(Circulation. 1995;91:222-230.)
© 1995 American Heart Association, Inc.
Articles |
Quantitative Three-Dimensional Reconstruction of Aneurysmal Left Ventricles
In Vitro and In Vivo Validation
From the Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Department of Medicine, Harvard Medical School, Boston, Mass.
Correspondence to Leng Jiang, MD, Cardiac Ultrasound Laboratory, Vincent-Burnham 5, Massachusetts General Hospital, Fruit St, Boston, MA 02114.
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Abstract |
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 Top Abstract IntroductionMethods Results Discussion References |
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Background Current two-dimensional (2D) echocardiographic measures of left ventricular (LV) volume are most limited by aneurysmal distortion, which restricts application of simple geometric models that assume symmetrical shape. 2D methods also fail to provide separate volumes of the aneurysm and nonaneurysmal residual LV cavity, which could help assess the stroke volume wasted by dyskinesis and the potential residual LV body to guide surgical approaches and predict their outcome. Three-dimensional (3D) echocardiographic reconstruction has potential advantages for assessing aneurysmal left ventricles because it is not dependent on geometric assumptions, does not require standardized views that may exclude portions of the aneurysm, and can potentially measure separate aneurysm and nonaneurysm cavity volumes of any shape. The purpose of this study was first, to validate the accuracy of 3D echocardiographic reconstruction for quantifying total LV and separate LV body and aneurysm volumes in vitro so as to provide direct standards for the separate volumes; and second, to determine the feasibility and accuracy of 3D echocardiographic reconstruction for quantifying the total volume and function of aneurysmal left ventricles in an animal model, providing a reference standard for instantaneous LV volume.
Methods and Results A recently developed 3D system that automatically combines 2D images and their locations was applied (1) to reconstruct 10 aneurysmal ventricular phantoms and 12 gel-filled autopsied human hearts with aneurysms, comparing cavity volumes (total and aneurysm) to those measured by fluid displacement; and (2) to reconstruct the left ventricle during 19 hemodynamic stages in four dogs with surgically created LV aneurysms, comparing total volumes with actual instantaneous values measured by an intracavitary balloon attached to an external column for validation and also calculating the stroke volume wasted by aneurysmal dyskinesis. 3D reconstruction reproduced the distorted aneurysmal LV shapes. In vitro, calculated volumes (aneurysm, nonaneurysm, and total) agreed well with actual values, with correlation coefficients of .99 and SEEs of 3.2 to 6.1 cm3 for phantoms and 3.4 to 4.2 cm3 for autopsied hearts (mean error, <4% for both). In vivo, LV end-diastolic, end-systolic, and stroke volumes as well as ejection fraction calculated by 3D echocardiography correlated well with actual values (r=.99, .99, .95, and .99, respectively) and agreed closely with them (SEE=4.3 cm3, 3.5 cm3, 1.7 cm3, and 2%, respectively). The stroke volumes wasted by the aneurysm were -20.1±19.3% of LV body (nonaneurysm) stroke volume.
Conclusions Despite distorted ventricular shapes, a recently developed 3D echocardiographic system and surfacing algorithm can accurately reconstruct aneurysmal left ventricles and quantify total LV volume (validated in vivo and in vitro) as well as the separate volumes of the aneurysm and residual LV body (validated in vitro). This should improve our ability to evaluate such ventricles and guide surgical approaches.
Key Words: aneurysm • ventricles • echocardiography
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Introduction |
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TopAbstractIntroductionMethods Results Discussion References |
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Left ventricular (LV) aneurysm is a common complication of acute myocardial infarction.1 2 3 The advent of two-dimensional echocardiography (2DE) provided a noninvasive tool for detecting LV aneurysm4 5 6 7 8 9 with a high level of sensitivity (93%) and specificity (94%).9 Although quantitative analysis is especially important for patients undergoing aneurysmectomy,10 11 12 13 current 2DE measures of LV volume are most limited by aneurysmal distortion, which restricts application of simple geometric models that assume symmetrical shape.14 15 The 2D methods also fail to provide separate volumes of the aneurysm and nonaneurysmal residual LV cavity, which could help assess the stroke volume wasted by dyskinesis10 11 and the potential residual LV body to guide surgical approaches and predict their outcome.13 These limitations are particularly important because of the controversy regarding the prognostic ability of measures of LV dysfunction for risk of surgery and survival in patients with aneurysms16 17 18 19 : this controversy may reflect the limitations of methods that assume symmetrical shape to calculate global function as well as the limitations of methods for directly measuring the separate function of the aneurysm and nonaneurysmal LV portions, which may be the strongest predictor of outcome.19 20 21 22 23 24 25 26 27 28 Three-dimensional echocardiography (3DE), which has recently been validated for determining LV volume,29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 has potential advantages for assessing aneurysmal left ventricles because it is not dependent on geometric assumptions, does not require standardized views that may exclude portions of the aneurysm, and can potentially measure separate aneurysm and nonaneurysm cavity volumes of any shape.
