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• W2023606650 abstract "Table of contentsI. INTRODUCTIONII. TECHNIQUES IN CARDIOVASCULAR ULTRASOUNDTwo-Dimensional EchocardiographyM-Mode EchocardiographyDoppler Echocardiography and Color Flow ImagingStress EchocardiographyTransesophageal EchocardiographyThree-Dimensional EchocardiographyContrast EchocardiographyDigital Acquisition and StorageIII. ANATOMIC AND FUNCTIONAL QUANTITATION OF CARDIAC CHAMBERSLV Linear Dimension and Wall ThicknessLV Volumes and EFProlate-EllipseArea-Length and Truncated EllipsoidMethod of DiscsMethod of Multiple DiametersLV MassReproducibilityLV Systolic FunctionEjection FractionReproducibilitySegmental LV FunctionTissue Doppler Mitral Annular Systolic VelocityMidwall Fractional Shortening/LV Systolic Stress RelationshipPitfalls in LV Quantitation and Strategies for Obtaining Quantifiable ImagesRecommendations for Measurement of LV Volumes, EF, Segmental Wall Motion, and LV Mass LV Volumes and EF Segmental LV Function LV MassDiastolic LV FunctionMitral Inflow VelocitiesPulmonary Venous FlowTissue Doppler Measurement of Mitral Annular VelocityColor M-Mode Flow Propagation VelocityReproducibilityRecommendations for Assessment of Diastolic FunctionRight Ventricular Mass, Function, and PressureLeft Atrial Size, Volume, and Function Reproducibility Recommendations for Measurement ofLA SizeIV. VALVULAR STRUCTURE AND FUNCTIONReproducibilityRecommendations for Assessment of Valvular Structure and FunctionV. RELATED TECHNIQUES IN CARDIOVASCULAR RESEARCHIntravascular and Intracoronary UltrasoundReproducibilityRecommendations for Performance of IVUS and ICUSFlow-Mediated Brachial Arterial Dilation Assessment of Endothelial FunctionReproducibilityRecommendations for Assessment of FMD With Brachial UltrasoundCarotid Artery Imaging in Cardiovascular Clinical Trials—Measurement of Intima-Media ThicknessReproducibilityRecommendations for Measurement of CIMTVI. APPLICATIONS OF ECHOCARDIOGRAPHY IN CLINICAL TRIALSEpidemiological and Observational StudiesHypertensionEvaluation of Treatment Effects on LV MassEffects of Treatment of Systolic and Diastolic LV FunctionIntercenter Differences in Acquisition QualityRecommendations for Echocardiography in Hypertension Clinical TrialsHeart FailureResynchronization/Biventricular Pacing Studies in Heart FailureWhat to Measure With Echocardiography in Heart Failure TrialsRecommendations for Echocardiography in Heart Failure StudiesMyocardial InfarctionClinical Trials With TEE: Stroke, Atrial Fibrillation, and Guidance of Interventional ProceduresClinical Trials in Atrial Fibrillation: TEE-Guided CardioversionLA Appendage Closure DevicesPFO Closure DevicesRecommendations for TEE-Guided Clinical TrialsProsthetic ValvesEvaluating Prosthetic Aortic and Pulmonic ValvesEvaluating Prosthetic Mitral and Tricuspid ValvesRecommendations for Echocardiography in Assessment of Prosthetic ValvesEchocardiographic Assessments of Cardiac Toxicity: Opportunity and ChallengeRecommendationsCommercial vs Noncommercial Studies: Influence on Trial Design, Data Interpretation, and PublicationRecommendations for Echocardiographer-Investigator Participation in Clinical TrialsVII. HOW TO EVALUATE AND CONTROL ECHO VARIABILITY IN CLINICAL TRIALS: METHODS FOR QUALITY CONTROLMethods to Limit Measurement VariabilityEquipmentSite TrainingCore LaboratorySonographer TrainingVIII. SUMMARY AND RECOMMENDATIONS FOR USE OF CARDIOVASCULAR ULTRASOUND IN CLINICAL TRIALSList of tablesTable 1. Major Applications of Echocardiography in Clinical TrialsTable 2. Echocardiographic Measures of Diastolic FunctionTable 3. Recommendations for Echocardiography in Clinical Trials of HypertensionTable 4. Summary of Selected Trials With Ultrasound Measurements of Carotid Intima-Media Thickness as a Surrogate for AtherosclerosisTable 5. Echocardiography in Epidemiological StudiesTable 6. Selected Multicenter Treatment Trials in Hypertension With EchocardiographyTable 7. Echocardiography in Clinical Trials of Congestive Heart FailureTable 8. Commonly Used Echocardiography Measures in Heart Failure TrialsTable 9. Echocardiography in Clinical Trials of StrokeTable 10. Recommendations for Use of All Cardiac Ultrasound Techniques in Multicenter Clinical TrialsI. IntroductionEchocardiography is one of the most commonly performed noninvasive diagnostic tests in patients with known or suspected cardiovascular diseases. Echocardiography provides comprehensive evaluation of the cardiovascular structure, function, and hemodynamics that characterize disease processes (readers are referred to published ACC/AHA/ASE guidelines1Quinones M.A. Douglas P.S. Foster E. et al.ACC/AHA clinical competence statement on echocardiography: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on clinical competence.J Am Soc Echocardiogr. 