or smoking status, or with the inclusion of participants with abnormal LV mass or function. Classification and regression tree analysis revealed that no combination of ECG variables was better than the criteria used singly.

CONCLUSIONS

The recommended ECG screening criteria for RVH are not sufficiently sensitive or specific for screening for mild RVH in adults without clinical cardiovascular disease.

Assessment of right ventricular volumes in hypoplastic left heart syndrome by real-time three-dimensional echocardiography: comparison with cardiac magnetic resonance imaging

BACKGROUND

Accurate assessment of right ventricular (RV) volumes and function is important in patients with hypoplastic left heart syndrome (HLHS). We prospectively sought to determine the reproducibility of three-dimensional (3D) echocardiography and its agreement with cardiac magnetic resonance imaging (CMR) in HLHS.

METHODS AND RESULTS

Twenty-eight patients underwent CMR followed immediately by transthoracic 3D echocardiography under general anaesthesia. Semi-automated border detection software was used to determine echocardiographic RV volumes. Inter- and intra-observer variability, correlation and levels of agreement between techniques were determined. The median age was 0.37 years (0.18-9.28 years) and weight 6.24 kg (3.42-32.50 kg). Intra- and inter-observer variability was excellent for both techniques. Median (range) measurements for 3D echocardiography and CMR were; end-diastolic volume (EDV) 23.6 mL (6.5-63.2) and 30.6 mL (11.8-87.9), end-systolic volume (ESV) 12.6 mL (3.7-37.0) and 14.9 mL (5.8-33.9), stroke volume (SV) 11.2 mL (2.8-33.0) and 17.1 mL (6.0-54.1), ejection fraction (EF) 48.2% (31.2-64.9), and 56.5% (42.7-72.2). Correlation coefficients were r = 0.85, 0.84, 0.83, and 0.74, respectively (P < 0.01 for all). Volumetric data were expressed as a percentage of the echocardiographic volume to CMR volume. When compared with CMR, 3D echocardiography underestimated EDV, ESV and SV by 26.7% (SD ± 20.2), 10.6% (±28.1), and 37.5% (±20.1), respectively. The difference in volume appeared largest at low ventricular volumes. EF was 8.3% (±7.3) lower by 3D echocardiography compared with CMR.

CONCLUSION

Both 3D echocardiography and CMR volumes appear highly reproducible. Measurements obtained by 3D echocardiography are significantly lower than those obtained by CMR, with wide limits of agreement such that these two methods cannot be used interchangeably.

Review of novel clinical applications of advanced, real-time, 3-dimensional echocardiography

Advances in computer processing speed and memory along with the advent of the microbeam former that can sample an entire crystal of the ultrasound transducer made possible the performance of 3-dimensional echocardiography in real time (RT3DE). The miniaturization of a 3-dimensional transducer permitting its extension to transesophageal mode rapidly expanded its use in a variety of conditions. Recent development of user-friendly automated/semiautomated cropping and display software may make it rather simple, even for the novice to gather useful information from RT3DE. We discuss the background, technique, and cutting-edge research and novel clinical applications of advanced RT3DE, including left ventricular dyssynchrony assessment, 3-D speckle tracking, myocardial contrast echocardiography, complete 4-dimensional (4-D) shape and motion analysis of the left ventricle, 4-D volumetric analysis of the right ventricle, 3-D volume rendering of the mitral valve, and other percutaneous and surgical procedural applications.

Variables influencing the accuracy of 2-dimensional and real-time 3-dimensional echocardiography for assessment of small volumes, areas, and distances: an in vitro study using static tissue-mimicking phantoms

OBJECTIVES

The aim of this study was to assess the validity, accuracy, and reproducibility of real-time 3-dimensional (3D) echocardiography for small distances, areas, and volumes.

METHODS

Real-time 3D echocardiography using matrix technology was performed in small calibrated tissue-mimicking phantoms and compared with 2-dimensional (2D) echocardiography. In a systematic variation of variables on data acquisition and analysis including different 3D workstations (manual disk summation versus semiautomatic border detection), the relative contributions of sources of errors were determined. The clinical relevance of the in vitro findings was assessed in 5 neonates and infants.

RESULTS

Distance calculation was valid (mean relative error ± SD, -0.15% ± 1.2%). Underestimation of areas and volumes was significant for both 2D and 3D echocardiography (area: 2D, -7.0% ± 2.9%; 3D, -6.0% ± 2.8%; volume: 2D, -13.1% ± 4.5%; 3D, -6.7% ± 2.5%; P < .05). Adjustment of compression and gain on data acquisition (difference of the means: 2D, 11.6%; 3D, 17.9%), gain on postprocessing (3D, 3.4%), and the border detection algorithm on analysis (2D, 4.8%; 3D, 16.6%) had a highly significant effect on volume and area calculations (P < .001). In vivo, compression and gain on acquisition (3D, 19.1%) and the 3D workstation on analysis (3D, 22.2%) had a highly significant impact on left ventricular volumetry (P < .001).