Therefore, the purposes of this study were (1) to validate the accuracy of 3DE reconstruction for quantifying separate LV body and aneurysm volumes in vitro to provide direct standards for those volumes and (2) to determine the feasibility and accuracy of 3DE reconstruction for measuring the volume and function of aneurysmal left ventricles in an animal model, providing a reference standard for instantaneous LV volume.
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Methods |
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TopAbstractIntroductionMethods Results Discussion References |
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In Vitro Study
The accuracy of 3D reconstruction was tested in ventricular phantoms and gel-filled autopsied hearts with aneurysms.
Phantom
Preparation
Twenty balloons filled with known volumes of water were
connected to form 10 aneurysmal LV phantoms to obtain a range of total
volumes between 127 and 403 cm3, body volumes
between 106.5 and 368 cm3, and aneurysm volumes
between 15 and 160 cm3 (Table 1
).
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Excised Ventricular Preparation
Twelve autopsied
human hearts with LV aneurysms were filled with
heated 5% agarose in water to provide a range of shapes and volumes,
with total LV volume ranging from 55.5 to 368 cm3,
body volume from 19 to 135 cm3, and aneurysm volume
from 16.4 to 233 cm3 (Table 2).
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In Vivo Study
Four mongrel dogs (weight, 26±3 kg) were
anesthetized with
pentobarbital (30 to 50 mg/kg IV), intubated, and ventilated. A midline
thoracic incision was performed, the pericardium incised, and the heart
suspended in a pericardial cradle. To create thinner-walled,
distensible aneurysms with a variety of shapes and sizes, various
portions of the LV apex were removed and portions of the urinary
bladder were sutured to the LV body (because acute infarction produced
only mild distortion compared with that in patients with chronic
ischemic heart disease). To obtain actual total LV volume in vivo, a
model adapted from the method of Suga and Sagawa,47 as
applied by Weiss et al,33 was used in which instantaneous
LV volume can be measured directly with an intracavitary balloon
connected to an external reservoir. The animal was placed on total
heart bypass,48 49 50 with systemic and
coronary sinus venous
return drained into a reservoir, oxygenated, and pumped into the
systemic circulation with cannulas into the ascending aorta and femoral
arteries to maintain perfusion. The great vessels were proximally
ligated. The left coronary artery was normally perfused from the
ascending aorta; if the proximal right coronary artery was obstructed
by the aortic ligature, it was perfused by a left internal mammary
artery bypass. An incision was made in the left atrium, and a
high-compliance latex balloon was introduced into the LV through the
mitral valve. To ensure that the balloon could fill the entire LV
cavity and conform maximally to its contour, the mitral chordae were
cut, and thebesian venous return was drained by a 24-gauge cannula in
the LV apex. The balloon was connected at the aortic valve level to an
extracardiac vertical polyurethane column (fixed 3/4-in ID).
Compressing Tygon tubing on top of the column varied the resistance to
LV contraction. During the experiment, known amounts of saline were
incrementally introduced into the balloon-column system. Fluid height
was assessed by continuous video recording of the calibrated column and
subsequent off-line analysis. (The fluid was colored with blue dye
for better visibility.) LV cavity (balloon) volume was determined as
total volume (balloon and column) minus the volume in the column,
measured from the video images. Systolic cavity volume was determined
from the peak fluid level in the column and diastolic volume from the
lowest level, averaged over five consecutive beats. To maintain a
constant heart rate, the sinoatrial node was crushed and the RV paced
at 80 to 90 beats per minute.
