Short-axis Method Research Articles

Assessment of Left Atrial Volumes at 1.5 Tesla and 3 Tesla Using FLASH and SSFP Cine Imaging

To investigate left atrial volumes and function and their variability in healthy volunteers using steady state free precession (SSFP) and fast low angle shot (FLASH) sequences at both 1.5 and 3 T using both the short-axis and biplane area-length methods. Ten healthy volunteers underwent CMR at both 1.5 and 3 Tesla. The biplane area-length method utilized volumes from the horizontal and vertical long axis images. There were no significant differences between left atrial short-axis volumes or function between 1.5 and 3 T assessed using either FLASH or SSFP sequences. The biplane area-length method underestimated maximal left atrial volume using FLASH by 12 mL at 3 T (18%) and by 10 mL (14%) at 1.5 T (p = 0.003 and p = 0.05 respectively). Variability was larger for left atrial measurements using the biplane area-length method. Field strength had no effect on left atrial volume and function assessment using either FLASH or SSFP. The use of the short-axis method for the acquisition of left atrial parameters is more reproducible than the biplane area-length for serial measurements.

Evaluation von zwei „schnellen” Softwareprogrammen zur Bestimmung der linksventrikulären Volumina in der retrospektiv EKG-gegateten Mehrzeilen-Spiral-CT des Schweineherzens: Biplanare Flächen-Längen-Methode und „Shape-tracking”-Methode

Evaluation of 2 "fast" software tools, a biplane area-length method, and a new automatic "shape tracking" method, for the calculation of left ventricle volumes (end-diastolic volume EDV, end-systolic volume ESV, stroke volume SV) and ejection fraction (EF) in retrospectively ECG-gated multidetector computed tomography. 60 contrast-enhanced cardiac CT datasets (16 x 0.75 mm collimation, normal dose: 120-140 kV, 400-500 mAs (eff) [n = 44], low dose 120 kV, 100 mAs (eff) [n = 16]) were acquired from eight intubated healthy pigs on different days. Images were reconstructed with a slice thickness and increment of 2 mm every 10 % of the cardiac cycle. The LV function was evaluated via the common short axis method as the reference method, the biplane area-length method, and the automatic "shape tracking" method. In the latter a three-dimensional triangulated deformable surface model was used to segment the endocardial border of the left ventricle and to track its motion through the cardiac phases. The results were compared using the Bland-Altman-plot, the correlation coefficient, and the Wilcoxon test. All 60 data sets could be evaluated with all three methods. Good correlations were found for left ventricular functional parameters for all data sets, the normal dose (ND), and low dose (LD) data sets between 0.65 and 0.89 for the "shape tracking" method and between 0.7 and 0.87 for the area-length method. The "shape tracking" method showed a mean overestimation of the EDV of 3.1 (LD, p = 0.38) to 4.3 ml (ND, p < 0.05), the SV of 4.0 (LD, p = 0.08) to 4.9 ml (ND, p < 0.05) and the EF of 1.3 (LD, p = 0.16) to 2.0 % (ND, p < 0.05). The EDV was underestimated between 0.3 (LD, p = 0.7) and 1.1 ml (ND, p = 0.08). The area-length method showed an overestimation of the EDV (6.6 to 6.7 ml [p < 0.05]), the SV (5.9 to 8.4 ml [p < 0.05]), the EF (1.2 to 3.0 % [p < 0.05]) and the normal dose ESV (0.6 ml [p = 0.74]). The low dose ESV was underestimated (1.3 ml [p = 0.21]). The left ventricular functional parameters acquired with both "fast" software methods correlate well with the common semi-automatic short axis method, and both methods significantly overestimate the EDV, SV and EF. Both methods can be used in low dose examinations.

