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Year : 2008  |  Volume : 9  |  Issue : 2  |  Page : 71-79 Table of Contents     

Echocardiographic evaluation of ejection fraction: 3DE versus 2DE and M-Mode

Associate Professor of Internal Medicine, Faculty of Medicine, II° Naples University, Italy

Date of Web Publication17-Jun-2010

Correspondence Address:
Federico Cacciapuoti
Internal Medicine Department, Faculty of Medicine, Second University of Naples, Piazza L. Miraglia 2, 80138 Naples, Italy

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Source of Support: None, Conflict of Interest: None

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Using echocardiography, left ventricular function was evaluated in accordance with the diverse ultrasound methods. M-Mode and two-dimensional methods have some limitations due to the geometric assumptions to calculate the different parameters, which may cause important errors. 3-D imaging can be used for direct calculation of intracavitary volumes and global/regional ejection fraction. In the present review, the first and second scanner's generation of 3D echocardiography are illustrated. The image acquisition and reconstruction were exposed and the advantages and limitations of this technique are also reported. "Live" 3D echocardiography, which directly and more rapidly provides a free quantification of global and regional LV function, appears to be superior to other versions of real-time 3D imaging. Finally, rapid three-dimensional echocardiography allows the immediate collection of data within a few seconds, making this technique feasible in most clinical scenarios.

Keywords: Left ventricular function, ejection fraction, conventional echocardiography, RT3D, live 3D, rapid 3D echocardiography

How to cite this article:
Cacciapuoti F. Echocardiographic evaluation of ejection fraction: 3DE versus 2DE and M-Mode. Heart Views 2008;9:71-9

How to cite this URL:
Cacciapuoti F. Echocardiographic evaluation of ejection fraction: 3DE versus 2DE and M-Mode. Heart Views [serial online] 2008 [cited 2023 Mar 24];9:71-9. Available from: https://www.heartviews.org/text.asp?2008/9/2/71/63703

   Introduction Top

Over the last decades, Echocardiography has evolved from single-beam imaging to 3-D techniques that enables us to study cardiac structures, function and hemodynamics in detail [1] . At present, echocardiography is the most commonly used tool to evaluate left ventricular function. Today, two-dimensional echocardiography is the most prevalently used mode among all ultrasound methods to define the structural and functional cardiac status. But this mode has some limitations dependent on geometric assumptions that may introduce important errors. In addition, in 2D echocardiography, an intraobserver variability exists because individual observers interpolate the data in different ways.

In the early 1990s, von Ramm and coworkers developed the first 3-D echocardiographic scanner [2] to acquire multiple slices of the left ventricle. This generation of scanners however offered limited image quality and data processing was slow. The second generation scanners and transducers strongly reduced these limitations and offered an improved image quality and better spatial resolution. These transducers are capable of near real-time acquisition of lager pyramidal 3D datasets from an apical acoustic window. As a result, the measurement of cardiac function was improved because they provide more precise and rapid identification of cardiac abnormalities and ventricular function [3],[4] . The potential applications of 3D-echo can be categorized into some major areas:

  • Congenital heart disease;
  • anatomy and pathology of the heart and the great vessels;
  • Mitral valve disease/repair and aortic dissection;
  • Global and regional left ventricular volumes, function and mass;
  • Visualization of complex anatomic features;
  • Catheter visualization.
In the present review, we describe the validity of 3-D echocardiography in comparison to other conventional echocardiographic methods and to define left ventricular function through global and regional definition of ejection fraction.

   Measurement of ejection fraction Top

With M-Mode echocardiography, ejection fraction is estimated as a percentage derived from the mid-left ventricular diameters measured in end-diastole and end-systole and is expressed as fractional shortening (% LV shortening) [Figure 1].

Measurements of left ventricular diameters are also obtained with 2-D echocardiography. In spite of some limitations due to the cardiac morphology, this technique considerably improved the accuracy of left ventricular volume measurement. Of the different mathematical models, modified biplane Simpson's (based on disc summation) provided more accurate data [Figure 2].

The calculation of each disc is automatically performed by an ultrasound machine software and biplane data acquisition is obtained in apical four and two chambers views and is averaged. Simpson's biplane method underestimates left ventricular volumes when compared with MRI and radionuclide ventriculography which are considered as the gold standard [5] . To obtain E. F.% with this method, the systolic ventricular volume (in ml) is subtracted from the diastolic ventricular volume (in ml). The difference is divided by the diastolic ventricular volume and the result is %, in accordance with the formula :

Another 2-dimensional method employed for the calculation of ventricular volumes in diastole and systole and E. F. is the area-length method. Measurements of LV can be performed from the apical two and four chamber views [Figure 3].

