Assessment of left ventricular mass and volumes by three-dimensional echocardiography in patients with or without wall motion abnormalities: comparison against cine magnetic resonance imaging.

Abstract

To evaluate if three-dimensional echocardiography (3-DE) is as accurate and reproducible as cine magnetic resonance imaging (cMR) in estimating left ventricular (LV) parameters in patients with and without wall motion abnormalities (WMA).
83 patients (33 with WMA) underwent 3-DE and cMR. 3-DE datasets were analysed using a semi-automatic contour detection algorithm. The accuracy of 3-DE was tested against cMR in the two groups of patients. All measurements were made twice by two different observers.
LV mass by 3-DE was similar to that obtained by cMR (149 (SD 42) g vs 148 (45) g, p = 0.67), with small bias (1 (28) g) and excellent interobserver agreement (-2 (31) g vs 4 (26) g). The two measurements were also highly correlated (r = 0.94), irrespective of WMA. End-diastolic and end-systolic LV volumes and ejection fraction by 3-DE and cMR were highly correlated (r = 0.97, 0.98, 0.94, respectively). Yet, 3-DE underestimated cMR end-diastolic volumes (167 (68) ml vs 187 (70) ml, p<0.001) and end-systolic volumes (88 (56) ml vs 101 (65) ml, p<0.001), but yielded similar ejection fractions (50% (14%) vs 50% (16%), p = 0.23).
3-DE permits accurate determination of LV mass and volumes irrespective of the presence or absence of WMA. LV parameters obtained by 3-DE are also as reproducible as those obtained by cMR. This suggests that 3-DE can be used to follow up patients with LV hypertrophy and/or remodelling.

