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.

This protocol follows the guidelines of the Semmelweis University Regional and Institutional Committee of Science and Research Ethics. The present protocol applies to a specific vendor. Although some steps remain valid regardless of the ultrasound machine and postprocessing software, important differences may exist if using other vendors&#39; solutions.
1. Technical requirements
<ol>
	<li>Utilize an echocardiography machine capable of 3D imaging.</li>
	<li>Connect a 3D transthoracic echocard...

<ol>
	<li>Guta, A. C., 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+to+assess+left+ventricular+geometry+and+function.">Three-dimensional echocardiography to assess left ventricular geometry and function.</a> Expert Review of Cardiovascular Therapy. 17 (11), 801-815 (2019).</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=Current+Clinical+Applications+of+Three-Dimensional+Echocardiography:+When+the+Technique+Makes+the+Difference.">Current Clinical Applications of Three-Dimensional Echocardiography: When the Technique Makes the Difference.</a> Current Cardiology Reports. 18 (11), 109 (2016).</li><li>Lang, R. 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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=Relationship+between+Cardiac+Remodeling+and+Exercise+Capacity+in+Elite+Athletes:+Incremental+Value+of+Left+Atrial+Morphology+and+Function+Assessed+by+Three-Dimensional+Echocardiography.">Relationship between Cardiac Remodeling and Exercise Capacity in Elite Athletes: Incremental Value of Left Atrial Morphology and Function Assessed by Three-Dimensional Echocardiography.</a> Journal of the American Society of Echocardiography. 33 (1), 101-109 (2020).</li><li>Muraru, 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=Intervendor+Consistency+and+Accuracy+of+Left+Ventricular+Volume+Measurements+Using+Three-Dimensional+Echocardiography.">Intervendor Consistency and Accuracy of Left Ventricular Volume Measurements Using Three-Dimensional Echocardiography.</a> Journal of the American Society of Echocardiography. 31 (2), 158-168 (2018).</li><li>Kalam, K., Otahal, P., Marwick, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+implications+of+global+LV+dysfunction:+a+systematic+review+and+meta-analysis+of+global+longitudinal+strain+and+ejection+fraction.">Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction.</a> Heart. 100 (21), 1673-1680 (2014).</li><li>Muraru, 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=Validation+of+a+novel+automated+border-detection+algorithm+for+rapid+and+accurate+quantitation+of+left+ventricular+volumes+based+on+three-dimensional+echocardiography.">Validation of a novel automated border-detection algorithm for rapid and accurate quantitation of left ventricular volumes based on three-dimensional echocardiography.</a> European Journal of Echocardiography. 11 (4), 359-368 (2010).</li><li>Doronina, A., 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+Female+Athlete's+Heart:+Comparison+of+Cardiac+Changes+Induced+by+Different+Types+of+Exercise+Training+Using+3D+Echocardiography.">The Female Athlete's Heart: Comparison of Cardiac Changes Induced by Different Types of Exercise Training Using 3D Echocardiography.</a> BioMed Research International. 2018, 3561962 (2018).</li><li>Takeuchi, 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=Measurement+of+left+ventricular+mass+by+real-time+three-dimensional+echocardiography:+validation+against+magnetic+resonance+and+comparison+with+two-dimensional+and+m-mode+measurements.">Measurement of left ventricular mass by real-time three-dimensional echocardiography: validation against magnetic resonance and comparison with two-dimensional and m-mode measurements.</a> Journal of the American Society of Echocardiography. 21 (9), 1001-1005 (2008).</li><li>Armstrong, A. 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LV morphological and functional measurements represent cornerstones of diagnosis, management, and follow-up of cardiac diseases; moreover, they are powerful predictors of outcome. Generally, 2D echocardiography-based evaluation of the LV is recommended by current practice guidelines; however, 3D echocardiography has been proven to be more accurate as it is free from geometrical assumptions concerning LV shape7,8. Deformation imaging by speckle tracking is a robus...