The volumes are derived from the areas (measured in diastole and systole) of LV squared, divided by length and multiplied by 0.85 (automatically calculated with a software dedicated). This method is appropriate in presence of symmetrical LV cavities alone.

Three-dimensional echocardiography has been shown to be a more accurate assessment of ventricular volume and ejection fraction than its 2D echocardiography counterpart. This has been shown in multiple studies in comparisons to the left ventricular angiography and MRI [6],[7],[8],[9],[10],[11],[12] . Most approaches towards 3D echocardiography were based on the sequential rotational scanning and acquisition of multiple cross-sectional images. To minimize reconstruction artifacts, images are gated to both electrocardiography and respiration. The quality of 3D reconstructions from 2D depends on numerous factors, such as the quality of ultrasound images, their number and the ability to limit motion artifact.

Once the 2D images have been obtained, they are processed with an available software. Fundamental steps in the performance of 3D echocardiography include image acquisition, image processing and analysis, reconstruction, digital storage and archiving. Acquisition of a complete data set typically depends on respiration and heart rates. In addition, the quality of 3D reconstruction from 2D images depends on numer of factors, including the quality of the ultrasound images, the number of the 2D images used to reconstruct the 3D image, the ability to limit motion artifact, and adeguate ECG and respiratory gating. Usually, a variable number from 4 to 6 serial images is adeguate for volume reconstruction of the left ventricle. Once the 2D images have been obtained, they are processed offline with commercially available software.

The earliest devices employed have been developed by Von Ramm at Duke University2. This system (Volumetric Medical Imaging) makes use of a sparse-array matrix transducer consisting of 256 elements to scan 60° x 60° pyramidal tissue volume using parallel processing technology. Left ventricular volumes are calculated with a dedicated analytic software from either a series of parallel-C scans (short-axis view) or a series of rotated apical long-axis views. The main obstacles of this 3D include difficult image acquisition, limited image quality and laborious data manual analysis. Images are recorded during end-expiratory apnea and the recording is completed in less than five minutes.

RT3D system is a real-time 3D ultrasound that instantaneously acquires the image container in a pyramidal volume. It uses a massive matrix array transducer with more than 3000 elements compared with the 256 elements present in the sparse array transducer. To minimize reconstruction artifacts, data should be acquired during suspended respiration. Images of the ventricles are obtained from various orthogonal planes: the sagittal plane which corresponds to a vertical long-axis view of the heart; the coronal plane which corresponds to a 4-chamber view and the transverse plane which corresponds to a short axis plane [Figure 4].

RT3D system generally has 3 acquisitions: real time (narrow), zoom (magnified), and wide-angle. The real-time mode displays a pyramidal data set 50΀ x 30΀. The zoom mode displays a pyramidal data set of 30΀ x 30΀. The wide-angle mode provides a pyramidal data 90΀ x 90΀, which allows inclusion af a lager cardiac volume. The choice of narrow-angle or wide-angle imaging acquisition modes depends on the cardiac structure to be examined. For imaging of the ventricles, it is best to use a wide-angle acquisition in the apical window (4-chamber) so as to include the entire ventricle obtained during 4 consecutive heart beats. Ejection fraction obtained is referred to entire ventricle [Figure 5].

To better define the ventricular volumes, the delineation of endocardial border is requested. Manual endocardial tracing is both laborious and prone for subjective errors. Development of various automatic or semiautomatic border detection algorithms should be able to avoid the need of manual border tracing and facilitate volume measurement.

Once a 3 data set is acquired, if the small cardiac structures are to be evaluated, the data must be sliced to visualize them. Instead, ventricular volumes can be calculated with the centroid-algorithm when the LV volumes are appropriately aligned. LV volumes can be segmented, which allows for regional LV function assessment [Figure 6]. To obtain the regional LVEF, volumes obtained can be segmented by dividing the LV into 16 segments [13] but into seventeen zones. In fact, 3D echocardiography also evaluates the LV apex.

In addition, the function of any ventricular wall can be objectively assessed by measuring a variety of wall motion parameters [14] [Figure 7].

In clinical scenarios, the commonly measured parameters of regional function are wall thickening [15],[16] and wall motion [17],[18] . Wall-thickening analysis measures absolute wall thickening and fractional wall thickening. Wall motion analysis measures the displacement of the left ventricular endocardial wall at two instant in the cardiac cycle. Real-time 3D imaging has also been used during dobutamine stress testing and found to be feasible and useful for the detection of stress-induced wall motion abnormalities [19] .