Full text

Page 1

Assessment of left ventricular mass and volumes by
three-dimensional echocardiography in patients with
or without wall motion abnormalities: comparison
against cine magnetic resonance imaging
A-C Pouleur,1J-B le Polain de Waroux,1A Pasquet,1B L Gerber,1O Ge ´rard,2P Allain,2
J-L J Vanoverschelde1
1Division of Cardiology,
Department of Cardiovascular
Diseases, Cliniques
Universitaires St Luc, Universite ´
Catholique de Louvain, Brussels,
Belgium;2Philips Medical
Systems Research, Paris, France
Correspondence to:
Dr Jean-Louis Vanoverschelde,
Division of Cardiology, Cliniques
Universitaires St Luc, Avenue
Hippocrate 10, 2881, B-1200
Brussels, Belgium;
vanoverschelde@card.ucl.ac.be
A-CP and J-BPW contributed
equally to the work.
Accepted 11 September 2007
Published Online First
1 November 2007
This paper is freely available
online under the BMJ Journals
unlocked scheme, see http://
heart.bmj.com/info/unlocked.dtl
ABSTRACT
Aim: To evaluate if three-dimensional echocardiography
(3-DE) is as accurate and reproducible as cine magnetic
resonance imaging (cMR) in estimating left ventricular
(LV) parameters in patients with and without wall motion
abnormalities (WMA).
Methods: 83 patients (33 with WMA) underwent 3-DE
and cMR. 3-DE datasets were analysed using a semi-
automatic contour detection algorithm. The accuracy of 3-
DE was tested against cMR in the two groups of patients.
All measurements were made twice by two different
observers.
Results: LV mass by 3-DE was similar to that obtained by
cMR (149 (SD 42) g vs 148 (45) g, p=0.67), with small
bias (1 (28) g) and excellent interobserver agreement
(22 (31) g vs 4 (26) g). The two measurements were
also highly correlated (r=0.94), irrespective of WMA.
End-diastolic and end-systolic LV volumes and ejection
fraction by 3-DE and cMR were highly correlated
(r=0.97, 0.98, 0.94, respectively). Yet, 3-DE under-
estimated cMR end-diastolic volumes (167 (68) ml vs 187
(70) ml, p,0.001) and end-systolic volumes (88 (56) ml
vs 101 (65) ml, p,0.001), but yielded similar ejection
fractions (50% (14%) vs 50% (16%), p=0.23).
Conclusion: 3-DE permits accurate determination of LV
mass and volumes irrespective of the presence or
absence of WMA. LV parameters obtained by 3-DE are
also as reproducible as those obtained by cMR. This
suggests that 3-DE can be used to follow up patients with
LV hypertrophy and/or remodelling.
Left ventricular (LV) volumes, ejection fraction
(EF) and mass are important prognostic factors in
patients with cardiac diseases and are therefore
frequently requested for serial testing.123Because of
its widespread availability, two-dimensional echo-
cardiography (2-DE) is usually the first choice non-
invasive imaging method for obtaining these
measurements in daily clinical practice.4 5Yet,
several studies have shown that one-dimensional
M-mode (1-DE) and 2-DE had limited test-retest
reproducibilityandthat
impacted by many factors including image quality,
foreshortening of the LV cavity and geometric
assumptions regarding LV volumes calculation.
Because it provides superior image quality, is
intrinsically three-dimensional
require any geometric assumption for volume
calculation, cardiac magnetic resonance (cMR)
has progressively become the reference method
their accuracywas
anddoes not
for assessing LV volumes, EF and mass, especially
in clinical trials.6 7However, its cost and avail-
ability remain problematic for routine clinical
evaluation.
Three-dimensional echocardiography (3-DE) is a
promising new method for assessing LV volumes
and EF in patients with structural heart disease.
When used in combination with computerised
endocardial contour tracking algorithms, it indeed
permits faster, more accurate and less operator-
dependent quantitation of LV volumes and func-
tion than 1-DE or 2-DE.8211Preliminary data also
suggest that it can be used to measure LV mass.12216
So far, however, this requires both the endocardial
and the epicardial contours to be traced manually
on 3D-derived orthogonal 2-D cross-sections and
has only been evaluated in a limited number of
patients, most of whom had a normal LV
geometry.
We have recently developed a computerised
semi-automated volumetric contour tracking algo-
rithm that enables both the endocardial and the
epicardial contours to be detected with minimal
interaction by the investigator. In this context, the
aims of the present study were: (1) to validate this
new border detection algorithm for quantitation of
LV mass by using cMR as the reference method; (2)
to assess the variability of 3-DE estimates of LV
mass in patients with or without wall motion
abnormalities (WMA); and (3) to evaluate the day-
to-day variability of LV mass measurements
obtained by 3-DE in comparison with those
obtained by cMR.
METHODS
Study population
The study population consisted of 83 consecutive
subjects (67 men, mean age 54 (SD 19) years, range
7–85 years) who underwent cMR and 3-DE in
random order on the same day. There were 20
volunteers (15 men, mean age 29 (13) years, range
7–50 years) and 63 patients with heart disease (52
men, mean age 62 (13) years, range 37–85 years), of
whom 20 had aortic valve disease, 10 severe mitral
regurgitation and 33 a previous myocardial infarc-
tion. All subjects were in sinus rhythm. Patients
with haemodynamic instability, constant arrhyth-
mia (atrial fibrillation or more than five premature
beats per minute) or any contraindication to cMR
(ferrometallic cerebral aneurysm clips, pacemaker or
implantable defibrillator, or severe claustrophobia)
Cardiac imaging and non-invasive testing
1050Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711