The assessment of left ventricular (LV) morphology and function is the predominant purpose of general and even more specific investigations in cardiology1. The widely available and noninvasive transthoracic echocardiography (TTE), which can provide dense amounts of information, is the method of choice for a convenient, fast, and cost-effective evaluation.
Measurement of LV mass, volumes, and subsequent ejection fraction holds significant diagnostic and also prognostic value2. The more accurate a given measure is, the higher its value will be. A better correlation with gold standard cardiac magnetic resonance (CMR) imaging derived values is an ongoing chase for echocardiographic techniques. Generally, clinical practice guidelines recommend the biplane Simpson&#39;s method for LV volume and ejection fraction measurement3. However, the LV is a three-dimensional (3D) structure with an often irregular shape, and therefore, several tomographic planes will undoubtedly fail in some clinical scenarios to accurately delineate LV morphology and function. Recent advancements in ultrasonic hardware and software technology permitted the development of real-time 3D imaging, which revolutionalizes echocardiographic protocols.
Moreover, the need for a quantitative approach concerning wall motion abnormalities resulted in the rise of deformation imaging4. Strain and strain rate parameters can be calculated by speckle tracking using standard grey-scale images. 3D echocardiography may also overcome several shortcomings of a two-dimensional strain assessment5. From an expensive scientific tool, 3D echocardiography started to become a powerful technique used in everyday clinical practice, and the quantification of the LV is certainly in the first line in this breakthrough.
The present article aims to guide the reader through a detailed 3D protocol by presenting tips and tricks and also by highlighting the potential pitfalls to facilitate the widespread but technically sound use of this important technique concerning the LV.

<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 LVQ</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>

evaluation of left ventricular structure and function using 3d echocardiography

Three-dimensional (3D) quantification of the left ventricle (LV) provides significant added value in terms of diagnostic accuracy and precise risk stratification in various cardiac disorders. Recently, 3D echocardiography became available in routine cardiology practice; however, high-quality image acquisition and subsequent analysis have a steep learning curve. The present article aims to guide the reader through a detailed 3D protocol by presenting tips and tricks and also by highlighting the potential pitfalls to facilitate the widespread but technically sound use of this important technique concerning the LV. First and foremost, we show the acquisition of a high-quality 3D dataset with optimal spatial and temporal resolution. Then, we present the analytical steps toward a detailed quantification of the LV by using one of the most widely applied built-in software. We will quantify LV volumes, sphericity, mass and also systolic function by measuring ejection fraction and myocardial deformation (longitudinal and circumferential strain). We will discuss and provide clinical examples about the essential scenarios where the transition from a conventional echocardiographic approach to a 3D-based quantification is highly recommended.

3D analysis of the LV is feasible in the majority of patients. Case 1 is a healthy volunteer with normal ventricular volumes and function (Figure 1). Case 2 (Figure 2) is a 64-year old male patient with dilated cardiomyopathy and a wide QRS complex (160 ms) of left bundle branch block morphology. Gold standard CMR measurements were the following: end-diastolic volume: 243 mL, end-systolic volume: 160 mL, ejection fraction: 34%, L...

Watch this Scientific Journal Video about Evaluation of Left Ventricular Structure and Function using 3D Echocardiography at JoVE.com

Evaluation of Left Ventricular Structure and Function using 3D Echocardiography

In this article, we provide a step-by-step acquisition and analysis protocol for the volumetric assessment and speckle-tracking analysis of the left ventricle by 3D echocardiography, particularly focusing on practical aspects that maximize the feasibility of this technique.

Three-dimensional (3D) quantification of the left ventricle (LV) provides significant added value in terms of diagnostic accuracy and precise risk ...