2003; 16: 379-402Abstract Full Text Full Text PDF PubMed Google Scholar, 2Cahalan M.K. Stewart W. Pearlman A. et al.American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography.J Am Soc Echocardiogr. 2002; 15: 647-652Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 3Gardin J.M. Adams D.B. Douglas P.S. et al.Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography's Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography Report.J Am Soc Echocardiogr. 2002; 15: 275-290Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar, 4Quinones M.A. Otto C.M. Stoddard M. Waggoner A. Zoghbi W.A. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography.J Am Soc Echocardiogr. 2002; 15: 167-184Abstract Full Text Full Text PDF PubMed Google Scholar, 5Ehler D. Carney D.K. Dempsey A.L. et al.Guidelines for cardiac sonographer education: recommendations of the American Society of Echocardiography Sonographer Training and Education Committee.J Am Soc Echocardiogr. 2001; 14: 77-84Abstract Full Text PDF PubMed Google Scholar, 6Shanewise J.S. Cheung A.T. Aronson S. et al.ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.J Am Soc Echocardiogr. 1999; 12: 884-900Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar, 7Armstrong W.F. Pellikka P.A. Ryan T. Crouse L. Zoghbi W.A. Stress echocardiography: recommendations for performance and interpretation of stress echocardiography: Stress Echocardiography Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography.J Am Soc Echocardiogr. 1998; 11: 97-9104Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar, 8Cheitlin M.D. Alpert J.S. Armstrong W.F. et al.ACC/AHA guidelines for the clinical application of echocardiography: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Application of Echocardiography): developed in collaboration with the American Society of Echocardiography.Circulation. 1997; 95: 1686-1744Crossref PubMed Google Scholar, 9American Society of EchocardiographyRecommendations for continuous quality improvement in echocardiography.J Am Soc Echocardiogr. 1995; 8: S1-28Abstract Full Text PDF PubMed Google Scholar, 10Pearlman A.S. Gardin J.M. Martin R.P. et al.Guidelines for physician training in transesophageal echocardiography: recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography.J Am Soc Echocardiogr. 1992; 5: 187-194PubMed Google Scholar for an overview on clinical aspects of echocardiography). Moreover, there are no known side effects associated with echocardiography, even with frequent and repeat testing. Its real-time nature, portability, and relatively low cost make echocardiography adaptable to most clinical or research situations. Hence, echocardiography has been used successfully to provide mechanistic insights on therapeutic outcomes, and in some cases to measure functional and structural changes that are considered to be of therapeutic importance (ie, “surrogate” end points).New advances in echocardiography bring increased opportunity and enormous potential to evaluate the cardiac effects of disease and its treatment repetitively and noninvasively in clinical trials (Table 1). Although many clinical studies have been performed to evaluate echocardiographic techniques per se, these are not the focus of this report. The purpose of this communication is to discuss the utility of echocardiography in enhancing the value of clinical trials by identifying potential mechanisms of clinical end points and determining surrogate end points and to offer recommendations regarding its use. In addition to physicians with expertise in echocardiography, this document is intended for project officers and others working with government or industrial sponsors who may not be familiar with echocardiography but need an in-depth overview of the types of information that can be provided by echocardiography and related techniques in clinical research.Table 1Major applications of echocardiography in clinical trials1. Epidemiology and genetics Define cardiac structural and functional phenotype. Identify cardiac parameters of prognostic significance.2. Hypertension Measure LV mass and assess systolic and diastolic cardiac function. Assess effects of treatment on cardiac structure and function.3. Prosthetic valves Assess prosthetic valve hemodynamics; required by FDA.4. Myocardial infarction and coronary artery disease Assess disease impact on LV remodeling and LV function. Use of stress echocardiography to determine ischemic vulnerability, viability, functional capacity. Assess effects of interventions on cardiac structure and function.5. Heart failure Assess LV systolic and diastolic function, LV remodeling, comorbidity (eg, mitral regurgitation, pulmonary hypertension). Patient selection for device therapy. Assess treatment effects, including reverse remodeling.6. Noncardiovascular