European Journal of Echocardiography (2009) 10, 82–88

doi:10.1093/ejechocard/jen166

Quantitative assessment of left ventricular volume

and ejection fraction using two-dimensional
speckle tracking echocardiography
Tomoko Nishikage1, Hiromi Nakai2, Victor Mor-Avi3, Roberto M. Lang3, Ivan S. Salgo4,
Scott H. Settlemier4, Stephane Husson4, and Masaaki Takeuchi2*
1
Echocardiographic Laboratory, Tane General Hospital, Osaka, Japan; 2Second Department of Internal Medicine, University of

Downloaded from http://ehjcimaging.oxfordjournals.org/ by guest on December 3, 2012

Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahataniishi-ku, Kitakyushu 807-8555, Japan;
3
Cardiac Imaging Center, University of Chicago, Chicago, IL, USA and 4Philips Medical Systems, Andover, MA, USA
Received 19 November 2007; accepted after revision 20 April 2008; online publish-ahead-of-print 13 May 2008

KEYWORDS
2-Dimensional speckle
tracking echocardiography;
Left ventricular function
Aims Two-dimensional speckle tracking echocardiography (2DSTE) allows measurements of left ventri-
cular (LV) volumes and LV ejection fraction (LVEF) without manual tracings. Our goal was to determine
the accuracy of 2DSTE against real-time 3D echocardiography (RT3DE) and against cardiac magnetic res-
onance (CMR) imaging.
Methods and results In Protocol 1, 2DSTE data in the apical four-chamber view (iE33, Philips) and CMR
images (Philips 1.5T scanner) were obtained in 20 patients. The 2DSTE data were analysed using custom
software, which automatically performed speckle tracking analysis throughout the cardiac cycle. LV
volume curves were generated using the single-plane Simpson’s formula, from which end-diastolic
volume (LVEDV), end-systolic volume (LVESV), and LVEF were calculated. In Protocol 2, the 2DSTE and
RT3DE data were acquired in 181 subjects. RT3DE data sets were acquired, and LV volumes and LVEF
were measured using QLab software (Philips). In Protocol 1, excellent correlations were noted
between the methods for LVEDV (r ¼ 0.95), ESV (r ¼ 0.95), and LVEF (r ¼ 0.88). In Protocol 2, LV
volume waveforms suitable for analysis were obtained from 2DSTE images in all subjects. The time
required for analysis was ,2 min per patient. Excellent correlations were noted between the
methods for LVEDV (r ¼ 0.95), ESV (r ¼ 0.97), and LVEF (r ¼ 0.92). However, 2DSTE significantly under-
estimated LVEDV, resulting in a mean of 8% underestimation in LVEF. Intra- and inter-observer variabil-
ities of 2DSTE were 7 and 9% in LV volume and 6 and 8% in LVEF, respectively.
Conclusions Two-dimensional speckle tracking echocardiography measurements resulted in a small but
significant underestimation of LVEDV and EF compared with RT3DE. However, the accuracy, low intra-
and inter-observer variabilities and speed of analysis make 2DSTE a potentially useful modality for LV
functional assessment in the routine clinical setting.

Introduction clinical practice. The biplane Simpson’s formula is rec-

Accurate estimation of left ventricular (LV) volumes and sys-
tolic function using cardiac ultrasound is essential for the
routine management of patients in clinical practice.
Although several previous studies have demonstrated that
real-time three-dimensional echocardiography (RT3DE) is
more accurate for evaluating LV volumes and LV ejection
fraction (LVEF) compared with M-mode and two-dimensional
(2D) echocardiography.1–12 Two-dimensional echocardiogra-
phy remains the most widely utilized technique in routine
* Corresponding author. Tel: þ81 93 603 1611; fax: þ81 93 691 6913.
E-mail address: masaaki_takeuchi@hotmail.com
ommended by the guidelines13 as the preferred method for
the calculation of LV volumes and LVEF. However, this
method requires manual tracing of the endocardial borders
in the apical four- and two-chamber views, which is
tedious and time consuming, and also dependent on the
reader’s experience. Moreover, accurate endocardial
border tracing is difficult in still end-diastolic and end-
systolic frames, particularly in the apical lateral segments.
The recent development of 2D speckle tracking echocar-
diography (2DSTE) has allowed automatic measurements
of regional displacement, tissue velocity, strain, and
rotation to be performed without the need for manual

