Two-dimensional echocardiographic measurement of left ventricular ejection fraction: Prospective analysis of what constitutes an adequate determination

2DE is increasingly being used to determine LVEF. There remain, however, important questions about the 2DE determination of EF: (1) which 2DE formulae correlate best with contrast ventriculography; (2) how often can a particular formula be applied to a large group of patients; and (3) what effect does 2DE quality or the presence of segmental wall motion abnormalities have on the accuracy of echo determined EF? To answer these questions, we prospectively determined the 2DE EF utilizing 10 differen formulae in 65 consecutive patients undergoing contrast ventriculogram within the following 24 hours. We also sought to examine the ability of trained observers to estimate EF from 2DE. The 2DE EF formulae that utilized biplane areas were generally more accurate than single-plane area or diameter only formulae, but were obtainable in fewer patients. The biplane Simpson's rule yielded a correlation with ventriculogram of r = 0.89, but was available in only 34 patients. While the single-plane formulae were slightly less accurate, they were measured in more patients; ellipsoid single-plane apical four-chamber r = 0.80, N = 56, and short ellipse r = 0.86, N = 47. The measured EF in patients with akinetic segments yielded a greater standard error of the mean, although correlations remained adequate when compared to the normal patient population. The EF from patients with poor quality as compared to good quality echo studies had a slightly greater standard error, but correlations were little affected. Thus biplane formulae for calculating EF yield better correlations, but are available from fewer patients than single-plane formulae. An estimate of EF was sufficiently accurate for most clinical situations and was available in 98% of the patients. The presence of abnormal wall motion or a poor quality 2DE study increased the standard error slightly, but had little effect on correlation with contrast ventriculogram.     

Quantitative radionuclide angiography in the right anterior oblique view: Comparison with contrast ventriculography

Because the right anterior oblique view is widely accepted as the best “single” projection for assessing wall motion, the utility of this view during first pass radionuclide angiography was studied in 44 patients who also underwent contrast ventriculography and coronary arteriography. Of the 44 patients, 8 had a normal heart and 14 had coronary artery disease with normal wall motion on contrast ventriculography. All also had normal contraction on radionuclide angiography. On contrast ventriculography, 22 patients had coronary artery disease and asynergy involving 34 left ventricular segments. Of 17 segments localized to the anterior and apical asynergic areas on contrast ventriculography, 16 were accurately localized with radionuclide angiography. Similarly, of 17 inferior asynergic areas, 13 were also shown to be inferior on radionuclide angiography. In addition, quantitative assessment of the severity of asynergy using the hemiaxis method demonstrated a good correlation between asynergic severity as defined with radionuclide angiography and contrast ventriculography. Of 11 anterior areas, 7 defined as hypokinetic with contrast ventriculography demonstrated chordal shortening of 20.1 ± 5.2 percent (mean ± standard error of the mean) (P < 0.005 compared with normal) on radionuclide angiography. Similarly, four akinetic or dyskinetic segments on contrast ventriculography demonstrated a greater reduction (4.0 ± 4.0 percent) in chordal shortening on radionuclide angiography (P < 0.05 compared with hypokinetic segments). Akinetic apical and inferior segments as defined with contrast ventriculography also showed a marked reduction in wall motion to 10.4 ± 7.3 percent and 7.5 ± 4.1 percent, respectively.After appropriate background subtraction, determination of ejection fraction using radionuclide angiography showed a correlation of 0.839 between the left anterior oblique and right anterior oblique projections independent of the sequence of injection. In addition, ejection fraction determined with radionuclide angiography in the left (r = 0.824) and right (r = 0.801) anterior oblique views correlated well with ejection fraction assessed from contrast ventriculography. Thus, first pass radionuclide angiography performed in the right anterior oblique view is a sensitive noninvasive means of assessing the location and severity of asynergy as well as global left ventricular performance in patients with coronary artery disease.     

