3DE Data Sets Research Articles

Deep learning for the single-view echocardiographic assessment of biventricular ejection fractions: the dual-task EF2Net model

Abstract Background 2D echocardiography requires multiple views for the assessment of left ventricular (LV) systolic function and does not enable the calculation of right ventricular (RV) ejection fraction (EF). 3D echocardiography (3DE) has clear incremental value over 2D echocardiography; nevertheless, its availability and feasibility is limited. Purpose We aimed to develop a dual-task deep learning model – EF2Net – for predicting 3DE-derived LVEF and RVEF from 2D apical 4-chamber (A4C) view echocardiographic videos. Methods The EF2Net model comprises two video transformers, which were first pre-trained on 29,424 unlabeled A4C videos from 15,533 echocardiographic studies in a self-supervised fashion. In the subsequent supervised training phase, one of the transformers was trained for predicting LVEF on the publicly available EchoNet-Dynamic dataset and a dual-center international 3DE dataset comprising 5,341 labeled A4C videos from 1,408 echocardiographic studies, whereas the other transformer was trained for predicting RVEF only on the latter. Beyond testing the model internally on 20% of the dual-center dataset (i.e., internal test set), it was also validated in a labeled external validation set comprising (1) 244 A4C videos of 244 patients with different cardiac diseases and available outcome data and (2) 4,421 A4C videos of 853 healthy adults from the World Alliance of Societies of Echocardiography (WASE) study. Last, we evaluated the model on a low-risk, community-based cohort (1,166 unlabeled A4C videos of 1,166 individuals) with a 10-year follow-up to investigate the associations between the predictions and all-cause mortality. Results In the internal test set and the labeled external validation set, EF2Net predicted 3DE-derived LVEF with a mean absolute error (MAE) of 4.58 and 4.67 percentage points, respectively, whereas it achieved an MAE of 4.82 and 5.43 percentage points in predicting 3DE-derived RVEF. In the labeled external validation set, the model identified an LVEF <50% and an RVEF <45% with an area under the receiver operating characteristic curve of 0.95 and 0.86, respectively. In patients with cardiac diseases, the EF2Net-predicted LVEF and RVEF values were associated with the composite of all-cause death and heart failure hospitalization (LVEF – HR: 0.94 [0.91-0.98], p=0.001; RVEF – HR: 0.92 [0.88-0.98], p=0.004) independent of age and sex. Moreover, in the community-based cohort, the EF2Net-predicted EF values were also associated with 10-year all-cause mortality (LVEF – HR: 0.97 [0.95-0.99], p=0.026; RVEF – HR: 0.91 [0.88-0.95], p<0.001) independent of age, sex, and LV diastolic function. Conclusions EF2Net enabled the automated and accurate assessment of biventricular systolic function based on a single 2D echocardiographic view. It also exhibited robust performance when validated in a multi-ethnic dataset, and the prognostic value of its predictions was confirmed in patients with cardiac diseases and in the community.

Association with outcomes of the planimetry of vena contracta area by 3-dimensional color Doppler echocardiography in patients with secondary tricuspid regurgitation

Abstract Background The cut-off value for defining severe secondary tricuspid regurgitation (STR) using the planimetry of color Doppler three-dimensional echocardiography (3DE) vena contracta area (VCA) has been determined in previous studies based on its correlation with the values of the effective regurgitant orifice area (EROA), obtained using the proximal isovolumic surface area (PISA) method, in patients with severe STR. However, the association of VCA with outcomes has not been examined in these studies. Purpose We sought to 1) identify the cut-off value of 3DE VCA associated with an increased risk of death for any cause or heart failure hospitalizations (HF) in patients with STR; 2) test if the planimetry of 3DE VCA may improve the risk stratification over the quantitative parameters of STR severity. Methods Retrospective analysis of patients with STR consecutively enrolled in the FUTURE 3DECHO study who had good quality 3DE dataset for VCA planimetry. Results We selected 184 patients (76±13 years, 43% women). According to the guideline-recommended multiparametric approach, 15% of the patients had mild, 51% moderate, 22% severe, and 12% massive STR. The mean 3DE VCA was 0.72±0.41 cm2 and it increased significantly with the severity of STR. Among all the quantitative parameters of STR severity, the strongest correlation of 3DE VCA was found with EROA by PISA (Spearman: 0.63, p < 0.001). Using spline curve analysis, a 3DE VCA of 0.65 cm2 was identified as the threshold value associated with increased risk of experiencing the composite endpoint in the whole population (Figure 1A). At univariate analysis, a 3DE VCA > 0.65 cm2 carried a 4-fold increased risk of combined events and it also stratified the risk in patients with EROA < 0.4 cm2 (Figure 1B). When added to a multivariable model including right atrial volume, right ventricular ejection fraction, pulmonary arterial systolic pressure, STR EROA and regurgitant volume, VCA increased significantly the predictive power of the model and mainteined its independent correlation with outcomes (HR: 1.011, CI 95%: 1.003-1.019, P=0.007; X2 of models: 44 vs 39, p value <0.001) (Figure 2). Conclusion 3DE VCA has independent and incremental value over the other parameters of severity for predicting the risk of events in patients with STR. 3DE VCA> 0.65 cm2 identified STR patients with EROA< 0.4 cm2 at higher risk of experiencing the composite endpoint of death and HF. Figure 1 A and B Figure 2. Cox Regression multivariate

Size and Function of the Right Atrium in Healthy Children by Three-Dimensional Echocardiography.

