Donate Help Contact The AHA Sign In Home
American Heart Association
Circulation
Search: search_blue_button Advanced Search
« Previous Article | Table of Contents | Next Article »
Circulation. 1995;91:222-230

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jiang, L.
Right arrow Articles by Levine, R. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jiang, L.
Right arrow Articles by Levine, R. A.

(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

Leng Jiang, MD; Jose Antonio Vazquez de Prada, MD; Mark D. Handschumacher, BA; Cedric Vuille, MD; J. Luis Guererro, BS; Michael H. Picard, MD; J. Talbot Joziatis, BA; John T. Fallon, MD; Arthur E. Weyman, MD; Robert A. Levine, MD

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.


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowMethods
down arrowResults
down arrowDiscussion
down arrowReferences
 
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


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowMethods
down arrowResults
down arrowDiscussion
down arrowReferences
 
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.


*    Methods
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 *Methods
down arrowResults
down arrowDiscussion
down arrowReferences
 
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 1Down).


View this table:
[in this window]
[in a new window]
  		Table 1. 3D Echo Volumes vs Actual Volumes in Aneurysmal LV Phantoms

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 2Down).


View this table:
[in this window]
[in a new window]
  		Table 2. 3D Echo Volumes vs Actual Volumes in Autopsied Human Hearts With LV Aneurysms

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 3Down). 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.


View this table:
[in this window]
[in a new window]
  		Table 3. 3D Echo Volumes vs Actual Volumes: In Vivo Study

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.


*    Results
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
*Results
down arrowDiscussion
down arrowReferences
 
Reconstructed Images
The 3D algorithm visually reconstructed the shape of the aneurysmal cavities in the in vitro and beating heart studies. Fig 1Down shows examples of the reconstructed traces (A, phantom; B, excised heart; C, beating heart).



View larger version (K):
[in this window]
[in a new window]
  		Figure 1. Previous page. Representative three-dimensional echocardiographic reconstructions: top, the reconstructed traces of an aneurysmal phantom (A) and an autopsied human heart (B), with left ventricular (LV) body in yellow, aneurysm in green, and their demarcation in blue; the large size of the aneurysm relative to the LV body in the human heart corresponds to that seen grossly on the sectioned heart and agarose gel cast (B); bottom, the reconstructed traces of an aneurysmal LV in vivo (C) and in a patient (D), with end-diastolic images in red for the body and blue for the aneurysm and end-systolic images in green and blue for the same segments. Inward contraction of the LV body and the distortion produced by aneurysm shape can be appreciated.

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 2Down, Table 1Up).



View larger version (25K):
[in this window]
[in a new window]
  		Figure 2. Graphs showing three-dimensional (3D) echocardiographic versus actual volumes (vol) in aneurysmal left ventricular (LV) phantoms: aneurysm (AN) (left); LV body (middle); and total LV (right). The line of identity is dashed. 95% prediction limits are shown.

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 3Down, Table 2Up).



View larger version (25K):
[in this window]
[in a new window]
  		Figure 3. Graphs showing three-dimensional (3D) echocardiographic versus actual volumes (vol) in autopsied human hearts: aneurysm (AN) (left); left ventricular (LV) body (middle); and total LV (right). The line of identity is dashed. 95% prediction limits are shown.

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 3Up). As seen in Fig 4ADown and 4BDown, 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 4CDown); and for ejection fraction (y=0.97x+0.01, r=.99, SEE=2%, mean error=7.3%; Fig 4DDown). 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).



View larger version (33K):
[in this window]
[in a new window]
  		Figure 4. Fig 4. Graphs showing three-dimensional (3D) echocardiographic versus actual volumes (vol) in vivo: upper left, diastolic volume; upper right, systolic volume; lower left, stroke volume; and lower right, ejection fraction. 95% prediction limits are shown.

Patient Example
Fig 1DUp 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).


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
up arrowResults
*Discussion
down arrowReferences
 
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.