trials Assess potential cardiac toxicity of treatment of disease, eg, cancer (radiation, chemotherapy), diabetes (glitazones).7. Miscellaneous Diet-drug valvulopathy, echocardiographic contrast agents, TEE-guided cardioversion, atrial fibrillation, interventional device trials, cardiac surgery trials.FDA, Food and Drug Administration; LV, left ventricular; TEE, transesophageal echocardiography. Open table in a new tab As with other diagnostic techniques, the various sources of acquisition and measurement variability need to be considered in the application of cardiovascular ultrasound to clinical research. Data are presented in the following sections on reproducibility of echocardiography; however, diagnostic reproducibility and accuracy may vary according to the clinical or research context in which echocardiography is used. The importance of determining reproducibility for specific laboratories, readers, clinical trials, and potential changes over time is discussed later in this document.II. Techniques in cardiovascular ultrasoundThe cardiovascular ultrasound examination (“echocardiography”) offers several imaging and hemodynamic modalities.Two-dimensional echocardiographyTwo-dimensional (2D) echocardiography is the backbone of echocardiography. By displaying anatomic structures in real-time tomographic images, comprehensive visualization of the components of the beating heart is achieved. The distance of ultrasound echoes along the vertical axis represents the depth of echo-producing structures, with brightness indicating the intensity of the returning echo. The examiner is required to obtain multiple, precisely oriented anatomic “slices” by aiming an ultrasound probe at the heart (cross-sectional scanning). Information regarding cardiac chamber size, wall thickness, global and regional systolic function, and valvular and vascular structures is readily available. B-mode imaging refers to cross-sectional 2D images displayed without motion. Such images can provide excellent detail of static structures and are used in vascular imaging to show high-resolution detail of atherosclerotic plaque and vascular structure.M-mode echocardiographyM-mode or motion-mode images are a continuous 1-dimensional graphic display that can be derived by selecting any of the individual sector lines from which a 2D image is constructed. M-mode echocardiography is useful for quantitating single dimensions of walls and chambers, which can be used to estimate chamber volumes and left ventricular (LV) mass when those structures are geometrically uniform. M-mode echocardiography also has high temporal resolution, which makes it useful for timing valve motion.Doppler echocardiography and color flow imagingThe Doppler technique uses reflections from moving red blood cells to characterize blood flow in the central and peripheral circulation. Doppler echocardiography complements M-mode and 2D echocardiography by providing functional information regarding intracardiac hemodynamics, including systolic and diastolic flow, blood velocities and volumes, severity of valvular lesions, location and severity of intracardiac shunts, and assessment of diastolic function. There are 4 types of Doppler: pulsed-wave, continuous-wave, color flow mapping, and tissue Doppler. Pulsed-wave Doppler is useful for localizing and timing flow that is moving within the physiological range of velocities. Continuous-wave Doppler, which lacks spatial resolution, is useful for accurately measuring the gradients that drive pathological flow jets. Color flow mapping, by measuring velocity along each sector line of the 2D image and displaying the information as color-coded pixels, provides a composite picture of flow over a larger area; it is most useful for screening the valves for regurgitation and stenosis, imaging systolic and diastolic flow, detecting the presence of intracardiac shunts, and detecting coronary flow. Tissue Doppler detects the amplitude and phases of the relatively slow motion of the LV myocardium (usually at the base of the heart). It is useful as a means of studying diastolic function. Strain rate imaging11Edvardsen T. Gerber B.L. Garot J. Bluemke D.A. Lima J.A. Smiseth O.A. Quantitative assessment of intrinsic regional myocardial deformation by Doppler strain rate echocardiography in humans: validation against three-dimensional tagged magnetic resonance imaging.Circulation. 2002; 106: 50-56Crossref PubMed Scopus (301) Google Scholar, 12Hoffmann R. Altiok E. Nowak B. et al.Strain rate measurement by Doppler echocardiography allows improved assessment of myocardial viability in patients with depressed left ventricular function.J Am Coll Cardiol. 2002; 39: 443-449Abstract Full Text Full Text PDF PubMed Scopus (148) Google Scholar, 13Belohlavek M. Bartleson V.B. Zobitz M.E. Real-time strain rate imaging: validation of peak compression and expansion rates by a tissue-mimicking phantom.Echocardiography. 