Page 2

were not considered for inclusion. In five volunteers, 3-DE and
cMR were repeated twice, on two different days, to assess test-
retest reproducibility. Ten volunteers and 11 patients with
previous myocardial infarction also had 3-DE with and without
LV opacification using the commercially available ultrasound
contrast agent Sonoview (Bracco, Geneva, Switzerland). The
study protocolwas approvedbythe localethics committee and all
patients gave informed consent before inclusion into the study.
Two-dimensional echocardiography
A complete M-mode, two-dimensional and Doppler examina-
tion was performed using a Sonos 7500 system or IE33 (Philips
Medical Systems, Andover, MA, USA) with harmonic imaging.
Images were acquired from standard parasternal and apical
views, with short breath-holds if needed. The presence or
absence of regional wall motion abnormalities (WMA) was
assessed by using the 16-segments scoring model proposed by
the American Society of Echocardiography (1= normal wall
motion, 2= hypokinesia, 3= akinesia). LV mass was derived
from M-mode echocardiography as previously described.17
Three-dimensional echocardiography
Three-dimensional echocardiography was performed using a
Sonos 7500 or a IE33 echocardiographic systems (Philips
Medical Systems, Andover, MA, USA) equipped with a
dedicated broadband, wide angle, matrix array transducer.
Images were acquired from the apical window, with the patient
in the left lateral decubitus position. Care was taken to include
the entire LV cavity within the pyramidal scan volume. 3-DE
datasets were acquired using a wide-angled acquisition (93680u)
mode in which four wedge-shaped subvolumes (93u620u each)
are obtained over four different cardiac cycles during a short
breath-hold. Acquisition was triggered to the R wave of every
other cardiac cycle to allow time for storage of each subvolume,
resulting in a total acquisition time of eight heart beats.
Cardiac magnetic resonance imaging
cMR imaging was performed on a 1.5 T magnet (Intera CV,
Philips Medical Systems, Best, The Netherlands) using a five-
element cardiac synergy coil for signal reception. After localisa-
tion of the heart using three-plane and oblique survey images,
10–12 contiguous short-axis cine images were prescribed to
cover the entire left ventricle from base to apex. Images were
acquired using a multislice cine vectocardiographic (VCG) gated
balanced fast-field echo sequence with SENSE during serial
breath-holds. Twenty cine phases were acquired using retro-
spective gating with a temporal resolution varying between 25–
50 ms. Slice thickness was 8 mm and slice spacing was 2 mm.
Imaging parameters were: repetition time 3.1 ms, echo time
1.6 ms, flip angle 60u, field of view 38 cm, image matrix of
1606128 pixels, SENSE acceleration factor 1.6, 12–20 lines
acquired per phase.
Data analysis
Images were transferred to dedicated workstations (QLab and
View Forum R4.1 for analysis of 3-DE and cMR images
Figure 1
correct apical four-chamber and two-
chamber views (upper left and right,
respectively) and short-axis view (bottom
left) selected off-line from a 3-DE dataset
obtained in the same subject and
resulting 3D-shell (bottom right).
Superimposed semi-automatically
detected endocardial and epicardial
boundaries were used to calculate LV
mass.
End-diastolic, anatomically
Cardiac imaging and non-invasive testing
Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.1237111051

Page 3

respectively, all Philips Medical systems). Patient information
was removed. In all patients, measurements were performed in
duplicate by two blinded observers, who were both familiar
with 3-DE and cMR. To avoid recalling the patient’s images, the