Recently, a more advanced version of real-time 3D imaging was introduced by Philips Medical System and is called "live 3D". The major advantage of this latest version of real-time 3D imaging is the improved image quality due to a fully sampled or dense array configuration of the transducer. This dense array transducer, called as "matrix array" consists of 3000 elements. The elements are divided into subgroups and each subgroup is connected to one of the 128 channels of the ultrasound system. Live 3D imaging is based on the premise that a 3D image can be created using ultrasound beam through a 3D volume. A semiautomated detection of LV borders from 3D images is then applied to perform a quantitative assessment of left ventricular volume and ejection fraction with accurate results and then reconstruct them into an entire cardiac volume. Each cardiac cycle provides one fourth of the volume data set.

Using live 3D echocardiography, significant advantages were obtained in patients who have heart failure despite optimal medical therapy. In these, delayed activation of LV segments from conduction delays leads to ventricular dyssynchrony which compromises ventricular function. Resynchronization can be obtained by simutaneously pacing both ventricles. This, in turn, leads to improved functional class, exercise tolerance, quality of life, and LV function. In this arena, live 3D Echo has been used by some investigators to measure the dyssynchronous motion of the heart [Figure 8].

These indexes will be useful not only in determining which patients will benefit from the resynchronization cardiac therapy, but to guide physicians in finding the optimal position of the pacing lead [20] .

Others have proposed a rapid (6 seconds) acquisition technique that collects apical tomograms using an internal continuously rotating transthoracic transducer [21] . This approach represents a solution to a clinically feasible acquisition of 3D data and provide precise and accurate diastolic and systolic volumes for functional assessment of the left ventricle.

In summary, 3D echocardiography is significantly better than 2D echocardiography in defining ventricular volumes and ejection fraction and there are some studies which show very good correlation between MRI and live 3D echocardiography [22],[23],[24] . Nevertheless, further technological improvements and additional clinical studies will broaden the list of appropriate applications for this exciting new ultrasound modality.