Right atrial volume (RAV) and function have proven prognostic value in the assessment of cardiac disease and may be more accurately assessed using three-dimensional echocardiography (3DE). Normal 3DE reference values for the right atrial (RA) volume and function in healthy children have not yet been published. Furthermore, current methods of indexing cardiac measurements to body surface area (BSA) alone may be insufficient. We aimed to develop reference values for 3DE-derived RAV and function in the pediatric population, to provide a comparison of regression methods using BSA, height, weight, and sex, and to compare 3DE values to two-dimensional echocardiography (2DE) derived volumes. We retrospectively analyzed 187 3DE datasets acquired for a multi-center study on healthy children at two international centers. 3DE volumes were measured with vendor-agnostic software (Tomtec), and 2DE endo-diastolic volume (EDV) using the area-length single-plane approach. Regression curve-fitting of height (Ht), weight (Wt), BSA, and sex were explored to optimize Pearson coefficient and homoscedasticity. The relationship of 3DE RAVs to BSA alone was heteroscedastic, with a residual positive relationship on indexing (R2 = 0.2506). Optimal regression of Ln (Volume) = b0 + x*Ln (Ht) + y*Ln (Wt) + z*Sex was homoscedastic. Total RA emptying fraction (EF) did not vary across age or sex, however active and passive emptying was best fit by a spline curve with a knot at approximately BSA = 1 m2. Strong agreement with 2DE-derived EDV was present (r2 = 0.83). We provide reference values for RA size and function in the pediatric population and provide a comparison of methods for indexing these values.

Evaluation of the image quality and validity of handheld echocardiography for stroke volume and left ventricular ejection fraction quantification: a method comparison study.

Bedside quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is valuable in hemodynamically compromised patients. Miniaturized handheld ultrasound (HAND) devices are now available for clinical use. However, the performance level of HAND devices for quantified cardiac assessment is yet unknown. The aim of this study was to compare the validity of HAND measurements with standard echocardiography (SE) and three-dimensional echocardiography (3DE). Thirty-six patients were scanned with HAND, SE and 3DE. LVEF and SV quantification was done with automated software for the HAND, SE and 3DE dataset. The image quality of HAND and SE was evaluated by scoring segmental endocardial border delineation (2 = good, 1 = poor, 0 = invisible). LVEF and SV of HAND was evaluated against SE and 3DE using correlation and Bland-Altman analysis. The correlation, bias, and limits of agreement (LOA) between HAND and SE were 0.68 [0.46:0.83], 1.60% [-2.18:5.38], and 8.84% [-9.79:12.99] for LVEF, and 0.91 [0.84:0.96], 1.32ml [-0.36:4.01], 15.54ml [-18.70:21.35] for SV, respectively. Correlation, bias, and LOA between HAND and 3DE were 0.55 [0.6:0.74], -0.56% [-2.27:1.1], and 9.88% [-13.29:12.17] for LVEF, and 0.79 [0.62:0.89], 6.78ml [2.34:11.21], 12.14ml [-26.32:39.87] for SV, respectively. The image quality scores were 9.42 ± 2.0 for the apical four chamber views of the HAND dataset and 10.49 ± 1.7 for the SE dataset and (P < 0.001). Clinically acceptable accuracy, precision, and image quality was demonstrated for HAND measurements compared to SE. In comparison to 3DE, HAND showed a clinically acceptable accuracy and precision for LVEF quantification.

Study of mitral valve remodling in patients with atrial functional mitral valve regurgitation using three-dimensional echocardiography

Abstract Background The global burden of atrial fibrillation (AF) is enormous for healthcare systems. AF is typically classified into five distinct patterns depending on the onset, progression, and resolution of AF episodes, first diagnosed AF, paroxysmal AF, persistent AF, long-standing persistent AF&amp; permanent AF. Atrial structural remodeling or exacerbation of atrial cardiomyopathy are generally defining features of the transition from paroxysmal to non-paroxysmal AF. The duration of rhythm monitoring and the presence of a substrate are both important factors in determining the rate of AF development. In the existence of a structurally normal valve, functional MR develops when there is a mismatch between the tethering forces exerted by the heart &amp; the closing forces exerted by the heart. In the context of functional MR annular dilation alone, can constitute a separate etiology of MR (atrial functional MR). TEE provides supplementary imaging, particularly if TTE windows are technically challenging, making it a useful tool even if TTE is the primary technique for assessing and quantifying mitral valve disease. 3DE data sets can be acquired from either TTE or TEE approach, allowing real-time visualization of the cardiac structures, it is superior to 2DE in quantification of cardiac chamber volumes and function, assessment of the mechanisms and severity of heart valve diseases, evaluation of cardiac complex anatomy. Aim of the work To study mitral valve apparatus remodeling in patients with atrial functional mitral valve regurgitation using three-dimensional echocardiography. Methods This study included a total of 30 patients with diagnosis of atrial fibrillation divided in to two groups, 15 patients having no/ mild mitral regurgitation while 15 patients having moderate/severe mitral regurgitation, they were subjected to 2D and 3D TEE echocardiographic assessment of MR degree, LA volumes, mitral leaflets and mitral annulus parameters. Results There was statistically significant difference between the two groups as regard the posterior leaflet area as larger area was estimated in (Mod/severe MR) group compared to (No/ mild MR) group, with mean posterior leaflet area in group I was (8.96 ± 2.60) and (7.30 ± 2.17) in group II with (P value = 0.029) as well as there was statistically significant difference between the two groups as regard total leaflet area/Mitral annular area ratio as smaller ratio was estimated in (Mod/severe MR) group as compared to (No/mild MR) group, with the mean total leaflet area /mitral annular area ratio in group I was (1.22 ± 0.04) and (1.26 ± 0.04) in group II with (P value = 0.008). Conclusion Isolated annular dilatation can cause significant functional atrial mitral regurgitation while mitral leaflet area increases in AF as the annulus dilates, but this adaptation may plateau at larger annular areas, with the resulting leaflet deficiency causing functional atrial mitral regurgitation. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