*    Acknowledgments
 
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.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowMethods
up arrowResults
up arrowDiscussion
*References
 

  1. Berman B, McGuire J. Cardiac aneurysm. Am J Med. 1950;8:480-488. [Medline] [Order article via Infotrieve]
  2. Abram DL, Edelist A, Luria MH, Miller AJ. Ventricular aneurysm: a reappraisal based on a study of 65 consecutive autopsied cases. Circulation. 1963;27:164-169. [Abstract/Free Full Text]
  3. Graber JD, Oakley CM, Pickering BN, Goodwin JF, Raphad MJ, Steiner RE. Ventricular aneurysm: an appraisal of diagnosis and surgical treatment. Br Heart J. 1972;34:830-838.
  4. Weyman AE, Peskoe SM, Williams ES, Dillon JC, Feigenbaum H. Detection of left ventricular aneurysms by cross-sectional echocardiography. Circulation. 1976;54:936-944. [Abstract/Free Full Text]
  5. Lengyel M, Tajik AJ, Seward JB, Hagler DJ, Smith HC. Sensitivity and specificity of two-dimensional echocardiography in the detection of left ventricular aneurysms. Am J Cardiol. 1980;45:436. Abstract.
  6. Rakowski H, Martin RP, Schapira JN, Wexler L, Silverman JF, Cipriano PR, Guthaner DF, Popp RL. Left ventricular aneurysm: detection and determination of resectability by two-dimensional ultrasound. Circulation. 1977;56(suppl III):III-153. Abstract.
  7. Baur HR, Daniel JA, Nelson RR. Detection of left ventricular aneurysm on two-dimensional echocardiography. Am J Cardiol. 1982; 50:191-196.
  8. Visser CA, Kan G, David GK, Lie KI, Durrer D. Echocardiographic-cineangiographic correlation in detection of left ventricular aneurysm: a prospective study of 422 patients. Am J Cardiol. 1982;50:337-341. [Medline] [Order article via Infotrieve]
  9. Ryan T, Petrovic O, Armstrong WF, Feigenbaum H. Quantitative two-dimensional echocardiographic assessment of patients undergoing left ventricular aneurysmectomy. Am Heart J. 1986;111:714-720. [Medline] [Order article via Infotrieve]
  10. Klein MD, Herman MV, Gorlin R. Hemodynamic study of left ventricular aneurysm. Circulation. 1967;35:614-630. [Abstract/Free Full Text]
  11. Herman MV, Gorlin R. Implications of left ventricular asynergy. Am J Cardiol. 1969;23:538-547. [Medline] [Order article via Infotrieve]
  12. Forman MB, Collins HW, Kopelman HA, Vaughn WK, Perry JM, Virmani R, Friesinger GC. Determinants of left ventricular aneurysm formation after anterior myocardial infarction: a clinical and angiographic study. J Am Coll Cardiol. 1986;8:1256-1262.[Abstract]
  13. Nicolosi AC, Spotnitz HM. Quantitative analysis of regional systolic function with left ventricular aneurysm. Circulation. 1988; 78:856-862.
  14. Teichholz LE, Kreulen T, Herman MV, Gorlin R. Problems in echocardiographic volume determinations: echocardiographic-angiographic correlations in the presence or absence of asynergy. Am J Cardiol. 1976;37:7-11. [Medline] [Order article via Infotrieve]
  15. Wyatt HL, Meerbaum S, Heng MK, Gueret P, Corday E. Cross-sectional echocardiography, III: analysis of mathematic models for quantifying volume of symmetric and asymmetric left ventricles. Am Heart J. 1980;100:821-828. [Medline] [Order article via Infotrieve]
  16. Martin JL, Untereker WJ, Harken AH, Horowitz LN, Josephson ME. Aneurysmectomy and endocardial resection for ventricular tachycardia: favorable hemodynamic and antiarrhythmic results in patients with global left ventricular dysfunction. Am Heart J. 1982;103:960-965. [Medline] [Order article via Infotrieve]