Left ventricular volumes by single-plane cineangiography: in vivo validation of the Kennedy regression equation

This study was performed to assess the accuracy and reliability of the regression equations of Kennedy et al and Wynne et al in the quantitation of single plane left ventricular (LV) volumes. In 15 patients with normal LV function and without intracardiac shunting or valvular insufficiency, gated equilibrium blood pool scintigraphy was performed simultaneously with the measurement of cardiac output (by thermodilution), after which left ventriculography was performed in the 30 degrees right anterior oblique (RAO) projection. From the scintigraphically determined LV ejection fraction (EF) and the thermodilution-measured stroke volume (SV), absolute LV volumes were calculated. The cineangiographic LV volumes obtained with the regression equation of Kennedy et al closely approximated those calculated by scintigraphy/thermodilution, whereas the volumes determined using the regression equation of Wynne et al were larger (p less than 0.05) than the calculated volumes. In 204 patients without intracardiac shunting or valvular insufficiency, SV was measured by the Fick or indicator dilution methods, after which single-plane left ventriculography was performed in the 30 degrees RAO projection. In the 83 patients without coronary artery disease with normal (n = 69) or depressed (n = 14) LVEF, cineangiographic SV (obtained using the regression equation of Kennedy et al) closely approximated forward SV. Similarly, this relation was excellent in the 142 patients whose LVEFs were greater than or equal to 0.50.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac reserve during isoproterenol stress in patients with aortic valve disease before and after corrective surgery

The relations between left ventricular (LV) hypertrophy as estimated by LV mass and LV function and between LV hypertrophy and cardiac reserve were evaluated in 26 patients with aortic valve disease and in nine normal patients who served as controls. Ejection fraction (EF) and mean circumferential fiber shortening rate (VCF) served as indices of LV function. Reserve force of the left ventricle was tested by ventriculography during infusion of 0.3 μg/Kg. body weight/min. isoproterenol. EF and VCF were not significantly different (p > 0.05) either at rest or during isoproterenol infusion if patients with aortic stenosis were compared to patients with aortic regurgitation having comparable LV masses. Therefore we correlated the EF and VCF to the LV mass of all patients irrespective of the type of aortic valve lesion. Poor but significant inverse correlations were found at rest between LV mass and EF (r = 0.62) and between LV mass and VCF (r = 0.57). These correlations improved considerably during isoproterenol: r = 0.84 for EF and r = 0.74 for VCF.LV function was evaluated in another six patients with aortic valve disease before and nine months after successful aortic valve replacement by Björk-Shiley prostheses. LV mass before surgery was 3.6 times control and decreased after surgery to 1.7 times control (p < 0.01) which is still significantly elevated (p < 0.05). EF and VCF which were depressed before surgery (p < 0.05, p < 0.001) normalized after surgery (p . 0.05) but were reduced during isoproterenol infusion if compared to controls (p < 0.05). Thus, stress ventriculography in aortic valve disease could demonstrate a linear decrease of cardiac reserve with increasing severity of hypertrophy when resting function was normal or depressed only slightly. Regression of hypertrophy was incomplete 9 months after correction of overload and LV function, which was depressed before surgery, normalized at rest but was impaired during stress suggesting that cardiac reserve was not fully restored.     

Effects of angiographic contrast medium on left ventricular function: Evaluation by contrast angiography and radionuclide angiography

The purpose of this study was to evaluate the effect of angiographic contrast medium on left ventricular (LV) function in 26 patients undergoing diagnostic cardiac catheterization. Beat-by-beat analysis during contrast ventriculography showed that the ejection fraction (EF) was lower in the last beats than in the first beats (P <.02). Radionuclide angiograms were obtained the day before, as well as 15 to 65 minutes after catheterization, which included contrast ventriculography and coronary anteriography. The EF by radionuclide angiography was lower after catheterization than before (43 ± 14% vs 47 ± 17%, P <.01). The EF decreased by ≥ 5% in 11 of the 26 patients (42%) after catheterization. The decrease in EF in some patients was observed up to 65 minutes after catheterization and was not associated with symptoms or ST-T changes. The EF decreased in only one of nine patients who received nitroglycerin during catheterization, whereas it decreased in 10 of 17 patients who did not receive nitroglycerin (P <.05). The EF decreased in 9 of 14 patients (64%) who had normal resting LV function, whereas it decreased in only 2 of 12 patients (17%) who had abnormal resting function (P <.05). Thus, contrast material may depress LV function up to 1 hr and is more frequent in patients with normal resting EF. The use of nitroglycerin during catheterization may mask this effect.     