MITEA: A dataset for machine learning segmentation of the left ventricle in 3D echocardiography using subject-specific labels from cardiac magnetic resonance imaging.

Segmentation of the left ventricle (LV) in echocardiography is an important task for the quantification of volume and mass in heart disease. Continuing advances in echocardiography have extended imaging capabilities into the 3D domain, subsequently overcoming the geometric assumptions associated with conventional 2D acquisitions. Nevertheless, the analysis of 3D echocardiography (3DE) poses several challenges associated with limited spatial resolution, poor contrast-to-noise ratio, complex noise characteristics, and image anisotropy. To develop automated methods for 3DE analysis, a sufficiently large, labeled dataset is typically required. However, ground truth segmentations have historically been difficult to obtain due to the high inter-observer variability associated with manual analysis. We address this lack of expert consensus by registering labels derived from higher-resolution subject-specific cardiac magnetic resonance (CMR) images, producing 536 annotated 3DE images from 143 human subjects (10 of which were excluded). This heterogeneous population consists of healthy controls and patients with cardiac disease, across a range of demographics. To demonstrate the utility of such a dataset, a state-of-the-art, self-configuring deep learning network for semantic segmentation was employed for automated 3DE analysis. Using the proposed dataset for training, the network produced measurement biases of -9 ± 16 ml, -1 ± 10 ml, -2 ± 5 %, and 5 ± 23 g, for end-diastolic volume, end-systolic volume, ejection fraction, and mass, respectively, outperforming an expert human observer in terms of accuracy as well as scan-rescan reproducibility. As part of the Cardiac Atlas Project, we present here a large, publicly available 3DE dataset with ground truth labels that leverage the higher resolution and contrast of CMR, to provide a new benchmark for automated 3DE analysis. Such an approach not only reduces the effect of observer-specific bias present in manual 3DE annotations, but also enables the development of analysis techniques which exhibit better agreement with CMR compared to conventional methods. This represents an important step for enabling more efficient and accurate diagnostic and prognostic information to be obtained from echocardiography.

Abstract 15467: Bi-Leaflet Tricuspid Valve in Children With Hypoplastic Left Heart Syndrome is Rarely Incompetent, While Bi-Leaflet With a Cleft Results in Tricuspid Valve Regurgitation

Introduction: Tricuspid valve (TV) regurgitation in Hypoplastic Left Heart Syndrome (HLHS) increases the risk of death/transplantation by 2 to 3 times. Abnormalities in TV annular shape, leaflets expansion and subvalve apparatus position, have been associated in HLHS with subsequent tricuspid regurgitation (TR). As TV morphological variation is increasingly recognized, its role on tricuspid valve function remains unknown. This study aims to describe and examine the relationship between the TV leaflet morphologies in HLHS and its association with TV repair. Methods: Cross sectional study of selected 38 “classic” HLHS patients from a prospective longitudinal 3DE study of HLHS TV. TV leaflet morphology from 3DE datasets were reviewed (S.Z and N.S.K) blinded to TR grade. We adapted a previously proposed nomenclature to describe the TV leaflets (Figure 1). Using the Chi-squared test, we compared the frequencies of TV morphological types of HLHS with mild or less TR (n = 23) vs. HLHS who had TV repair (n = 15) at latest follow up. Results: Incidence of TV morphological type is summarized in Figure 2. Bi-leaflet TV was the second most common, followed by bi-leaflet with a cleft. When comparing HLHS with mild or less TR vs. HLHS with TVR, only 1 of 9 bi-leaflet TV had subsequent TVR, while all bi-leaflet TV with a cleft, underwent TVR (p&lt;0.05). Conclusion: HLHS has considerable TV leaflet variations with bi-leaflet TV being the second most common variation. While bi-leaflet TV is more likely to be found in a competent TV, those with a bi-leaflet TV with a cleft, all required TVR. Bi-leaflet TV with a cleft, warrants further study to assess its relationship and relative role with TVR.

Evaluation of a Linear Measurement Tool in Virtual Reality for Assessment of Multimodality Imaging Data-A Phantom Study.

