January 10th, 2013
A New Dimension in Serial LVEF Measurement
Thomas Marwick and John Ryan, MD
In a study published this week in the Journal of the American College of Cardiology, Thavendiranathan et al compared 2D and 3D echocardiography with and without contrast administration in patients receiving chemotherapy to determine the most accurate serial assessment of left ventricular ejection fraction (LVEF). The authors found the noncontrast 3D echocardiogram to be the most reproducible technique. CardioExchange’s Dr. John Ryan discusses this finding with the study’s Senior Author, Dr. Thomas Marwick.
Ryan: Dr. Marwick, based on your findings, what are your recommendations to physicians regarding serial echocardiography evaluations of LVEF in patients undergoing chemotherapy?
Marwick: This is a really important group of patients: One of the biggest issues in cancer survivorship is heart failure, and decisions regarding cancer therapy are based on temporal EF changes, so we need to be careful about how these at-risk patients are followed.
There are two issues with measuring EF. First, the reproducibility of repeat 2D EF measurement isn’t great — the 95% confidence intervals are over 10%. This means that most of our efforts to follow patients with 2D EF measurement are futile, unless we are looking for huge changes. The problem is that we are cutting a 3D structure in 2D, and reproducing cut-planes is very difficult. However, 3D measurement is a good alternative, as the imaging planes are irrelevant. And that’s what this study shows — the most reliable measure was with noncontrast 3D echocardiography, so my recommendation is to use this method for sequential follow up.
The second problem is that measuring EF itself isn’t such a great tool for picking up early disease. I actually think that global longitudinal strain is better — but that’s another topic.
Ryan: Did it surprise you that noncontrast 3D echocardiography was found to be more reproducible than contrast images? What do you feel were the factors accounting for this finding?
Marwick: We were surprised, yes. We did hope 3D with contrast would be the best tool as some of our earlier study data had suggested. But as we all know, performance in studies and clinical practice can be quite different. The main problem was the ambiguity of the mitral valve plane when the LV was filled with contrast — it can be really hard to identify when the LV stops and the left atrium begins.
Ryan: What do you think we should do today, given that 3D echocardiography is not available? And if 3D disseminates, how can we be sure that everyone can get the same results that you do?
Marwick: Actually, 3D is available in more labs than you might believe. Very frequently there’s at least one machine in any given lab, but nobody is using it because they are unsure of the indication. We think serial EF for this patient group is a really important indication! If there is truly no 3D machine available then the best alternative is to measure using 2D echocardiography with contrast. In terms of getting the same results, I don’t think this is rocket science. There is a learning curve for good acquisition, but the measurement is automated. My advice is to engage with this technology.
3 Responses to “A New Dimension in Serial LVEF Measurement”
NEJM Journal Watch — Recent Cardiology Articles- Anticoagulation in Patients with Cancer-Associated Pulmonary Embolism: How Long is Long Enough?
- Spironolactone Use After Percutaneous Intervention for Acute Myocardial Infarction
- CRISPR/Cas9 Gene Editing for Transthyretin Cardiomyopathy
- Does Colchicine Reduce Cardiac Events After Myocardial Infarction?
- First-Line Therapy for Ventricular Tachycardia After MI: What's the Best Approach?
I haven’t read the study yet, but did the investigators compare 3D echo with MUGA?
Ian- 3D echo was not compared with MUGA in this study. I agree though, that is typically what we use as well to follow LVEF over the course of chemotherapy. Thus, the question is, does 3D echo remove the need to do MUGA?
The implications of these findings in patients receiving chemotherapy is certainly interesting but studies like this are also relevant in any setting where 2D LVEF is used as the main determinant of treatment eligibility. Should we still be using single and biplane MOD when assessing LVEF and reverse remodeling prior to primary prevention ICD placement?