Early detection of left ventricular dysfunction in chronic aortic regurgitation as assessed by contrast angiography, echocardiography, and rest and exercise scintigraphy

The best method for detecting early left ventricular (LV) dysfunction in patients with chronic aortic regurgitation is uncertain. Variables used previously to identify LV dysfunction have included (1) angiographic measurements to identify an LV end-systolic volume index (LVESVI) ≥60 ml/m², (2) echocardiographic measurements to identify LV end-systolic dimension (LVESD) ≥5.5 cm or LV fractional shortening ≤25%, and (3) depressed LV ejection fraction (EF) at rest and/or an LVEF or LVESVI that deteriorates with exercise as detected by myocardial scintigraphic measurements. The hypothesis was tested that radionuclide ventriculography with exercise allows earlier detection of important LV dysfunction in patients with aortic regurgitation than the other variables. In 15 consecutive asymptomatic or only minimally symptomatic patients (8 men and 7 women, mean age 44 years) with isolated 2 to 4+ aortic regurgitation (1) rest and exercise-gated radionuclide ventriculography, (2) M-mode echocardiography, and (3) LV angiography were performed. No other cause of LV dysfunction was apparent in 13 patients; 1 patient had moderate systemic arterial hypertension and 1 had 50% luminal diameter narrowing of the proximal left anterior descending coronary artery. Ten patients did not have an increase in LVEF >0.05 EF units at peak exercise (0.58 ± 0.11 to 0.50 ± 0.12, mean ± standard deviation [SD]) (Group 2), whereas 5 had a normal LVEF response to exercise (0.63 ± 0.08 to 0.69 ± 0.07) (Group 1). Eight of the 10 patients with abnormal LVEF responses to exercise had a decrease in LVEF >10% during exercise. The same 8 patients also had an increase in LVESVI with exercise, whereas the 5 patients with normal LVEF responses to exercise had normal or blunted LVESVI responses to exercise. Only 4 of the 10 patients with exercise-induced LV dysfunction had an angiographic LVESVI ≥60 ml/m², and only 1 had an echocardiographically determined LVESD ≥5.5 cm. Serial follow-up rest and exercise scintigraphic and echocardiographic measurements were made in 8 of the patients a mean of 9.4 months after the initial measurements; 3 patients were in Group 1 and 5 in Group 2. The 5 patients in Group 2 again demonstated abnormal LV function during exercise stress, and 2 of the 3 patients in Group 1 then demonstrated an abnormal LV functional response during exercise.Therefore, it is concluded that (1) exercise radionuclide ventriculography identifies LV dysfunction earlier than traditionally used assessments, (2) LV dysfunction appears to persist in patients that demonstrate it and develop in others that did not have it originally, and (3) echocardiographic dilatation of the LVESD to 5.5 cm appears to be a late and relatively unusual occurrence.     

Left ventricular performance during exercise in patients with left bundle branch block: evaluation by gated radionuclide ventriculography

To investigate changes in left ventricular (LV) function during exercise in patients with left bundle branch block (LBBB), 22 patients without a history or physical findings of previous myocardial infarction or LV dysfunction were studied by gated radionuclide ventriculography (GRNV) at rest and during bicycle exercise. Coronary arteriography demonstrated greater than 75% diameter narrowing of at least one coronary artery in nine patients. Of the remaining 13 patients, GRNV demonstrated wall motion abnormalities in seven patients either at rest or with exercise. During exercise, mean ejection fraction (EF) did not increase in patients without coronary artery disease (CAD). Patients with CAD had a 12-point fall in mean EF with exercise. We conclude that LV reserve, as demonstrated by ability to increase EF with exercise, is impaired in patients with LBBB even in the absence of CAD or other underlying cardiac disease and that standard GRNV criteria to exclude the presence of CAD (a greater than five-point increase in EF with exercise and normal wall motion) are not strictly applicable in screening patients with LBBB.     

