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Computer-assisted determination of left ventricular endocardial borders reduces variability in the echocardiographic assessment of ejection fraction
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences.
Linköping University, Department of Medicine and Health Sciences, Clinical Physiology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Heart Centre, Department of Clinical Physiology.
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2008 (English)In: Cardiovascular Ultrasound, ISSN 1476-7120, Vol. 6, no 55Article in journal (Refereed) Published
Abstract [en]

Background: Left ventricular size and function are important prognostic factors in heart disease. Their measurement is the most frequent reason for sending patients to the echo lab. These measurements have important implications for therapy but are sensitive to the skill of the operator. Earlier automated echo-based methods have not become widely used. The aim of our study was to evaluate an automatic echocardiographic method (with manual correction if needed) for determining left ventricular ejection fraction (LVEF) based on an active appearance model of the left ventricle (syngo (R) AutoEF, Siemens Medical Solutions). Comparisons were made with manual planimetry (manual Simpson), visual assessment and automatically determined LVEF from quantitative myocardial gated single photon emission computed tomography (SPECT).

Methods: 60 consecutive patients referred for myocardial perfusion imaging (MPI) were included in the study. Two-dimensional echocardiography was performed within one hour of MPI at rest. Image quality did not constitute an exclusion criterion. Analysis was performed by five experienced observers and by two novices.

Results: LVEF (%), end-diastolic and end-systolic volume/BSA (ml/m(2)) were for uncorrected AutoEF 54 +/- 10, 51 +/- 16, 24 +/- 13, for corrected AutoEF 53 +/- 10, 53 +/- 18, 26 +/- 14, for manual Simpson 51 +/- 11, 56 +/- 20, 28 +/- 15, and for MPI 52 +/- 12, 67 +/- 26, 35 +/- 23. The required time for analysis was significantly different for all four echocardiographic methods and was for uncorrected AutoEF 79 +/- 5 s, for corrected AutoEF 159 +/- 46 s, for manual Simpson 177 +/- 66 s, and for visual assessment 33 +/- 14 s. Compared with the expert manual Simpson, limits of agreement for novice corrected AutoEF was lower than for novice manual Simpson (0.8 +/- 10.5 vs. -3.2 +/- 11.4 LVEF percentage points). Calculated for experts and with LVEF (%) categorized into < 30, 30-44, 45-54 and >= 55, kappa measure of agreement was moderate (0.44-0.53) for all method comparisons (uncorrected AutoEF not evaluated).

Conclusion: Corrected AutoEF reduces the variation in measurements compared with manual planimetry, without increasing the time required. The method seems especially suited for unexperienced readers.

Place, publisher, year, edition, pages
2008. Vol. 6, no 55
National Category
Medical and Health Sciences
URN: urn:nbn:se:liu:diva-16221DOI: 10.1186/1476-7120-6-55OAI: diva2:133465
Available from: 2009-02-19 Created: 2009-01-09 Last updated: 2009-08-19Bibliographically approved
In thesis
1. Noninvasive Evaluation of Myocardial Ischemia and Left Ventricular Function
Open this publication in new window or tab >>Noninvasive Evaluation of Myocardial Ischemia and Left Ventricular Function
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general aim of this thesis was, following the path of the ischemic cascade, to evaluate the feasibility of some new non-invasive techniques for the detection of myocardial ischemia, the extent of infarcted myocardium, and for the quantification of systolic left ventricular function.

Reduced longitudinal myocardial velocity and displacement may be early signs of ischemia. We evaluated the diagnostic sensitivity and specificity of pulsed tissue Doppler for the detection of ischemia and scar during dobutamine stress testing and compared it with myocardial perfusion scintigraphy (SPECT) in patients with a history of unstable angina. Pulsed tissue Doppler was useful for objective quantification of left ventricular longitudinal shortening and for differentiation between patients with a normal, ischemic or necrotic myocardium.

The coronary flow velocity reserve (CFVR) of the left anterior descending artery (LAD) was studied with transthoracic Doppler echocardiography (TTDE) during adenosine stress. Patients with a clinical suspicion of stress induced myocardial ischemia were investigated, and the results were compared with the findings from SPECT. A CFVR >2 in the LAD could exclude significant coronary artery disease in a clinical setting, however, in cases with low CFVR, multiple cardiovascular and metabolic risk factors as well as epicardial coronary artery disease or microvascular dysfunction might be responsible. TTDE is a promising tool, e.g. for follow-up after coronary interventions or for evaluating endothelial function over time.

A third study focused on the importance of accurate and reproducible measurements of left ventricular volumes and ejection fraction (LVEF). Patients with known or suspected coronary artery disease with different levels of LVEF were enrolled. We compared the LVEF determined with an automatic echocardiographic method with manual planimetry, visual assessment of LVEF and with quantitative myocardial gated SPECT. The software using learned pattern recognition and artificial intelligence (AutoEF) applied on biplane apical echocardiographic views reduced the variation in measurements without increasing the time required. The method seems to be able to reduce variation in the assessment of LVEF in clinical patients, especially for less experienced readers.

We evaluated a new feature tracking software for its ability to detect infarcted myocardium on cine-MR images. Patients were selected based on the presence or absence of myocardial scar in the perfusion area of the LAD. The software tracked myocardial wall motion and allowed the calculation of velocity, displacement and strain in radial and longitudinal directions. Feature tracking of cine-MR images detected scar segments with transmurality >50% within the distribution of the LAD with 80% sensitivity and 86% specificity (radial strain), without the need for the administration of gadolinium-based contrast.

In summary, we have evaluated some of the noninvasive techniques in the wide array of diagnostic tools available for the diagnosis of ischemic heart disease. Their availability, low costs, freedom from radiation and repeatability are essential as well as their diagnostic ability.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2009. 74 p.
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1109
National Category
Medical and Health Sciences
urn:nbn:se:liu:diva-18315 (URN)978-91-7393-675-0 (ISBN)
Public defence
2009-05-27, Aulan, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Available from: 2009-05-18 Created: 2009-05-18 Last updated: 2009-08-21Bibliographically approved

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Maret, EvaBrudin, LarsLindström, LenaNylander, EvaEngvall, Jan
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