Quantification of Left Ventricular Volumes

by Two-dimensional Echocardiography:
A Simplified and Accurate Approach
FRANCISCO A. TORTOLEDO, M.D., MIGUEL A. QUINONES, M.D., GENARO C. FERNANDEZ, M.D.,
ALAN D. WAGGONER, R.D.M.S. AND WILLIAM L. WINTERS, JR., M.D.
,

SUMMARY A new and simplified method to determine left ventricular (LV) volumes with two-dimen-
sional echocardiography (2-D echo) was developed using the parasternal long-axis and apical four- and two-
chamber views. An end-diastolic area (EDA) was derived using the longest minor axis (Dmax) from either of
the three views and the major long axis (Lmax) from the apical views, with the formula EDA = Dmax * L
Tr/4. LV end-diastolic volumes (EDVs) obtained by single-plane angiograms were correlated with the EDAs
derived from 2-D echo in 25 initial patients and the resultant equation, EDV = (EDA x 4.35) 6.44 (r = -

0.82, SEE = 34 ml), was applied prospectively to 27 patients (r = 0.95, SEE = 19 ml) and to the 52 combined
patients without underestimation according to the equation y = 1.07 x - 7.3. Twenty-nine of the 52
patients had coronary artery disease and regional dyssynergy. Ejection fraction (EF) measured with a
previously validated method that uses the average of several LV dimensions correlated well with angio-
graphic EF in the initial (r = 0.96, SEE = 5%) and prospective (r = 0.87, SEE = 8%) series and in both
series combined (r = 0.92, SEE = 7%). End-systolic volume (ESV) was derived by substracting stroke
volume (EDV x EF) from EDV. Correlation coefficients for 2-D echo ESV vs angiographic ESV were 0.91,
0.97 and 0.94, with SEES of 25, 12 and 19 ml for the initial, prospective and combined series, respectively.
Two-dimensional echo EDV, EF and ESV also correlated well (r = 0.89-0.97) with biplane angiographic
results in 15 of 27 prospective patients. Comparisons between two independent observers revealed high r
values (0.958-0.965) and mean differences for EDV, EF and ESVof + 3%, 6% and 8%, respectively.
Thus, a simplified method of determining LV volumes with 2-D echo without a need for planimetry or
computer assistance has been validated.
TWO-DIMENSIONAL echocardiography (2-D echo) gle-plane LV angiography were performed within 24
has been established as a noninvasive technique that hours of each other. Five patients were excluded, three
allows calculation of left ventricular (LV) volumes and because of poor-quality 2-D echoes and two because of
ejection fraction (EF). Although methods with accept- poor-quality LV angiograms. Among the remaining 25
Downloaded from http://ahajournals.org by on February 24, 2019

