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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Determination of normal gender-specific left atrial dimensions by cardiovascular magnetic resonance imaging.

BACKGROUND: Because cardiovascular magnetic resonance imaging (CMR) is becoming increasingly available in clinical practice, there is a need to establish normal values for left atrial dimensions as determined by this method to allow accurate assessment of cardiac dimensions and to provide standardization for follow up studies. For clinical purpose measurements of the left atrial end diastolic diameter (LAEDD) are most appropriate to assess left atrial size. We aimed to establish normal values for LAEDD using CMR and a fast gradient-echo sequence with steady-state free precession (SSFP). METHODS: A total of 111 healthy subjects (52 women and 59 men, mean age 51.5 +/- 14.5 years) were examined by CMR. Images were acquired using SSFP in the horizontal (HLA) and vertical (VLA) long axis planes and the left ventricular outflow tract plane (LVOT) to measure the LAEDD. RESULTS: Age between men and women was not different (p = 0.7050). CMR yielded the following normal ranges for LAEDD: HLA 4.5 +/- 0.4 cm for men and 4.2 +/- 0.5 for women, VLA 4.5 +/- 0.5 cm for men and 4.2 +/- 0.4 for women, and LVOT 2.8 +/- 0.3 cm for men and 2.8 +/- 0.4 for women. LAEDD were significantly larger in HLA and VLA than in LVOT (p < or = 0.0001). There was no significant difference in the measurements between HLA and VLA (p = 0.4617). Gender-related differences for LAEDD were found in HLA (p = 0.0087) and VLA (p = 0.0015) but not in LVOT (p = 0.5281). LAEDD were not found to be age-related (p > or = 0.0994). CONCLUSIONS: LAEDD differ significantly according to the image plane. We provide reference values for CMR using prospective triggering in the evaluation of left atrial diameters to identify patients with enlarged left atria and for follow-up studies.

How much are atrial volumes and ejection fractions assessed by cardiac magnetic resonance imaging influenced by the ECG gating method?

PURPOSE: 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. MATERIALS AND METHODS: 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. RESULTS: 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). CONCLUSION: 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.

PURPOSE: 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. MATERIALS AND METHODS: 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). RESULTS: 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). CONCLUSION: 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.

How reliable is electrocardiography in differentiating transmural from non-transmural myocardial infarction? A study with contrast magnetic resonance imaging as gold standard.

Cardiovascular magnetic resonance (CMR) using contrast enhancement allows exact determination of the site and transmural extent of myocardial infarction (MI). We evaluated whether 12-lead electrocardiography can differentiate transmural from non-transmural MI or determine the site of MI by comparing the findings with those of contrast-enhanced CMR. A total of 27 patients (59.5+/-12.9 years) with a history of MI (6.4+/-2.9 months) underwent CMR (Magnetom, Siemens, Erlangen, Germany). Cine images were acquired in the horizontal and vertical long axes and short axis by TrueFISP. Contrast-enhanced CMR images were acquired in the same axes by segmented FLASH 15 min after administration of gadolinium-DTPA (0.15 mmol/kg). This showed the MI to be transmural in 11 patients and non-transmural in 16. An electrocardiogram (ECG) was recorded in all patients before CMR. T-wave alterations, descending ST-depression, pathological Q-waves and absent R waves were more frequent in non-transmural MI than transmural MI, as defined by contrast-enhanced CMR (p> or =0.618). However, none of the differences were statistically significant. R-wave reduction, q waves and horizontal ST-depression were more frequent in transmural than in non-transmural MI (p> or =0.157). Again, the differences were not significant. The sensitivity of the ECG for MI localization was highest in inferior infarctions (85.71%), the specificity was highest in anterior infarctions (100%), the best positive predictive value (80%) was achieved for anterolateral infarctions, and the best negative predictive value for lateral infarctions (95.83%). Transmural and non-transmural MI cannot be differentiated by ECG. The ECG is most accurate in detecting anterolateral MI.

Right ventricular wall motion abnormalities found in healthy subjects by cardiovascular magnetic resonance imaging and characterized with a new segmental model.

