Right ventricular ejection fraction determined in three projections

The right ventricular ejection fraction (RVEF) was successively determined in three projections in ten healthy volunteers aged 28-53, mean 37 years, with a first-pass technique using 99Tcm-labelled red blood cells and a gamma camera coupled to a computer. In the anterior-posterior projection (AP) the mean RVEF was 39.3%, range 26-49%, in the left anterior oblique (LAO) 43.7% (36-58), and in the right anterior oblique (RAO) 44.5% (36-54). These mean values do not differ significantly (P = 10%). The results from one of the subjects were withdrawn, as they deviated markedly from the general pattern, and the data were reanalysed from the remaining 9 subjects. Now the mean RVEF in the AP projection was 38.2%, which is significantly lower (P = 1%) than the corresponding RVEF of 44.3% in the LAO projection and of 45.2% in the RAO projection. Our results suggest that when using the classic first-pass technique, the right ventricle histograms will in any projection be influenced by the activity in the right atrium and the large vessels.     

Volumetric analysis of right ventricular cadaver models viewed in axially angled projections

Axial cinematography of 15 cadaver cast models of the right ventricle was performed, using 16 different real and simulated single and biplane axial oblique projections. Heart volumes were then calculated by Dodge's area-length method and Ferlinz' method. In our volumetric studies of models, the smallest positive deviation from real volumes was 3.7% with the simulated long-axis projection (SLP₂), evaluated from the frontal plane and calculated by the area-length method. Volumetric determinations of most usefulness, as ranked by mean differences and mean quadratic deviations, were achieved with the simulated long-axis projection, (SLP₁-ranked third and SLP₂-ranked first), evaluated from the frontal plane and calculated by Dodge's method; with biplane orientation and calculation by Ferlinz' method (SLP₁+SLP₁C₁-ranked seventh, deviation from real volumes was 23%, SLP₂+SLP₂C₂-ranked fourth). We found that single-plane hepatoclavicular projection (HCP-ranked second and fifth), calculated by Dodge's or Ferlinz' method, as well as single-plane sitting-up projection (SUP-ranked sixth), calculated by the area-length method, were also acceptable for right ventricular volume measurements.     

Value of combined assessment of global and segmental ventricular contraction with right anterior oblique ECG-gated first-pass and left anterior oblique equilibrium radionuclide ventriculography

A semi-automated, variable-region-of-interest method of analysis was used to measure both global and segmental left ventricular (LV) and global right ventricular (RV) contraction with ECG-gated first-pass and equilibrium radionuclide ventriculography. Normal values were defined in 20 healthy volunteers, and in 24 symptomatic patients, the results were compared with right anterior oblique (RAO) contrast left ventriculography. The global LV ejection fraction (LVEF) obtained by equilibrium imaging in the left anterior oblique (LAO) projection correlated closely with the results obtained by the gated first-pass method in the RAO projection (r = 0.95) and those obtained with contrast left ventriculography (r = 0.94); furthermore, the interobserver variability was small (r = 0.985). The normal values for LVEF obtained using radionuclide techniques and contrast ventriculography did not differ, but with the equilibrium radionuclide method, the RV ejection fraction (RVEF) values were underestimated in comparison to those obtained by the RAO gated first-pass technique. In five patients with localised inferior segmental akinesis at contrast angiography, the RAO first-pass cine display demonstrated a corresponding wall-motion abnormality in all cases, but LAO equilibrium cine displays did so in only one out of five patients. For segmental quantitation of LV contraction, a computer programme defined the ventricular edge, divided the RAO LV images into five segments and determined both the segmental area contraction (SAC) and the counts-based segmental ejection fraction (SEF). Radionuclide SAC measurements correlated very strongly with SEF measurements (r = 0.94-0.99). Both radionuclide SAC and radionuclide SEF correlated well with contrast angiographic SAC, except in the inferobasal segment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thick maximum intensity projections for the assessment of left ventricular function with 64-slice computed tomography

OBJECTIVE: The objective of this study was to assess the accuracy of thick maximum intensity projections (MIP) from computed tomography (CT) data sets mimicking projection images from biplane ventriculography for evaluation of left ventricular (LV) parameters. MATERIALS AND METHODS: Fifty-eight patients underwent 64-slice CT. Multiphase images were reconstructed in 10% steps of the RR interval. MIP images (70-mm thickness) of the contrast-enhanced LV in fixed 30 degrees right anterior oblique (RAO)/60 degrees left anterior oblique (LAO) and in adapted short-/long-axis planes were reconstructed. LV parameters were calculated using the area-length method formula. Three-dimensional assessment with semiautomated software served as reference standard. RESULTS: Use of thick MIP reconstructions had a high intermethod reliability (86-94%) compared with the 3-dimensional approach. Smaller measurement errors were found for thick MIP reconstructions in adapted short-/long-axis planes. A significant projection error (3.0%, P < 0.001) of thick MIP reconstructions was found using fixed 30 degrees RAO/60 degrees LAO compared with adapted short-/long-axis reconstructions. CONCLUSION: Thick MIP reconstructions with adapted short-/long-axis planes allow an accurate assessment of LV parameters compared with the established 3-dimensional method.     