Experimental Protocol
Each
animal was studied in a series of hemodynamic stages
created by volume loading of the LV, giving LV
end-diastolic volumes of 33.7 to 113 cm3 and
end-systolic volumes of 21.3 to 103 cm3 (Table 3).
During the 19 hemodynamic stages, 3DE images were
recorded simultaneously with video recordings of the fluid column
height. The studies conformed to the guiding principles of the American
Physiological Society.
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Patient Examples
Previous studies with this particular
technique have imaged only
subjects with normal LVs.45 Although the purpose of this
study was limited to the in vivo and in vitro validation work, six
patients with LV aneurysms, defined by an altered diastolic endocardial
contour,4 were studied simply to illustrate what such a
reconstruction would look like and to demonstrate that it is in fact
possible to apply this technique in some human beings with distorted
ventricles. (A seventh patient did not have 2D images suitable for
reconstruction.) These illustrative patients were scanned in the left
lateral decubitus position to image the LV in multiple intersecting
views during quiet end expiration. (Thermodilution stroke volumes
[average of three injections] were also independently available
from routine clinically indicated catheterization within 2 to 6 hours
[mean, 4.2 hours] of the echocardiogram in these patients, who did
not have significant mitral, aortic, or tricuspid insufficiency that
would produce differences between thermodilution and 3D outputs.)
3D Echocardiography
Data Acquisition
Studies
were performed with a 3.5-MHz transducer
(Hewlett-Packard phased array sector scanner 77020A). Hearts were
scanned with intersecting long- and short-axis sweeps or by apical
rotation. The 3D positions of the images were recorded automatically
and in real time by use of three spark-gap locating
devices30 40 42 44 45 46
placed on a plate perpendicular to
the long axis of the transducer; the plate was mounted on a Plexiglas
sleeve reproducibly fixed to the transducer. During the scan, the three
spark gaps were fired in rapid succession by a microprocessor (Science
Accessories, Inc); a square array of four microphones continuously
received and timed the arrival of sound emitted from the spark gaps and
located each one by triangulation. The ultrasound machine and the
transducer locating system were interfaced to a single SUN 386i
personal computer (Sun Microsystems), which encoded the positional data
in real time as a binary pattern overlaid on an unused portion of the
imaging video signal45 and recorded the composite on
videotape for convenient storage and retrieval without need for manual
coordination.
Data Analysis
After data acquisition, the same computer
system and video board
(AT Vista, True Vision) were used to select and digitize 13 or 14
different tomographic images from video playback to span the entire
ventricle and to decode the locating data automatically (within 1
second). In vivo, end diastole was defined by the largest LV body
(nonaneurysmal) cavity area (closest to and just following the QRS
peak) and end systole by the smallest LV body cavity area
(corresponding to the greatest height of fluid in the column). Only
images in quiet end expiration were used, as determined by a
respiratory gating signal recorded on the videotape. Cavity borders in
the selected images were traced with a digital tracing device
(Summagraphics Inc), with different colors used to code and separate
end-systolic and end-diastolic borders of the aneurysm and
LV body. The end-diastolic and end-systolic volumes of the
LV and its component parts could be obtained rapidly by selecting which
color traces to enter into the surfacing algorithm (done automatically
by the computer). The borders of the aneurysm were defined by a shape
change that distorted the smooth LV contour.4 Areas of
lateral dropout or indistinct borders were not traced, since the
computer algorithm was designed to tolerate incomplete or partial
traces. During and after tracing, the group of traces were displayed by
the computer in 3D space, so that the observer could review the
consistency of tracing and the adequacy of sampling.
The surfaces of the total LV and its separate parts were reconstructed and their volumes calculated with a surfacing algorithm that takes advantage of the full 3D data set.45 An initially spherical template was used to create 800 latitudinal and longitudinal grid points. Rays were drawn from the center of the sphere through each grid point, and the length of each ray was calculated to provide the best weighted fit to the actual traced borders in its vicinity. Any missing data points were filled in with a weighted fit to interpolate between nearest neighbors based on distance between grid points. The ends of the rays were connected to form a surface. Ventricular volume was obtained by summing the volumes of tetrahedrons formed by connecting the surface points to the center. Stroke volume and ejection fraction were calculated from these volumes in a standard manner. For the excised ventricles, actual volume was obtained by water displacement of the agarose cast obtained when the myocardium was incised and carefully peeled off the agarose. The aneurysm borders were defined by a shape change that distorted the smooth LV contour,4 and the cast was cut through this circumferential border to obtain the separate aneurysm and body volumes.