Comparison of digital intravenous ventriculography with direct left ventriculography for quantitation of left ventricular volumes and ejection fractions

Digital images of the left ventricle obtained at 30 frames/second from continuous fluoroscopy after intravenous injection of contrast medium (digital intravenous Ventriculography) were used to estimate left ventricular (LV) volumes and ejection fraction with use of several techniques for identifying the ventriculographic silhouette. The digital technique was compared with direct contrast left Ventriculography in 26 patients undergoing diagnostic cardiac catheterization. End-diastolic and end-systolic volumes calculated from digital intravenous and direct left ventriculograms were obtained with use of a standard area-length formula. Both end-diastolic volume (EDV) (r = 0.88, y = 1.06x ? 17.1 ml) and end-systolic volume (ESV) (r = 0.89, y = 0.96x + 0.43 ml) determined from digital intravenous ventriculography (mask mode images) correlated closely with those obtained by direct left ventriculography. Combining the EDV and ESV to define the relation between the 2 techniques yielded an even closer correlation (r = 0.96). There was also good correlation between the 2 techniques for measurement of ejection fraction (r = 0.81, standard error of the estimate 6.7%). Measurements from direct left Ventriculography were frequently invalidated by ventricular arrhythmias during the time of opacification of the left ventricle; this was rarely the case for digital intravenous Ventriculography. It is concluded that area-length estimates of LV volumes and ejection fraction can be accurately obtained from digital processing of fluoroscopic LV images after intravenous injection of contrast medium.     

Evaluation of automated measurement of left ventricular volume by novel real-time 3-dimensional echocardiographic system: Validation with cardiac magnetic resonance imaging and 2-dimensional echocardiography

BackgroundTraditional 3-dimensional echocardiography (3DE) with volumetric scanning technique requires several heart cycles for full-volume acquisition and complicated manual contouring of left ventricular (LV) endocardium. The new real-time 3DE (RT3DE) system allows acquisition of an instantaneous full-volume dataset in a single heart cycle and automated measurement of LV volume by the algorithm software. However, it has not been evaluated adequately whether automated measurement by RT3DE has better agreement with cardiac magnetic resonance imaging (CMR) than 2-dimensional echocardiography (2DE) with CMR.PurposeThis study aimed to evaluate the accuracy of automated measurement of LV volume using RT3DE compared with 2DE and CMR.Methods and resultsForty-four consecutive patients who underwent RT3DE, 2DE, and CMR were evaluated in this study. The feasibility of automated measurement by RT3DE was 93.2% and the mean operation time was 6 min. LV volume and ejection fraction (EF) from semi-automated measurement [end-diastolic volume: r = 0.96, limits of agreement (LOA) ?30.5 to 39.3 ml; end-systolic volume: r = 0.97, LOA ?22.6 to 32.7 ml; EF: r = 0.90, LOA ?16.1 to 14.2%, respectively] had better agreement with CMR than those from 2DE (r = 0.87, LOA ?50.5 to 72.2 ml; r = 0.93, LOA ?34.1 to 65.2 ml; r = 0.89, LOA ?20.9 to 10.0%, respectively).ConclusionSemi-automated measurement by RT3DE has better agreement with CMR than 2DE in LV volume and EF. In addition, it is simple to operate and acceptable in feasibility for the clinical setting although there may be room for further learning required to incorporate small hypertrophic LV into the automated algorithm software.     

Comparison of LVEF Obtained with Single-Plane RAO Ventriculography and Echocardiography in Patients with and without Obstructive Coronary Artery Disease

The left ventricular ejection fraction (LVEF) determined by invasive ventriculography (routine cardiac cath; LV-gram) was compared with that determined by echocardiography in 100 patients scheduled for angiography (86% had LV-gram and 2DE during same hospital admission). Seventy percent of patients had at least single-vessel obstructive coronary artery disease, defined as more than 50% stenosis. By all estimates, the LVEF was higher in patients without coronary artery disease (CAD) compared to patients with CAD. There was an excellent correlation between the LVEF by cath and echo, but this correlation was noticeably less strong in patients with CAD, especially with involvement of the left circumflex artery.     