  17. Lawrie GM, Pacifico A, Kaushik R, Nahas C, Earle N. Factors predictive of results of direct ablative operations for drug-refractory ventricular tachycardia: analysis of 80 patients. J Thorac Cardiovasc Surg. 1991;101:44-55. [Abstract]
  18. Cox JL. Patient selection criteria and results of surgery for refractory ischemic ventricular tachycardia. Circulation. 1989;79(suppl I):I-163-I-177.
  19. Johnson RA, Daggett WM Jr. Heart failure resulting from coronary artery disease. In: Johnson RA, Haber E, Austen WG, eds. The Practice of Cardiology. Boston, Mass: Little, Brown & Co; 1980:339-369.
  20. Feild BJ, Russell RO Jr, Dowling JT, Rackley CE. Regional left ventricular performance in the year following myocardial infarction. Circulation. 1972;46:679-689. [Abstract/Free Full Text]
  21. Kapelanski DP, Al Sadir J, Lamberti JJ, Anagnostropoulos CE. Ventriculographic features predictive of surgical outcome for left ventricular aneurysm. Circulation. 1978;58:1167-1174. [Abstract/Free Full Text]
  22. Lee DCS, Johnson RA, Boucher CA, Wexler LF, McEnany MT. Angiographic predictors of survival following left ventricular aneurysmectomy. Circulation. 1977;56(suppl II):II-12-II-18.
  23. Watson LE, Dickhaus DW, Martin RH. Left ventricular aneurysm: preoperative hemodynamics, chamber volume, and results of aneurysmectomy. Circulation. 1975;52:868-873. [Abstract/Free Full Text]
  24. Smulyan H, Eich RH, Johnson LW, Parker FB, Potts JL, Tracy GP. An evaluation of the results of left ventricular aneurysmectomy: use of a simplified method for analysis of the left ventriculogram. Am Heart J. 1978;96:596-604. [Medline] [Order article via Infotrieve]
  25. Garan H, Nguyen K, McGovern B, Buckley M, Ruskin JN. Perioperative and long-term results after electrophysiologically directed ventricular surgery for recurrent ventricular tachycardia. J Am Coll Cardiol. 1986;8:201-209. [Abstract]
  26. van Hemel NM, Kingma JH, Defauw AM, Vermeulen FEE, Mast EG, Ernst JMPG, Ascoop CA. Left ventricular segmental wall motion score as a criterion for selecting patients for direct surgery in the treatment of postinfarction ventricular tachycardia. Eur Heart J. 1989;10:304-315. [Abstract/Free Full Text]
  27. Louagie Y, Alouini T, Lesperance J, Pelletier LC. Left ventricular aneurysm complicated by congestive heart failure: an analysis of long-term results and risk factors of surgical treatment. J Cardiovasc Surg. 1989;30:648-655. [Medline] [Order article via Infotrieve]
  28. Nath S, Haines DE, Kron IL, Barber MJ, DiMarco JP. Regional wall motion analysis predicts survival and functional outcome after subendocardial resection in patients with prior anterior myocardial infarction. Circulation. 1993;88:70-76. [Abstract/Free Full Text]
  29. Geiser EA, Ariet M, Conetta DA, Lupkiewicz SM, Christie LG, Conti CR. Dynamic three-dimensional echocardiographic reconstruction of the intact human left ventricle: technique and initial observations in patients. Am Heart J. 1982;103:1056-1065. [Medline] [Order article via Infotrieve]
  30. Moritz WE, Pearlman AS, McCabe DH, Medema DS, Ainsworth ME, Boles MS. An ultrasound technique for imaging the ventricle in three-dimensions and calculating its volume. IEEE Trans Biomed Eng. 1983;30:482-491. [Medline] [Order article via Infotrieve]