This study aimed to evaluate the accuracy and reliability of a virtual reality (VR) system line measurement tool using phantom data across three cardiac imaging modalities: three-dimensional echocardiography (3DE), computed tomography (CT) and magnetic resonance imaging (MRI). The same phantoms were also measured using industry-standard image visualisation software packages. Two participants performed blinded measurements on volume-rendered images of standard phantoms both in VR and on an industry-standard image visualisation platform. The intra- and interrater reliability of the VR measurement method was evaluated by intraclass correlation coefficient (ICC) and coefficient of variance (CV). Measurement accuracy was analysed using Bland-Altman and mean absolute percentage error (MAPE). VR measurements showed good intra- and interobserver reliability (ICC ≥ 0.99, p &lt; 0.05; CV &lt; 10%) across all imaging modalities. MAPE for VR measurements compared to ground truth were 1.6%, 1.6% and 7.7% in MRI, CT and 3DE datasets, respectively. Bland-Altman analysis demonstrated no systematic measurement bias in CT or MRI data in VR compared to ground truth. A small bias toward smaller measurements in 3DE data was seen in both VR (mean -0.52 mm [-0.16 to -0.88]) and the standard platform (mean -0.22 mm [-0.03 to -0.40]) when compared to ground truth. Limits of agreement for measurements across all modalities were similar in VR and standard software. This study has shown good measurement accuracy and reliability of VR in CT and MRI data with a higher MAPE for 3DE data. This may relate to the overall smaller measurement dimensions within the 3DE phantom. Further evaluation is required of all modalities for assessment of measurements &lt;10 mm.

Three-Dimensional Echocardiography Right Ventricular Volumes and Ejection Fraction Reference Values in Children: A North American Multicentre Study.

Three-dimensional echocardiography (3DE) evaluation of right ventricular (RV) volumes and ejection fraction (EF) is increasingly used for clinical serial assessments and management in children. This study aims to generate sex-specific reference values and z-score equations for RV volumetric parameters, independent of age and body size indices, derived from multiple populations across North America. We prospectively recruited 455 healthy children (ages 0 to 18 years) from 5 centres. 3DE of the RV were acquired using various vendors with analyses performed offline using vendor-independent software. 3DE datasets with all walls of the RV endocardium visible were included. We reported data on RV EF, and generated z scores for end-systolic volumes (ESV), end-diastolic volumes (EDV) and stroke volume (SV). Differences between the sexes were explored. Of 455 3DE datasets, 312 (68%) met imaging criteria for analysis. Median age was 10.1 years (interquartile ratio [IQR]: 5.6, 14.0) with 17% being younger than 3 years of age. The mean and standard deviation for RV EDV, ESV, and SV for male and female patients were reported. We provided a downloadable z-score calculator with height and weight as independent variables to facilitate clinical utility. Although statistically significant differences between male and female RVEF was present (female 52.9 ± 3.9% vs male 51.6 ± 3.5%, P= 0.006), after adjusting for age, height, and weight, the magnitude of difference was clinically insignificant. Sex-specific reference values for pediatric RV volumes and EF, and z-score equations were derived from children 3DE datasets across 5 centres in North America.

Prognostic Value of Right Ventricular Strains Using Novel Three-Dimensional Analytical Software in Patients With Cardiac Disease.

BackgroundRight ventricular (RV) three-dimensional (3D) strains can be measured using novel 3D RV analytical software (ReVISION). Our objective was to investigate the prognostic value of RV 3D strains.MethodsWe retrospectively selected patients who underwent both 3D echocardiography (3DE) and cardiac magnetic resonance from January 2014 to October 2020. 3DE datasets were analyzed with 3D speckle tracking software and the ReVISION software. The primary end point was a composite of cardiac events, including cardiac death, heart failure hospitalization, or ventricular tachyarrhythmia.Results341 patients were included in this analysis. During a median of 20 months of follow-up, 49 patients reached a composite of cardiac events. In univariate analysis, 3D RV ejection fraction (RVEF) and three 3D strain values [RV global circumferential strain (3D RVGCS), RV global longitudinal strain (3D RVGLS), and RV global area strain (3D RVGAS)] were significantly associated with cardiac death, ventricular tachyarrhythmia, or heart failure hospitalization (Hazard ratio: 0.88 to 0.93, p < 0.05). Multivariate analysis revealed that 3D RVEF, three 3D strain values were significantly associated with cardiac events after adjusting for age, chronic kidney disease, and left ventricular systolic/diastolic parameters. Kaplan-Meier survival curves showed that 3D RVEF of 45% and median values of 3D RVGCS, 3D RVGLS, and 3D RVGAS stratified a higher risk for survival rates. Classification and regression tree analysis, including 22 clinical and echocardiographic parameters, selected 3D RVEF (cut-off value: 34.5%) first, followed by diastolic blood pressure (cut-off value: 53 mmHg) and 3D RVGAS (cut-off value: 32.4%) for stratifying two high-risk group, one intermediate-risk group, and one low-risk group.ConclusionsRV 3D strain had an equivalent prognostic value compared with 3D RVEF. Combining these parameters with 3D RVEF may allow more detailed stratification of patient's prognosis in a wide array of cardiac diseases.