The measurement of pulmonic valve area by angiocardiographic and hemodynamic methods

The validity of angiocardiographic measurements in assessing the severity of pulmonic valve stenosis was determined. The pulmonic valve orifice area was measured in the lateral projection on cineangio-cardiographic films in 24 patients with valvar pulmonic stenosis. The valve orifice area was also obtained in the same patients by the Gorlin and Bache formulae. The right ventricular output value required for insertion in these formulae was obtained by angiocardiographic right ventricular volume measurement and by the Fick method. The correlation between the directly measured valve orifice area and the area calculated using the Fick principle and the Bache formula was 0.80. The substitution of angiocardiographically measured right ventricular stroke volume for the Fick value gave a correlation of 0.82. The results support validity of employing direct angiocardiographic measurements of pulmonic valve orifice area and angiocardiographic right ventricular volume measurements for quantitative assessment of the severity of pulmonic valve stenosis. The angiocardiographic methods thus represent an alternative to the Fick technique which can be used in conditions where the Fick method cannot be expected to give valid results. This work was supported in part by National Heart and Lung Institute Training Grant in Cardiovascular Radiology HL 05824     

Assessment of left ventricular diastolic function: comparison of contrast ventriculography and equilibrium radionuclide angiography.

Twenty-two patients with coronary artery disease were studied first by radionuclide angiography (RNA) and then by contrast ventriculography. Cardiac medications were discontinued at least 72 hr before study. The patients were studied during atrial pacing at heart rates close to their spontaneous sinus rhythm. Contrast ventriculography was performed at 50 frames/sec in the 30 degrees right anterior oblique projection using 40 ml of a nonionic contrast medium (iopamidol) at a flow rate of 10-12 ml/sec. The contours of the left ventricular silhouette at contrast ventriculography were traced, frame by frame, on a graphic table with a digitizing penlight. Equilibrium 99mTc RNA was performed in the best septal 45 degrees left anterior oblique projection, acquiring 150,000 cts/frame, at 50 frames/sec and with a 5% gate tolerance. Time-activity curves from both end-diastolic and end-systolic ROIs were built and interpolated. Both RNA and contrast ventriculography volume curves were filtered with Fourier five harmonics. A close relationship was found between RNA and contrast ventriculography measurements of peak filling rate normalized to end-diastolic cps (r = 0.87, p less than 0.001) and stroke count (r = 0.87, p less than 0.001), ejection fraction (r = 0.94, p less than 0.001). Thus, in patients with coronary artery disease, LV filling can be accurately assessed using RNA.     

81mKr equilibrium radionuclide ventriculography for the assessment of right heart function

Right heart 81mKr equilibrium radionuclide ventriculography was used to derive right ventricular ejection fraction (RVEF) in 12 healthy male volunteers. Anatomical lung subtraction using 99mTc-MAA perfusion scintigraphy was compared with conventional background correction and the effect of imaging projection on the techniques of image analysis evaluated. Both intra and inter observer variability were reduced by anatomical lung subtraction when compared to conventional background correction. In the right anterior oblique (RAO) projection, background corrected RVEF was lower than lung subtracted RVEF - 0.544 +/- 0.05 and 0.612 +/- 0.08 (mean +/- SD) (P less than 0.02). Lung subtracted RVEF in the anterior projection was lower than that with background correction (P less than 0.05) and lower than lung subtracted RVEF in the RAO projection (P less than 0.001). We conclude that optimal separation of right heart structures is achieved in the RAO projection and that reproducibility of the analytical technique is improved by anatomical lung subtraction.     