  31. Ghosh A, Nanda NC, Maurer G. Three-dimensional reconstruction of echocardiographic images using the rotation method. Ultrasound Med Biol. 1982;8:655-661. [Medline] [Order article via Infotrieve]
  32. Nixon JV, Saffer SI, Lipscomb K, Blomqvist CG. Three-dimensional echocardiography. Am Heart J. 1983;106:435-443. [Medline] [Order article via Infotrieve]
  33. Weiss JL, Eaton LW, Kallman CH, Maughan WL. Accuracy of volume determination by two-dimensional echocardiography: defining requirements under controlled conditions in the ejecting canine left ventricle. Circulation. 1983;67:889-895. [Abstract/Free Full Text]
  34. Sawada H, Fujii J, Kato K, Onoe M, Kuno K. Three-dimensional reconstruction of the left ventricle from multiple cross sectional echocardiograms: value for measuring left ventricular volume. Br Heart J. 1983;50:438-442. [Abstract/Free Full Text]
  35. Raichlen JS, Trivedi SS, Herman GT, St John Sutton MG, Reichek N. Dynamic three-dimensional reconstruction of the left ventricle from two-dimensional echocardiograms. J Am Coll Cardiol. 1986;8:364-370. [Abstract]
  36. Sapoznikov D, Fine DG, Masseri M, Gotsman MS. Left ventricular shape, wall thickness, and function based on three-dimensional reconstruction echocardiography. Comput Cardiol. 1987;495-498.
  37. McCann HA, Chandrasekaran K, Hoffman EA, Sinak LJ, Kinter TM, Greenleaf JF. A method for three-dimensional ultrasonic imaging of the heart in vivo. Dynamic Cardiovasc Imaging. 1987;1:97-109.
  38. Collins SM, Chandran KB, Skorton DJ. Three-dimensional cardiac imaging. Echocardiography. 1988;5:311-319.
  39. Martin RM, Graham MM, Kao R, Bashein G. Measurement of left ventricular ejection fraction and volumes with three-dimensional reconstructed transesophageal ultrasound scans: comparison to radionuclide and thermal dilution measurements. J Cardiothorac Anesth. 1989;3:260-268. [Medline] [Order article via Infotrieve]
  40. Levine RA, Handschumacher MD, Sanfilippo AJ, Hagege AA, Harrigan P, Marshall JE, Weyman AE. Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation. 1989;80:589-598. [Abstract/Free Full Text]
  41. Zoghbi WA, Buckey JC, Massey MA, Blomqvist CG. Determination of left ventricular volumes with use of a new nongeometric echocardiographic method: clinical validation and potential application. J Am Coll Cardiol. 1990;15:610-617. [Abstract]
  42. King DL, King DL Jr, Shao MYC. Three-dimensional spatial registration and interactive display of position and orientation of real-time ultrasound images. J Ultrasound Med. 1990;9:525-532. [Abstract]
  43. Mensah GA, Pini R, Monnini E, Masotti L, Novins KL, Greenberg DP, Grappi B, Cerofolini M, Devereux RB. Three-dimensional echocardiographic reconstruction: experimental validation of volume measurement. J Am Coll Cardiol. 1991;17:291A. Abstract.
  44. Gopal AS, King DL, Katz J, Boxt LM, King DL Jr, Shao MYC. Three-dimensional echocardiographic volume computation by polyhedral surface reconstruction: in vitro validation and comparison to magnetic resonance imaging. J Am Soc Echocardiogr. 1992;5:115-124. [Medline] [Order article via Infotrieve]
  45. Handschumacher MD, Lethor J-P, Siu SC, Mele D, Rivera JM, Picard MH, Weyman AE, Levine RA. A new integrated system for three-dimensional echocardiographic reconstruction: development and validation for ventricular volume with application in human subjects. J Am Coll Cardiol. 1993;21:743-753. [Abstract]