blinded readers analysed 3-DE and cMR images on separate
days. To assess intra-observer variability, in a randomly selected
subgroup of 45 patients, measurements were repeated by one of
the readers, one month after the first reading.
Three-dimensional echocardiography
Image quality of 3-DE images was graded semi-quantitatively
by both readers on a five-point scale as 1 = non-analysable, 2
= fair, 3 = moderate, 4 = good and 5 = excellent.
Measurements of LV volumes, mass and EF were performed
off-line. The 3-DE datasets were analysed with a prototype
version of 3DQ-QLab software that allows for semi-automatic
detection of endocardial and epicardial borders. Briefly, the 3D
volume dataset is first displayed in three different cross-sections
that can be modified interactively. For the detection algorithm
to work properly18the anatomically correct four-chamber and
two-chamber views need to be displayed simultaneously.
Markers are then placed onto the mitral annulus and the apex,
both in end-diastole and end-systole. Using these markers, the
software program first creates truncated ellipsoid end-diastolic
and end-systolic 3D meshes of the LV. The vertices of these
meshes are then automatically attracted to the image borders
(3D gradient of image intensity) while respecting prespecified
surface smoothing constraints (in order to minimise local
curvature on the surface). The end-diastolic and the end-systolic
3D meshes deform until equilibrium is reached between
closeness to the borders and minimal curvature. If needed,
manual adjustments can be applied. The volumes of the
obtained 3D- end-diastolic and end-systolic LV meshes include
the papillary muscles into the LV cavity and correspond to the
LV end-diastolic and end-systolic LV volumes. The end-diastolic
epicardial contours are next automatically estimated by adding
a fixed myocardial wall thickness of 8.8 mm to the endocardial
mesh.19Manual corrections can then be applied, if needed.
These epicardial contours are used to calculate the myocardial
volume by subtracting the end-diastolic endocardial volume
from the end-diastolic epicardial volume. The difference
between these two volumes is then multiplied by the specific
mass of myocardial tissue (1.05 g/ml) to obtain LV mass (fig 1).
Cine magnetic resonance imaging
cMR loops were analysed off-line with a commercial software
(View Forum R4.1). In every end-diastolic short-axis slice,
endocardial and epicardial contours were manually traced to
calculate LV volumes, mass and EF, while including papillary
muscles in the LV cavity.
Statistical analysis
Statistical analysis was performed using SPSS version 11.5.
Values are reported as mean (plus or minus 1 SD). The average
of duplicate measurements was used for statistical analysis.
Linear regression analysis and Bland-Altman plots with assess-
ment of systematic bias and 95% confidence intervals, as well as
two-way mixed intraclass correlation coefficient (ICC) were
Figure 2
agreement between estimates of LV mass
by 1-DE and cMR.
Linear regression and limits of
Table 1
Clinical and echocardiographic characteristics
All patients ControlsWMA group
Clinical characteristics
No of patients
Age (years)
Gender (males/females)
NYHA
83 5033
54 (19)
67/16
38 (46%)
21 (25%)
24 (29%)
46 (19)
36/14
36 (72%)
11 (22%)
3 (6%)
67 (11)
31/2
2 (6%)
10 (30%)
21 (63%)
I
II
III
Echocardiographic characteristics
RWMS
AR >3
AS
MR >3
cMR ejection fraction
21 (8)
13 (16%)
7 (8%)
10 (12%)
50 (16%)
16 (0)
13 (26%)
7 (14%)
10 (20%
59 (9%)
30 (6)
0 (0%)
0 (0%)
0 (0%)
36 (14%)
AR, aortic regurgitation; AS, aortic stenosis; MR, mitral regurgitation; RWMS, regional wall motion score.
Cardiac imaging and non-invasive testing
1052Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711