Value of combined assessment of global and segmental ventricular contraction with right anterior oblique ECG-gated first-pass and left anterior oblique equilibrium radionuclide ventriculography

A semi-automated, variable-region-of-interest method of analysis was used to measure both global and segmental left ventricular (LV) and global right ventricular (RV) contraction with ECG-gated first-pass and equilibrium radionuclide ventriculography. Normal values were defined in 20 healthy volunteers, and in 24 symptomatic patients, the results were compared with right anterior oblique (RAO) contrast left ventriculography. The global LV ejection fraction (LVEF) obtained by equilibrium imaging in the left anterior oblique (LAO) projection correlated closely with the results obtained by the gated first-pass method in the RAO projection (r=0.95) and those obtained with contrast left ventriculography (r=0.94); furthermore, the interobserver variability was small (r=0.985). The normal values for LVEF obtained using radionuclide techniques and contrast ventriculography did not differ, but with the equilibrium radionuclide method, the RV ejection fraction (RVEF) values were underestimated in comparison to those obtained by the RAO gated first-pass technique. In five patients with localised inferior segmental akinesis at contrast angiography, the RAO first-pass cine display demonstrated a corresponding wall-motion abnormality in all cases, but LAO equilibrium cine displays did so in only one out of five patients. For segmental quantitation of LV contraction, a computer programme defined the ventricular edge, divided the RAO LV images into five segments and determined both the segmental area contraction (SAC) and the counts-based segmental ejection fraction (SEF). Radionuclide SAC measurements correlated very strongly with SEF measurements (r=0.94–0.99). Both radionuclide SAC and radionuclide SEF correlated well with contrast angiographic SAC, except in the inferobasal segment. Mean radionuclide SAC (29%) for the five segments did not differ from mean contrast SAC (29%). This combined protocol enables rapid and accurate biventricular assessment of global and segmental contraction. Significant diagnostic value exists in combining these two acquisition protocols in specific clinical situations.     

Three-dimensional imaging of the right ventricle using blood pool tomography

Gated tomography of the cardiac blood pool has been found to be useful for detecting regional wall motion abnormalities of the left ventricle. We have applied this technique to study regional wall motion of the right ventricle.Twenty normal controls and 38 patients with previous myocardial infarction underwent tomography of the right ventricle following in vivo labelling of the blood pool. Three dimensional images were produced using a transputer based display system. These images were oriented into a right anterior oblique projection, and phase maps of the right ventricle superimposed onto them. The phase maps from the controls showed contraction to begin in the region of the apex and spread laterally and superiorly up the free wall of the right ventricle. Normal right ventricular phase was found to lie in a 200 degree range.In one of 20 patients with anterior and in 11 of 18 patients with inferior myocardial infarction, there were focal areas of right ventricle with phase angles outside this range. These results suggest that the contraction phase pattern of the right ventricle may be used to detect right ventricular contraction abnormalities after myocardial infarction. Offprint requests to: S.J. Cross     

Clinical utility of a multigated modified anterior projection in the detection of left ventricular inferior and apical wall motion abnormalities

Recent evidence indicates that the left anterior oblique projection (LAO) multigated radionuclide ventriculogram (RVG) underestimates presence and extent of apical and inferior left ventricular (LV) wall motion abnormalities. We investigated, prospectively, the sensitivity and specificity of a modified anterior projection (MAP), which incorporates cephalad tilting. Thirty-three consecutive patients undergoing cardiac catheterization suspected to have coronary artery disease were studied with RVG, using both the MAP and LAO views. LAO views were analyzed using the ejection fraction image (REFI), and the regional ejection fraction (REF) of the inferoapical region. The MAP studies were analyzed using stroke volume image (SVI) to evaluate apical and inferior LV regions. Results were as follows: (Formula: see text), Both intraobserver and interobserver variabilities were comparable to those of conventional angiographic studies used in detection of apical and inferior asynergy. It is concluded that the multigated MAP offers additional information about abnormalities of the LV inferior and apical regions.     

Gated cardiac MRI: ejection-fraction determination using the right anterior oblique view

Fifteen adults underwent gated cardiac MR scans in the right anterior oblique position. End-diastolic and end-systolic images were acquired in an imaging plane parallel to the ventricular septum using spin-echo image acquisition on a 0.35-T system. Analysis of ventricular volumes and ejection fractions was performed using the area-length method. These results were correlated with ejection fractions obtained from angiocardiography. The linear regression line obtained for ejection fraction was y = 0.74x + 16 and the r value was 0.789, indicating a reasonable correlation between the two methods.     