able degrees of accuracy and reproducibility have been
reported, they require drawing images for planimetry
and often computer assistance to determine volumes,1-7
which limits their routine clinical use. We previously
reported a simplified and accurate method for quanti-
tating EF from direct measurements of LV dimensions
and a formula that obviates having to determine vol-
umes.8 In the present investigation, we report a method
for calculating LV end-diastolic volume (EDV) from
2-D echo LV dimensions that, combined with our
method of measuring EF, allows accurate derivation of
end-systolic volume (ESV).
Methods
Initial Series
The initial series consisted of 30 patients in regular
sinus rhythm in whom 2-D echocardiography and sin-
From the Section of Cardiology, Baylor College of Medicine, the
Methodist Hospital and Ben Taub General Hospital, Houston, Texas.
Presented in part at the 54th Annual Scientific Sessions of the Ameri-
can Heart Association, November 1981, Dallas, Texas.
Supported in part by grant HL-17269, National Heart, Lung and
Blood Vessel Research and Demonstration Center, Baylor College of
Medicine. Computational assistance was provided by the CLINFO Proj-
ect, funded by grant RR-00350, Division of Research Resources, NIH.
Dr. Tortoledo is the recipient of a postdoctoral fellowship award from
the Council for Scientific and Humanistic Development, Universidad
Central, Caracas, Venezuela.
Address for correspondence: Miguel A. Quinones, M.D., Section of
Cardiology, The Methodist Hospital, 6535 Fannin - MS F905, Hous-
ton, Texas 77030.
Received July 23, 1982; revision accepted October 5, 1982.
Circulation 67, No. 3, 1983.
579
patients (17 males and eight females, mean age 54
years, range 29-77 years), 18 had coronary artery dis-
ease (CAD), 16 with regional dyssynergy and two with
normal wall motion; two patients had aortic insuffi-
ciency, one patient had mitral regurgitation, one pa-
tient had congestive cardiomyopathy, and three pa-
tients had normal heart evaluations.
Echocardiographic Measurement of Volumes
Wide-angle, 2-D echoes were recorded using a me-
chanical sector scanner (Advanced Technology Labo-
ratories Mark V) or a phased-array sector scanner
(Varian V-3400). All studies were videotaped on 3/4-
inch Umatic videocasette recorders equipped with a
back-spacer search module, which allows frame-by-
frame bidirectional playback. The video frame rate of
the system is approximately 60 frames/sec.
All patients were studied in the left lateral recum-
bent position using multiple views through the left
parasternal and apical windows. Three views were se-
lected for measurements: parasternal long-axis, apical
four-chamber and apical two-chamber. Several minor-
axis LV dimensions at the upper, middle and lower
third of the LV cavity were measured at end-systole
and end-diastole, as previously described8 (fig. 1). The
LV long axis (Lmax) was measured at end-diastole as the
longest major axis in either of the two apical views.
The measurement of Lmax was rounded off to the closest
whole number to ensure reproducibility. LV end-dia-
stolic area (EDA) was derived according to the ellipse
 580 CIRCULATION
Parast. LA Apx 4C Apx 2C
Apx
Anterior
Post
average minor axis (D) = D1 +D2 ... Dn
n
EF=(%AD2)+(l -%AD2) (%AL)
formula using the largest of all the LV minor axes
measured (Dmax) and Lmax:
EDA = Dmax X Lmax x 7T/4 (1)
EF was measured using the averages of all the mi-
nor-axis dimensions measured at end-diastole (Ded)
and end-systole (Des) with a formula previously vali-
dated in this laboratory:8
EF = (%AD2) + [(1 - %zAD2)(%iAL)], (2)
where %AD = (Ded2 - Des2)/Ded2, and %AL =
fractional shortening of the long axis estimated from
Downloaded from http://ahajournals.org by on February 24, 2019
apical contraction8 as 0.15 with normal apical wall
motion, 0.05 with apical hypokinesis, 0 with apical
akinesis, and - 0.05 with apical dyskinesis.
Angiographic Measurements
Single-plane LV angiography was performed in the
300 right anterior oblique projection with the injection
of 40-50 ml of contrast medium (Renografin-76) dur-
ing held midinspiration at a flow rate of 10-15 ml/sec.
The LV silhouette from cardiac cycles in sinus rhythm
and not preceded by premature complexes was traced
at end-diastole (largest cavity size) and at end-systole
(smallest cavity size). LV volumes and EF were de-
rived with the single-plane modification of the area-
length method;9 a 1-cm grid was filmed to correct for
magnification.
Echocardiographic Derivation of LV Volumes
The LV EDAs derived from the 2-D echo measure-
ments were correlated to the angiographic EDVs in the
initial 25 patients. From this correlation a regression
equation was derived to calculate EDV from EDA.
The derived EDV and the measured EF were used to
calculate stroke volume (SV) and ESV as follows:
SV = EDV x EF
ESV = EDV - SV
Prospective Series
A series of 31 patients in sinus rhythm was assessed
VOL 67, No 3, MARCH 1983
Apx FIGURE 1. The three views used to measure
left ventricular diameters (D) in the upper,
middle and lower thirds of the left ventricular
cavity. The long axis (L) was measured in the
apical four-chamber (Apx 4C) or apical two-
I nferior chamber (Apx 2C) view from the junction of the
mitral valve with the lateral (Lat) or anterior
wall to the LVapex. See Methodsfor the expla-
nation of the ejection fraction (EF) formula.
Parast LA = parasternal long axis; Post =
posterior.
prospectively to test the results from the initial series.
Echocardiographic and angiographic studies were per-
formed within 24 hours of each other. Four patients
were excluded: two because of poor-quality 2-D ech-
oes and two because of poor-quality LV angiograms.
The remaining 27 patients consisted of 17 males and
10 females, mean age 48 years (range 17-78 years).
Fifteen patients had CAD alone, one patient had CAD
associated with mitral and aortic regurgitation, and one
had CAD with aortic stenosis. Four patients had con-
genital defects: one patient had an atrial septal defect,
one had a ventricular septal defect, one had both atrial
and ventricular septal defects and one had a partial
atrioventricular canal. Two patients had mitral regur-
gitation and two had congestive cardiomyopathy. Two
patients were considered to have normal hearts. Thir-
teen of the 17 patients with CAD had abnormal wall
motion on the LV angiogram.
Echocardiographic studies and measurements were
performed as in the initial series. In addition to single-
plane ventriculography, a simultaneous biplane cine-
angiogram was obtained in the left anterior oblique
projection in 15 of the 27 patients. In these patients,
LV volumes were also calculated with the biplane
cineangiographic modification of the area-length
method. '°
The interobserver variability of the method was as-
sessed in 15 of the 27 patients in the prospective series
by two investigators who interpreted the same 2-D
echoes and measured and calculated volumes and EF.
Statistical Analysis
Statistical correlations between methods were made
by linear regression analysis.
Results
The echocardiographic and angiographic data for
the initial and prospective series are listed in tables 1
and 2. Three views of diagnostic quality (parasternal
long-axis, apical four-chamber and apical two-cham-
ber) were available in 31 of 52 patients (60%); at least
two views were available in all patients. The largest
Dmax was measured from the parasternal long-axis view
in 56% of all patients, from the apical four-chamber
 LV VOLUMES BY 2-D ECHOITortoledo et al. 581