Statistical Analysis
Results for LV volumes (total and
separate portions) by 3D
echocardiography in vitro were compared with actual values by linear
regression analysis. The total LV end-diastolic,
end-systolic, and stroke volumes as well as ejection fraction by 3DE in
vivo were similarly compared with actual values from the fluid column.
The mean difference between 3D and actual values was also calculated.
Observer variability was obtained by calculating the SD of the
differences between the measurements of two independent observers for
the in vitro (6 phantoms and hearts), in vivo (7 stages), and patient
(n=6) studies; the coefficients of variability were then calculated as
the SD of differences divided by the mean value measured.
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Results |
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TopAbstractIntroductionMethods Results Discussion References |
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Reconstructed Images
The 3D algorithm visually reconstructed the shape of the aneurysmal cavities in the in vitro and beating heart studies. Fig 1
shows examples of the reconstructed
traces (A, phantom; B, excised heart; C, beating heart).
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LV Volume and Function
Aneurysmal LV Phantoms
Cavity volumes reconstructed by 3D echocardiography agreed well
with actual values. For total LV volume, linear regression gave
y=0.99x-1.3 (r=.99,
SEE=6.1
cm3, mean error=1.9%). For LV body volume, linear
regression gave y=0.98x-2.0
(r=.99, SEE=4.1 cm3, mean
error=3.2%).
For aneurysm volume, it gave y=0.97x+3.0
(r=.99, SEE=3.2 cm3, mean error=3.5%)
(Fig 2, Table 1
).
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Autopsied
Human Hearts With LV Aneurysms
In 2 of the 12 autopsied hearts, a
discrete aneurysm border was
not evident after gel filling, so that only the total cavity was
traced. (Aneurysm borders are better highlighted in vivo as the hinge
point of abnormal motion and shape.) The total LV cavity volumes
calculated from 3D reconstruction agreed well with actual volumes:
y=1.06x-6.7 (r=.99,
SEE=4.2
cm3, mean error=3.3%). Similar agreement was also
found for the separate volumes in the 10 hearts in which the aneurysm
could be demarcated: for body volume,
y=0.98x+1.9 (r=.99,
SEE=3.4
cm3, mean error=3.9%); and for aneurysm volume,
y=1.04x-1.2 (r=.99,
SEE=3.5
cm3, mean error=3.5%) (Fig 3, Table
2).
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In Vivo Ventricular Reconstruction
(Animal Model)
LV volumes were analyzed during 19 paired diastolic and
systolic
stages and used to determine stroke volume and ejection fraction
(Table 3). As seen in Fig 4A and
4B,
end-diastolic and end-systolic volumes calculated from 3D
reconstruction both correlated closely with actual values: for
end-diastolic volumes,
y=1.04x-4.2 (r=.99,
SEE=4.3
cm3, mean error=4.4%); and for end-systolic
volumes, y=1.05x-3.8 (r=.99,
SEE=3.5 cm3, mean error=4.6%). Agreement was
similarly good for stroke volume
(y=0.82x+2.3, r=.95,
SEE=1.7 cm3, mean error=12%; Fig 4C);
and for
ejection fraction (y=0.97x+0.01,
r=.99, SEE=2%, mean error=7.3%; Fig
4D). The stroke volume
wasted by aneurysmal expansion was calculated to be -20.1±19.3%
of
LV body stroke volume (no direct comparison available in vivo).
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Patient Example
Fig 1D shows an
example of a reconstructed LV with aneurysm in a
patient. (Although the purpose of these patient studies was
illustrative, not quantitative, the 3D stroke volumes correlated well
with those routinely available and independently analyzed by
thermodilution: y=0.93x+2.46,
r=.84, SEE=4.4 cm3, mean error=6%;
and
the stroke volume wasted by aneurysmal expansion was calculated to be
-8.3±6.5% [up to -18%] of LV body stroke volume.)