Visual estimation versus quantitative assessment of left ventricular ejection fraction: A comparison by cardiovascular magnetic resonance imaging

The aim of this study was to compare the visual and quantitative assessment for left ventricular ejection fraction (LVEF) in normal subjects and patients with impaired LV function. One hundred subjects (40 normal subjects, 40 patients with ischemic cardiomyopathy, and 20 patients with nonischemic cardiomyopathy) were investigated using a 1.5-T cardiovascular magnetic resonance imager. Images were acquired by a fast gradient-echo sequence with steady-state free precession using the standard short-axis method. Left ventricular EF was calculated from the sums of the outlined areas using the Simpson rule. Interobserver variability between the calculated and the visual EF was assessed. Analyses were performed randomly and blinded by 2 independent observers. Left ventricular EF was significantly underestimated by the visual read in all 3 groups (mean difference: normal subjects -2.6% +/- 2.6%, ischemic cardiomyopathy -1.7% +/- 2.1%, and nonischemic cardiomyopathy -1.2% +/- 2.1%; P < or = .02). The difference was larger in normal subjects than in patients with cardiomyopathy (P = .04). The interobserver variability was smaller for the quantitative assessment than for the visual estimation. Left ventricular EF is underestimated by visual estimation compared with the quantitative assessment. The visual approach for EF assessment may be used for rapid assessment of left ventricular function in clinical practice where accuracy is of less concern. For most accurate analysis, the quantitative standard short axis approach is required.

How Much are Atrial Volumes and Ejection Fractions Assessed by Cardiac Magnetic Resonance Imaging Influenced by the ECG Gating Method?

Most magnetic resonance imaging (MRI) centers currently use prospective electrocardiographic (ECG) triggering for image acquisition. Retrospectively gated sequences allow the coverage of the entire cardiac cycle. It has been recently shown that ventricular volumes and ejection fraction (EF) differ according to the gating method used for image acquisition. The authors sought to evaluate how much measurements of atrial volumes and EF differ depending on the gating method. Eighteen subjects with no cardiovascular disease were investigated by MRI using a 1.5 Tesla scanner. Images were acquired with a gradient-echo sequence with steady-state free precession (SSFP) using the standard short-axis method for volume and EF measurements. Images were acquired with 6 mm thick slices using both prospective triggering and retrospective gating. Left and right atrial volumes (end diastolic volume [EDV]; end systolic volume [ESV]; stroke volume [SV]) and EF were determined with a commercially available software package. ESV was significantly smaller with the retrospectively gated SSFP sequence than with the prospectively triggered sequence (mean difference: ESV left 3.97 +/- 1.3 ml, p < 0.0001; ESV right 4.34 +/- 1.8 ml, p < 0.0001). EF and SV were significantly smaller with prospective triggering (mean difference: EF left -5.94 +/- 0.9%, p < 0.0001; EF right -5.52 +/- 1.3 %, p < 0.0001; SV left -3.99 +/- 1.3 ml, p < 0.0001; SV right -4.32 +/- 1.9 ml, p < 0.0001). EDV remained unchanged (mean difference: EDV left -0.03 +/- 0.8 ml, p = 0.902; right EDV 0.04 +/- 0.7 ml, p = 0.882). The gating method has a significant impact on atrial volume and EF measurements. Atrial EF is underestimated by using the prospective triggering technique.

Impact of the ECG Gating Method on Ventricular Volumes and Ejection Fractions Assessed By Cardiovascular Magnetic Resonance Imaging

Most MRI centers currently use prospective ECG triggering and fast gradient-echo sequences for image acquisition. Retrospectively gated sequences allow the coverage of the entire cardiac cycle. There is concern about whether ventricular volumes and ejection fraction (EF) differ according to the gating method used for image acquisition. We sought to evaluate the impact of the gating method on measurements of right and left ventricular volumes and EF in normal subjects. Fifteen subjects with no cardiovascular disease were investigated by MRI using a 1.5 Tesla scanner. Images were acquired with a gradient-echo sequence with steady-state free precession (SSFP) using the standard short-axis method for volume and EF measurements. Images were acquired with 6-mn-thick slices using both prospective triggering and retrospective gating. Left and right ventricular volumes (EDV, ESV, SV) and EF were determined with a commercially available software package (Argus, Siemens). EDV and SV calculated from short-axis images were significantly smaller with the prospectively triggered SSFP sequence (mean difference: EDV left: 13.9 +/- 4.4 mL, p < 0.0001; SV left: 13.5 +/- 4.8 mL, p < 0.0001; EDV right: 14.2 +/- 3.9 mL, p < 0.0001; SV right: 14.7 +/- 5.9 mL, p < 0.0001). EF was significantly smaller for the right ventricle (mean difference -3.6 +/- 3.3%, p = 0.0008) and the left ventricle (mean difference -2.3 +/- 3.3%, p = 0.02). ESV remained unchanged (mean difference: ESV left: 0.47 +/- 3.5 mL, p = 0.6179; right ESV: 0.5 +/- 3.7 mL, p = 0.6083). The gating method has a significant impact on volume and EF measurements. The global ventricular EF is underestimated by using the prospective triggering technique. However, the difference in the left ventricle is small and might not be of clinical relevance.