2001; 18: 565-571Crossref PubMed Google Scholar, 14Abraham T.P. Nishimura R.A. Holmes D.R. Belohlavek M. Seward J.B. Strain rate imaging for assessment of regional myocardial function: results from a clinical model of septal ablation.Circulation. 2002; 105: 1403-1406Crossref PubMed Scopus (92) Google Scholar is a relatively new technique in echocardiography of potential utility for evaluation of systolic and diastolic LV function. This modality records myocardial tissue velocities to provide information about rates of local compression and expansion, and in contrast to endocardial excursion, it is free of tethering by adjacent myocardial segments.Stress echocardiography7Armstrong W.F. Pellikka P.A. Ryan T. Crouse L. Zoghbi W.A. Stress echocardiography: recommendations for performance and interpretation of stress echocardiography: Stress Echocardiography Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography.J Am Soc Echocardiogr. 1998; 11: 97-9104Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar, 15Voight J.U. Exner B. Schmiedehausen K. Huchzermeyer C. Reulbach U. Nixdorff U. Strain-rate imaging during dobutamine stress echocardiography provides objective evidence of inducible ischemia.Circulation. 2003; 107: 2120-2126Crossref PubMed Scopus (199) Google Scholar, 16Gottdiener J.S. Overview of stress echocardiography: uses, advantages, and limitations.Prog Cardiovasc Dis. 2001; 43: 315-334Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 17Krivokapich J. Child J.S. Walter D.O. Garfinkel A. Prognostic value of dobutamine stress echocardiography in predicting cardiac events in patients with known or suspected coronary artery disease.J Am Coll Cardiol. 1999; 33: 708-716Abstract Full Text Full Text PDF PubMed Scopus (75) Google ScholarA stress echocardiogram7Armstrong W.F. Pellikka P.A. Ryan T. Crouse L. Zoghbi W.A. Stress echocardiography: recommendations for performance and interpretation of stress echocardiography: Stress Echocardiography Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography.J Am Soc Echocardiogr. 1998; 11: 97-9104Abstract Full Text Full Text PDF PubMed Scopus (272) Google Scholar uses any combination of the above echocardiography modalities, before and during (or shortly after) a physical or pharmacological stress intervention. Most commonly, a treadmill or exercise bicycle is used for exercise echocardiography. Alternatively, in patients who are unable to exercise, stress testing can be performed with pharmacological agents that increase myocardial oxygen demand (eg, dobutamine, often given with atropine) or vasodilators that produce coronary steal. These tests may have utility primarily in the detection of myocardial ischemia and viability but may also be used to assess the efficacy of coronary revascularization or antianginal medication. Special interventions such as isometric handgrip, cold pressor (immersion of the hand in ice water), mental stress tasks, and cardiac pacing have also been used in some research applications. Hemodynamic changes with stress can be assessed by Doppler. Overall, the sensitivity and specificity of stress echocardiography for detection of coronary disease has been comparable to that of nuclear scintigraphy, and stress echocardiography has had excellent prognostic value for prediction of clinical outcome.16Gottdiener J.S. Overview of stress echocardiography: uses, advantages, and limitations.Prog Cardiovasc Dis. 2001; 43: 315-334Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarTransesophageal echocardiographyTransesophageal echocardiography (TEE) uses a miniature ultrasound probe mounted at the end of an endoscope. A physician inserts the probe into the esophagus and performs the examination while a nurse monitors the patient and administers sedative medications. Two-dimensional, M-mode, and Doppler techniques are performed during a TEE examination. TEE has the advantages of generally superior image quality to 2D echocardiography and better imaging of selected structures such as the left atrial (LA) appendage, pulmonary veins, and mitral regurgitant jets in patients with prosthetic mitral valves. However, TEE may be of limited utility in clinical trials because of its semi-invasive nature and added requirements for equipment and personnel. Nonetheless, in the STICH (Surgical Treatments for Ischemic Heart Failure) trial,18Joyce D. Loebe M. Noon G.P. et al.Revascularization and ventricular restoration in patients with ischemic heart failure: the STICH trial.Curr Opin Cardiol. 