TABLE 1. Initial Series: Echocardiographic and Angiographic Data

Echocardiographic Angiographic
L EDA EDV EF ESV EDV ESV EF
Pt Diagnosis Dmax/View* (cm) (CM2) (ml) (%) (ml) (ml) (ml) (%)
-

CAD 4. 1/D2 9 29 120 62 46 115 51 56

2 CAD 6.2/D4 10 49 207 35 135 205 129 37
3 CAD 4.6/D, 9 33 135 79 28 130 30 77
4 CAD 5.3/D2 9 38 157 35 102 161 121 25
S CAD 6.5/D6 10 51 215 33 144 208 141 32
6 NL 4.2/DI 9 30 123 52 59 120 60 50
7 CAD 5. 1/D2 8 32 133 49 68 104 57 45
8 CAD 5.2/D6 10 41 171 36 109 243 158 35
9 CAD 6.6/D6 9 47 197 28 142 187 136 27
10 Al 3.7/D2 9 26 107 58 45 75 34 55
11 CAD 6.5/D4 10 51 215 21 170 219 173 21
12 CAD 4.3/D2 8 27 111 57 48 137 62 55
13 CAD 5.3/D4 10 42 175 46 95 140 83 41
14 CCM 7.8/D4 11 67 287 22 224 234 180 23
15 Al 4.7/D3 9 33 138 62 52 158 54 66
16 CAD 6.5/D4 11 56 237 30 166 216 127 41
17 MR 4.6/D3 9 33 135 74 35 116 27 77
18 CAD 4.3/D3 8 27 111 59 46 104 35 66
19 CAD 6.3/D2 10 50 209 32 142 318 219 31
20 NL 4.5/D, 8 28 117 65 41 101 28 72
21 CAD 5. 1/D2 9 36 150 52 72 137 53 61
22 CAD 6.0/D, 10 47 198 26 147 223 165 26
23 CAD 5.0/D, 11 43 181 49 92 160 82 49
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24 CAD 5.5/D1 8 35 144 44 81 165 102 38

25 NL 4. 1D6 9 29 120 74 31 123 42 66
*Diameters (D) are identified as outlined in figure 1.
Abbreviations: Dmnax = largest LV minor-axis diameter; L = long axis; EDA = end-diastolic area; EDV = end-diastolic volume; EF =
ejection fraction; ESV = end-systolic volume; CAD = coronary artery disease; NL = normal; Al = aortic insufficiency; CCM = congestive
cardiomyopathy; MR = mitral regurgitation.

