Assessments of Right Ventricular Volume and Function Using Three-Dimensional Echocardiography in Older Children and Adults With Congenital Heart Disease: Comparison With Cardiac Magnetic Resonance Imaging

doi:10.1016/j.echo.2009.08.011

Journal of the American Society of Echocardiography

Volume 22, Issue 11, November 2009, Pages 1279-1288

https://doi.org/10.1016/j.echo.2009.08.011 Get rights and content

Background

The utility of three-dimensional echocardiography (3DE) for right ventricular (RV) assessment is uncertain in older children and adults with congenital heart disease (CHD), in whom the right ventricle is often dilated and dysfunction is common.

Methods

RV assessments using 3DE were compared with manual tracing and automated border detection (ABD) with magnetic resonance imaging (MRI) as the reference method. Twenty-eight of 54 consecutive patients (52%; median age, 17 years) with CHD had adequate three-dimensional echocardiographic data sets for analysis.

Results

There were wide ranges of RV size (mean RV end-diastolic volume index, 143 ± 43 mL/m²) and function (mean RV ejection fraction [EF], 48 ± 10%) on MRI. End-diastolic volume was underestimated on 3DE by 20% (P < .001) and to a greater degree in larger ventricles (P < .001). There was no significant difference in EF measurements between 3DE methods and MRI except for ABD (−2.6 ± 6, P = .03). The mean analysis time for ABD was 5 minutes, compared with 19 minutes for manual tracing (P < .0001).

Conclusion

Approximately half the patients with CHD had adequate three-dimensional echocardiographic images. Three-dimensional echocardiography accurately estimated EF but underestimated volume, particularly when the right ventricle was dilated. ABD minimally underestimated EF but offered a significant reduction in analysis time.

Section snippets

Study Design

We recruited 54 consecutive patients with CHD who were referred for cardiac MRI on the basis of clinical indications. Three-dimensional echocardiography was performed within 2 hours of MRI to minimize any change in hemodynamic status. Height and weight were measured, and demographic data, including age, cardiac lesions, and previous surgical procedures, were obtained from medical records. All patients were in sinus rhythm and had biventricular physiology. This study was approved by the relevant

Feasibility

A total of 54 patients (31 male; median age, 17 years; range, 9-75 years) were enrolled in the study. All patients had CHD: 24 (44%) had undergone repair of tetralogy of Fallot; 5 (9%) had the right ventricle as the systemic ventricle; 9 (17%) had other lesions with significant involvement of the right ventricle, including Ebstein's anomaly, atrial septal defects with pulmonary hypertension, double-chamber right ventricles, and pulmonary atresia with pulmonary homograft; and 16 (30%) had

Discussion

The measurement of RV volume and RVEF using two-dimension echocardiography is unreliable because the RV shape is not accommodated by simple geometric assumptions. Three-dimensional echocardiography may overcome these limitations.2, 18 Early technology for 3DE was cumbersome and time consuming for both acquisition and analysis,7, 8, 9, 10 preventing its routine use in a clinical setting. With the introduction of real-time 3DE, the acquisition of a full-volume data set is rapid and more suited as

Conclusion

Approximately half of the patients with CHD had adequate images for RV analysis. There was no difference between 3DE and MRI for RVEF estimation, but 3DE underestimated RV volume compared with MRI. This underestimation was greater in larger ventricles. The ABD algorithm minimally underestimated RVEF but offered a significant reduction in analysis time.

Acknowledgments

We are indebted to Megan Burrows, cardiac sonographer; Annette Rief, adult CHD nurse practitioner; Mathangi Shanthakumar, statistician; Agustin Okamura, MRI analyst; Congbin Wen, MRI analyst; Sandra Winsor; and Anna Lydon, MRI technician for their contribution and assistance in this project.