CONCLUSIONS

Real-time 3D echocardiography is a reliable method for calculation of small distances, areas, and volumes comparable with the size of the neonatal and infant heart. Variables influencing boundary identification during image acquisition and analysis have a significant impact on 2D and 3D area and volume calculations. Standardized protocols are mandatory to avoid these sources of error in both clinical practice and research.

Validation of 3D echocardiographic assessment of left ventricular volumes, mass, and ejection fraction in neonates and infants with congenital heart disease: a comparison study with cardiac MRI

BACKGROUND

quantitative assessment and validation of left ventricular (LV) volumes and mass in neonates and infants with complex congenital heart disease (CHD) is important for clinical management but has not been undertaken. We compared matrix-array 3D echocardiography (3D echo) measurements of volumes, mass, and ejection fraction (EF) with those measured by cardiac MRI in young patients with CHD and small LVs because of either young age or LV hypoplasia.

METHODS AND RESULTS

thirty-five patients aged <4 years (median, 0.8 years) undergoing MRI were prospectively enrolled. Three-dimensional echo was acquired immediately after MRI, and volume, mass, and EF measurements, using summation of discs methodology, were compared with MRI. Three-dimensional echo end-diastolic volume (24.4±15.7 versus 24.8±46.4 mL; P=0.01; intraclass correlation coefficient [ICC], 0.96) and end-systolic volume (12.3±8.6 versus 9.6±6.8 mL; P<0.001; ICC, 0.90) correlated with MRI with small mean differences (-0.49 mL [P=0.6] and 2.7 mL [P=0.001], respectively). Three-dimensional echo EF was smaller than MRI by 9.3% (P<0.001), and 3D echo LV mass measurements were comparable to MRI (17.3±10.3 versus 17.6±12 g; P<0.77; ICC, 0.93), with a small mean difference (1.1 g; P=0.28). There was good intra- and interobserver reliability for all measurements.

CONCLUSIONS

in neonates and infants with CHD and small LVs (age appropriate or hypoplastic), matrix-array 3D echo measurements of mass and volumes compare well with MRI, providing an important modality for ventricular size and performance analysis in these patients, particularly in those with left-side heart obstructive lesions.

The gold standard for noninvasive imaging in congenital heart disease: echocardiography

PURPOSE OF REVIEW

Echocardiography in pediatric and congenital heart disease is a key diagnostic technique in patients with congenital heart disease. Due to new technological developments, it has become a rapidly evolving field.

RECENT FINDINGS

In this review, we focus on recent developments in standardization and validation of standard techniques in pediatric and congenital echocardiography. This is mainly related to standardization of image acquisition and normalization of measurements for body size. The rest of the review is focused on the application of three-dimensional echocardiography, tissue Doppler imaging and Speqle tracking techniques to pediatric heart disease.

SUMMARY

New developments in standardization of echocardiography, the introduction of three-dimensional echocardiography and new functional techniques such as tissue Doppler and Speqle tracking strengthen the position of pediatric echocardiography as the most important diagnostic tool for patients with congenital heart disease.

Assessment of the right ventricle by echocardiography: a primer for cardiac sonographers

The assessment of right ventricular (RV) structure and function by echocardiography has been improved by advancements that include Doppler tissue imaging, strain imaging, and three-dimensional imaging. Doppler tissue imaging and strain imaging can be useful for the assessment of regional RV systolic and diastolic function. Three-dimensional imaging has been reported to determine RV volumes and ejection fraction, which have previously been cumbersome to measure with conventional two-dimensional echocardiography. This article addresses the role of conventional and newer methods of echocardiography to assist sonographers in understanding the technical considerations, limitations, and pitfalls of image acquisition and analysis of RV structure and function.

Accuracy of guideline recommendations for two-dimensional quantification of the right ventricle by echocardiography

BACKGROUND

The accuracy of the guidelines of the American Society of Echocardiography (ASE) for the two-dimensional (2D) quantitative assessment of right ventricular (RV) size and function has not been evaluated against MRI-derived RV volumes in patients with congenital heart disease and RV volume overload.

METHODS

Three groups of patients were studied: a normal RV group (Group I, n = 31), a repaired tetralogy of Fallot group (Group II, n = 33), and an unrepaired atrial septal defect and/or partially anomalous pulmonary venous connection group (Group III, n = 23). Recommended 2D linear and cross-sectional area measurements were made on clinical echocardiographic and MRI studies performed less than 6 months apart.

RESULTS

Most 2D RV parameters were smaller by echocardiography versus MRI. There was weak correlation between 2D RV measurements by echocardiography and MRI-derived RV volumes (Group I: r = 0.15-0.54, Group II: r = 0.33-0.61, Group III: r = 0.32-0.85), and only modest improvement when the same 2D measurements were performed by MRI (Group I: r = 0.37-0.61, Group II: r = 0.44-0.69, Group III: r = 0.28-0.74). The difference between 2D RV measurements by echocardiography and MRI-derived RV volumes was more pronounced in the RV volume overload groups.

CONCLUSIONS

The correlation between currently recommended 2D RV measurements by echocardiography and MRI-derived RV volumes was weak, and improved only modestly when MRI was used to make the same 2D measurements. Moreover, 2D echocardiographic assessment of the RV appears to be less accurate in patients with congenital heart disease and a dilated RV.