Page 4

used to compare LV mass between 1-DE, 3-DE and cMR.20
Systematic differences in measurements between these methods
were assessed using the Student test. Inter-observer reliability
for measurement of LV volumes and mass for each technique
was assessed using two-way random, single measure ICC. Intra-
observer and intra-subject reliability was assessed using one-
way random two measures ICC. All tests were two-sided and a
p value ,0.05 was considered as statistically significant.
RESULTS
Patient characteristics/study protocol
The characteristics of the study population are summarised in
table 1. All patients successfully completed 3-DE and cMR. The
duration of a complete 3-DE examination was shorter (5 min-
utes on average, including patient preparation) than that of the
cMR examination (25 minutes on average, including patient
preparation and acquisition of scout images, reference scan for
SENSE and cine short-axis slices). By contrast, the time needed
to complete the analysis (LV volumes and mass) tended to be
longer with 3-DE (434 (162) seconds, including 25 (7) seconds
for automated contour tracking and 408 (160) seconds for
manual correction) than for cMR (344 (162) seconds).
None of the patients were excluded because of poor image
quality or non-interpretable 3-DE images. Thirteen patients had
excellent (16%), 29 good (35%), 27 moderate (32%) and 14
patients fair (17%) 3-DE image quality. Manual corrections
were necessary to optimise endocardial and epicardial contours
in all patients for the two imaging methods. With 3-DE, these
corrections resulted in only minor changes in the estimated
epicardial LV volumes (on average 10 (15) ml from 282 (67) ml
before correction to 292 (71) ml after correction). Correction
also tended to be larger in patients with normal wall motion
(NWM) (17 (10) ml) than in those with WMA (7 (16) ml).
Based on the 2-DE, 33 patients had wall motion abnormalities
(WMA group, mean wall motion score: 30 (6)). Subjects with
NWM (n=50, NWM group) served as a controls.
Comparison of 1-DE and cMR-derived LV mass
Linear regression and Bland-Altman plots of LV mass by 1-DE
versus cMR are shown in figure 2. 1-DE yielded significantly
higher LV mass values than cMR (209 (77) g and 149 (42) g,
respectively, p,0.001). Although both measurements correlated
reasonably well (r=0.78, p,0.001), a large bias was noted (62
(42) g).
Comparison of 3-DE and cMR-derived LV mass
Mean LV mass values by 3-DE and cMR are reported in table 2.
Linear regression and Bland-Altman plots of LV mass by these
two methods are shown in figure 3. LV mass by 3-DE and cMR
were not significantly different from each other (149 (42) g and
148 (45) g, respectively, p=0.67) and were highly correlated
(r=0.94, p,0.001).
Measurement of LV mass in patients with and without wall
motion abnormalities
3-DE and cMR yielded similar values for LV mass in patients
with (167 (35) g vs 164 (37) g, p=0.11) and without (137 (43) g
vs 138 (47) g, p=0.77) WMA. In both groups, 3-DE and cMR
values were highly correlated (r = 0.94 each) with only small
absolute biases (3 (20) g vs 21 932) g, p=0.25) and relative
biases (5% (8%) vs 9% (14%), p=0.17) (fig 4).
Comparison of LV volumes and ejection fraction between RT-3DE
and cMR
3-DE measurements of LV volumes and EF were also highly
correlated with those obtained by cMR (r=0.97, 0.98, 0.94 for
EDV, ESV and EF, respectively). Yet, volumes were significantly
underestimated by 3-DE (167 (68) ml vs 187 (70) ml for EDV,
p,0.001; 88 (56) ml vs 101 (65) ml for ESV, p,0.001), resulting
in small negative biases (220 ml for EVD and 213 ml for ESV,
both p,0.05, table 2 and fig 5A).
Figure 3
agreement between estimates of LV mass
by 3-DE and cMR.
Linear regression and limits of
Table 2
Mean values for LV mass, EDV, ESV, EF by 3-DE versus cMR
3-DE cMR
Comparison between 3-DE and cMR
rBiasp Value
LV mass (g)
EDV (ml)
ESV (ml)
EF (%)
149 (42)
167 (68)
88 (56)
50 (14)
148 (45)
187 (70)
101 (65)
50 (16)
0.94
0.97
0.98
0.94
1 (28)0.67
,0.001
,0.001
0.23
220 (31)
212 (31)
1 (11)
EDV, end-diastolic volume; EF, ejection fraction; ESV, end-systolic volume; ICC, intraclass correlation coefficient.
Cardiac imaging and non-invasive testing
Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.1237111053

