Project no. NVKP_16-1&#8211;2016-0017 (&#8217;National Heart Program&#8217;) has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University.

The protocol follows the guidelines of the institution&#39;s human research ethics committee and the patients of the clinical cases gave their written informed consent to the study.
1. Technical requirements
<ol>
	<li>For 3D acquisition and analysis, use appropriate software and hardware. Use ECG cables of the echocardiography device; moreover, it is mandatory for the complete 3D acquisition protocol described below.</li>
	<li>For 3D acquisition, use a 3D echocardiographic probe and 3D-compa...

<ol>
	<li>Edler, I., Lindstrom, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+history+of+echocardiography.">The history of echocardiography.</a> Ultrasound in Medicine and Biology. 30 (12), 1565-1644 (2004).</li><li>Ho, S. Y., Nihoyannopoulos, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomy,+echocardiography,+and+normal+right+ventricular+dimensions.">Anatomy, echocardiography, and normal right ventricular dimensions.</a> Heart. 92 (Suppl 1), i2-i13 (2006).</li><li>Genovese, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+Between+Four-Chamber+and+Right+Ventricular-Focused+Views+for+the+Quantitative+Evaluation+of+Right+Ventricular+Size+and+Function.">Comparison Between Four-Chamber and Right Ventricular-Focused Views for the Quantitative Evaluation of Right Ventricular Size and Function.</a> Journal of the American Society of Echocardiography. 32 (4), 484-494 (2019).</li><li>Kovacs, A., Lakatos, B., Tokodi, M., Merkely, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+ventricular+mechanical+pattern+in+health+and+disease:+beyond+longitudinal+shortening.">Right ventricular mechanical pattern in health and disease: beyond longitudinal shortening.</a> Heart Failure Reviews. 24 (4), 511-520 (2019).</li><li>Antoni, M. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+value+of+right+ventricular+function+in+patients+after+acute+myocardial+infarction+treated+with+primary+percutaneous+coronary+intervention.">Prognostic value of right ventricular function in patients after acute myocardial infarction treated with primary percutaneous coronary intervention.</a> Circulation: Cardiovascular Imaging. 3 (3), 264-271 (2010).</li><li>Amsallem, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+Heart+End-Systolic+Remodeling+Index+Strongly+Predicts+Outcomes+in+Pulmonary+Arterial+Hypertension:+Comparison+With+Validated+Models.">Right Heart End-Systolic Remodeling Index Strongly Predicts Outcomes in Pulmonary Arterial Hypertension: Comparison With Validated Models.</a> Circulation: Cardiovascular Imaging. 10 (6), (2017).</li><li>Merlo, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Prognostic+Impact+of+the+Evolution+of+RV+Function+in+Idiopathic+DCM.">The Prognostic Impact of the Evolution of RV Function in Idiopathic DCM.</a> JACC: Cardiovascular Imaging. 9 (9), 1034-1042 (2016).</li><li>Addetia, K., Muraru, D., Badano, L. P., Lang, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+Directions+in+Right+Ventricular+Assessment+Using+3-Dimensional+Echocardiography.">New Directions in Right Ventricular Assessment Using 3-Dimensional Echocardiography.</a> JAMA Cardiology. , (2019).</li><li>Nagata, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+Value+of+Right+Ventricular+Ejection+Fraction+Assessed+by+Transthoracic+3D+Echocardiography.">Prognostic Value of Right Ventricular Ejection Fraction Assessed by Transthoracic 3D Echocardiography.</a> Circulation: Cardiovascular Imaging. 10 (2), (2017).</li><li>Surkova, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relative+Prognostic+Importance+of+Left+and+Right+Ventricular+Ejection+Fraction+in+Patients+With+Cardiac+Diseases.">Relative Prognostic Importance of Left and Right Ventricular Ejection Fraction in Patients With Cardiac Diseases.</a> Journal of the American Society of Echocardiography. 32 (11), 1407-1415 (2019).</li><li>Maffessanti, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Age-,+body+size-,+and+sex-specific+reference+values+for+right+ventricular+volumes+and+ejection+fraction+by+three-dimensional+echocardiography:+a+multicenter+echocardiographic+study+in+507+healthy+volunteers.">Age-, body size-, and sex-specific reference values for right ventricular volumes and ejection fraction by three-dimensional echocardiography: a multicenter echocardiographic study in 507 healthy volunteers.</a> Circulation: Cardiovascular Imaging. 6 (5), 700-710 (2013).</li><li>. GE 4D RVQ White Paper Available from: <a target="_blank" href="https://www.imv-imaging.com/media/5879/4d_auto_rvq_whitepaper_v8.pdf">https://www.imv-imaging.com/media/5879/4d_auto_rvq_whitepaper_v8.pdf</a> (2017)</li><li>Medvedofsky, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+Approach+to+Three-Dimensional+Echocardiographic+Quantification+of+Right+Ventricular+Volumes+and+Function+from+Focused+Views.">Novel Approach to Three-Dimensional Echocardiographic Quantification of Right Ventricular Volumes and Function from Focused Views.