Assessment of Regional Left Ventricular Function: Accuracy and Reproducibility of Positioning Standard Short-Axis Sections in Cardiac MR Imaging

The assessment of regional left ventricular (LV) function with cardiac magnetic resonance (MR) cine techniques requires a standardized section positioning. A simple selective short-axis method for selective positioning of three short-axis sections (basal, midcavity, apical) was tested for its accuracy, compared with accepted criteria, in 21 volunteers (mean age, 32 years +/- 11) and in 23 patients with myocardial infarction (mean age, 56 years +/- 12). Reproducibility of section positioning and of regional LV parameters was tested in the volunteers. Among the six accuracy criteria defined for standard sections, the selective short-axis approach had an average accuracy of 90.9% in volunteers and 87.7% in patients, compared with 92.1% and 90.6%, respectively, for a multisection approach covering the whole LV. There was very good reproducibility of the selected intersection gap (r = 0.89, P < .001) and of measured midcavity end-diastolic diameters in vertical (r = 0.83, P < .001) and horizontal (r = 0.85, P < .001) long-axis orientations. The proposed method produces standardized short-axis section positions that meet the recommendations for cardiac imaging. The study was approved by the local ethics committee, and all subjects gave written informed consent.

Assessment of systolic function by atrioventricular plane displacement in patients with diastolic dysfunction

Objectives — Early recognition and appropriate therapy of diastolic dysfunction (DD) is advisable to prevent further progression to diastolic or systolic heart failure and death. The mitral atrioventricular plane displacement (AVPD) method has been shown to be a reliable and simple technique to study left ventricular systolic function in patients, because the mitral annulus can be visualized in almost all patients even if the endocardial borders are difficult to trace. The aim of our study is to estimate the left ventricular ejection fraction by AVPD method (EFAVPD), in addition to Teicholz’s short axis method (EF-T) and Simpson’s biplane method (EF-2D) in patients with DD.Material and methods — One hundred and two subjects were submitted to complete echocardiographic assessment, and DD was shown in 62 patients. The systolic mitral AVPD was recorded at 4 sites (septal, lateral, anterior, and posterior) using M-mode and left ventricular ejection fraction was calculated from the AVPD-mean in 62 patients with DD (mean age 55.67 ± 5.65, 24 men and 38 women) and in 40 age-matched control subjects (mean age 54.07 ± 6.96, 15 men and 25 women). There were no statistically significant group differences related to age, gender, heart rate or body mass index. However, in the patients with DD, presence of hypertension and/or diabetes mellitus was significantly higher than control subjects.Results — The systolic functions, as assessed by conventional measures in patients with DD and healthy subjects were not stastically different, and were within normal limits. The septal, anterior, lateral and posterior part of the atrioventricular plane values and AVPD-mean during systole were statistically lower in the DD group (12.35 ± 1.42 mm) compared with controls (15.32 ± 1.38 mm) (p < 0.001). EFAVPD in patients with DD was statistically lower (62.97 ± 7.85%) than healthy subjects (79.30 ± 7.60%) (p < 0.001). Significant positive correlations between EFAVPD and EF-2D (r = 0.325, p < 0.01) and EF-T (r = 0.355, p < 0.01) and FS (r = 0.314, p < 0.01) were found. EFAVPD correlated only with velocity of mitral flow propagation (VPR) in diastolic function parameters (r = 0.374, p < 0.01).Conclusions — The AVPD method may indicate a systolic dysfunction with a relatively lower AVPD-mean and relatively lower EFAVPD in the DD group compared with controls.This indicated the presence of a statistically significant and mildly reduced left ventricular systolic function by the AVPD method in patients with DD. It might be suggested that DD might be combined with systolic dysfunction. However, isolated diastolic dysfunction is uncommon.The mitral AVPD is reproducible, widely applicable and a simple non-invasive method for the estimation of left ventricular systolic function in patients with DD.