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Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
Three-Dimensional Echocardiography Right Ventricular Volumes and Ejection Fraction Reference Values in Children: A North American Multicentre Study
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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.
L’évaluation par échocardiographie tridimensionnelle (E3D) des volumes et de la fraction d’éjection (FE) du ventricule droit (VD) est de plus en plus mise à contribution pour les évaluations séquentielles et la prise en charge cliniques des enfants. Cette étude vise à présenter des valeurs de référence sexospécifiques et des formules de calcul du score z applicables aux paramètres volumétriques du VD, indépendamment de l’âge et des indices de taille corporelle, à partir de données acquises au sein de plusieurs populations en Amérique du Nord.
Nous avons recruté prospectivement 455 enfants et adolescents en bonne santé (âgés de 0 à 18 ans) dans cinq centres. Les images E3D du VD ont été captées à l’aide d’appareils de différents fournisseurs. Leur analyse a été effectuée hors ligne au moyen de logiciels indépendants des fournisseurs. Les ensembles de données E3D permettant de visualiser toutes les parois de l’endocarde du VD ont été retenus. Nous avons consigné les données sur la FE du VD et calculé les scores z des volumes télésystolique (VTS), télédiastolique (VTD) et systolique (VS). Les différences entre les sexes ont été étudiées.
Parmi les 455 ensembles de données E3D examinés, 312 (68 %) répondaient aux critères d’imagerie pour les besoins de notre analyse. L’âge médian était de 10,1 ans (rapport interquartile [RIQ] : 5,6, 14,0); 17 % des sujets avaient moins de 3 ans. L’écart moyen et l’écart type du VTD, du VTS et du VS du ventricule droit ont été consignés chez les patients des deux sexes. Nous avons fourni un calculateur de score z téléchargeable traitant la taille et le poids comme des variables indépendantes à des fins pratiques. Des différences significatives sur le plan statistique entre les garçons et les filles ont été notées au chapitre de la FE du VD (52,9 ± 3,9 % chez les filles vs 51,6 ± 3,5 % chez les garçons, p = 0,006). Toutefois, après correction en fonction de l’âge, de la taille et du poids, ces différences se sont révélées non significatives sur le plan clinique.
Des valeurs de référence sexospécifiques des volumes et de la FE du VD, de même que des formules de calcul du score z, ont été obtenues à partir d’ensembles de données E3D pédiatriques acquises dans cinq centres situés en Amérique du Nord.
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Certain categories of patients (with highly irregular arrhythmias, very enlarged right ventricle, marked obesity, resting dyspnea, chronic obstructive pulmonary disease, with mechanical assist devices or mechanical ventilation, etc.) are particularly challenging for 3D transthoracic echocardiographic acquisition. Overall, the feasibility of 3D TTE for assessing the right ventricle has been reported to be about 85% to 90%37,100,101 and may decrease to 56% in LV assist device recipients102; for the TV, the estimated rates of adequate complete visualization are 85% to 90% for 3D TTE and 65% to 70% for 3D TEE.51 Given its complexity and anterior position in the chest, a combination of 3D TTE with TEE and cardiac computed tomography and/or fluoroscopy, ideally by fusion imaging, is required for a comprehensive evaluation of candidates before TTVI.47
Three-dimensional echocardiography is the only ultrasound technique that offers the ability to image the complex right heart in its complete dimensionality. Over the years, the benefits of three-dimensional echocardiography to improve our understanding of right heart pathologies and ultimately patients' care have emerged from numerous publications. The aims of this review article are to highlight the importance of three-dimensional echocardiography for a more accurate evaluation of the right heart structures, to discuss the most important recent developments in the field and highlight future directions and needs.
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Doppler echocardiography is essential for assessment of hemodynamic assessment such as RV pressure, degree of pulmonary, and tricuspid regurgitation and diastolic dysfunction. 3D echocardiography can be used to quantitate RV volumes; however, the feasibility is low at 55% secondary to poor acoustic windows and challenges in defining the resolution between the endocardium and prominent trabeculations of the RV.18 Despite an underestimation when reconstructing 3D images compared to CMR, it is promising that future developments may enable echocardiography to replace CMR for RV quantification.19
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The echocardiographic assessment of diseases affecting the right ventricle has until recently lagged behind that of the left ventricle, despite knowledge demonstrating that diseases affecting the right heart have been shown to have the same clinical consequences as those affecting the left heart. This chapter will provide an up-to-date review of current echocardiographic methods for assessing right ventricular anatomy and function using m-mode, two-dimensional, three-dimensional, and Doppler echocardiographic techniques.
Validation and Reference Values for Three-Dimensional Echocardiographic Right Ventricular Volumetry in Children: A Multicenter Study
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Functional assessment of the right ventricle using real-time three-dimensional echocardiography (RT3DE) has fundamental relevance in young patients with congenital heart disease. Reference values for the pediatric population are scarce. This multicenter study was designed to (1) validate new evaluation software for RT3DE and (2) establish pediatric reference values.
For validation, right ventricular (RV) end-diastolic volume (EDV) and end-systolic volume (ESV) were determined from real-time three-dimensional echocardiographic data sets of 38 subjects (n = 17 healthy individuals and n = 21 patients with congenital heart disease) using new dedicated evaluation software (RV-Function 2.0) and compared with cardiac magnetic resonance investigations of the same patient cohort. In a prospective multicenter design, 360 real-time three-dimensional echocardiographic data sets of healthy children (172 girls) were analyzed. To create reference centiles, the cohort was subdivided into group I (children <7 years of age, n = 136 [female and male]), group II (girls 7–18 years of age, n = 106), and group III (boys 7–18 years of age, n = 118).
Using RT3DE, RV volumes were slightly higher than using cardiac magnetic resonance (EDV, 0.8 ± 5.8% [limits of agreement, −10.8% to 12.5%; r = 0.993]; ESV, 2.0 ± 13.1% [limits of agreement, −24.2% to 28.2%; r = 0.989). Reproducibility was promising (intraobserver variability, 3.9 ± 11.4% for EDV and −1.7 ± 13.4% for ESV [intraclass correlation coefficient range, 0.94–0.98]; interobserver variability, 1.9 ± 11.8% for EDV and −0.3 ± 22.8% for ESV [intraclass correlation coefficient range, 0.85–0.96]). Regarding functional parameters, no significant gender differences were found among children in group I. In contrast, children in groups II and III differed in RV volumes, dimensional parameters, and tricuspid annular plane systolic excursion (P < .005); the children did not differ in deformation parameters. Feasibility was 90%.
RT3DE yields accurate and reproducible RV volumes. The calculated percentile curves may facilitate the clinical use of RT3DE to analyze RV function in children.