</a> Journal of the American Society of Echocardiography. 28 (10), 1222-1231 (2015).</li><li>Lakatos, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+the+relative+contribution+of+the+different+right+ventricular+wall+motion+components+to+right+ventricular+ejection+fraction:+the+ReVISION+method.">Quantification of the relative contribution of the different right ventricular wall motion components to right ventricular ejection fraction: the ReVISION method.</a> Cardiovascular Ultrasound. 15 (1), 8 (2017).</li><li>Lakatos, B. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dominance+of+free+wall+radial+motion+in+global+right+ventricular+function+of+heart+transplant+recipients.">Dominance of free wall radial motion in global right ventricular function of heart transplant recipients.</a> Clinical Transplantation. 32 (3), e13192 (2018).</li><li>Raina, A., Vaidya, A., Gertz, Z. M., Susan, C., Forfia, P. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Marked+changes+in+right+ventricular+contractile+pattern+after+cardiothoracic+surgery:+implications+for+post-surgical+assessment+of+right+ventricular+function.">Marked changes in right ventricular contractile pattern after cardiothoracic surgery: implications for post-surgical assessment of right ventricular function.</a> Journal of Heart and Lung Transplantation. 32 (8), 777-783 (2013).</li><li>Nowak-Machen, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Regional+Right+Ventricular+Volume+and+Function+Analysis+Using+Intraoperative+3-Dimensional+Echocardiography-Derived+Mesh+Models.">Regional Right Ventricular Volume and Function Analysis Using Intraoperative 3-Dimensional Echocardiography-Derived Mesh Models.</a> Journal of Cardiothoracic and Vascular Anesthesia. 33 (6), 1527-1532 (2019).</li><li>Pettersen, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Contraction+pattern+of+the+systemic+right+ventricle+shift+from+longitudinal+to+circumferential+shortening+and+absent+global+ventricular+torsion.">Contraction pattern of the systemic right ventricle shift from longitudinal to circumferential shortening and absent global ventricular torsion.</a> Journal of the American College of Cardiology. 49 (25), 2450-2456 (2007).</li><li>Moceri, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+right-ventricular+regional+deformation+and+survival+in+pulmonary+hypertension.">Three-dimensional right-ventricular regional deformation and survival in pulmonary hypertension.</a> European Heart Journal - Cardiovascular Imaging. , (2017).</li><li>Addetia, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Three-dimensional+echocardiography-based+analysis+of+right+ventricular+shape+in+pulmonary+arterial+hypertension.">Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension.</a> European Heart Journal - Cardiovascular Imaging. 17 (5), 564-575 (2016).</li><li>Addetia, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morphologic+Analysis+of+the+Normal+Right+Ventricle+Using+Three-Dimensional+Echocardiography-Derived+Curvature+Indices.">Morphologic Analysis of the Normal Right Ventricle Using Three-Dimensional Echocardiography-Derived Curvature Indices.</a> Journal of the American Society of Echocardiography. 31 (5), 614-623 (2018).</li><li>Lakatos, B. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Exercise-induced+shift+in+right+ventricular+contraction+pattern:+novel+marker+of+athlete's+heart?.">Exercise-induced shift in right ventricular contraction pattern: novel marker of athlete's heart?.</a> American Journal of Physiology - Heart and Circulatory. , (2018).</li><li>Corrado, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Arrhythmogenic+right+ventricular+cardiomyopathy:+evaluation+of+the+current+diagnostic+criteria+and+differential+diagnosis.">Arrhythmogenic right ventricular cardiomyopathy: evaluation of the current diagnostic criteria and differential diagnosis.</a> European Heart Journal. , (2019).</li><li>Luo, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Right+ventricular+outflow+tract+systolic+function+correlates+with+exercise+capacity+in+patients+with+severe+right+ventricle+dilatation+after+repair+of+tetralogy+of+Fallot.">Right ventricular outflow tract systolic function correlates with exercise capacity in patients with severe right ventricle dilatation after repair of tetralogy of Fallot.</a> Interactive Cardiovascular and Thoracic Surgery. 24 (5), 755-761 (2017).</li></ol>

3D analysis of the RV represents an important step in everyday cardiology practice. In parallel with the growing interest of the morphology and function of the previously neglected cardiac chamber, these novel solutions provide clinically meaningful information about the right side of the heart. While 3D acquisition has several aspects that markedly differ from 2D echocardiographic imaging, by keeping special attention to the critical points and by using a thorough protocol, 3D RV analysis may progress from a scientific ...