  46. Sapin PM, Schroeder KD, Smith MD, DeMaria AN, King DL. Three-dimensional echocardiographic measurement of left ventricular volume in vitro: comparison with two-dimensional echocardiography and cineventriculography. J Am Coll Cardiol. 1993;22:1530-1537. [Abstract]
  47. Suga H, Sagawa K. Accurate measurement of absolute intraventricular volume. Rep Inst Med Dent Eng. 1973;7:71-74.
  48. Palacios I, Newell JB, Powell WJ Jr. Effects of acute global ischemia on diastolic relaxation in canine hearts. Am J Physiol. 1978;235:720-727.
  49. Powell WJ Jr, Daggett WM, Magro AE, Bianco JA, Buckley MJ, Sanders CA, Kantrowitz AR, Austen WG. Effects of intraaortic balloon counterpulsation on cardiac performance, oxygen consumption and coronary blood flow in dogs. Circ Res. 1970; 26:753-764.
  50. Powers ER, Powell WJ Jr. Effect of arterial hypoxia on myocardial oxygen consumption. Circ Res. 1973;33:749-756. [Abstract/Free Full Text]
  51. Kesler KA, Fiore AC, Naunheim KS, Sharp TG, Mahomed Y, Zollinger TW, Sawada SG, Brown JW, Labovitz AJ, Barner HB. Anterior wall left ventricular aneurysm repair: a comparison of linear versus circular closure. J Thorac Cardiovasc Surg. 1992;103:841-848. [Abstract]
  52. Nicolosi AC, Spotnitz HM. Quantitative analysis of regional systolic function with left ventricular aneurysm. Curr Surg. 1988;45:387-389. [Medline] [Order article via Infotrieve]
  53. Geiser EA, Skorton DJ, Conetta DA. Quantification of left ventricular function by two-dimensional echocardiography: consideration of factors restricting image quality. Am Heart J. 1982;103:905-910. [Medline] [Order article via Infotrieve]
  54. Snyder JE, Kisslo J, von Ramm OT. Real-time orthogonal mode scanning of the heart, I: system design. J Am Coll Cardiol. 1986;7:1279-1285. [Abstract]
  55. Sheikh KH, Smith SW, von Ramm OT, Kisslo J. Real-time, three-dimensional echocardiography: feasibility and initial use. Echocardiography. 1991;8:119-125. [Medline] [Order article via Infotrieve]
  56. Linker DT, Pearlman AS, Huntsman LL. Comparison of ten right ventricular cross sectional area algorithms using a Monte Carlo simulation of sampling. Comput Cardiol. 1993:391-394.
  57. Thedens DR, Skorton DJ, Fleagle SR. A three-dimensional graph searching technique for cardiac border detection in sequential images and its application to magnetic resonance image data. Comput Cardiol. 1991;57-60.
  58. Belohlavek M, Foley DA, Gerber TC, Greenleaf JF, Seward JB. Three-dimensional ultrasound imaging of the atrial septum: normal and pathologic anatomy. J Am Coll Cardiol. 1993;22:1673-1678. [Abstract]
  59. Wollschlager H, Zeiher AM, Klein HP, Kasper W, Geibel A, Wollschlager S. Transesophageal echo computer topography: a new method for dynamic 3-D imaging of the heart. Circulation. 1989;80(suppl II):II-569. Abstract.
  60. Fulton DR, Marx GR, Pandian NG, Romero BA, Mumm B, Krauss M, Wollschlager H, Ludomirsky A, Cao QL. Dynamic three-dimensional echocardiographic imaging of congenital heart defects in infants and children by computer-controlled topographic parallel slicing using a single integrated ultrasound instrument. Echocardiography. 1994;11:155-164. [Medline] [Order article via Infotrieve]
  61. Schwartz SL, Cao QL, Azevedo J, Pandian NG. Simulation of intraoperative visualization of cardiac structures and study of dynamic surgical anatomy with real-time three-dimensional echocardiography. Am J Cardiol. 1994;73:501-507. [Medline] [Order article via Infotrieve]