2003; 18: 454-457Crossref PubMed Scopus (39) Google Scholar TEE is being used for assessment of mitral valve structure and regurgitation. TEE has been used successfully in clinical trials during surgery to evaluate and monitor cardiac function and in trials of atrial fibrillation treatment and closure of patent foramen ovale (PFO).Three-dimensional echocardiographyThree-dimensional (3D) echocardiography provides displays of cardiac structures or flow and offers the display of any 2D imaging plane within the 3D data set.19Rodevand O. Bjornerheim R. Aakhus S. Kjekshus J. Left ventricular volumes assessed by different new three-dimensional echocardiographic methods and ordinary biplane technique.Int J Card Imaging. 1998; 14: 55-63Crossref PubMed Scopus (16) Google Scholar Three-dimensional echocardiography can be performed in 2 ways: real-time acquisition or sequential acquisition and reconstruction of multiple 2D planes into a 3D model with a locator device. Real-time 3D technology has recently been introduced clinically and is currently being refined. Disadvantages of the non–real-time technique include nonsimultaneous acquisition and significant postacquisition reconstruction time. In clinical trials, 3D echocardiography offers the potential of improved quantitation of cardiac volumes and LV mass, which leads to greater accuracy, sensitivity, and reduced sample size.Contrast echocardiographyCommercially available contrast agents can be administered via venous injection to enhance the diagnostic quality of the echocardiogram.20Mulvagh S.L. De Maria A.N. Feinstein S.B. et al.Contrast echocardiography: current and future applications.J Am Soc Echocardiogr. 2000; 13: 331-342Abstract Full Text Full Text PDF PubMed Google Scholar Currently, contrast agents are only approved by the Food and Drug Administration (FDA) for LV opacification, although many clinical studies have evaluated their use to assess myocardial perfusion. Venous contrast injections are used to enhance LV endocardial borders and Doppler signals and to assess myocardial perfusion. The use of contrast may permit utilization of technically difficult studies and increase the yield of 2D echocardiography for assessment of global and segmental LV function. This advantage must be balanced against the expense, inconvenience, and need for an intravenous line.Digital acquisition and storageClinical echocardiography is quickly moving from analogue videotape to digital acquisition and storage, and it is anticipated that multicenter clinical trials will also move in a similar direction. Digital acquisition and storage has many advantages in clinical trials, including high image quality, reproduction of images without loss of information, and long-term storage and transportability. Another important advantage is the ability to link study sites to core laboratories via the Internet or secure servers, with virtually no concern about geographic distance. In addition to elimating the mailing costs of physical media and reducing missing data, this facilitates rapid qualification of studies, quality control, and rapid data turnover. With digital acquisition, it is necessary to ensure that representative beats are obtained. Media used to transport the images (eg, compact disc, DVD, or magneto-optical disc) must be standardized so both the acquisition sites and central laboratory can view the images and calibration information.III. Anatomic and functional quantitation of cardiac chambersLV linear dimensions and wall thicknessThese fundamental measurements are used for almost all clinical trials that incorporate echocardiography. Linear dimensions are obtainable from correctly aligned 2D and M-mode images. M-mode recordings provide better temporal resolution for accurate timing of motion of cardiac walls and valves, whereas 2D provides better spatial orientation. From LV chamber internal dimensions in diastole and systole, LV ejection fraction (EF) and fractional shortening can be readily determined, and the addition of wall thickness allows derivation of LV mass.LV volumes and EFThe use of single dimensions to accurately reflect volumes and global LV function requires symmetrical geometry and contraction of the LV, respectively, to minimize error. LV volume is one of the best prognostic parameters in patients after myocardial infarction and is a prerequisite for calculation of EF (the difference between end-diastolic and end-systolic volumes divided by end-diastolic volume), as well as LV mass (see below). Because 2D echocardiography is a tomographic technique, the slices it creates must be converted mathematically to volumes by one or more of several methods based on geometric models of the LV. These methods have been validated21Feigenbaum H. Popp R.L. Wolfe S.B. et al.Ultrasound measurements of the left ventricle: a correlative study with angiocardiography.Arch Intern Med. 1972; 129: 461-467Crossref PubMed Google Scholar, 22Folland E.D. Parisi A.F. Moynihan P.F. Jones D.R. Feldman C.L. Tow D.E. Assessment of left ventricular ejection fraction and volumes by real-time, two-dimensional echocardiography: a comparison of cineangiographic and radionuclide techniques.Circulation. 