Observer Variability
The observer variability of
the 3D method for calculating total
and separate volumes was 3.4% in vitro, 5.1% in vivo, and 9.1% in
the patients studied (coefficients of variability).
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Discussion |
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TopAbstractIntroductionMethods Results Discussion References |
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LV aneurysm is a serious complication of myocardial infarction,1 2 with adverse consequences that include arrhythmias, emboli, and congestive heart failure, since the aneurysm causes not only localized geometric distortion but also global cardiac remodeling and dilatation. Although 2D echocardiography can detect or exclude LV aneurysm with high sensitivity and specificity,4 5 6 7 8 9 the heterogeneous geometry and function of such ventricles make it difficult to appreciate their entire shape from 2D images and to quantify their volume and function, especially before surgical repair,13 51 52 on the basis of geometric assumptions that are most prone to error with such distortion. The prognostic ability of measures of LV dysfunction for risk of surgery and survival has been controversial,16 17 18 19 20 21 22 23 24 25 26 27 28 possibly reflecting the limitations of measurement techniques and their difficulty in separately evaluating aneurysm and nonaneurysmal LV function. 3D reconstruction has potential advantages that could improve our ability to test hypotheses regarding the prognostic value of regional and global measures of function.
The results of this study demonstrate that the 3DE system described can accurately reconstruct aneurysmal left ventricles and measure their volume and function in vitro and in vivo compared with directly measured standards. This technique provides, for the first time, a noninvasive technique for evaluating the separate volumes of the aneurysm and residual LV body and thus assessing the wasted stroke volume imposed by aneurysmal dyskinesis and the size and function of the potential residual LV cavity after aneurysmectomy.19 20 21 22 23 24 25 26 27 28 (Unlike total volume, these latter measures of separate aneurysm and body volumes cannot, unfortunately, be directly verified by the in vivo balloon model as they can in the phantoms and excised ventricles.) Such quantification may be of additional value because the ratio of aneurysm to total LV size has been shown to predict increases in LV end-diastolic pressure and volume.10 11
3D Echocardiography
3D reconstruction overcomes the
above-described limitations of 2D
techniques by reconstructing the ventricle without the need for
simplifying geometric assumptions or standardized imaging planes. It
provides several other advantages45 : (1) It combines
multiple intersecting planes, improving the consistency of border
detection by allowing each traced image to be reviewed in 3D relation
to the others, even during the tracing process. (2) The surfacing
algorithm can accept partial traces, filling in missing data from
intersecting views; this can be especially important for LV aneurysms,
parts of which may be difficult to visualize in a given view. The
averaging effect of the surfacing algorithm will also minimize the
impact of isolated tracing errors. (3) The spark-gap locating system
permits the operator to vary transducer position and view to optimize
image quality. (4) The 3D system provides a surface that can be viewed
and rotated to improve 3D appreciation. The present system also
provides several additional advantages: (1) The location data are
generated in real time and recorded simultaneously and automatically
with the 2D images without manual coordination. (2) Rapid data
collection minimizes potential errors due to subject motion or
respiration and ensures that positions and images are obtained at the
same time. (3) The surfacing algorithm uses the full strength of the
intersecting 3D data set to produce a polyhedral-type volumetric
calculation.42 44
Limitations and Future Work
There are several sources of
variability in this method, including
(1) the resolution of spark-gap location (<1 mm by selection of data
sets to have the computed distances between spark gaps differ by <1 mm
from actual values); (2) observer variability; and (3) a tendency of
the surfacing algorithm to round out sharply protruding edges, although
total volume tends to be preserved by the averaging procedure used to
calculate the grid points; this should be less of a problem with a
rounded or aneurysmal apex. The results of this study indicate that
these effects are acceptably small for the ventricles examined, even in
the initial patient examples, in which greater variability may also
reflect the number of subjects as well as several other factors:
respiration can cause changes both in the position of the heart
(relative to the external frame of reference) and in its size and
shape. Such variability can be decreased by respiratory gating, while
variability of cycle length could be dealt with by selecting beats
within a specified range of cycle length for reconstruction. Limited
image quality53 and acoustic access will decrease the
number of planes available for reconstruction. Variability caused by
patient motion can be minimized by rapid acquisition as provided by
this system; acquisition could be made even faster by transducers
providing two simultaneous orthogonal views54 or multiple
views by phased-array parallel processing.55 Variability
is further compounded by limitations of comparative techniques such as
thermodilution.