Left ventricular ejection and filling rate measurement based on the automatic edge detection method of ECG-gated blood pool single-photon emission tomography

The objective of the present investigation was to determine the feasibility of assessing left ventricular systolic ejection and diastolic filling via the automatic edge detection method employing ECG-gated blood pool single-photon emission tomography (SPET GBP) data. METHODS: Thirty-five patients, who had undergone both SPET GBP and ECG-gated equilibrium blood pool scintigraphy by the planar method (planar GBP), were enrolled in this study. Planar GBP was performed with a single-headed gamma camera. From the left anterior oblique projection, data were acquired at 24 frames/cardiac cycle with ECG-gating during the equilibrium state. SPET GBP was conducted utilizing a triple-headed gamma camera, with 60 projection views over 360 degrees by 60 sec per view, in 16 frames/cardiac cycle. In each frame, left ventricular volume was determined by automatic edge detection employing a quantitative gated SPET program. Additionally, the time-volume curve was fitted by the 4th harmonics of Fourier transform. Ejection fraction (EF, %), peak ejection rate (PER, /sec), peak filling rate (PFR, /sec) and mean filling rate during the initial one-third of diastolic time (1/3 FRm) were calculated from the fitted curve. These parameters were also calculated with planar GBP data. RESULT: Left ventricular ejection and filling parameters were calculated by SPET GBP with the automatic edge detection program for all patient data. Correlation coefficients of EF, PER, PFR and 1/3 FRm between SPET and planar GBP were 0.91 (p < 0.001), 0.82 (p < 0.001), 0.78 (p < 0.001) and 0.74 (p < 0.001), respectively. CONCLUSION: Ejection and filling rates can be calculated using SPET GBP with the edge-detection software. These parameters displayed significant correlations with those values obtained via planar GBP. Additional studies are warranted to determine the reliability of parameters with SPET GBP.     

Factors influencing the quantification of valvular regurgitation by gated equilibrium radionuclide angiography

To test the clinical validity of the stroke volume ratio (SVR) and the factors influencing its value we determined it in a population of 41 patients free of valvular regurgitation. The SVR was estimated from multigated blood pool scans in left anterior oblique position by two methods. The first method followed the classical formula of the left to right ventricular stroke count ratio. The second method used the same formula except that the right atrial activity emanating from the area of right atrioventricular overlap as traced at right ventricular end-systole, was subtracted from the right ventricular stroke count. The SVR averaged 1.25 +/- 0.18 (range 0.97-1.80) by the first technique and 1.05 +/- 0.12 (range 0.82-1.36) by the second (P less than 0.001). In our results the SVR is not correlated to either ejection fraction or angiographically determined left ventricular volumes. Conversely the SVR is correlated with the left to right end-diastolic volume ratio evaluated from radionuclide counts measured at right and left ventricular end-diastole (r = 0.48, P less than 0.01). This may be due to variations in the area of right atrioventricular overlap, depending on the size of the ventricular chamber. It is postulated that the accuracy of SVR determination could be enhanced by subtraction of the right atrial activity from the right ventricular activity at end-systole. In patients free of valvular regurgitation the LV/RV stroke volume ratio approaches unity and the variability of the results is smaller. Interobserver and intraobserver variability is reduced using the Fourier phase approach.     

Comparison of left anterior oblique, anterior and geometric mean methods for determining gastric emptying times.

The accurate determination of gastric emptying time requires correction or compensation for tissue attenuation. The gold standard for tissue attenuation correction for gastric emptying is the geometric mean of the gastric counts from the anterior and posterior views. For reasons of efficiency, many community hospitals acquire only the anterior projection. This study addressed the hypothesis that, using the left anterior oblique view alone, one can minimize the effect of variation in attenuation as the meal moves from the fundus to the stomach to the more anterior antrum to a degree equal to that of the geometric mean technique. We studied 42 consecutive patients using a standardized 300-g meal labeled with 650 muCi of 99mTc-sulfur colloid. The patients were imaged in the anterior (ANT), posterior (POST) and left anterior oblique (LAO) views every 15 min for 90 min. Linear regressions were obtained using the ANT, LAO and GM data. Cross-correlation of the T1/2 for 35 cases showed an R value for the GM versus LAO of 0.95 and GM versus ANT of 0.84. The p value greater than 0.49, for the paired two-tailed t-test of the LAO and GM methods. The p value for the ANT and GM methods is 0.0058 indicating a significant difference between these methods. The cross-correlation, F-test p and t-test p values support the hypothesis that there is no significant difference between the geometric mean and left anterior oblique gastric emptying times. It is therefore reasonable to substitute the left anterior oblique for routine GET when using a solid meal in patients with normal gastric anatomy, albeit altered physiology.     