view in 31% and from the two-chamber view in 13%.
Lmax was obtained from the apical four-chamber view
in 50 patients and from the two-chamber view in two.
Table 3 lists the correlation coefficients and equa-
tions for the linear regression analyses. In the initial
series, echocardiographic LV EDA correlated well
with angiographic EDV (r = 0.82, SEE = 34 ml; fig.
2). The regression equation
EDV = (4.35 EDA) - 6.44
was used to calculate EDV from EDA, and the results
correlated well with angiographic EDV in both the
prospective series (r = 0.95, SEE = 19 ml) and the
combined series (r = 0.88, SEE = 28 ml) (fig. 3A).
The regression equations from these comparisons were
close to a line of identity (table 3), suggesting no
significant underestimation of EDV by the 2-D echo.
Excellent correlations were observed between 2-D
echo and single-plane angiographic EF for the initial (r
= 0.96, SEE = 5%) and prospective series (r = 0.87,
SEE = 8%) and for the two series combined (r = 0.92,
SEE = 7%) (fig. 3B). ESV by 2-D echo also correlated
very well with single-plane angiographic ESV (r =
0.919 0.97 and 0.94, SEE = 25, 12 and 19 ml for the
initial, prospective and the combined series, respec-
tively) (fig. 3C). Again, the regression equations were
close to the line of identity for all the ESV comparisons
(table 3).
Figure 4 illustrates the comparison between 2-D
echo and biplane angiography for the measurement of
EDV, ESV and EF. All three 2-D echo measurements
(5) correlated very well with the angiographic standard (r
= 0.89-0.97), and the regression equations were
close to a line of identity.
Excellent correlations were observed between the
measurements made by the two observers for EDV (r
= 0.967, SEE = 14 ml), ESV (r = 0.960, SEE = 14
ml) and EF (r = 0.95, SEE = 5%). The mean differ-
ences between the two observers were + 3% for EDV,
8% for ESV and + 6% for EF.
Discussion
In this study, developed a simplified method to
we
derive LV volumes from 2-D echoes in adults with
various types of heart diseases. As with our previous
 582 CIRCULATION VOL 67, No 3, MARCH 1983

TABLE 2. Prospective Series: Echocardiographic and Angiographic Data

Echocardiographic Angiographic
L EDA EDV EF ESV EDV/BP ESV/BP EF/BP
Pt Diagnosis Dma,/View* (cm) (cm2) (ml) (%) (ml) (ml) (ml) (%)
I VSD, ASD 4.8/D2 9 34 141 69 43 142 51 64
2 CAD 5.0/D2 9 35 147 73 40 181 36 80
3 CAD 6.1/D3 9 43 181 25 136 182 136 25
4 MR 51O/D3 9 35 147 65 51 172 52 70
5 CAD 5.0/D3 10 39 164 52 79 131/184 71/94 46/49
6 CAD 4.0/D3 11 35 144 46 78 144/160 88/82 39/49
7 CAD, MR, AI 4.0/D2 7 22 89 36 57 120 66 45
8 CAD 5.0/Dl 9 35 147 69 46 155 51 67
9 NL 4.3/D6 7 24 96 72 27 83 30 64
10 CAD 5.5/D6 11 47 200 42 116 219 109 50
11 CAD 4.0/D3 8 25 103 56 45 87 48 45
12 CAD, AS 5.7/D2 10 45 188 48 98 186 110 41
13 CAD 6.4/D3 11 55 234 27 171 279 187 33
14 VSD 4.2/D2 8 26 108 69 33 120/130 44/34 63/74
15 CAD 6.0/D2 9 42 178 28 128 181/237 128/149 29/37
16 ASD 3.5/D1, 8 22 89 60 36 87/86 29/23 67/73
17 CAD 4.2/D2 9 30 123 50 61 113/132 49/44 57/67
18 CAD 4.4/D2 8 28 114 63 42 137/131 41/38 70/71
19 NL 4.5/D2 8 29 118 54 54 142/129 36/36 75/72
20 CCM 6.8/D6 11 59 249 32 169 292/292 187/190 36/35
21 AVC 3.2/D2 7 18 70 71 20 67/68 27/17 60/75
22 CAD 4.2/D2 8 26 108 58 45 103/123 49/53 52/57
23 CAD 4.8/D3 8 30 125 58 53 127/139 50/46 61/67
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24 CAD 3.7/D3 8 23 95 61 37 68/77 34/32 50/58

