Test-Retest Variability of Volumetric Right Ventricular Measurements Using Real-Time Three-Dimensional Echocardiography

doi:10.1016/j.echo.2011.02.007

Journal of the American Society of Echocardiography

Volume 24, Issue 6, June 2011, Pages 671-679

https://doi.org/10.1016/j.echo.2011.02.007 Get rights and content

Background

Substantial variability in sequential echocardiographic right ventricular (RV) quantification may exist. Interobserver and intraobserver values are well known, but acquisition (test-retest) variability has been rarely assessed. The objective of this study was to determine the test-retest variability of sequential RV volume and ejection fraction (EF) measurements by real-time three-dimensional echocardiography in patients with congenital heart disease and healthy controls.

Methods

Twenty-eight participants (21 patients with congenital heart disease, seven healthy controls; mean age, 30 ± 14 years; 43% men) underwent a series of three echocardiographic studies. To obtain interobserver and intraobserver test-retest variability, two sonographers acquired sequential RV data sets in each participant during one outpatient visit. RV volumetric quantification was done using semiautomated three-dimensional border detection. The variability data were analyzed using correlation coefficients, Bland-Altman analysis, and coefficients of variation.

Results

Absolute mean differences for sequential intraobserver acquisitions were 12 ± 12 mL for end-diastolic volume, 7 ± 6 mL for end-systolic volume, and 4 ± 3% for EF. Interobserver and intraobserver test-retest variability, respectively, were 7% and 7% for RV end-diastolic volume, 14% and 7% for end-systolic volume, and 8% and 6% for EF.

Conclusions

Good test-retest variability, besides the practical nature of real-time three-dimensional echocardiography for RV volume and EF assessment, makes it a valuable technique for serial follow-up. Although it may be challenging to diminish all factors that can influence echocardiographic examination for serial follow-up, standardization of RV size and functional measurements should be a goal to produce more interchangeable data.

Section snippets

Study Design

We prospectively recruited 33 participants (21 patients with complex and/or surgically repaired CHD and 12 healthy controls) in sinus rhythm, who all underwent RT3DE. The patients were referred to the echocardiography laboratory for routine measurements of their cardiac function and had sufficient acoustic windows. The healthy controls were employees of the university or the hospital who had no medical histories or current symptoms suggestive of cardiovascular disease, including hypertension

Results

Of the original 33 participants, five were excluded from analysis for echocardiographic images of insufficient quality (four because of poor acoustic windows and one because of the inability to include the RV lateral wall and apex). The baseline characteristics of 28 participants (mean age, 30 ± 14 years; 43% men) are listed in Table 1. The patients who were included had the following types of CHD: atrial septal defect (n = 5), tetralogy of Fallot (n = 3), aortic valve pathology (n = 5),

Discussion

In this study, we investigated the test-retest variability of RT3DE for RV volumes and EF assessment. To include a heterogeneous population with wider ranges of observed measurements, we included not only healthy controls but patients with various types of CHD as well. The smallest coefficients of variation were found for end-diastolic volume and EF. The larger variability found in the end-systolic volumes can be attributed to the more difficult endocardial border identification in end-systole

Conclusions

The good test-retest variability of RT3DE for RV volume and EF assessment makes it a valuable technique for serial follow-up. Furthermore, sequential use of this technique is attractive because no ionizing radiation is needed and patient discomfort is minimal. In clinical practice, different approaches to echocardiographic examination for repeated studies influence the acquisition variability adversely. Even though it may be challenging to diminish these influences, standardization of RV size