Routine use of automated strain analysis and 3D echocardiography provides a more comprehensive assessment of cardiac chambers than conventional 2D echocardiography and is time-saving

Abstract Funding Acknowledgements Type of funding sources: None. Background. In most laboratories three-dimensional echocardiography (3DE) and longitudinal strain (Lstrain) analysis are not part of the routine studies. Although these modalities have been shown to provide additional clinical information and prognostic value compared to conventional two-dimensional echocardiography (2DE), their acquisition and analysis are perceived as being time-consuming. Recently, new automated tools have been developed to perform accurate, fast and reproducible analyses of heart chambers’ geometry and function. However, their cost-effectiveness when compared to conventional 2DE remains to be demonstrated. Aim. We designed a prospective, multicenter, observational study aimed to compare the time required for the acquisition and analysis of conventional transthoracic 2DE vs advanced echocardiography (AEcho, i.e. 3DE+ Lstrain) for the assessment of cardiac chambers and myocardial mechanics. Methods. According to current guidelines, 196 consecutive patients referred for clinically indicated echocardiography underwent complete 2DE and Doppler echocardiography. In addition, 3DE datasets of the left atrium (LA), left and right ventricle (LV, RV) were acquired using automated 3DE software package (Heart Model). Acquisition time for both 2DE and 3DE images were recorded. Conventional 2DE analyses of LA (biplane volume), LV (biplane volumes and mass) and RV (both linear dimensions, areas, and longitudinal function) were performed following current guidelines, and the time required for acquisition and analysis was recorded. The time spent for AEcho analysis (both 3DE volumetric analysis and Lstrain of LA, LV and RV) was also recorded. Results. Feasibility of AEcho was 86% (169 patients). The additional time for 3D dataset acquisition over conventional 2DE was 38 ± 0.16 sec. Quantitative analysis of the cardiac chambers by 2DE required an average of 5.55 ± 1.51 min vs 4.25 ± 1.23 min using AEcho (p &amp;lt; 0.001). Total time for both 3D dataset acquisition and AEcho assessment was 5.03 ± 1.28 min vs 5.55 ± 1.51 min of 2DE analysis alone (p &amp;lt; 0.001). Globally, AEcho provided a more comprehensive assessment of heart chambers than 2DE (Table). Moreover, the time spent for 3DE dataset acquisition and AEcho analysis on top of standard 2DE acquisition was significantly shorter compared to the 2DE acquisition and analysis (18:50 ± 4.23 vs 19:42 ± 4.24 min, p &amp;lt; 0.001) (Table). Conclusions. Our data showed that the use of new AEcho automated tools are highly feasible resulting in significant time-savings compared to standard 2DE evaluation, while providing significant additional information. Abstract Table

Prognostic Value of the Three-Dimensional Right Ventricular Ejection Fraction in Patients With Asymptomatic Aortic Stenosis.

Background: The right ventricular (RV) function is an important prognostic marker of asymptomatic aortic stenosis (AS). However, previous publications have not addressed the additive value of conventional RV parameters over left heart parameters. Whether three-dimensional echocardiography (3DE)-derived RV ejection fraction (RVEF) has prognostic utility independent of 3DE derived left heart parameters is also unknown. We investigated the prognostic utility of 3DE RVEF in patients with asymptomatic AS.Methods: We retrospectively selected 392 asymptomatic AS patients. RVEF, left ventricular ejection fraction (LVEF) and left atrial volumes (LAVs) were measured using 3DE datasets. We determined the association of those parameters, as well as of aortic valve replacement (AVR), and Charlson's comorbidity index with cardiac events. We also analyzed whether RVEF has incremental value over two-dimensional echocardiography (2DE) RV parameters.Results: During a median follow-up of 27 months, 57 patients developed cardiac events, and 68 patients received AVR. Univariate Cox proportional hazard analysis revealed that RVEF was associated with cardiac events (p < 0.001). Multivariate analysis revealed that RVEF was significantly associated with cardiac events (p < 0.001) even after adjusting for AVR, Charlson's comorbidity index, LVEF, LAV, E/e', and indexed aortic valve area (iAVA). An incremental value of RVEF over left heart parameters was also demonstrated using a nested regression model. Classification and regression-tree analysis selected RVEF first with a cut-off value of 41%. RVEF had incremental value over iAVA, LVEF, and 2DE conventional RV parameters for its association with future outcomes.Conclusions: 3DE RVEF had significant prognostic value even after adjusting for comorbidities, left heart parameters, and conventional 2DE RV parameters in asymptomatic aortic stenosis.

Differences in mitral and tricuspid annular geometry in elite athletes with versus without functional mitral regurgitation: a 3D echocardiographic study

Abstract Intense exercise exposes the heart to significant hemodynamic demands, resulting in adaptive changes in cardiac morphology and function. Nevertheless, the athletic adaptation of the atrioventricular valves remains to be elucidated. Our study aimed to characterize the geometry of mitral (MA) and tricuspid (TA) annuli in elite athletes using 3D echocardiography. Thirty-four athletes presented with functional mitral regurgitation (FMR) were retrospectively identified and compared to 34 athletes without MR, and 34 healthy, sedentary volunteers. 3DE datasets were used to quantify MA and TA geometry and leaflet tenting by dedicated softwares. MA and TA areas, as well as tenting volumes, were higher in athletes compared to controls. MA area was significantly higher in athletes with MR compared to those without (8.2±1.0 vs. 7.2±1.0 cm2/m2, p&amp;lt;0.05, Figure 1). Interestingly, athletes with MR also presented with a significantly higher TA area (7.2±1.1 vs. 6.5±1.1 cm2/m2, p&amp;lt;0.05, Figure 2). Non-planar angle describing the MA's saddle shape was less obtuse in athletes without MR, whereas the values of athletes with MR were comparable to controls (Figure 1). The exercise-induced relative increases in left ventricular (35±25%) and left atrial (40±29%) volumes were similar; however, the increment in the MA area was disproportionately higher (63±23%, overall p&amp;lt;0.001). The relative increase in TA area (40±23%) was also higher compared to the increment in right ventricular volume (34±25%, p&amp;lt;0.05). Atrioventricular annuli undergo a disproportionate remodeling in response to regular exercise. Athletic adaptation is characterized by both annular enlargement and increased leaflet tenting of both valves. There are differences in MA geometry in athletes presented with versus without FMR. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program). The research was partly financed by the Thematic Excellence Programme (Tématerületi Kiválόsági Program, 2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University. Figure 1Figure 2