1979; 60: 760-766Crossref PubMed Google Scholar, 23Erbel R. Krebs W. Henn G. et al.Comparison of single-plane and biplane volume determination by two-dimensional echocardiography, 1: asymmetric model hearts.Eur Heart J. 1982; 3: 469-480PubMed Google Scholar; the accuracy of the prolate-ellipse, area-length, and truncated ellipsoid methods is limited to normally shaped and sized ventricles, whereas the biplane method of discs is accurate in abnormally shaped ventricles. Three-dimensional echocardiography methods are less geometry-dependent than 2D and may supplant 2D methods in the future.Prolate-ellipseThe so-called cube formula is based on a model of the LV as a prolate ellipse of revolution where V = 4/3 π L/2 × D1/2 × D2/2, where D1 and D2 are orthogonal minor axes; L is the long axis, which equals 2 × D; and D1 = D2. Hence, the volume approximates D3, which has been taken as the single linear dimension representing the short axis of the LV at the tips of the mitral valve.Area-length and truncated ellipsoidThe area-length formula (so-called bullet formula) for LV volumes (V = 5/6 AL, where A = LV short-axis area and L = LV long axis) assumes a bullet shape of the LV. The truncated ellipsoid formula assumes that the ventricle resembles a truncated ellipsoid. Both methods use the parasternal cross-sectional short-axis image at the level of the papillary muscles. Similar to volumes obtained from linear dimensions, these methods are also subject to error in the case of distortions of LV geometry. In patients in whom only a low parasternal window can be obtained, the short-axis view will distort LV geometry, resulting in gross overestimation of LV volume by either of these formulas. In these patients, it is better to use the prolate-ellipse formula with linear dimensions taken from anatomically correctly oriented apical views or a parasternal long-axis view, with care taken to obtain the minor dimension perpendicular to the long axis, which will be angulated on the monitor screen.Correct alignment of short-axis images (for the 2D bullet formula) is characterized by a circular image just at the level of minimal motion of the mitral valve structures (indicating a level between mitral tips and chordae tendineae). Linear dimensions from 2D-targeted M-mode echocardiography should be derived through the center of this circular image, whereas optimal 2D linear dimensions (for cavity and walls) are obtained perpendicular to the septum and posterior wall in the parasternal long-axis view that shows the largest LV cavity area.Method of discs (Simpson's Rule)This method summates volumes of multiple cylinders of equal height along the LV. It is the most useful in obtaining LV cavity volumes in the presence of distorted LV geometry. However, a technical trade-off is incurred, because apical views (preferably paired biplane views) of the LV must be used. These views, which image the LV endocardium in lateral (poor, relative to axial) resolution, generally result in larger LV cavity volumes than the parasternal short-axis view required by the bullet formula, which images the LV endocardium mostly in axial (good) resolution. Moreover, it is sometimes difficult to identify the epicardial contour with certainty. Myocardial areas and derived volumes can be subject to substantial error. Hence, this method is not optimal for measurement of LV mass.Method of multiple diametersLV EF and volumes can also be measured by the multiple diameter method,24Quinones M.A. Waggoner A.D. Reduto L.A. et al.A new, simplified and accurate method for determining ejection fraction with two-dimensional echocardiography.Circulation. 1981; 64: 744-753Crossref PubMed Google Scholar, 25Tortoledo F.A. Quinones M.A. Fernandez G.C. Waggoner A.D. Winters W.L. Quantification of left ventricular volumes by two-dimensional echocardiography: a simplified and accurate approach.Circulation. 1983; 67: 579-584Crossref PubMed Google Scholar which uses the average of several diameters of the LV measured at end diastole and end systole from the parasternal long-axis and apical views. The diameter method is helpful in situations in which the apical views are suboptimal for adequate tracing of the endocardial contour or if the tomographic plane foreshortens the LV cavity. Its main advantage is incorporation of the parasternal long-axis view, which is available in the majority of patients. This method was applied by the SOLVD (Studies of Left Ventricular Dysfunction) investigators in an evaluation of LV remodeling.26Greenberg B. Quinones M.A. Koilpi" @default.
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