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To compare right ventricular (RV) volumetry using state-of-the-art three-dimensional (3D) transthoracic echocardiography (3DE) and cardiac magnetic resonance imaging (CMR) near-simultaneously in a clinical setting.
Forty-seven consecutive patients received comprehensive echocardiography including 3DE within 30 minutes of CMR. RV volumetry was performed offline with semi-automated 3D endocardial border tracing as well as manual delineation of the compacted myocardium in short-axis views by CMR.
Forty-two examinations (89%) could be analysed offline by 3D RV reconstruction. Mean RV volumes assessed by CMR and 3DE were 215±63 and 127±42 ml for end-diastole (RV-EDV), as well as 110±43 and 62±27 ml for end-systole (RV-ESV). RV-EDV, RV-ESV, and RV stroke volume measured by 3DE were significantly lower than RV volumetry by CMR. Mean bias were –88, –48, and –41 ml, respectively. Mean RV ejection fraction (-EF) showed a non-significant deviation of +2% between 3DE and CMR and the correlation coefficient was r=0.58 for RV-EF.
RV-EF can be assessed reliably using transthoracic 3DE in patients with good image quality; however, absolute RV volumes measured by 3DE show a systematic deviation to CMR volumetry that has been previously neglected and requires careful interpretation regarding anatomical cardiac imaging.
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There are two distinct approaches to 3-dimensional imaging of the RV: use of a special matrix-array transducer to fully cover the entire RV and knowledge-based reconstruction of the RV based on 2-dimensional images with spatial position and orientation of the probe defined by a magnetic field tracking system [44,45]. Three-dimensional echo RV measurements are reproducible [46], and both approaches agree reasonably well with cardiac magnetic resonance volumes [44]. While the appeal of the knowledge-based approach, since it requires additional proprietary hardware, may be fading with improvements in 3-dimensional image acquisition, the anterior sub-sternal position of the RV precludes complete acquisition in a substantial minority of patients [35].
Doppler echocardiography is extensively used in clinical practice for the screening and detection of pulmonary hypertension (PH). It allows for accurate estimates of pulmonary artery pressures, but with moderate precision, which explains why it is more appropriate for population studies than for definitive diagnosis of PH in individual patients. Moreover, echocardiography allows one to distinguish different patterns of right ventricular remodelling in various forms of PH and enables clinically satisfactory differentiation between pre- and post-capillary PH.
This article will review the methods for evaluating PH by echocardiography, while also providing an insight into specific strengths and weaknesses.
Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography
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The disparity between 3DE and MRI becomes larger in the severely dilated RV where there are particular difficulties in the incorporation of the whole RV, particularly the RV outflow tract in a single volume.105,106,108,114 Intraobserver, interobserver, and test–retest reliability varies among studies, but is generally acceptable (Table 4).104,106,107 In children with hypoplastic left heart syndrome, 3DE has good reproducibility during serial follow-up.115
Three-dimensional echocardiography (3DE) has become important in the management of patients with congenital heart disease (CHD), particularly with pre-surgical planning, guidance of catheter intervention, and functional assessment of the heart. 3DE is increasingly used in children because of good acoustic windows and the non-invasive nature of the technique. The aim of this paper is to provide a review of the optimal application of 3DE in CHD including technical considerations, image orientation, application to different lesions, procedural guidance, and functional assessment.
Accuracy and Test-Retest Reproducibility of Two-Dimensional Knowledge-Based Volumetric Reconstruction of the Right Ventricle in Pulmonary Hypertension
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The reproducibility of FAC postprocessing alone (not including variability in image acquisition) has also been shown to have significant interobserver bias and wide limits of agreement in children after surgical repair of tetralogy of Fallot compared with 2D KBR.22 The test-retest reproducibility of 2D KBR RV volumetric quantification is also improved compared with that previously demonstrated by 3DE in either congenital heart disease15 or acquired PH.7 The superior reproducibility of 2D KBR compared with conventional 2DE and that previously reported for 3DE may be accounted for by several reasons.
Right heart function is the key determinant of symptoms and prognosis in pulmonary hypertension (PH), but the right ventricle has a complex geometry that is challenging to quantify by two-dimensional (2D) echocardiography. A novel 2D echocardiographic technique for right ventricular (RV) quantitation involves knowledge-based reconstruction (KBR), a hybrid of 2D echocardiography–acquired coordinates localized in three-dimensional space and connected by reference to a disease-specific RV shape library. The aim of this study was to determine the accuracy of 2D KBR against cardiac magnetic resonance imaging in PH and the test-retest reproducibility of both conventional 2D echocardiographic RV fractional area change (FAC) and 2D KBR.
