Left ventricular ejection fraction and volumes: it depends on the imaging method

Abstract

Background and methods: In order to provide guidance for using measurements of left ventricular (LV) volume and ejection fraction (LVEF) from different echocardiographic methods a PubMed review was performed on studies that reported reference values in normal populations for two-dimensional (2D ECHO) and three-dimensional (3D ECHO) echocardiography, nuclear imaging, cardiac computed tomography, and cardiac magnetic resonance imaging (CMR). In addition all studies (2 multicenter, 16 single center) were reviewed, which included at least 30 patients, and the results compared of noncontrast and contrast 2D ECHO, and 3D ECHO with those of CMR.

Results: The lower limits for normal LVEF and the normal ranges for end-diastolic (EDV) and end-systolic (ESV) volumes were different in each method. Only minor differences in LVEF were found in studies comparing CMR and 2D contrast echocardiography or noncontrast 3D echocardiography. However, EDV and ESV measured with all echocardiographic methods were smaller and showed greater variability than those derived from CMR. Regarding agreement with CMR and reproducibility, all studies showed superiority of contrast 2D ECHO over noncontrast 2D ECHO and 3D ECHO over 2D ECHO. No final judgment can be made about the comparison between contrast 2D ECHO and noncontrast or contrast 3D ECHO.

Conclusion: Contrast 2D ECHO and noncontrast 3D ECHO show good reproducibility and good agreement with CMR measurements of LVEF. The agreement of volumes is worse. Further studies are required to assess the clinical value of contrast 3D ECHO as noncontrast 3D ECHO is only reliable in patients with good acoustic windows.

Keywords: contrast imaging; echocardiography; left ventricular ejection fraction; left ventricular function; three‐dimensional transthoracic echocardiography.

Figure 1

Comparison of echocardiographic techniques with cardiac magnetic resonance imaging for measurement of ejection fraction (%). Red square box indicates bias compared with magnetic resonance imaging. Blue line at each end of the plots indicates the lower and upper limits of agreement calculated by Bland–Altman. 2D ECHO = two-dimensional echocardiography; 3D ECHO = three-dimensional echocardiography; NSR = normal sinus rhythm; MOD = method of disks; QLAB = Philips online and offline LV volume calculation tool; TomTec = offline left ventricular volume calculation tool. † indicates multicenter studies. Values in square brackets are the percentage of patients without disease within each study.

Figure 2

Comparison of echocardiographic techniques with cardiac magnetic resonance imaging for measurement of end-diastolic volume (mL). Red square box indicates bias compared with magnetic resonance imaging. Blue line at each end of the plots indicates the lower and upper limits of agreement calculated by Bland–Altman. MRI = magnetic resonance imaging; 2D ECHO = two-dimensional echocardiography; 3D ECHO = three-dimensional echocardiography; NSR = normal sinus rhythm; MOD = method of disks; QLAB = Philips online and offline LV volume calculation tool; TomTec = offline left ventricular volume calculation tool.

Figure 3

Comparison of echocardiographic techniques with cardiac magnetic resonance imaging for measurement of end-systolic volume (mL). Red square box indicates bias compared with magnetic resonance imaging. Blue line at each end of the plots indicates the lower and upper limits of agreement calculated by Bland–Altman. MRI = magnetic resonance imaging; 2D ECHO = two-dimensional echocardiography; 3D ECHO = three-dimensional echocardiography; NSR = normal sinus rhythm; MOD = method of disks; QLAB = Philips online and offline LV volume calculation tool; TomTec = offline left ventricular volume calculation tool.