Partitioning the Right Ventricle Into 15 Segments and Decomposing Its Motion Using 3D Echocardiography-Based Models: The Updated ReVISION Method.

Three main mechanisms contribute to global right ventricular (RV) function: longitudinal shortening, radial displacement of the RV free wall (bellows effect), and anteroposterior shortening (as a consequence of left ventricular contraction). Since the importance of these mechanisms may vary in different cardiac conditions, a technology being able to assess their relative influence on the global RV pump function could help to clarify the pathophysiology and the mechanical adaptation of the chamber. Previously, we have introduced our 3D echocardiography (3DE)-based solution—the Right VentrIcular Separate wall motIon quantificatiON (ReVISION) method—for the quantification of the relative contribution of the three aforementioned mechanisms to global RV ejection fraction (EF). Since then, our approach has been applied in several clinical scenarios, and its strengths have been demonstrated in the in-depth characterization of RV mechanical pattern and the prognostication of patients even in the face of maintained RV EF. Recently, various new features have been implemented in our software solution to enable the convenient, standardized, and more comprehensive analysis of RV function. Accordingly, in our current technical paper, we aim to provide a detailed description of the latest version of the ReVISION method with special regards to the volumetric partitioning of the RV and the calculation of longitudinal, circumferential, and area strains using 3DE datasets. We also report the results of the comparison between 3DE- and cardiac magnetic resonance imaging-derived RV parameters, where we found a robust agreement in our advanced 3D metrics between the two modalities. In conclusion, the ReVISION method may provide novel insights into global and also segmental RV function by defining parameters that are potentially more sensitive and predictive compared to conventional echocardiographic measurements in the context of different cardiac diseases.

Real-time three-dimensional echocardiography for left atrial volume assessment in Thoroughbred racehorses: Observer variability and comparison with two-dimensional echocardiography.

Left atrial size predicts cardiac morbidity and mortality in humans and dogs. Real-time three-dimensional echocardiography (3DE) may be reliable for assessing left atrial volume (LAV) in horses. To determine intra- and interobserver variability estimates of 3DE-LAV and compare it to that of 2DE-LAV estimates. Method comparison. 3DE datasets were obtained from 40 horses, then graded for quality, creating a final study population of 22 horses. The 3DE and 2DE maximum LAV (LAVmax ) and minimum LAV (LAVmin ) were measured, and left atrial emptying volume (LA EV) and left atrial ejection fraction (LA EF) were calculated, from the same 3D dataset on four occasions using (a) a semi-automatic surface recognition algorithm and (b) a modified Simpson's method of discs. 3DE LAV measurements were repeated by a second observer. For 3DE, median LAVmax was 596cm3 for observer one, and 852cm3 for observer two, LAVmin was 373cm3 for observer one and 533cm3 for observer two. Low intraobserver measurement variation was observed for LAVmax and LAVmin , with horse-level intraclass correlation coefficients (ICChorse ) for both observers between 76% and 85% (horse added as random effect). The interobserver ICC was 58% for LAVmax and 50% for LAVmin on averaged measurements (with observer added as random effect), indicating consistent differences between observers. While intraobserver variation was similar for 2DE LAVmax measurements, it was greater for LAVmin (ICChorse =67%). The intermethod ICC for 3DE vs 2DE was low at 14% for LAVmax and ~0% for LAVmin , indicating less-consistent differences with method. Small study population, low observer number, use of different imaging modalities (fundamental frequency and octave harmonics). 3DE assessment of LAV was reliable, suggesting suitability for longitudinal evaluation of clinical cases. Clinicians should be aware of differences in LAV measurements between observers. More defined measurement guidelines may improve repeatability.