Evaluation of left ventricular contractile pattern by intravenous digital subtraction ventriculography: Comparison with cineangiography and assessment of interobserver variability

The accuracy and reproducibility of measurements of left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF) and regional wall motion obtained by digital subtraction ventriculography (DSV) were compared with values of direct cineangiography in 40 patients, 21 of whom were ambulatory. DSV was performed with a 1-second, 30-ml contrast injection, which yielded real-time fluoroimages composed of 512 × 512 pixels at 30 frames/s. Single-plane right anterior oblique LV volumes were calculated by area-length methods for both DSV and cineangiography. Wall motion was assessed as percent area shortening for 12 equal myocardial segments, with results classified as abnormal if greater than 2 standard deviations below the mean of 20 normal values. DSV exhibited close correlation with angiography for EDV (r = 0.88), ESV (r = 0.92) and EF (r = 0.93). Intravenous DSV and direct cineangiography were concordant in classification of LV contractile pattern in 436 of 480 (91%) myocardial segments. Measurements of DSV obtained by 2 observers showed close correlations for EDV (r = 0.88), ESV (r = 0.95) and EF (r = 0.94), and wall motion classification was in agreement in 434 of 480 (90%) LV segments. Artifacts induced by respiratory motion, persistence of contrast in the right ventricle or left atrium, or low cardiac output may have contributed to the discrepancies observed. These data indicate that DSV is accurate in assessing LV volume and EF, correlates well with cineangiography and exhibits good interobserver reproducibility.     

New generation 3-dimensional echocardiography for left ventricular volumetric and functional measurements: comparison with cardiac magnetic resonance.

AIMS: Non-invasive assessment of left ventricular (LV) structure and function is important in the evaluation of cardiac patients. This study was designed to test the accuracy and reproducibility of new generation 3-dimensional echocardiography (3DE) in measuring volumetric and functional LV indices as compared with current "gold standard" of non-invasive cardiac imaging, cardiac magnetic resonance (CMR). METHODS AND RESULTS: Sixty-four subjects with good acoustic windows, including 40 cardiac patients with LV ejection fraction (EF)<45%, 14 patients with EF>45% and 10 normal volunteers underwent 3DE using a commercially available Philips Sonos 7500 scanner equipped with a matrix phase-array x4 xMATRIX transducer, and CMR on a 1.5 T Signa CV/i scanner (GE Medical Systems). Volumetric assessment was performed with analytical 4D-LV-Analysis software (TomTec) for 3DE and MRI-Mass software (Medis) for CMR. We found no significant differences in LV end-diastolic volume (EDV), end-systolic volume (ESV) and EF with excellent correlations between the indices measured using 3DE and CMR (r=0.97, r=0.98, and r=0.94, respectively). Bland-Altman analysis showed bias of 7 ml for EDV, 3 ml for ESV and -1% for EF with 3DE with corresponding limits of agreement (2SD) of 28 ml, 22 ml and 10%, respectively. Intraobserver and interobserver variabilities were for EDV: 3% and 4% (3DE) vs 2% and 2% (CMR), for ESV: 3% and 6% (3DE) vs 2% and 3% (CMR), and for EF: 4% and 4% (3DE) vs 2% and 4% (CMR), respectively. CONCLUSION: New generation 3DE provides accurate and reproducible quantification of LV volumetric and functional data in subjects with good acoustic windows as compared with CMR.     

Limitations of digital subtraction contrast echocardiography in enhancing left ventricular endocardial definition

The purpose of this study was to evaluate whether the digital subtraction technique, applied to contrast echocardiography of the left ventricle (LV), might improve endocardial edge identification by two-dimensional echocardiography. Injections of the polysaccharide agent SHU-454 were made into the LV of five closed-chest dogs. Data were obtained at different levels of election fraction (EF) induced by pharmacologic or mechanical interventions and were documented by left ventriculography (VGRAM) in the right anterior oblique projection. Contrast echocardiography was recorded in the apical four-chamber view. The echocardiographic images were digitized off-line into a 256 × 256 pixel matrix with 256 gray levels/pixel. Two end-diastolic frames prior to contrast appearance were averaged to obtain a mask that was subtracted from end-diastolic contrast frames corresponding to the two beats of peak intensity. The same procedure was repeated for the systolic frames. LV edges from echocardiographic images prior to contrast appearance, from digitally subtracted echo-contrast images, and from VGRAM were traced on two occasions by two different observers. LV volumes were calculated by single-plane Simpson's rule and EF was derived by the classical equation. The intra- and interobserver reproducibility in the measurement of EF was excellent for VGRAM (r = 0.95 and 0.94, respectively), it was good for two-dimensional echocardiography (r = 0.87 and 0.73), and was fair for contrast-echo (r = 0.79 and 0.68). Estimates of EF by two-dimensional echocardiography correlated with those of VGRAM (r = 0.82) slightly better than with those of contrast-echo (r = 0.76). In conclusion, in this experimental study, the application of digital subtraction to contrast echocardiography of the LV did not help to improve LV edge identification by two-dimensional echocardiography, as evaluated by the reproducibility and accuracy in EF calculation.     