Page 5

Comparison of LV volumes and ejection fraction with and
without injection of contrast
Use of contrast to opacify the LV cavity attenuated the
differences between the two techniques (23 ml for EDV and
23 ml for ESV, both p,0.05) but did not affect the measure-
ment of EF (48% (15%) vs 50% (15%), p=0.62). As shown in
table 3, the extent to which contrast enhancement corrected the
underestimation of LV volumes by 3-DE was similar in patients
with (+20 ml for EDV and + 9 ml for ESV) and without (+18 ml
for EDV and +3 ml for ESV) wall motion abnormalities
(p=0.68 and p=0.08 for EDV and ESV respectively).
Reproducibility
Results of inter-observer and intra-observer reproducibility are
summarised in table 4. The inter-observer and intra-observer
reproducibility of 3-DE and cMR was similarly high. Test-retest
reproducibility was also very good for both methods (table 5).
DISCUSSION
The results of our study indicate that 3-D imaging of the LV with
either 3-DE or cMR produces comparable results in terms of LV
volumes, EF and mass in patients with or without wall motion
abnormalities. Our data also show that 3-DE and cMR provide
similarly low inter-observer variability for all LV measurements
and well as similarly high test-retest reproducibility.
Accuracy of 3-DE assessment of LV volumes, ejection fraction
and mass
Over the past 5 years, numerous studies have validated the use
of 3-DE for assessment of LV volumes and EF, using various
imaging methods as reference standards. All these studies have
shown a greater accuracy of 3-DE compared with 1-DE or 2-
DE.9211 15 21223The results of this study confirm and extend these
previous observations. As in previous studies, we found that
semi-automated 3-DE measurements of LV volumes and EF
were strongly correlated with those obtained by cMR. We also
observed that 3-DE LV volumes were significantly under-
estimated compared with
Underestimation of LV volumes by 3-DE has been reported
previously and has been attributed to technical limitations
inherent in ultrasound imaging in general and 3-DE in
particular, such as the inability to visualise the endocardial
contours, the exclusion of trabecular structures from the LV
cavity or the partial cut-off of the left ventricle.24Divergent
inclusion of the papillary muscles into the LV cavity between
the two techniques has been incriminated as well. However,
this was unlikely to be the case in our study, since the papillary
muscles were treated in exactly the same way with both
techniques. Interestingly, we found that the use of ultrasound
contrast agents to opacify the LV cavity almost completely
abolished the underestimation of LV volumes by 3-DE. This
suggests that improved border delineation and exclusion of
trabecular structures are the most likely contributors to the
underestimation of LV volumes by 3-DE.
In the present study, we also evaluated the possibility of
semi-automatically measuring LV mass using 3-DE. For this
purpose, we modified the computerised contour-tracking algo-
rithm used for endocardial border detection to allow for the
estimation of the epicardial contours as well. Our data indicate
that LV mass measurements obtained using this novel approach
are highly accurate, even in patients whose LV cavity and walls
thoseobtained bycMR.
Figure 4
agreement of estimates of LV mass in
patients with normal wall motion (A) or
with wall motion abnormalities (B) by 3-
DE and cMR.
Linear regression and limits of
Cardiac imaging and non-invasive testing
1054Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711