   References Top

1.Lange A.; Palka P.; Burstow D.; Godman M.: Three-dimensional echocardiography: historical development and current applications, J. Am. Soc. Echocardiogr. 2001; 14, 403-412.   Back to cited text no. 1      
2.Sheikh K.; Smith SW.; von Ramm O., Kisslo J.: Real-time three-dimensional echocardiography; feasibility and initial use. Echocardiography 1991; 8,119-125.  Back to cited text no. 2      
3.Surgeng L.; Weinert I.; Lang RM.: Left ventricular assessment using real-time three dimensional echocardiography. Heart 2003; 89 (suppl.III), iii29-iii36.  Back to cited text no. 3      
4.Nanda NC.,; Kisslo J.; Lang RM.; Nabda N.; Marwick T.; Shirali G.: Examination protocol for three-dimensional echocardiography. Echocardiography 2004; 21, 763-768.   Back to cited text no. 4      
5.Darasz KH.; Underwood SR.; Bayliss J.; Forbat SM.; Keegan J.; Poole-Wilson PA.; Sutton GC.: Measurement of left ventricular volume after anterior myocardial infarction: comparison of magnetic resonance imaging, echocardiography, and radionuclide ventriculography. J. Cardiac Imaging 2002; 18, 135-142.   Back to cited text no. 5      
6.Matsumoto M.; Inoue M.; Tanaka K.; Abe H.: Three-dimensional echocardiography for spatial visualization and volume calculation of cardiac structures. J. Clin. Ultrasound 1981; 9, 157-165.  Back to cited text no. 6      
7.Raiclhen JS.; Trivedi SS.; Herman GT.; John Sutton MG.; Reichek N.: Dynamic three-dimensional reconstruction of the left ventricle from two-dimensional echocardiograms. J. Am. Coll. Cardiol. 1986; 8, 364-370.  Back to cited text no. 7      
8.Nixon JV.; Saffer SI.; Lipscomb K.; Blomquist CG.: Three-dimensional echo-ventriculography. Am. Heart J. 1983; 106 435-443.  Back to cited text no. 8      
9.Sapin PM.; Schroeder KD.; Smith MD.; De Maria AN.; King DI.: Three-dimensional echocardiographic measurement of left ventricular volume in vitro: comparison with two-dimensional echocardiography and cine-ventriculography. J. Am. Coll. Cardiol. 1993; 22, 1530-1537.  Back to cited text no. 9      
10.Nosir YF.; Salustri A.; Kasprzak JD.; Brebuda CS.; Ten Cate FJ.; Roelandt JR.: Left ventricular ejection fraction in patients with normal and distorted left ventricular shape by three-dimensional echocardiographic method: a comparison with radionuclide ventriculography. J. Am. Soc. Echocardiogr. 1998; 11, 620-630.  Back to cited text no. 10      
11.Buck T.; Hunold P.; Wentz KU.; Tkalec W.; Nasser HJ.; Erbel R.: Tomographic three-dimensional determination of chamber size and systolic function in patients with left ventricular aneurysm: comparison to magnetic resonance imaging. Cine-ventriculography, and two-dimensional echocardiograpohy. Circulation 1997; 96, 4286-4297.  Back to cited text no. 11      
12.Nosir YF.; Fioretti PM.; Vletter WB.; et al.: Accurate measurement of left ventricular ejection fraction by three-dimensional echocardiography: a comparison with radionuclide angiography. Circulation 1996; 94; 460-466.   Back to cited text no. 12      
13.Schiller NB.; Shah PM.; Crawford M.; et al.: Recommendations for quantitation of the left ventricle by two-dimensional. American Society of Echocardiography Committee on Standards, Subcommittee on Quantitation of two-dimensional echocardiograms. J. Am. Soc. Echocardiogr. 1989; 2, 358-367.  Back to cited text no. 13      
14.Corsi C.; Lang RM.; Veronesi F.; et al.: Volumetric quantification of global and regional left ventricular function from real-time three-dimensional images. Circulation 2005; 112, 1161-1170.  Back to cited text no. 14      
15.Frielingsdorf J.; Franke A.; Kuhl HP.; et al.: Evaluation of regional systolic function in hypertrophic cardiomyopathy and hypertensive heart disease: a three-dimensional echocardiographic study. J. Am. Soc. Echocardiogr. 1998; 11, 778-786.  Back to cited text no. 15      
16.Dong SJ.; MacGregor JH.; Crawley AP.; et al.: Left ventricular wall thickness and regional systolic function in patients with hypertrophic cardiomyopathy. A three dimensional tagged magnetic resonance imaging study. Circulation 1994; 90; 1200-1209.   Back to cited text no. 16      
17.Collins M.; Hsieh A.; Ohazama CJ.; et al.: Assessment of regional wall motion abnormalities with real-time 3 dimensional echocardiography. J. Am. Soc. Echocardiogr. 1999; 12, 7-14.  Back to cited text no. 17      
18.Bjornstad K.; Maehle J.; Askhus S.; Trop HG.; Hatle LK.; Angelsen BA.: Evaluation of reference systems for quantitative wall motion analysis from three-dimensional endocardial surface reconstruction: an echocardiographic study in subjects with and without myocardial infarction. Am. J. Imaging 1996; 10, 244-253.  Back to cited text no. 18      
19.Takeuchi M.; Otani S.; Weinert L.; Spencer KT.; Lang RM.: Comparison of contrast-enhanced real time live 3-dimensional dobutamine stress echocardiography with contrast 2-dimensional echocardiography for detecting stress-induced wall-motion abnormalities. J. Am. Soc. Echocardiogr. 2006; 19, 294-299.   Back to cited text no. 19      
20.Bacha EA.; Zimmerman FJ.; Mor-Avi V.; Weinert L.; Starr JP.; Surgeng L.: Ventricular resynchronization by multisite pacing improves myocardial performance in the post-operative single ventricle patients. Annals Thor. Surg. 2004; 78, 1678-1683.  Back to cited text no. 20      
21.Belohlavek M.; Tanabe K.; Jakranichakul D.; Breen JF.; Steward JB.; Rapid three-dimensional echocardiography: clinically feasible alternative for precise and accurate measurement of left ventricular volumes. Circulation 2001; 103, 2882-2884.  Back to cited text no. 21      
22.Jenkins C.; Bricknell K.; Hanekom L.; Marwick TH.: Reproducibility and accuracy of echocardiographic measurements of left ventricular parameters using real time three-dimensional echocardiography. J. Am. Coll. Cardiol. 2004; 44, 878-886.  Back to cited text no. 22      
23.Khul HP.; Schreckenberg M.; Rulands D. et al.: High-resolution transthoracic real-time three-dimensional echocardiography. J. Am. Soc. Echocardiogr. 2004; 43, 2083-2090.  Back to cited text no. 23      
24.Mor-Avi V.; Sugeng L.; Weinert L.; et al.: Fast measurement of left ventricular mass using real-time three-dimensional echocardiography: comparison with magnetic resonance imaging. Circulation 2004; 110, 1814-1818.  Back to cited text no. 24      


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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