A novel technique using biplane cine magnetic resonance imaging to evaluate left ventricular volume in children

The purpose of the study is to determine the feasibility of a novel simplified technique using cine magnetic resonance imaging (MRI) to assess left ventricular (LV) volume and ejection fraction (EF) validated by comparison with biplane LV angiography. Previous MRI studies to assess LV volumes have used multiple axial planes, which are compromised by partial volume effects and are time consuming to acquire and analyze. Accordingly, we developed a simplified imaging approach using biplane cine MRI and imaging planes aligned with the intrinsic cardiac axes of the LV. We studied 20 children (aged 4 months to 10 years) with various heart diseases. The accuracy of cine MRI was compared with that of LV angiography in all patients. LV volumes were calculated using Simpson's rule algorithm, for both MRI and LV angiography. LV volumes determined from MRI were slightly underestimated but correlated reasonably well with angiographic volumes (LVEDV: Y = 0.88X + 1.58, r = 0.99, LVESV: Y = 0.73X + 1.03, r = 0.98). Most importantly, even in patients who had abnormal ventricular curvature such as in tetralogy of Fallot, MRI determined LV volumes correlated well with angiographic values. The MR study was completed within 35 min in all patients. In conclusion, simplified biplane cine MRI, using the intrinsic LV axis planes, permits noninvasive assessment of LV volumes in views comparable to standard angiographic projections and appears practical for clinical use in childhood heart disease since the scan and analysis times are relatively short.     

Ejection fraction derived using dye dilution and angiographic methods

Ventriculographically derived ejection fraction (EF-V) is the most frequently used method to measure left ventricular (LV) function. However, significant error may result in the measurement of end-systolic volume (ESV), which is used to calculate EF-V. This error is ascribed to the variable, irregular, nonellipsoidal geometry of the end-systolic ventricular chamber. Since stroke volume (SV) is determined more accurately by dilution methods than by ventriculography, an improved measure of ESV can be calculated by subtracting green dye determined SV from the ventriculographic determined end-diastolic volume (EDV). The purpose of this study was to measure a corrected ejection fraction (EF-C) using EDV by ventriculography and SV derived using green dye. In eight anesthesized dogs cardiac outputs (COs) were calculated by green dye and left ventriculography. CO determined by ventriculography was greater than that measured by green dye (p < 0.005). EF-V (55 ± 15%) was always greater than EF-C (32 ± 12%) (p < 0.005). These studies (1) may partially explain the discrepancy in CO calculated from the use of dilution methods and ventriculography and (2) present a method to improve the calculation of LV ejection fraction.     

Measurement of left ventricular mass by contrast ventriculography

BACKGROUND: Elevated left ventricular mass (LVM) has been shown to be an important predictor of adverse cardiac events. Calculation of LVM using contrast ventriculography, as described by Rackley, involves measuring left ventricular wall thickness in a single plane, with assumptions made about ventricular geometry. HYPOTHESIS: We hypothesized that a modification of the Rackley method, involving multiple measurements of left ventricular (LV) wall thickness in 2 orthogonal planes, may add value in the determination of LVM in patients with LV remodeling and dysfunction. METHODS: The LVM was determined in 24 patients with LV dysfunction who had undergone both cardiac magnetic resonance imaging (CMRI) and contrast left ventriculography. Right anterior oblique (RAO) and left anterior oblique (LAO) still frames in diastole were used to measure LV length, chamber area, and wall thickness. From these variables, LV volume, myocardial volume, and LVM were calculated. The LVM calculations using an average wall thickness from the LAO and RAO projections were compared with LVM measured by CMRI. RESULTS: Eighty eight percent of patients had hypertension, 100% had coronary artery disease, and mean left ventricular ejection fraction by contrast left ventriculography was 41 +/- 14%. Averaging left ventricular wall thickness from RAO and LAO projections using biplane ventriculography for LVM calculation yielded a strong correlation (r = 0.77, p < 0.01) with LVM calculated from CMR. CONCLUSIONS: In patients with left ventricular dysfunction, biplane left ventricular wall thickness measurements for contrast ventriculography LVM calculations render a strong correlation with LVM calculated by CMRI.     