Assessment of Left Atrial Volumes in Sinus Rhythm and Atrial Fibrillation Using the Biplane Area?Length Method and Cardiovascular Magnetic Resonance Imaging with TrueFISP

To determine whether the biplane area-length method can be used for the evaluation of left atrial volumes and ejection fraction with cardiovascular magnetic resonance imaging (CMR) by TrueFISP in normal subjects and patients with atrial fibrillation. Atrial fibrillation is the most common arrhythmia in elderly patients. Left atrial size and volumes play an important role in predicting short and long-term success after cardioversion. Fifteen healthy subjects (mean age 65.6+/-6.4 years) and 18 patients (mean age 67.2+/-8.8 years) with atrial fibrillation were examined by CMR (Magnetom, Siemens, Erlangen, Germany). Images were acquired by TrueFISP using the horizontal and vertical long-axis plane to measure left atrial end-diastolic and end-systolic areas and longitudinal dimensions. Volumes were determined with commercially available software. Left atrial end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), and ejection fraction (EF) were determined by the biplane area-length method and compared to findings obtained by the standard short-axis method. Images were acquired and analyzed a second time in the patients with atrial fibrillation. There was no difference in age between men and women (p=0.147) and healthy subjects and patients (p=0.128) included in the study. EDV and ESV were significantly higher and SV and EF significantly lower in patients with atrial fibrillation than in healthy subjects (p < or = 0.009), regardless of the method used. The values obtained for EDV and ESV by the biplane area-length method were significantly higher in both healthy subjects (p<0.001) and patients with atrial fibrillation (p<0.001) than those obtained by the standard short-axis approach, whereas SV (p> or = 0.057) and EF (p> or = 0.118) did not differ significantly. In the second investigation in patients with atrial fibrillation, ESV, SV, and EF did not differ significantly between the two methods (p> or =0.481). Assessment of interobserver variability revealed good agreement in the findings of the two observers, both in normal sinus rhythm and atrial fibrillation (overall variability 0.8+/-6.5%). The biplane area-length method can be used in CMR images obtained by TrueFISP to assess left atrial volumes and ejection fraction in normal subjects and patients with varying cardiac cycle length, as in atrial fibrillation.

Rapid Quantification of Left Ventricular Function and Mass Using Transoesophageal Three-dimensional Echocardiography: Validation of a Method that uses Long-axis Cutplanes*

Despite its proven superiority compared to conventional echocardiographic techniques, three-dimensional (3D) echocardiography has not gained widespread acceptance in clinical medicine for the quantification of left ventricular volumes, function and mass. This is mainly due to the large, time-consuming process of data analysis. We sought to validate a new method that enables the accurate quantification of the left ventricle in a clinically acceptable short period of time. Left ventricular volumes, ejection fraction and mass were determined in 44 patients using 3D echocardiography. The 3D echocardiographic data sets were analysed: (i) using the conventional 'summation of slices' algorithm (slice thickness 5 and 10mm), which is based on the analysis of the 3D reconstructed left ventricle in short-axis cross-sections; and (ii) using the new method which is based on the analysis of the 3D reconstructed left ventricle in long-axis images. In each patient measurements were repeated using 3, 6, 7, 8, 9, 12 and 15 long-axis images. For all volumetric measurements there was a continuous reduction of measurement variability using increasing numbers of long-axis images. The use of more than nine long-axis images for volumes, and eight long-axis images for ejection fraction and mass, did not result in a further reduction of variability. The analysis time for volumes and masses averaged less than 5 min for the long-axis method using nine component images, compared to 20-43 min for the short-axis method. 3D echocardiography combined with a novel method based on the analysis of long-axis cross-section allows accurate quantification of left ventricular volumes, function and mass in a clinically acceptable short period of time. In the future, the combination of a real-time 3D echocardiographic acquisition technique with this analysis method should have important implications for the introduction of 3D echocardiography in clinical practice.