3D echocardiographic assessment of cardiac structure and function, is a breakthrough innovation in cardiology. Quantification of left ventricle morphology and systolic performance, is the single most important step in every echocardiographic protocol. 3D echocardiographic-derived left ventricular volumes and ejection fraction correlate the most with core standard cardiac MRI and have shown to be more reproducible compared with conventional 2D techniques.More accurate results, turn into more tailored therapeutic decisions and that the end of the day, better patient outcomes. The scientific and clinical success of 3D based left ventricle assessment, paves the way to apply a similar technique to other cardiac structures such as right ventricle, the atria or even the valves. Proper image acquisition, followed by a comprehensive critical image analysis are the prerequisites for adequate use and accurate measurements.Our video article provides a step-by-step guide to achieve this. For the acquisition of 3D echocardiographic images, position the patient in the left lateral decubitus position and confirm that the ECG tracing on the screen is of good quality. Unfreeze the image and begin to examine the patient with the transducer, to visualize as a conventional apical four chamber view.To optimize the image quality, adjust the sector width to the left ventricle, lowering the depth to truncate the left atrium and using a slight over gain. Press the 4D button to switch to 3D mode and acquire 3D images in the multi or single-beat mode. Use the multi-beat mode to achieve a higher spatial and temporal resolution, from which the dataset will be reconstructed from two, three, four or six cardiac cycles.Obtain an end expiratory breath hold of the patient, maintaining the stable transducer positioning, to minimize the stitching artifacts. When the full volume is reconstructed from the sub-volumes and entire left ventricle is visible, freeze the image again. And using the cycle select and number of cycles knobs, select the optimal acquired cardiac cycles and press image store.For left ventricle morphology and function quantification, select a 3D data set appropriate for analysis and click measure and volume. Select 4D Auto LVQ. On the quad screen, the software will ask, modify alignment of apical slices to standard views?Correct the apical views manually as necessary by tilting and rotation, to obtain the corresponding standard view and thereby eliminating foreshortening. Drag and move the calipers on the long axis views to set the tilting to align the caliper with the long axis of the left ventricle and use the corresponding or rotate all knobs or adjust the calipers on the short axis image to set the rotation. After finishing the view alignment, click to the end-diastolic volume.For semiautomatic detection of the left ventricle endo and epicardial surface, select two landmark points manually on any apical views and successively identify the left ventricle apex and the middle of the left ventricle base in any apical view. The algorithm will automatically contour the endocardial border of the entire left ventricle. Check contour credibility in three apical views, three short axis views of different levels and a fourth user controlled short axis, to allow visual verification of the detected surface.Then proceed to and measure the end-systolic volume as just demonstrated for the end-diastolic volume, to identify and correct the endocardial contour on the end-systolic frame. Next, proceed to volume wave form. The software will display a dynamic 3D model of the left ventricle and a time volume curve as it traces the endocardial surface throughout the cardiac cycle frame by frame.Proceed to the left ventricle mass measurement. The software will automatically contour the left ventricle epicardial contour on the end-diastolic frame, and calculate the left ventricle mass. Click to assess the 4D strain region of interest.The software will automatically contour epicardial surface on the end-systolic frame, and calculate the left ventricle and systolic mass. Finally, click 4D strain results. The software will visualize the 3D myocardial tracking on multiple short and long axis planes and the corresponding strain values of the 17 standard left ventricle segments throughout the cardiac cycle frame by frame.Time strain curves and a bullseye plot will be displayed. The longitudinal, circumferential, radial and area strains, rotation and torsion, will also be calculated and can be demonstrated. Then to terminate the analysis, click approve and exit.Here, a 3D analysis of the left ventricle in a healthy volunteer with normal ventricular volumes and function, is shown. This 3D left ventricle analysis of a 64 year old male patient, shows a dilated cardiomyopathy and a wide QRS complex of the left bundle branch block morphology. The analysis of myocardial mechanics by 3D speckle tracking, provides meaningful data on dyssynchronous contractions and segmental dysfunction.When attempting this protocol, keep in mind that despite all these advancements in trans-user and software technology, a good quality image of the heart is necessary to achieve accurate results. 3D echocardiographic assessment of ventricle structure and function is no longer just a scientific toy. It is ready for everyday when called prime time.

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3.7K visualizações.  Semmelweis University. 3D echocardiographic assessment of cardiac structure and function, is a breakthrough innovation in cardiology. Quantification of left ventricle morphology and systolic performance, is the single most important step in every echocardiographic protocol. 3D echocardiographic-derived left ventricular volumes and ejection fraction correlate the most with core standard cardiac MRI and have shown to be more reproducible compared with conventional 2D techniques.More accurate results, turn into...