Present status of axially angled angiocardiography

Axial angiography visualizes anatomical details of normal and pathological hearts not previously demonstrated by conventional angiography. Progress in the diagnosis of congenital heart malformations using axial projection technique has been reconsidered, emphasizing that the anatomical details of each congenital heart malformation and their associated anomalies that can be revealed by axial angiography. Three angiographic views form the basis of this study: long axial, four chamber, and elongated right anterior oblique. Relevant findings are presented in isolated ventricular septal defect, tetralogy of Fallot, atrioventricular septa defects, common ventricle, and stradding atrioventricular valves. Variability in the position and orientation of the heart requires adjustment of the degree of obliquity and/or angulation of the X-ray beam in individual patients to obtain the appropriate angiographic views.     

81mKr equilibrium radionuclide ventriculography for the assessment of right heart function

Right heart^81mKr equilibrium radionuclide ventriculography was used to derive right ventricular ejection fraction (RVEF) in 12 healthy male volunteers. Anatomical lung subtraction using^99mTc-MAA perfusion scintigraphy was compared with conventional background correction and the effect of imaging projection on the techniques of image analysis evaluated. Both intra and inter observer variability were reduced by anatomical lung subtraction when compared to conventional background correction. In the right anterior oblique (RAO) projection, background corrected RVEF was lower than lung subtracted RVEF - 0.544 ±0.05 and 0.612±0.08 (mean ± SD) (P<0.02). Lung subtracted RVEF in the anterior projection was lower than that with background correction (P<0.05) and lower than lung subtracted RVEF in the RAO projection (P < 0.001). We conclude that optimal separation of right heart structures is achieved in the RAO projection and that reproducibility of the analytical technique is improved by anatomical lung subtraction.     

Left ventricular volume determination by first-pass radionuclide angiocardiography using a semi-geometric count-based method]

A new radionuclide technique for the calculation of left ventricular (LV) volume by the first-pass (FP) method was developed and examined. Using a semi-geometric count-based method, the LV volume can be measured by the following equation: CV = CM/(L/d). V = (CT/CV) x d3 = (CT/CM) x L x d2. (V = LV volume, CV = voxel count, CM = the maximum LV count, CT = the total LV count, L = LV depth where the maximum count was obtained, and d = pixel size.) This theorem was applied to FP LV images obtained in the 30-degree right anterior oblique position. Frame-mode acquisition was performed and the LV end-diastolic maximum count and total count were obtained. The maximum LV depth was obtained as the maximum width of the LV on the FP end-diastolic image, using the assumption that the LV cross-section is circular. These values were substituted in the above equation and the LV end-diastolic volume (FP-EDV) was calculated. A routine equilibrium (EQ) study was done, and the end-diastolic maximum count and total count were obtained. The LV maximum depth was measured on the FP end-diastolic frame, as the maximum length of the LV image. Using these values, the EQ-EDV was calculated and the FP-EDV was compared to the EQ-EDV. The correlation coefficient for these two values was r = 0.96 (n = 23, p less than 0.001), and the standard error of the estimated volume was 10 ml.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of patient imaging angle on apparent cardiac volumes and the potential impact on measurement of valvular regurgitant fractions

The accurate measurement of cardiac chamber volume is of major importance in assessing cardiac performance. Accurate equilibrium radionuclide volume estimations are difficult to obtain, due to the geometry of the chambers, and the physical characteristics of the imaging system. The purpose of this study was to examine the effects of imaging projections on relative cardiac chamber volumes, indexes, and stroke volume ratios. Twenty-two male patients, free of clinical evidence of disease, were studied. A series of four 2-minute acquisitions were made with the patient successively imaged in the anterior, 30 degrees left anterior oblique (LAO), 45 degrees LAO, and 60 degrees LAO projections with 15 degrees of caudal inclination. Filtered stroke volume and original images were used by the operator to assign right ventricular (RV), left ventricular (LV), and a combined right and left ventricular (TOT) regions-of-interest. From the data we determined end-diastolic counts (EDC), end-systolic counts (ESC), stroke counts (SC), ejection fractions (EF), and R/L stroke count ratios. The following changes were observed as the projection was moved from the anterior to 60 degrees LAO: 1) all RV parameters decreased in value, including, RVEDC (P less than .001), RVESC (P less than .01), RVESC (P less than .01) and RVEF (P less than .001); 2) LVEDC and LVESC (both P less than .01) increased while LVEF decreased (P less than .004); and 3) the R/L stroke count ratio decreased (P less than .001). Variability could be explained by 1) chamber overlap and geometry; 2) patient variability; and 3) intrachamber, interchamber and chest wall photon attenuation and scatter. We suggest that close attention to detail, with computer assistance, to optimally position the patient may reduce the effect of inherent limitations in radionuclide volumetric measurements, thus improving the reliability and usefulness of existing studies.