Twenty-eight patients with PH underwent same-day echocardiography and cardiac magnetic resonance imaging. Two operators performed serial RV FAC and 2D KBR acquisition and postprocessing to assess inter- and intraobserver test-retest reproducibility.
Bland-Altman analysis (mean bias ± 95% limits of agreement) showed good agreement for end-diastolic volume (3.5 ± 25.0 mL), end-systolic volume (0.9 ± 19.9 mL), stroke volume (2.6 ± 23.1 mL), and ejection fraction (0.4 ± 10.2%) measured by 2D KBR and cardiac magnetic resonance imaging. There were no significant interobserver or intraobserver test-retest differences for 2D KBR RV metrics, with acceptable limits of agreement (interobserver end-diastolic volume, −0.9 ± 21.8 mL; end-systolic volume, −1.3 ± 25.8 mL; stroke volume, −0.2 ± 24.2 mL; ejection fraction, 0.7 ± 14.4%). Significant test-retest variability was observed for 2D echocardiographic RV areas and FAC.
Two-dimensional KBR is an accurate, novel technique for RV volumetric quantification in PH, with superior test-retest reproducibility compared with conventional 2D echocardiographic RV FAC.
Accuracy and reproducibility of right ventricular quantification in patients with pressure and volume overload using single-beat three-dimensional echocardiography
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This is important clinically, as follow-up studies will vary depending on operator experience for both acquisition and postprocessing. Few studies so far have addressed 3D echocardiographic test-retest reproducibility for both the acquisition and postprocessing stages.22,41 Our interobserver test-retest study demonstrated a second operator bias for EDV underestimation, conferring lower SV and EF measurements.
The 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.
A 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.
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).
Single-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.
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Measurement variation seems to be concentrated around two main factors: the user and the image. Different users measuring the same image account for similar variation as the same user measuring two images of the same subject.31 This suggests that the potential source of variation is the individual interpretation of where each measurement should be made.
Despite the common practice of indexing left ventricular dimensions to body surface area, there remains a lack of indexed normal right ventricular (RV) two-dimensional caliper measurements. Variations in ranges for normal RV dimensions have been shown to exist, and indexing RV dimensions according to body surface area may help reduce this and provide a standardization useful for clinical practice. The aim of this study was to prospectively establish both absolute and indexed normal dimensions for the right ventricle using standardized positions in a multiethnic population. Furthermore, the effects of both gender and ethnicity on both the absolute and indexed results were also evaluated.
Two hundred five healthy volunteers from four ethnic backgrounds (Indian, Chinese, Malay, and European) were prospectively enrolled and underwent two-dimensional echocardiography according to a set protocol. Ten measurements were made in conjunction with previous research. Intraobserver and interobserver and test-retest variability was assessed using coefficients of variation and intraclass correlation coefficients.
Male absolute results exceeded female absolute results in 90% of measurements (P = .003). European absolute results (male and female) were significantly larger in up to eight of 10 measurements (P = .01). When indexed, female results became significantly larger (P < .001) than male results. Indexing was able to reduce the number of statistical differences between male ethnic groups. Measurements showed good levels of intraobserver and interobserver variability for apical and short-axis measurements.
Gender and body surface area play an important part in the determination of normal RV reference ranges, whereas ethnicity has little influence. Results using the suggested RV markers for these measurements showed good repeatability.

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Clinical InvestigationMeasurement of Chamber Volumes by Real-Time 3D TTETest-Retest Variability of Volumetric Right Ventricular Measurements Using Real-Time Three-Dimensional Echocardiography

Background

Methods

Results

Conclusions

Section snippets

Study Design

Results

Discussion

Conclusions

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J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Chest

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J Am Coll Cardiol

J Am Soc Echocardiogr

Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair

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Test-Retest Variability of Volumetric Right Ventricular Measurements Using Real-Time Three-Dimensional Echocardiography