Estimation of the left ventricular ejection fraction using a novel multiphase, dark-blood, breath-hold MR imaging technique.

In this paper, we evaluate a recently proposed dual-phase dark-blood MR sequence for estimating the left ventricular ejection fraction, compare Simpson's method of estimation of ejection fraction with a model based on the biplane method, assess the reproducibility of both methods, and finally, test a semiautomated method for contouring the endocardial border. An MR pulse sequence was implemented to acquire cardiac images in both diastolic and systolic phases within a single breath-hold. A special magnetization preparation scheme rendered blood dark while a segmented acquisition allowed breath-hold scan times. Five healthy volunteers and five patients with cardiac disease were imaged. Ejection fractions were estimated using (1) long-axis and four-chamber biplane views with an ellipsoid model and (2) a series of short-axis views in combination with Simpson's model. These values of ejection fractions were then compared with values obtained from echocardiography. Estimates of ejection fractions obtained using biplane ellipsoid volume and Simpson's rule methods varied by 14% in healthy volunteers. However, for patients with severe cardiomyopathy, differences between the values of ejection fraction obtained with the two methods varied by as much as 150%. Ejection fraction estimates obtained from MR images with the biplane ellipsoid method and from echocardiography varied by approximately 14% for all subjects. Ejection fraction estimates obtained with the semiautomated algorithm agreed well with estimates obtained with manual contours made by experienced radiologists. Intraobserver variability was low for both the short-axis (3%) and biplane (4%) methods. However, interobserver variability of the biplane method (12%) exceeded that of the short-axis method (4%). Interexamination variability (9%) was the largest factor in determining the reproducibility of the ejection fraction estimates. Breath-hold dark-blood MR imaging technique with simultaneous acquisition of a series of short-axis views during systolic and diastolic phases permits rapid and accurate estimates of ejection fractions in healthy subjects and in patients. Model based biplane MR imaging methods are less reliable in patients with global cardiomyopathy. The estimation of ejection fractions can be automated using the proposed contouring algorithm and the dark-blood short-axis views.

Global cardiac function using fast breath-hold MRI: validation of new acquisition and analysis techniques.

Calculation of global cardiac function parameters has been validated using fast, segmented k-space, breath-hold, gradient-echo, magnetic resonance images. Images of phantoms, experimental animals, normal volunteers, and patients were acquired with a 1.5 T clinical scanner. Humans were imaged using two phased-array surface coils in multicoil mode. Myocardial contours were extracted using a new interactive, semi-automated method based on the active contour model method. Images were acquired in the short-axis orientation, and, using a new imaging and analysis strategy, in rotating plane long-axis orientations, to provide better definition of the valve planes and the apex, and also to reduce the number of slices (compared with the short-axis method) required to sample the whole heart. Validation was accomplished through calculation of the volumes of phantoms and left and right ventricular masses of animal hearts. Functional parameters from MRI were compared with those from echocardiograms and radionuclide angiograms in normal volunteers and patients, respectively.

Estimation of left ventricular mass in conscious dogs.

The short-axis area-length method for the estimation of left ventricular mass (LVM) and volume was validated in 24 formaldehyde-fixed canine hearts, using the truncated ellipsoid model. Estimates of the short-axis muscle area were highly correlated with directly measured values (R = 0.92; P less than 0.001). Similarly, LVM calculated using the area-length method showed good correlation with the actual weight of the left ventricle (LVW) (R = 0.85; P less than 0.001). When the regression equation was used, retrospectively, to correct the LVM estimates, the correlation between the actual LVW and the calculated LVM was markedly improved (R = 0.96; P less than 0.001). In awake dogs instrumented for measuring transverse and long axis ventricular dimensions using sonomicrometry, short-axis two-dimensional echocardiograms were used to convert the sonar external transverse dimensions to true diameters. The combined use of the corrected diameters and the regression equation to calculate LVM in the intact dog resulted in values that were highly correlated with the actual LVW (R = 0.95; P less than 0.001). Application of this technique for monitoring LVM in awake instrumented dogs demonstrated the method to be reproducible from day to day and to be sensitive enough to detect serial changes in mass such as during the development of left ventricular hypertrophy.