Echocardiography came a long way from its first clinical applications in the 1950s1. The first one-dimensional ultrasound probes were designed to provide simple linear diameters of the chamber walls and lumens; however, they undoubtedly represent a milestone in cardiovascular imaging. The development of two-dimensional (2D) ultrasound imaging was another major step by providing much more precise quantification of morphology and function and is still considered to be the standard method in everyday clinical practice. Nevertheless, 2D echocardiography-based assessment still carries a major limitation of the technique: imaging of a given chamber from a few tomographic planes does not adequately characterize the morphology and function of a three-dimensional (3D) structure. This problem is even more pronounced in the case of the right ventricle (RV): compared to the relatively simple bullet-shaped left ventricle (LV), the RV has a complex geometry2 that cannot be adequately quantified using linear diameters or areas3. Despite these widely known facts, RV morphology and function are usually measured by such simple parameters in the clinical practice.
For many decades, the RV was considered to have a much less important role in circulation compared to its left counterpart. Several landmark papers defeated this standpoint showing the strong prognostic role of RV geometry and function in a wide variety of diseases4,5,6,7. Numerous studies demonstrated the incremental value of RV measurement even by using relatively simple conventional parameters, which highlights the importance and need for more precise quantification of the chamber with potentially meaningful clinical value.
3D echocardiography overcomes several limitations of the 2D assessment of the cardiac chambers. While the measurement of volumes and also functional parameters free of geometrical assumptions may be of high interest in the case of the LV as well, it may gain particular importance in the assessment of the RV8. 3D-derived RV volumes and ejection fraction (EF) are shown to have significant prognostic value in various cardiovascular conditions9,10.
Nowadays, several vendors provide semi-automated solutions for 3D RV assessment with validated results against gold standard cardiac magnetic resonance (MR) measurements11,12. The technical requirements of 3D assessment are essential parts of a state-of-the-art cardiovascular imaging department nowadays, and it is expected that it will soon be part of the general equipment in every echocardiography lab. With proper expertise in 3D acquisition and post-processing, 3D RV analysis can be easily implemented into the standard examination protocol.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3V-D/4V-D/4Vc-D</td>
			<td>General Electric</td>
			<td>n.a.</td>
			<td>ultrasound probe</td>
		</tr>
		<tr>
			<td>4D Auto RVQ</td>
			<td>General Electric</td>
			<td>n.a.</td>
			<td>software for analysis</td>
		</tr>
		<tr>
			<td>E9/E95</td>
			<td>General Electric</td>
			<td>n.a.</td>
			<td>ultrasound machine</td>
		</tr>
		<tr>
			<td>EchoPac v203</td>
			<td>General Electric</td>
			<td>n.a.</td>
			<td>software for analysis</td>
		</tr>
	</tbody>
</table>

morphological and functional assessment of the right ventricle using 3d echocardiography

Traditionally, it was believed that the right side of the heart has a minor role in circulation; however, more and more data suggest that right ventricular (RV) function has strong diagnostic and prognostic power in various cardiovascular disorders. Due to its complex morphology and function, assessment of the RV by conventional two-dimensional echocardiography is limited: the everyday clinical practice usually relies on simple linear dimensions and functional measures. Three-dimensional (3D) echocardiography overcame these limitations by providing volumetric quantification of the RV free of geometrical assumptions. Here, we offer a step-by-step guide to obtain and analyze 3D echocardiographic data of the RV using the leading commercially available software. We will quantify 3D RV volumes and ejection fraction. Several technical aspects may help to improve the quality of RV acquisition and analysis as well, which we present in a practical manner. We review the current opportunities and the limiting factors of this method and also highlight the potential applications of 3D RV assessment in current clinical practice.

3D analysis of the RV is feasible in a wide variety of cardiovascular diseases. Case 1 is a healthy volunteer with normal ventricular volumes and function (Figure 1). Case 2 is a post-mitral valve repair patient who is a typical example for the conflicting results of conventional 2D assessment: while TAPSE is markedly reduced, the patient does not show any signs of RV dysfunction and a maintained RV global systolic function was confirmed by normal 3D RV EF (<...

Watch this Scientific Journal Video about Morphological and Functional Assessment of the Right Ventricle Using 3D Echocardiography at JoVE.com

Morphological and Functional Assessment of the Right Ventricle Using 3D Echocardiography

Here, we provide a step-by-step acquisition and analysis protocol for the 3D volumetric assessment of the right ventricle, mainly focusing on the practical aspects that maximize the feasibility of this technique.

Traditionally, it was believed that the right side of the heart has a minor role in circulation; however, more and more data suggest that right ...