View all citing articles on Scopus

: This study was supported by Project Grant 1250 from the National Heart Foundation of New Zealand (Auckland, New Zealand).

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Clinical InvestigationCongenital Heart DiseaseAssessments of Right Ventricular Volume and Function Using Three-Dimensional Echocardiography in Older Children and Adults With Congenital Heart Disease: Comparison With Cardiac Magnetic Resonance Imaging

Background

Methods

Results

Conclusion

Section snippets

Study Design

Feasibility

Discussion

Conclusion

Acknowledgments

Chest

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Ultrasound Med Biol

J Am Soc Echocardiogr

Cardiol Clin

J Am Coll Cardiol

Relation between right ventricular enlargement, QRS duration, and right ventricular function in patients with tetralogy of Fallot and pulmonary regurgitation after surgical repair

Heart

Estimations of the right ventricular volume and ejection fraction by transthoracic three-dimensional echocardiography

Int J Cardiac Imaging

Comparison of transthoracic three dimensional echocardiography with magnetic resonance imaging in the assessment of right ventricular volume and mass

Heart

Clinical Investigation
Congenital Heart Disease
Assessments of Right Ventricular Volume and Function Using Three-Dimensional Echocardiography in Older Children and Adults With Congenital Heart Disease: Comparison With Cardiac Magnetic Resonance Imaging