Page 6

Figure 5
agreement of estimates of end-diastolic
volume (EDV) (A), end-systolic volume
(ESV) (B) and ejection fraction (EF) (C) by
3-DE and cMR.
Linear regression and limits of
Table 3
with RWMA (n=11) and with NWM (n=10)
Mean values for LV volumes measurements using unenhanced 3-DE, 3-D LVO and cMR in patients
EDV (ml)ESV (ml)EF (%)
3-DEAll groups
RWMA group
NWM group
All groups
RWMA group
NWM group
All groups
RWMA group
NWM group
137 (46)
145 (55)
129 (33)
156 (49)
156 (59)
147 (35)
159 (51)
168 (63)
149 (36)
75 (47)
94 (56)
54 (20)
81 (51)
103 (61)
57 (20)
84 (54)
107 (65)
58 (22)
48 (15)
39 (14)
59 (4)
50 (15)
40 (15)
61 (6)
50 (16)
39 (14)
59 (4)
3-D LVO
cMR
NWM, normal wall motion; RWMA, regional wall motion abnormalities. Other abbreviations as in table 2.
Cardiac imaging and non-invasive testing
Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711 1055

Page 7

are distorted by a previous myocardial infarction. So far, very
few studies have examined the ability of 3-DE to measure LV
mass. Although their results indicated that measurements of LV
mass by 3-DE are feasible and correlate reasonably well with
those obtained by cMR, most of these studies only recruited a
limited number of patients (around 20 each), few investigated
the accuracy of 3-DE in patients with distorted LV wall
geometry25227and none used a semi-automated tracking algo-
rithm that detects endocardial contours and facilitates epicardial
contouring. To the best of our knowledge, the present study is
the first to demonstrate the accuracy of such an approach in
assessing LV mass in a large cohort of normal and diseased
patients, with and without regional wall thickness abnormal-
ities.
Reproducibility of 3-DE assessment of LV volumes, ejection
fraction and mass
Previous studies using 3-DE to measure LV volumes and EF have
shown that this technique was more reproducible than 2-DE
and as reproducible as cMR.12 22These favourable results
probably reflect the combined use of 3-D datasets and semi-
automated edge-detection algorithms, both of which contribute
to better standardise the partition between the wall and cavity
and hence to minimise variation. The results of our study are
thus in line with these previous results. Our data also suggest
that LV mass measurements from 3-DE images are as
reproducible as those obtained by cMR, a particularly important
finding for the follow-up of patients with LV hypertrophy or
remodelling.
Test-retest variation
In contrast with the more widely reported parameters of intra-
observer and inter-observer variability, which relate to the
repeated measurement of a single dataset, test-retest variation
involves repetition of the entire acquisition and analysis.
Assessment of test-retest variations is important because both
physiological and imaging factors contribute to variations in LV
function and mass over time. Previous work found significant
test-retest variations with respect to both the angulation and
displacement of 2-DE imaging planes. These variations partially
explain the variability in 2-DE measurements of LV mass that
have been highlighted in several studies. The present study
demonstrates that test-retest variations in 3-DE and cMR
measurements of LV volumes, EF and mass are quite similar.
This is consistent with previous studies.12 20 28This is an
important finding because these measurements are often used
to help make decisions about initiating or altering treatment in
hypertensive subjects. They therefore need not only to be
accurate but also reproducible over time. Since 3-DE is far more
available and less costly than cMR, our findings suggest that 3-
DE could become the ideal non-invasive imaging method to
assess LV mass serially, whether in daily clinical practice or in
the context of clinical trials on the regression of LV hyper-
trophy.
Study limitations
First, the 3-D algorithm used to draw the epicardial contours is
not yet fully automatic and still requires manual adjustments.
Future development of the software should thus aim at tracking
the epicardial contours automatically. Second, because of its
robustness and reproducibility, we used cMR as the standard to
which 3-DE measurements of LV volumes and mass were
compared. When doing so, one should not forget that the
assessment of LV parameters by cMR has its own limitations,
including partial volume effects, the presence of a chemical shift
artefact at the muscle-cavity boundary and uncertainties about
whether or not to include the most basal slice of the cMR
dataset into the measurements of LV volumes. Including or
excluding the most basal cMR slice from the measurements can
indeed result in a plus or minus 10% variation in estimated
volumes.
CONCLUSION
The results of our study indicate that 3-DE, in combination
with semi-automated border detection, allows for a robust,
accurate and reproducible quantification of LV volumes, EF and
mass. The data also show that the robustness, accuracy and
reproducibility of 3-DE is equal to that of cMR and similar in
patients with and without regional wall motion abnormalities.
Funding: Work supported by the Fondation Nationale de la Recherche Scientifique of
the Belgian Government (FRSM). A-CP is aspirant of the Fondation Nationale de la
Recherche Scientifique of the Belgian Government. J-BPW is supported by the
Fondation Damman, Louvain-la-Neuve, Belgium.
Competing interests: None.
REFERENCES
1.
Hwang MH, Hammermeister KE, Oprian C, et al. Preoperative identification of
patients likely to have left ventricular dysfunction after aortic valve replacement.
Table 4
Intra-observer and inter-observer reproducibility of LV mass measurements using 3-DE and cMR
Reproducibility (ICC)
Limits of agreement
Mean (2 SD)
Intra-observerInter-observerIntra-observerInter-observer
RT-3DERWMA group
NWM group
RWMA group
NWM group
0.96
0.97
0.94
0.97
0.94
0.94
0.95
0.96
23 (14)
21 (26)
23 (18)
21 (30)
3 (27)
26 (31)
7 (26)
2 (26)
MRI
ICC, intraclass correlation coefficient. Other abbreviations as in tables 2 and 3.
Table 5
Test-retest reproducibility
Mean (SD) J0Mean (SD) J1
Limits of agreement
Mean (2 SD)p Value
3-DE J0 vs J1
cMR J0 vs J1
118 (25) g
116 (35) g
121 (24) g
116 (33) g
3 (9) g
1 (8) g
0.22
0.88
Cardiac imaging and non-invasive testing
1056Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711