Regarding the in vivo model used, the purpose of this study was not simply to validate LV stroke volume but also to prove the accuracy of the 3D method for calculating actual LV volumes against an ideal standard. The intracavitary model, as developed by Suga and Sagawa47 and modified by Weiss et al33 and in this study, serves this purpose. As implemented, even a 3-mm error in column height, which could be read to the nearest millimeter, produced <1 cm3 of error in volume.
With the improved efficiency of 3D data acquisition provided by this system, endocardial border definition has become the most time-consuming step, requiring 10 to 15 minutes, depending on observer experience, the number of images (13 or 14 in this study), and their complexity. This time could be reduced by defining the minimum number of views required33 56 and by using new methods to automate or semiautomate border extraction on the basis of signal amplitude or flow. Such systems could be particularly strong when applied to a 3D data set because gaps in individual 2D images could be filled in from other images by use of minimal-cost functions that optimize the detection of a spatial border.57 Future work applying existing computer-assisted design and modeling technology could potentially permit direct visualization (in advance of an operation) of LV size and potential function based on various surgical approaches51 to assist surgical planning.
The purpose of this study was in vitro and in vivo experimental validation, not clinical validation or application, which is likely to be a prolonged process. Illustrative patients were examined only to show what reconstructions would look like and that in fact it is possible to apply this technique to some human beings with distorted ventricles. Further work must be done to establish how often reconstruction can be performed and to use it as a quantitative tool to study clinical expression and consequences of ischemic heart disease. Unlike 2D or angiographic measures, which have been used retrospectively to achieve adequate patient numbers for analysis,28 our 3D technique cannot be applied retrospectively. Moreover, clinical correlations are obscured because multiple factors are likely to determine presentation, including extent of coronary artery disease,22 28 LV electrical properties, and factors affecting LV stasis (including mitral regurgitation) and thrombosis. Unlike distensible aneurysms, aneurysms in some patients, defined by altered diastolic contour,4 may waste relatively little stroke volume, so that other factors may determine presentation. Nevertheless, 3D reconstruction in principle provides quantitative information to test whether patients really do have large wasted stroke volumes, whether patients with such a mechanical disadvantage behave differently, and to what extent quantitative measures of aneurysm and residual LV body size and function contribute to clinical presentation. Although this is controversial,16 there is reason to believe, for example, that the function of the nonaneurysmal LV is of prognostic value in planning surgery19 20 21 22 23 24 25 26 27 28 ; studying this with refined 3D measures, however, lies beyond the scope of this validation study, which lays the foundation for subsequent quantitative investigation.
In addition to its use for investigation, anticipated potential applications of this technique include accurate assessment of LV function in patients with ischemic heart disease and surgical guidance through improved 3D spatial appreciation and computer-assisted anticipation58 of postoperative results. Automation of respiratory and ECG gating59 60 61 as well as intelligent model-based surfacing algorithms using the 3D data set should facilitate acquisition and reduce the time needed for accurate analysis.
Summary
Despite the distorted shapes of aneurysmal left
ventricles, the 3D
system and surfacing algorithm described can accurately reconstruct
their volumes and assess their function in vivo without geometric
assumptions or the need for standardized 2D planes. It has been
feasible to apply in the beating heart, limited only by the need for
2DE border definition, and can provide separate aneurysm and residual
LV body volumes to assess the physiological impact of the aneurysm
(wasted stroke volume) and the function of the nonaneurysmal LV. The
increased efficiency of the system used, which allows rapid 3D data
acquisition, has the potential for increasing applications to questions
of clinical and research interest; these validation studies lay the
foundation for subsequent work to address clinical hypotheses.
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Acknowledgments |
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This study was supported in part by research awards from the American Heart Association, Dallas, Tex, and the National Institutes of Health (grant HL-38176 to Dr Levine). Dr Levine is an Established Investigator of the American Heart Association (AHA), Dallas, Tex, with funds contributed in part by the Massachusetts Affiliate of the AHA, Needham, Mass. We thank Tracy Svizzero, BS, for her technical expertise with the experimental model.
Received April 29, 1994; accepted July 27, 1994.
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