Numerous clinical studies highlighted the diagnostic and prognostic role of right ventricle morphology and function, showing the need for detailed quantification of structure and function of the chamber. Compared to its left counterpart, the right ventricle has a much more complex anatomy and motion pattern. Therefore, only 3D acquisitions provide the opportunity of adequate volumetric measurements.3D echocardiographic assessment of the right ventricle is a precise, fast and highly reproducible technique with an established added clinical value in a wide variety of diseases. Beyond right ventricular measurements, 3D acquisitions give the opportunity of three-dimensional left ventricular or even heart in the same setting. Compared to the traditional echocardiographic examination, three-dimensional measurements require a slightly different approach.Nevertheless, the currently available semi-automatic methods facilitate an easy implementation through everyday clinical practice For the acquisition of 3D images, confirm the correct right ventricle focused view from the 2D echocardiography images. If the free wall of the right ventricle is poorly visualized in this view, the expected 3D image quality will not be optimal for further analysis. If the image is acceptable, use the 4D button to switch to live 3D imaging and use the 12-slice mode for the 3D view to acquire a triplane image of the region of interest, as well as nine cross-sectional planes that can be freely modified.By rotation and correct positioning of the cut planes, confirm the visibility of the entire right ventricle free wall, including the outflow tract and apical segments, and use the left tilting of the sector to further adjust the image. Using the single-beat mode, select an optimal image depth, width, and frame rate and obtain 3D loops of the right ventricle. Using the multi-beat mode, reconstruct the acquired 3D loop from a given number of heart cycles.When the acquired 3D volume has been stitched together, position the probe at the region of interest and ask the patient to take and hold a deep breath. The expanding lungs will typically cover the entire image. Ask the patient to exhale slowly.As the lungs deflate, the right ventricle should become visible again. When the entire right ventricle free wall and septum reappear, ask the patient to hold their breath in this state. Select multi-beat and begin the acquisition.The 3D loops will build up during the select number of heart cycles. When the entire right ventricle can be visualized, instruct the patient to breathe freely again. Then check the obtained loop to confirm that there are no stitching or dropout artifacts.For 4D right ventricle analysis, open the right ventricle-focused 3D loop from the patient library in the appropriate 4D analysis software program and orient the right ventricle on four predefined cut planes. Place two markers to the center of the tricuspid valve in the upper and lower left long axis planes and use the rotation tool to adjust the long axis of the image to the actual long axis of the right ventricle. Reference images on the upper right edges show how the correct orientation should appear.In the upper and lower right panels, use rotation to align the short axis images into the correct position using the reference images as a guide. Click set landmarks to set landmarks in two images, and mark the tricuspid annulus at the tricuspid valve free wall and septum and the right ventricle apex on the previously oriented apical four-chamber view. On the right side, set the right ventricle posterior and anterior insertion points and the right ventricle free wall using the reference images as a guide.When all of the landmarks have been set, the software will automatically jump to the review window. Review and manually correct the automatic endocardial border detection throughout the entire cardiac cycle as necessary. In the case of false tracking, click the endocardial borders to correct them as necessary.Using the rotation tool on the short axis, track along the entire circumference of the right ventricle to review the images. Select pen size to adjust the magnitude of correction. When the tracking is correct, click results and review the final 3D volumetric data and other calculated parameters in the worksheet panel.If further adjustments are needed, click on the appropriate parameter to make a modification. If the tracking and the 3D parameters appear to be valid, click approve and exit to save the values. Three dimensional analysis of the right ventricle is feasible in a wide variety of cardiovascular diseases.For example, these images were taken in a healthy volunteer with normal ventricular volumes and function. These images acquired in a post mitral valve repair patient provide a typical example of the conflicting results of conventional 2D assessment. While tricuspid annular plane systolic excursion was markedly reduced, the patient did not exhibit any signs of right ventricle dysfunction and maintained right ventricle global systolic function, as confirmed by a normal 3D right ventricle ejection fraction.In this semi-professional athlete with dilated cardiomyopathy, only a moderate image quality was achievable, resulting in a poorly visualized outflow tract. Three-dimensional right ventricle analysis was successful, however demonstrating good agreement with cardiac MR results. Using the currently available software solutions, 3D right ventricular assessment became easier than ever before.Still, the key for a precise and reproducible analysis is the proper acquisition at bedside. The added clinical value of three-dimensional right high parameters is no longer a question. Beyond being a fascinating research tool, these measures are part of the state-of-the-art patient management, as well.

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2.7K Views.  Semmelweis University Heart and Vascular Center. Numerous clinical studies highlighted the diagnostic and prognostic role of right ventricle morphology and function, showing the need for detailed quantification of structure and function of the chamber. Compared to its left counterpart, the right ventricle has a much more complex anatomy and motion pattern. Therefore, only 3D acquisitions provide the opportunity of adequate volumetric measurements.3D echocardiographic assessment of the right ventricle is a precise, fast and highly rep...