Prognostic Value of the Right Ventricular Ejection Fraction, Assessed by Fully Automated Three-Dimensional Echocardiography: A Direct Comparison of Analyses Using Right Ventricular–Focused Views versus Apical Four-Chamber Views

Right ventricular (RV) three-dimensional echocardiographic (3DE) data sets are acquired from either the RV-focused view (RVFV) or the apical four-chamber view (4CV). The prognostic value of 3DE RV ejection fraction (RVEF) was investigated using fully automated RV quantification software, and how measurement values with 3DE data sets from the RVFV compare with those from the 4CV was determined. One hundred seventy-four patients who had undergone both cardiac magnetic resonance (CMR) and 3DE imaging were retrospectively selected. RV 3DE data sets were acquired from both the RVFV and the 4CV and were analyzed separately using fully automated RV quantification software. Primary end points were cardiac events, including cardiac death, heart failure requiring hospitalization, nonfatal myocardial infarction, and ventricular tachyarrhythmia. The feasibility of RVEF measurements on 3DE imaging from the RVFV and 4CV was 92% and 92%, respectively. There was good correlation (r=0.83) and small bias (0.3%) between RVEF from the RVFV and that from the 4CV. Similar results were obtained when only data from patients whose echocardiograms had poor image quality in one or both views were analyzed (r=0.83, bias=1.7%, n=78). Although fully automated analysis in both the RVFV and 4CV significantly underestimated RV volumes compared with CMR, neither measurement differed significantly for RVEF compared with CMR. During a median follow-up period of 12.5months, 21 patients experienced primary end points. RVEF assessed by CMR and 3DE imaging was significantly associated with cardiac events. RVEF using fully automated analysis had a significant association with cardiac events, even in patients with poor image quality (RVFV: hazard ratio, 0.90 [P=.009, n=44]; 4CV: hazard ratio, 0.90 [P=.009, n=68]). RV 3DE data sets from the RVFV and 4CV yielded similar RVEF values using fully automated software. RVEFs from both approaches had significant association with outcomes. Thus, both provide accurate information regarding RV function and risk for adverse outcomes.

Virtual Reality Analysis of Three-Dimensional Echocardiographic and Cardiac Computed Tomographic Data Sets

Three-dimensional echocardiographic (3DE) imaging and cardiac computed tomographic (CCT) imaging are important cardiac imaging tools. Despite the three-dimensional nature of these image acquisitions and reconstructions, they are visualized on two-dimensional monitors with shading and coloring to create the illusion of three dimensions. Virtual reality (VR) is a novel tool that allows true three-dimensional visualization and manipulation. The aims of this study were to test the feasibility of converting 3DE and CCT data into three-dimensional VR models, compare the variability of measurements performed in VR and conventional software, assess the diagnostic quality of VR models, and understand the value of VR over conventional viewing. Custom software with clinically relevant postprocessing tools (interactively adjustable visualization parameters, multiplanar reconstructions, cropping planes, and nonplanar measurements) was developed to convert 3DE and CCT data into VR models. Anatomic measurements of 15 3DE and 15 CCT data sets of the mitral valve were compared using conventional software and in the VR environment. Additionally, the diagnostic quality of the VR models created from 3DE and CCT data sets was assessed. The 3DE and CCT data sets were successfully converted into VR models in <3min. The measurement variabilities were reduced by 40% (20.1% vs 12.2%) for 3DE imaging and 34% (15.3% vs 10.1%) for CCT imaging by using VR. The mean time needed for measurements was reduced by 31% (from 61 to 42sec) for 3DE imaging and 39% (from 37 to 23sec) for CCT imaging. Most users reported facile manipulation of VR models, diagnostic quality visualization of the anatomy, and high confidence in the measurements. This study demonstrates the feasibility of converting 3DE and CCT data into diagnostic-quality VR models. Compared with conventional imaging, VR analysis is associated with faster navigation and accurate measurements with lower variability.

Stereoscopic Display Is Superior to Conventional Display for Three-Dimensional Echocardiography of Congenital Heart Anatomy

Three-dimensional echocardiography (3DE) improves visualization of cardiac lesions. Current viewing of 3DE studies on a conventional display diminishes the encoded stereoscopic (stereo) information for depth perception. This study aims to evaluate clinician subjective and objective experience of stereo display compared with nonstereo display of 3DE in congenital heart disease. In this prospective study, 22 cardiologists, advanced cardiology trainees, and cardiothoracic surgeons used a commercially available stereo display system with proprietary software to view 10 3DE data sets, alternating between simple and complex lesions. In part A, participants viewed each data set, randomized to 1minute of stereo display followed by 1minute of nonstereo display, or vice versa. In part B, participants could freely toggle between stereo and nonstereo display for an additional 90seconds per data set. Participants answered a series of questions and rated their subjective experience using stereo versus nonstereo display mode on a Likert scale. Objective data on time spent in each display mode during part B and duration of interaction and degree of movement of the 3DE data set in parts A and B were also collected. All clinician groups found stereo display preferable to nonstereo display of 3DE (P<.0001). Viewing complex lesions was rated lower than simple lesions when using nonstereo display (P<.01). Simple and complex lesions were equally well rated when using stereo display (P=.14). When given a choice of display modes in part B, participants spent more time in stereo display (P<.0001) and interacted more with the 3DE data sets in stereo display (P<.0001). Interactive stereoscopic display of 3DE was preferred over conventional nonstereo display by all clinician groups for viewing both simple and complex lesions. This preference is especially true for viewing complex lesions.