Page 8

Participants in the Veterans Administration Cooperative Study on Valvular Heart
Disease. Circulation 1989;80:I65–76.
White HD, Norris RM, Brown MA, et al. Left ventricular end-systolic volume as the
major determinant of survival after recovery from myocardial infarction. Circulation
1987;76:44–51.
Wong M, Johnson G, Shabetai R, et al. Echocardiographic variables as prognostic
indicators and therapeutic monitors in chronic congestive heart failure. Veterans
Affairs Cooperative Studies V-HeFT I and II. V-HeFT VA Cooperative Studies Group.
Circulation 1993;87:VI65–70.
Kuhl HP, Hanrath P, Franke A. M-mode echocardiography overestimates left
ventricular mass in patients with normal left ventricular shape: a comparative study
using three-dimensional echocardiography. Eur J Echocardiogr 2003;4:312–9.
Myerson SG, Montgomery HE, World MJ, et al. Left ventricular mass: reliability of M-
mode and 2-dimensional echocardiographic formulas. Hypertension 2002;40:673–8.
Bottini PB, Carr AA, Prisant LM, et al. Magnetic resonance imaging compared to
echocardiography to assess left ventricular mass in the hypertensive patient.
Am J Hypertens 1995;8:221–8.
Grothues F, Smith GC, Moon JC, et al. Comparison of interstudy reproducibility of
cardiovascular magnetic resonance with two-dimensional echocardiography in normal
subjects and in patients with heart failure or left ventricular hypertrophy. Am J Cardiol
2002;90:29–34.
Caiani EG, Corsi C, Zamorano J, et al. Improved semiautomated quantification of left
ventricular volumes and ejection fraction using 3-dimensional echocardiography with
a full matrix-array transducer: comparison with magnetic resonance imaging. J Am
Soc Echocardiogr 2005;18:779–88.
Jacobs LD, Salgo IS, Goonewardena S, et al. Rapid online quantification of left
ventricular volume from real-time three-dimensional echocardiographic data. Eur
Heart J 2006;27:460–8.
Jenkins C, Chan J, Hanekom L, et al. Accuracy and feasibility of online 3-
dimensional echocardiography for measurement of left ventricular parameters. J Am
Soc Echocardiogr 2006;19:1119–28.
Lang RM, Mor-Avi V, Sugeng L, et al. Three-dimensional echocardiography: the
benefits of additional dimension. J Am Coll Cardiol 2006;48:2053–69.
Jenkins C, Bricknell K, Chan J, et al. Comparison of two- and three-dimensional
echocardiography with sequential magnetic resonance imaging for evaluating left
ventricular volume and ejection fraction over time in patients with healed myocardial
infarction. Am J Cardiol 2007;99:300–6.
Mor-Avi V, Sugeng L, Weinert L, et al. Fast measurement of left ventricular mass
with real-time three-dimensional echocardiography: comparison with magnetic
resonance imaging. Circulation 2004;110:1814–8.
Oe H, Hozumi T, Arai K, et al. Comparison of accurate measurement of left ventricular
mass in patients with hypertrophied hearts by real-time three-dimensional
echocardiography versus magnetic resonance imaging. Am J Cardiol 2005;95:
1263–7.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Sugeng L, Mor-Avi V, Weinert L, et al. Quantitative assessment of left ventricular
size and function: side-by-side comparison of real-time three-dimensional
echocardiography and computed tomography with magnetic resonance reference.
Circulation 2006;114:654–61.
Van den Bosch AE, Robbers-Visser D, Krenning BJ, et al. Comparison of real-time
three-dimensional echocardiography to magnetic resonance imaging for assessment
of left ventricular mass. Am J Cardiol 2006;97:113–7.
Devereux RB, Reichek N. Echocardiographic determination of left ventricular mass
in man. Anatomic validation of the method. Circulation 1977;55:613–8.
Gerard O, Billon AC, Rouet JM, et al. Efficient model-based quantification of left
ventricular function in 3-D echocardiography. IEEE Trans Med Imaging 2002;21:1059–
68.
Pluim B, Zwinderman A, Van der Laarse A, et al. The athlete’s heart: a meta-analysis
of cardiac structure and function. Circulation 2000;101–336
Bland JM, Altman DG. Statistical methods for assessing agreement between two
methods of clinical measurement. Lancet 1986;1:307–10.
Abdullah M, Maeno Y, Bigras JL et al. Superiority of 3-dimensional versus 2-
dimensional echocardiography for left ventricular volume assessment in small piglet
hearts. J Am Soc Echocardiogr 2000;13:918–23.
Jenkins C, Bricknell K, Hanekom L, et al. Reproducibility and accuracy of
echocardiographic measurements of left ventricular parameters using real-time three-
dimensional echocardiography. J Am Coll Cardiol 2004;44:878–86.
Van den Bosch AE, Robbers-Visser D, Krenning BJ, et al. Real-time transthoracic
three-dimensional echocardiographic assessment of left ventricular volume and
ejection fraction in congenital heart disease. J Am Soc Echocardiogr 2006;19:1–6.
Muller S, Bartel T, Katz M, et al. Partial cut-off of the left ventricule; determinants
and effect on volume parameters assessed by real-time 3-D echocardiography.
Ultrasound Med Biol 2003;29:25–30.
Chan J, Jenkins C, Khafagi F, et al. What is the optimal clinical technique for
measurement of left ventricular volume after myocardial infarction? A comparative
study of 3-dimensional echocardiography, single photon emission computed
tomography, and cardiac magnetic resonance imaging. J Am Soc Echocardiogr
2006;19:192–201.
Corsi C, Lang RM, Veronesi F, et al. Volumetric quantification of global and regional
left ventricular function from real-time three-dimensional echocardiographic images.
Circulation 2005;112:1161–70.
Mannaerts HF, van der Heide JA, Kamp O, et al. Early identification of left
ventricular remodelling after myocardial infarction, assessed by transthoracic 3D
echocardiography. Eur Heart J 25:680–7.
Nosir YF, Lequin MH, Kasprzak JD, et al. Measurements and day-to-day variabilities
of left ventricular volumes and ejection fraction by three-dimensional
echocardiography and comparison with magnetic resonance imaging. Am J Cardiol
1998;82:209–14.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Cardiac imaging and non-invasive testing
Heart 2008;94:1050–1057. doi:10.1136/hrt.2007.123711 1057