AIM: To evaluate right ventricular wall motion abnormalities in healthy subjects using a new segmental model for the right ventricle. METHODS AND RESULTS: 29 healthy subjects (9 female, 20 male, mean age 48.9+/-15 years) underwent cardiovascular magnetic resonance imaging (CMR; 1.5-Tesla Sonata, Siemens, Erlangen, Germany) for the evaluation of cardiac function and right ventricular wall motion. A steady-state free precession gradient-echo sequence (TrueFISP) was used. Right ventricular wall motion was analyzed, and the site of areas of disordered motion was classified according to the new segmental model. Such areas were seen in 27 (93.1%) of the 29 subjects. Dyskinesia was found in 22 subjects (75.9%), hypokinesia in 11 (37.9%), and bulging in 8 (27.6%). The number of wall motion abnormalities diagnosed was significantly higher in the transverse plane (86.2%) than in the short-axis plane (13.8%) and the horizontal longitudinal plane (41.4%; p = 0.000). CONCLUSION: Right ventricular wall motion abnormalities are one of the criteria for the diagnosis of arrhythmogenic right ventricular cardiomyopathy. However, our findings indicate that they may also be seen around the insertion of the moderator band in healthy subjects, so that the significance of their presence at this site in patients undergoing diagnostic investigations for this disease should be interpreted with caution.

Single and biplane TrueFISP cardiovascular magnetic resonance for rapid evaluation of left ventricular volumes and ejection fraction.

INTRODUCTION: Cardiovascular magnetic resonance (CMR) allows very accurate, but time-consuming, volume assessment by the short-axis slice summation technique. The single and biplane methods of volume assessment are used less, partly because FLASH cine imaging provides poor blood-myocardium contrast in long-axis views. TrueFISP gives excellent blood-myocardium contrast, even in patients with heart failure. We hypothesized that the single plane and biplane methods of volume assessment in TrueFISP images might provide an acceptable degree of accuracy and be quicker than the short axis method, and that single and biplane left ventricular volume assessment would be more accurate with TrueFISP than with FLASH in patients with impaired ventricular function. METHODS: Short- and long-axis CMR images were obtained by FLASH and TrueFISP with a 1.5-T scanner. We determined the accuracy of both single and biplane long-axis methods for left ventricular volume and ejection fraction (EF) measurements compared with the conventional short-axis method in 10 heart failure patients using both FLASH and TrueFISP and in 9 healthy subjects using TrueFISP. RESULTS: No difference in volumes and EF was found between the single plane method, the biplane method, and the short-axis method using TrueFISP for image acquisition, in both patients and healthy subjects. The same was true of the results obtained by FLASH in the patients with heart failure. CONCLUSIONS: The single and biplane methods, regardless of whether TrueFISP or FLASH is used, are a reasonable and rapid alternative to the conventional short-axis approach for left ventricular volume and EF assessment in patients with heart failure and impaired ventricular function.

Impact of papillary muscles in ventricular volume and ejection fraction assessment by cardiovascular magnetic resonance.

Cardiovascular magnetic resonance (CMR) is an accurate tool for the determination of right and left ventricular volumes and ejection fractions. However, the current standard short-axis technique is time-consuming and thus, often not practicable for routine daily use, because papillary muscles and trabeculations have to be marked and their volumes subtracted from the total ventricular volume. To reduce calculation time we evaluated the volumetric data that included papillary muscle and trabecular volumes and compared the outcome with the results of the standard technique. Thirty patients (17 healthy, 13 with coronary heart disease) were examined by CMR using TrueFISP (Magnetom, Siemens, Erlangen, Germany). Right and left ventricular volumes and ejection fractions were calculated using the standard short-axis technique and then again without subtracting papillary and trabecular volumes. The two methods were compared by determining the differences in results for ventricular volumes and ejection fractions. Statistically significant differences were found between the two methods for right and left ventricular stroke volumes and end-systolic volumes, and left ventricular end-diastolic volumes (EDV) (p < or = 0.011). No significant difference was found for right ventricular end-diastolic volumes (p > or = 0.149) or left or right ventricular ejection fraction (p > or = 0.130). Except in the case of left ventricular EDV, the deviations in the results of method 1 and method 2 did not vary significantly with the presence or absence of heart disease. Measurements were obtained considerably more quickly with the modified method than with the standard short-axis method (25 +/- 4 min vs. 13 +/- 3 min, p = 0.000). Although systematic differences were found when papillary and trabecular volumes were not subtracted, these differences are small and may not be of clinical relevance in healthy subjects or patients with coronary heart disease. Not subtracting the volumes of these structures enables faster determination of right and left ventricular volumes and ejection fractions without loss of the accuracy associated with the standard short-axis technique.