Quantitative assessment of left ventricular volume and ejection fraction using two-dimensional speckle tracking echocardiography

Aims: Two-dimensional speckle tracking echocardiography (2DSTE) allowsmeasurements of left ventricular (LV) volumes and LV ejectionfraction (LVEF) without manual tracings. Our goal was to determinethe accuracy of 2DSTE against real-time 3D echocardiography(RT3DE) and against cardiac magnetic resonance (CMR) imaging. Methods and results: In Protocol 1, 2DSTE data in the apical four-chamber view (iE33,Philips) and CMR images (Philips 1.5T scanner) were obtainedin 20 patients. The 2DSTE data were analysed using custom software,which automatically performed speckle tracking analysis throughoutthe cardiac cycle. LV volume curves were generated using thesingle-plane Simpson's formula, from which end-diastolic volume(LVEDV), end-systolic volume (LVESV), and LVEF were calculated.In Protocol 2, the 2DSTE and RT3DE data were acquired in 181subjects. RT3DE data sets were acquired, and LV volumes andLVEF were measured using QLab software (Philips). In Protocol1, excellent correlations were noted between the methods forLVEDV (r = 0.95), ESV (r = 0.95), and LVEF (r = 0.88). In Protocol2, LV volume waveforms suitable for analysis were obtained from2DSTE images in all subjects. The time required for analysiswas <2 min per patient. Excellent correlations were notedbetween the methods for LVEDV (r = 0.95), ESV (r = 0.97), andLVEF (r = 0.92). However, 2DSTE significantly underestimatedLVEDV, resulting in a mean of 8% underestimation in LVEF. Intra-and inter-observer variabilities of 2DSTE were 7 and 9% in LVvolume and 6 and 8% in LVEF, respectively. Conclusions: Two-dimensional speckle tracking echocardiography measurementsresulted in a small but significant underestimation of LVEDVand EF compared with RT3DE. However, the accuracy, low intra-and inter-observer variabilities and speed of analysis make2DSTE a potentially useful modality for LV functional assessmentin the routine clinical setting.     

Assessment of left ventricular function in patients with isolated severe disease of the left anterior descending artery: Clinical,electrocardiographic, hemodynamic,and angiographic correlations

The purpose of this study was to define the spectrum of left ventriculographic (LV) abnormalities in 60 patients with isolated ≥90% diameter narrowing of the left anterior descending artery (LAD). The patients were divided into three groups: Group I (26 patients) had normal left ventricular (LV) function with ejection fraction (EF) of >60% and no akinetic-dyskinetic segment representing abnormal contracting segments (ACS) of the left ventricular wall; Group II (15 patients) had mild to moderate LV dysfunction with EF of 40–60% and an akinetic-dyskinetic segment of < 30% of the end diastolic perimeter (0–30%; mean, 11.6%) and Group III (19 patients) had severe LV dysfunction with EF <40%, or an akinetic-dyskinetic segment of ≥30 % (30–81%; mean, 41.5%) or both. The data obtained from the history, physical examination, electrocardiogram (ECG), chest x-ray studies, hemodynamic studies, left ventriculography, and coronary arteriography were entered and filed on a memory disc in an IBM 370-168 computer. Analysis of the results showed: (1) more severe LV dysfunction is associated with increased incidence of large hearts, gallops, decreased cardiac output, and occlusion of the LAD. (2) ECG evidence of infarction is also associated with higher incidence of the abnormalities of the indices of LV dysfunction. (3) LAD occlusion (versus stenosis) has a higher incidence of severe LV dysfunction and prior infarction. (4) The site of LAD disease did not predict the extent of left ventricular dysfunction. (5) Collaterals did not protect against severe LV dysfunction.     