25 MR 6.3/D2 9 44 187 63 69 227/239 113/103 50/57
26 CCM 6.1/)D2 10 48 202 24 154 195/196 152/151 22/23
27 CAD 6.1/D2 10 48 202 43 115 213 113 47
*Diameters (D) are identified as outlined in figure 1.
Abbreviations: BP = biplane angiography; VSD = ventricular sseptal defect; ASD = atrial septal defect; AS = aortic stenosis; AVC -
atrioventricular canal. See table I for other abbreviations.

method of measuring EF,8 this method obviates the
need for planimetry or computer assistance, and is
therefore accessible to routine clinical use. The meth-
od consists of deriving EDV from a regression equa-
tion that relates EDA to angiographic EDV and mea-
suring EF with our previously validated method.8
Because EDA is calculated with the forrnula for an
ellipse (equation 1), the regression equation relates the
product of D x L to angiographic volume. In fact,
equation 5 may be simplified by substituting equation
1 for EDA, and EDV can be calculated as
EDV = (3.42 Dmax x Lmax) - 6.44.
ESV can be derived by subtracting SV from EDV.
The reliability of this method depends on two basic
assumptions. First, EF can be accurately determined
from an average of several LV minor-axis dimensions
and an estimate of the fractional shortening of the long
axis (%AL). This assumption was validated in our
previous study8 and confirmed in this investigation.
Second, the product of Dmax and Lmax reflects EDV
accurately regardless of the size of the left ventricle.
This second assumption should hold as long as the
ventricle is elliptical at end-diastole. Fortunately, dis-
eases such as ischemic injury affect LV geometry
much more during systole than during end-diastole."
Other conditions such as congestive cardiomyopathy
and volume overload reduce the L:D ratio as the ventri-
cle becomes more spherical,'2' l but this change in
itself should not mathematically limit the relation of
EDV to the product of D x L. However, conditions
that result in major differences between the two orthog-
(6) onal minor axes and thus affect the circular shape of the
left ventricle on cross section might alter the relation of
EDV to Dma x L 14 15
In this investigation, we used Dmax rather than an
average of several minor axes to compensate for the
known underestimation of LV volumes by 2-D echo.
Dmax was selected from one of three long-axis views
under the assumption that in that particular view the
tomographic plane of the 2-D echo bisected the ventri-
 LV VOLUMES BY 2-D ECHOITortoledo et al. 583

TABLE 3. Important Linear Regression Analysis 0

x y n r Equation SEE 300 r o Initial Series 0

2D-EDAIS SP-EDVIS 25 0.82 y = 4.35x - 6.44 34 ml * Prospective Series

2D-EDVps SP-EDVps 27 0.95 y = 1.18x - 18.95 19 ml 250 _ 0

2D-EDVTS SP-EDVTS 52 0.88 y = 1.07x - 7.30 28 ml O O

._ _) 0
2D-EDV BP-EDV 15 0.97 y = 1.25x - 19.40 16 ml c E 200 _
2D-EFIS SP-EFIS 25 0.96 y = 0.99x + 0.21 5.0% ai)o
c> 0
2D-EFps SP-EFps 27 0.87 y = 0.85x + 7.70 7.8% 150 1 >o0.0
Q> o

2D-EFTS SP-EFTS 52 0.92 y = 0.93x + 3.46 6.6% c

c- =
02 ._
n r SEE
2D-EF BP-EF 15 0.89 y = 0.99x + 5.00 7.6% c * * 0 o250.82 34
,

