Accuracy and Reproducibility of Right Ventricular Quantification in Patients with Pressure and Volume Overload Using Single-Beat Three-Dimensional Echocardiography

Abstract

BackgroundThe right ventricle is a complex structure that is challenging to quantify by two-dimensional (2D) echocardiography. Unlike disk summation three-dimensional (3D) echocardiography (3DE), single-beat 3DE can acquire large volumes at high volume rates in one cardiac cycle, avoiding stitching artifacts or long breath-holds. The aim of this study was to assess the accuracy and test-retest reproducibility of single-beat 3DE for quantifying right ventricular (RV) volumes in adult populations of acquired RV pressure or volume overload, namely, pulmonary hypertension (PH) and carcinoid heart disease, respectively. Three-dimensional and 2D echocardiographic indices were also compared for identifying RV dysfunction in PH.MethodsA prospective cross-sectional study was performed in 100 individuals who underwent 2D echocardiography, 3DE, and cardiac magnetic resonance imaging: 49 patients with PH, 20 with carcinoid heart disease, 11 with metastatic carcinoid tumors without cardiac involvement, and 20 healthy volunteers. Two operators performed test-retest acquisition and postprocessing for inter- and intraobserver reproducibility in 20 subjects.Results:RV single-beat 3DE was attainable in 96% of cases, with mean volume rates of 32 to 45 volumes/sec. Bland-Altman analysis of all subjects (presented as mean bias ± 95% limits of agreement) revealed good agreement for end-diastolic volume (−2.3 ± 27.4 mL) and end-systolic volume (5.2 ± 19.0 mL) measured by 3DE and cardiac magnetic resonance imaging, with a tendency to underestimate stroke volume (−7.5 ± 23.6 mL) and ejection fraction (−4.6 ± 13.8%) by 3DE. Subgroup analysis demonstrated a greater bias for volumetric underestimation, particularly in healthy volunteers (end-diastolic volume, −11.9 ± 18.0 mL; stroke volume, −11.2 ± 20.2 mL). Receiver operating characteristic curve analysis showed that 3DE-derived ejection fraction was significantly superior to 2D echocardiographic parameters for identifying RV dysfunction in PH (sensitivity, 94%; specificity, 88%; area under the curve, 0.95; P = .031). There was significant interobserver test-retest bias for RV volume underestimation (end-diastolic volume, −12.5 ± 28.1 mL; stroke volume, −10.6 ± 23.2 mL).ConclusionsSingle-beat 3DE is feasible and clinically applicable for volumetric quantification in acquired RV pressure or volume overload. It has improved limits of agreement compared with previous disk summation 3D echocardiographic studies and has incremental value over standard 2D echocardiographic measures for identifying RV dysfunction. Despite the ability to obtain and postprocess a full-volume 3D echocardiographic RV data set, the quality of the raw data did influence the accuracy of the data obtained. The technique performs better with dilated rather than nondilated RV cavities, with a learning curve that might affect the test-retest reproducibility for serial RV studies.

Current and future role of echocardiography in arrhythmogenic right ventricular dysplasia/cardiomyopathy

“…However, 3D-echocardiography is both feasible and comparable to MRI with respect to RV volumes and RV ejection fraction (RVEF) (Fig. 5) [19,20,35]. With the implementation of 3D-echocardiography, subtle global RV systolic dysfunction can be seen in the early stages of ARVD/C, and can contribute to early diagnosis [36].…”

Imaging the right heart pulmonary circulation unit: Insights from advanced ultrasound techniques

“…The acquisitions are gated by the electrocardiogram (ECG) and in the early phase obtained from multiple heartbeats with stitching of subpyramids into one full‐volume image . Lately, acquisitions can be obtained by single heartbeat with adequate accuracy, thereby overcoming potentially stitching artifacts of subpyramids into one image …”

Right Ventricle in Pulmonary Hypertension

“…Indeed, although standard 2D transthoracic echocardiography has provided merely 3 potential treatment goals-preserved tricuspid annulus systolic excursion, normal right atrial area, and the absence of pericardial effusion-modern right heart echocardiography has potentially more to offer. [10][11][12][13][14][15][16][17][18][19][20] Of note, in their study, Ryo et al did not follow this direction but limited the assessment to rather rudimental estimation of RV volumes, simply expecting better precision of the measurements assisted by 3D wall motion tracking when compared with traditional 2D echocardiography. Similar to CMR, this still required manual tracing of endocardial and epicardial borders.…”