1184 Left atrial volumes by 3-dimensional but not 2-dimensional echocardiography predict cardiac death and events in patients with heart failure with reduced ejection fraction

Abstract Background Patients with heart failure with reduced ejection fraction (HFrEF) are at high risk for mortality and morbidity. Left atrial volumes (LAVs), measured by 2-dimensional echocardiography (2DE), have been suggested as possible prognostic markers. However, LAVs measured by 2DE are prone to errors due to geometric assumptions and increased variability, whereas 3-dimensional echocardiography (3DE) has been proved to be a more accurate and reproducible method for volume assessment. Purpose To assess the comparative prognostic value of LAVs, measured by 2DE and 3DE, in patients with ischemic and non-ischemic HFrEF, on best clinical care. Methods 135 consecutive patients (59 ± 15 years, 91 males), diagnosed with HFrEF, in sinus rhythm, were assessed by 2DE and 3DE, including full-volume multi-beat acquisitions of the LA and left ventricle (LV). Maximal and minimal indexed LAVs were measured from the 2DE datasets using biplane area-length formula (2D_LAVmax and 2D_LAVmin); and from the 3DE datasets using a dedicated software package (3D_LAVmax and 3D_LAVmin). Patients were followed for 23 ± 14 months after the index event. Primary outcome was cardiac death (CD); secondary outcomes were: 1) HF hospitalization (HFH); 2) a composite cardiac events (CE) end-point, of cardiac death or hospitalization for heart failure, myocardial infarction, coronary revascularization, arrhythmias, or cardiac resynchronization therapy. Results 26 CD, 32 HFH, and 48 CE occurred during follow-up. 2DE and 3DE measurements are in the table. LAVs measured by 2DE did not correlate with outcome. However, 3D_LAVmax and 3D_LAVmin correlated with CD (r = 0.40 and r = 0.38) and CE (r = 0.30 and r = 0.29), all p &amp;lt; 0.05, but not with HFH. By multivariate linear regression analysis, only 3D_LAVmax and 3D_LAVmin were independent predictors for CD and CE, in patients with HFrEF (r²=0.30 and r²=0.32; p &amp;lt; 0.01). Conclusion In patients with HFrEF, LA volumes measured by 3DE, but not by 2DE, were independent predictors for cardiac death and events. However, even LA volumes by 3DE did not have predictive value for future HF rehospitalizations. Echo features for patients with HFrEF 3D end-diastolic LV volume (ml/m2) 101 ± 32 3D end-systolic LV volume (ml/m2) 71 ± 29 3D LV ejection fraction (%) 30 ± 8 2D_LAVmax (ml/m2) 52 ± 18 2D_LAVmin (ml/m&amp;sup2;) 31 ± 15 3D_LAVmax (ml/m2) 43 ± 18 3D_LAVmin (ml/m2) 29 ± 16

P695 Is reference value of left atrial strain using 2D echocardiography really reliable?

Abstract Funding Acknowledgements MT received research grant from GE Healthcare. Background Left atrial (LA) longitudinal strain (LALS) assessed by two-dimensional echocardiography (2DE) speckle tracking analysis is increasingly popular for the estimation of left ventricular diastolic dysfunction and the prediction of adverse outcome. Since standard apical 4-chamber and 2-chamber views often maximize the long-axis of the left ventricle, and the long axis of the left ventricle and that of the left atrium do not lie on the same 2D cutting plane, these views have a risk for the foreshortening of the left atrium. It may cause overestimation of LALS due to the reduction of initial perimeter of region of interest that is a denominator for the strain calculation. Purpose The aim of this study was to compare LALS values between 2DE and 3D echocardiography (3DE) in healthy subjects, and investigate whether 2DE speckle tracking analysis overestimates reference value of LALS. Methods LALS and LA longitudinal length were measured by both 2DE and 3DE in 105 healthy subjects (median age, 42 years; 59 men). For 2DE, LA longitudinal length from the mitral annulus to the roof of the left atrium were measured on apical 4-chamber and 2-chamber views at end-diastole and at end-systole, and the values were averaged. Apical 4-chamber and 2-chamber LALS was also measured using 2DE speckle tracking software (EchoPac PC, GE Healthcare) for calculating biplane LALS. 3DE LALS was measured using new 3DE LA strain software (4D Auto LAQ, GE Healthcare). 3DE determined LA longitudinal length at both end-diastole and end-systole was also measured using the same 3DE datasets. Results Mean values of biplane LALS was 39.6 ± 11.8%. 2DE LA longitudinal length at both end-diastole (r=-0.43) and end-systole (r=-0.54) was negatively correlated with biplane LALS. Multivariable regression analysis revealed that both end-diastolic and end-systolic LA longitudinal length had a significant negative association for biplane LALS after adjusting anthropometric and echocardiography image quality parameters. 3DE LALS analysis was not possible in 11 subjects due to the erroneous LA border determination (Feasibility: 90%). 3DE LALS (23.7 ± 7.6%) was significantly lower than biplane LALS (39.5 ± 12.0%, p &amp;lt; 0.001) with a weak correlation (r = 0.33) in 94 subjects who were possible in both analyses. Paired comparison of LA longitudinal length between 2DE and 3DE revealed that 2DE determined LA length at end-diastole (3.51 ± 0.72 cm vs. 4.85 ± 0.56 cm, p &amp;lt; 0.001) and at end-systole (4.63 ± 0.69 cm vs. 5.84 ± 0.54 cm, p &amp;lt; 0.001) was significantly shorter than that obtained from 3DE. Conclusions Our results highlighted that LA cavity visualizing on the standard apical 4-chamber and 2-chamber views are often longitudinally foreshortened, and this is a potential cause for the overestimation of LALS. 3DE may overcome this limitation.