This article has been cited by other articles:


Home page
 CirculationHome page
L. Sugeng, V. Mor-Avi, L. Weinert, J. Niel, C. Ebner, R. Steringer-Mascherbauer, F. Schmidt, C. Galuschky, G. Schummers, R. M. Lang, et al.
Quantitative Assessment of Left Ventricular Size and Function: Side-by-Side Comparison of Real-Time Three-Dimensional Echocardiography and Computed Tomography With Magnetic Resonance Reference
Circulation, August 15, 2006; 114(7): 654 - 661.
[Abstract] [Full Text] [PDF]

Home page
 Eur J EchocardiogrHome page
R. M. Lang, M. Bierig, R. B. Devereux, F. A. Flachskampf, E. Foster, P. A. Pellikka, M. H. Picard, M. J. Roman, J. Seward, J. Shanewise, et al.
Recommendations for chamber quantification
Eur J Echocardiogr, March 1, 2006; 7(2): 79 - 108.
[Abstract] [Full Text] [PDF]

Home page
 Eur J EchocardiogrHome page
J. X. Qin, T. Shiota, H. Tsujino, G. Saracino, R. D. White, N. L. Greenberg, J. Kwan, Z. B. Popovic, D. A. Agler, W. J. Stewart, et al.
Mitral annular motion as a surrogate for left ventricular ejection fraction: real-time three-dimensional echocardiography and magnetic resonance imaging studies
Eur J Echocardiogr, December 1, 2004; 5(6): 407 - 415.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
D. Gilon, E. G. Cape, M. D. Handschumacher, J.-K. Song, J. Solheim, M. VanAuker, M. E. E. King, and R. A. Levine
Effect of three-dimensional valve shape on the hemodynamics of aortic stenosis: Three-dimensional echocardiographic stereolithography and patient studies
J. Am. Coll. Cardiol., October 16, 2002; 40(8): 1479 - 1486.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
J. X. Qin, M. Jones, T. Shiota, N. L. Greenberg, H. Tsujino, M. S. Firstenberg, P. C. Gupta, A. D. Zetts, Y. Xu, J. P. Sun, et al.
Validation of real-time three-dimensional echocardiography for quantifying left ventricular volumes in the presence of a left ventricular aneurysm: in vitro and in vivo studies
J. Am. Coll. Cardiol., September 1, 2000; 36(3): 900 - 907.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J. H. Gorman III, R. C. Gorman, T. Plappert, B. M. Jackson, Y. Hiramatsu, M. G. St. John-Sutton, and L. H. Edmunds Jr.
Infarct Size And Location Determine Development Of Mitral Regurgitation In The Sheep Model
J. Thorac. Cardiovasc. Surg., March 1, 1998; 115(3): 615 - 622.
[Abstract] [Full Text]

Home page
 CirculationHome page
T. Buck, P. Hunold, K. U. Wentz, W. Tkalec, H. J. Nesser, and R. Erbel
Tomographic Three-dimensional Echocardiographic Determination of Chamber Size and Systolic Function in Patients With Left Ventricular Aneurysm : Comparison to Magnetic Resonance Imaging, Cineventriculography, and Two-dimensional Echocardiography
Circulation, December 16, 1997; 96(12): 4286 - 4297.
[Abstract] [Full Text]

Home page
 Ann. Thorac. Surg.Home page
J. H. Gorman III, R. C. Gorman, B. M. Jackson, Y. Hiramatsu, N. Gikakis, S. T. Kelley, M. G. St. J. Sutton, T. Plappert, and L. H. Edmunds Jr
Distortions of the Mitral Valve in Acute Ischemic Mitral Regurgitation
Ann. Thorac. Surg., October 1, 1997; 64(4): 1026 - 1031.
[Abstract] [Full Text]

Home page
 CirculationHome page
D. Gilon, E. G. Cape, M. D. Handschumacher, L. Jiang, C. Sears, J. Solheim, E. Morris, J. T. Strobel, S. M. Miller-Jones, A. E. Weyman, et al.
Insights From Three-dimensional Echocardiographic Laser Stereolithography: Effect of Leaflet Funnel Geometry on the Coefficient of Orifice Contraction, Pressure Loss, and the Gorlin Formula in Mitral Stenosis
Circulation, August 1, 1996; 94(3): 452 - 459.
[Abstract] [Full Text]

This Article
Right arrow Abstract Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow Request Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jiang, L.
Right arrow Articles by Levine, R. A.