Inotropic reserve of the left ventricle in patients with chronic ischemic cardiopathy, studied using adrenaline stimulation. Prognostic significance

AIMS: To study by equilibrium radionuclide angiography (ERNA) the cardiac inotropic reserve after a myocardial infarction, and to evaluate its prognostic value. DESIGN: Patients in a chronic status of a myocardial infarction were studied by ERNA at a basal state and after stimulation with epinephrine, in the same session. Left ventricle (LV) functional abnormalities, global and regional, were evaluated. A 3-to-5 years follow-up was done. PATIENTS AND METHODS: Twenty five patients with a post myocardial infarction were included: 19 with an anterior infarction, 2 with an inferior and 4 with a combined one. All patients had LV dysfunction evaluated by Echocardiogram at hospital discharge. Global and regional LV function were studied by ERNA before and after inotropic stimulation, using increasing doses of epinephrine from 4.8 to 12 micrograms/minute. Heart rate and blood pressure were monitored. ERNA acquisition were done on left oblique best-septal and lateral views, over 400 cardiac cycles, using a Gama-camera GE 400AC. Three groups of patients were considered, according with the change of LV global ejection fraction: increments greater than 2%--group A (positive response); changes between +2% and -2% - group B; decreases greater than 2%--group C (negative response). During a 3 to 5 years follow-up, the incidence of major cardiac events was analysed: cardiovascular mortality, angina, left ventricle failure, myocardial reinfarction and coronary artery by-pass graft surgery. RESULTS: LV global function-Inotropic stimulation was done with an average perfusion time of 30.8 minutes, with total doses of epinephrine between 176 and 660 ng. No significant changes of heart rate (5%) or blood pressure (5.3%) occurred. Basal LV global ejection fraction (EF) was 29.2%. Only 2 patients had a normal LV ejection fraction; 14 patients had a severe LV dysfunction (EF less than 30%) and 9 had a moderate reduction of ejection fraction (EF between 30% and 45%). From the 14 patients with EF less than 30%, twelve had an involvement of the LV anterior wall. After stimulation EF value ineditreased in 9 and decreased in one patient. From the 11 patients with EF greater than 30%, 6 experienced a increase of EF and 3 decreased of EF after stimulation. REGIONAL WALL MOTION: Group A--15 patients--75 segments. In this group 39 segments were related to necrotic ECG localization, and 79% of them contributed to EF increase after stimulation. Forty-one segments were not involved by necrosis, and 78% had a positive contribution to EF increase. Six patients had all LV segments contributing to the EF increase after stimulation. The other 9 patients, had 13 segments not responding to stimulation (EF increments greater than 2%): 5 of them were segments related to ECG site of infarction. Group B--6 patients--30 segments. Five patients had 9 segments with a positive contribution to EF after inotropic stimulation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Chronic recurrent right ventricular tachycardia in patients without ischemic heart disease: Clinical,hemodynamic, and angiographic findings

Surgical cure of right ventricular tachycardia (RVT) has been recently described in patients with “arrhythmogenic right ventricular dysplasia,” a disease characterized by abnormal electrical activation of the right ventricle and localized or generalized angiographic right ventricular (RV) wall motion abnormalities (WMA). In search of a selective RV cardiomyopathy complicated by chronic recurrent RVT, 38 consecutive patients (mean age 30.5 ± 12 years) with RVT and no ischemic heart disease were studied clinically, noninvasively, and by cardiac catheterization including left and right ventriculography. RV volumes were as follow: end-systolic volume ranged from 23 to 103 (mean ± SD, 45.8 ± 20) cc/m² and was abnormal in 14 patients (37%); end-diastolic volume ranged from 57 to 138 (90.5 ± 26) cc/m² and was abnormal in 15 patients (39%); ejection fraction (EF) ranged from 0.18 to 0.64 and was decreased in five patients (13%). Seventeen patients (45%) had abnormal RV volume, EF, and/or pressures (RVD), five (13%) of whom had abnormal LV volume, EF, and/or pressures (LVD), and 12 (32%) patients with RVD had no LVD. Twenty-one patients (55%) had no RVD, two of whom had LVD. Only two of the 17 patients had RV regional WMA, one with and one without LVD. Most patients with LVD five of seven (71%) also had RVD while 12 of 31 patients (39%) with no LVD had RVD. In conclusion, less than one half of patients with RVT had selective RV cardiomyopathy and more than one half of patients with RVT had normal RV hemodynamics and angiography.