100 0 . 27 0.95 19
0
2D-ESVIS SP-ESVIS 25 0.91 y = 0.98x + 2.80 25 ml 0o 52 0.88 28
LU.
2D-ESVpS SP-ESVps 27 0.97 y = 1.043x - 0.32 12 ml
2D-ESVTS SP-ESVTS 52 0.94 y = lx + 1.33 19 ml 50 y=1. 07x-7. 3
2D-ESV BP-ESV 15 0.97 y = 1.14x - 7.98 14 ml
I I I I
2D-EDV, 2D-EDV2 15 0.97 y = 0.94x + 4.64 14 ml 0 300
50 100 150 200 250
2D-EF, 2D-EF2 15 0.96 y = lx - 4.94 5.1%
2D-ESV1 2D-ESV2 15 0.96 y = 0.996x -6.73 14 ml
A 2D Echo End Diastolic Volume (ml)
Abbreviations: SEE = standard error of the estimate; SP = sin- 100 olnitial Series

gle-plane angiogram; BP = biplane angiogram; IS = initial series;

PS = prospective series; TS = total series; 1 = observer 1; 2 = * Prospective Series
observer 2; EDA = end-diastolic area; EDV = end-diastolic vol- e-
ume; ESV = end-systolic volume; EF = ejection fraction. 80
L*-

cle through its center. In theory, one would prefer to

cut the LV in multiple short-axis planes, but this prac- 0) 60
tice would limit the number of patients accessible to c
0)
quantification. c
The good correlations between EDV derived from 40
Downloaded from http://ahajournals.org by on February 24, 2019

the echocardiographic measurements and the angio-

graphic standards (single-plane and biplane) validate C*L~)
our second assumption. Mathematically, however, the 20
angiographic area-length methods also depend on the
product of two orthogonal minor axes and the long 0
axis. Interestingly, in our initial series we examined 20 40 60 80 100
the relation of angiographic EDV to a direct calcula-
B 2D Echo EF (%)
300 0
250 r o Initial Series
* Prospective Series
250 bI
0
.
0-
_
200 1 .
<
0
OP ECD
.
200
a E 0
0.
S
0
* c _
150i
_ 0
150 co o 0 o
VSEE
r
._
.
* . n r
qJ
0
0
fln
1001- *O o25 0.91 25
c 100 V)

0
r=0.82 n-25 0/- *27 0.97
52 0. 94
12
C
Lu SEE=34 50 o|b
0 19
50 _ y=4. 35 x - 6.44 y=lx+l. 33
I I
i I
O
-
I II
t' 20
I
30 40 50 60 70 0 50 100 150 200 250
E
c 2D Echo End-Systolic Volume (ml)
2D Echo End-Diastolic Area (cm2) FIGURE 3. Correlation of single-plane angiographic and two-
FIGURE 2. Correlation oftwo-dimensional echocardiograph- dimensional echocardiographic (2-D echo) measurements of
ic (2-D echo) end-diastolic area with single-plane angiographic (A) end-diastolic volume, (B) ejection fraction (EF) and (C)
end-diastolic volume in the initial series. end-systolic volume in both initial and prospective series.
 584 CIRCULATION
EDV (ml)
300 r
250 F 250
0 200 1 200
c
az 150 - 150 _
._= 100 100 -
r=0.97 n=l1 5
50 -/ 1SEE-1 50
y=1.25x.19.4
a I a I
0 50 100 150 200 250 0 50 100 150 200 250
FIGURE 4. Correlation of biplane angiographic (angio) and echocardiographic measurements of end-diastolic
volume (EDV), end-systolic volume (ESV) and ejection fraction (EF) in 15 patients.
tion of EDV as D2 x L and found it to be no more
accurate than deriving EDA from Dm., x L.
The accuracy of our results in terms of correlation
coefficients and standard error of estimates are compa-
rable to those reported with more complicated meth-
ods, including Simpson's rule.'-' However, the data
points were distributed close to a line of identity as
manifested by the intercepts and slopes of the rela-
tions. In many previous studies, volumes derived by 2-
D echo were consistently smaller than the angiograph-
ic standards. 1-' The use of an equation that relates echo
measurements to angiographic volumes and thus cor-
Downloaded from http://ahajournals.org by on February 24, 2019
rects, to some degree, for the inherent tendencies of 2-
D echo to underestimate LV size probably accounts for
the improvement of our results over the other methods.
This simplified method of determining LV volumes
is limited only to end-diastole and end-systole and
cannot be applied to construct volume-time curves.
However, its simplicity, its accuracy and its interob-
server reproducibilty may make it attractive for clinical
use.
Acknowledgment
The authors acknowledge the secretarial assistance of Almanubia
Cespedes.
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