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008.
For permissions please email: journals.permissions@oxfordjournals.org.
2DSTE for LV function
tracings.14–19 We hypothesized that application of this meth-
odology to the LV endocardial border would allow automatic
measurements of LV volume and LVEF. Accordingly, the aims
of this study were (i) to test the feasibility of 2DSTE for LV
volume and LVEF measurements in a large group of patients,
(ii) to validate these measurements against cardiac mag-
netic resonance (CMR) reference, and (iii) to determine
the accuracy of speckle tracking using RT3DE-derived LV
volumes and LVEF, as a reference technique.
Study design
This study included two separate protocols. In Protocol 1,
2DSTE measurements of LV volumes and LVEF were com-
pared against CMR reference, which is currently the
accepted standard reference method for LV volume
measurements. Once validated against this rather expensive
and time-consuming reference in a relatively limited
number of patients, 2DSTE measurements of LV volumes
and EF were obtained in a considerably larger number of
patients and validated against RT3DE estimates, which
were recently shown to compare favourably with CMR
measurements.2,3,6,7,12 Of note, the latter data were
obtained quickly and easily in the same setting and using
the same equipment as 2DSTE data.
Methods
Protocol 1
Twenty patients with a wide range of LV volume [mean LV end-
diastolic volume (LVEDV), 153 + 80 mL; range, 34–402 mL] and
LVEF (mean, 46 + 16%; range, 9–72%) referred for CMR imaging
were enrolled in this protocol (nine patients with dilated cardio-
myopathy, six with LV hypertrophy, and five normal volunteers).
Exclusion criteria were pacemaker or defibrillator implantation,
claustrophobia, and other well-known contraindications to CMR
imaging. Also, patients with cardiac arrhythmias and prior sternot-
omy were excluded. The 2DSTE data acquisition was performed on
the same day as the CMR study. The Institutional Review Board
approved the study.
Cardiac magnetic resonance assessment of left
ventricular volume and ejection fraction
Cardiac magnetic resonance images were obtained in each patient
using a 1.5 T scanner (Philips Medical Systems) with a phased-array
cardiac coil. ECG-gated localizing spin-echo sequences were used
to identify the LV long axis. Steady-state free-precession dynamic
gradient-echo cine loops were obtained during 10–15 s breath-
holds. Data were reconstructed to obtain 30 frames per cardiac
cycle. In all patients, 8–13 short-axis cine loops were obtained
from just above the mitral annulus to just below the LV apex
(9 mm slice thickness, no gaps). CMR cine loops were analysed
offline with commercial software (ViewForum, Philips). In every
short-axis slice, endocardial contour was manually traced at end-
diastole and end-systole, while including the papillary muscles and
the endocardial trabeculae in the LV cavity. LVEF was determined
by disk–area summation method. All tracings were performed by
an investigator experienced in the interpretation of CMR images,
who had no knowledge of the echocardiographic measurements.
Protocol 2
A total of 196 subjects with a wide range of LVEF were screened to
perform 2D and RT3D echocardiography. Patients were selected
based on image quality. Patients in whom the endocardium was
not adequately visualized in two contiguous segments or three or
83
more non-contiguous segments were excluded from the study.
Patients were also excluded if they had rhythm disturbances that
precluded the acquisition of adequate RT3DE data sets. A total of
15 patients were excluded using these criteria. Thus, the final
group consisted of 181 patients. Informed consent was obtained
from all patients.
Two-dimensional speckle tracking
echocardiography assessment of left ventricular
volume and left ventricular ejection fraction
In all subjects, apical four-chamber views were acquired during
three consecutive cardiac cycles using high frame rate harmonic
imaging (iE33, Philips system with a S5-1 transducer), while taking
care to maximize the LV long-axis dimension. Data were sub-
sequently transferred to a personal computer for off-line analysis
using newly developed 2D speckle tracking software (TMQ, QLab,
Philips). One cardiac cycle was analysed in each patient. In the end-
diastolic frame, three anatomic landmarks, including septal and
lateral points on the mitral annulus and the apical endocardium,
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were manually initialized. Following initialization, the software
automatically placed eight region of interests (ROIs) equidistantly
on the endocardial LV cavity surface. Manual adjustment of ROI
was performed when necessary. Subsequently, the software per-
formed speckle tracking analysis using a block matching algorithm
in the eight ROIs throughout the cardiac cycle. Further, manual
adjustments of the position of ROI in the end-diastolic frame were
performed as necessary followed by recalculation of speckle track-
ing algorithm throughout the cardiac cycle. LV volume vs. time
curves were generated by calculating LV volume at each phase of
the cardiac cycle using the single-plane Simpson’s formula, from
which LVEDV, LV end-systolic volume (LVESV), and LVEF were auto-
matically calculated (Figure 1).
Two-dimensional echocardiographic assessment
of left ventricular volume and left
ventricular ejection fraction
In each subject, 2D echocardiographic assessment of LV volumes and
LVEF was performed in the identical apical four-chamber image in
which 2DSTE was applied. The endocardial border at both end-
diastolic and end-systolic frames was manually traced, and LVEDV,
LVESV, and LVEF were calculated using the single-plane Simpson’s
formula.
Real-time three-dimensional echocardiography
assessment of left ventricular volume and left
ventricular ejection fraction
Harmonic real-time 3D imaging was performed using the same ultra-
sound system and a matrix-array transducer (X3-1, 1.9/3.8 MHz) to
obtain a pyramidal volume data sets. Gain and compression con-
trols, as well as time-gain compensation settings, were optimized
to enhance image quality. Care was taken to include the entire LV
cavity within the pyramidal scan volume. RT3DE data sets were
acquired using a wide-angle acquisition (938  808) mode in which
four wedge-shaped subvolumes (938  208 each) were obtained
from four consecutive cardiac cycles. Data were acquired from
the apical four-chamber position during held end-expiration. Acqui-
sition was triggered to the ECG R-wave of each cardiac cycle.
Data sets were subsequently analysed off-line using commercial
software (3DQ ADV, QLab, Phillips) as described previously.5,12
Briefly, five anatomic landmarks were manually initialized on the
end-diastolic frame in the non-foreshortened, apical four- and two-
chamber views obtained by cropping the pyramidal data set. The 3D
endocardial surface was automatically detected using a deformable
shell model. Thereafter, the end-systolic frame was selected by
identifying the frame with the smallest LV cavity cross-sectional
area in both apical views. Following initialization, surface detection
84
Figure 1 Example of 2D speckle tracking analysis for global LV function in a normal subject. Upper part shows end-diastolic apical four-
chamber view in which eight tracking points are used. Seven regions of interest are automatically generated (basal, middle and apical
septum, apex and basal, and middle and apical lateral wall). Lower part shows LV volume vs. time curve and ECG. Specific time points
(e.g. aortic valve opening and closure and mitral valve opening) can be overlaid. Note the stability of the LV volume curve during three con-
secutive cardiac cycles.
was then repeated on this frame to obtain end-systolic volumes.
Finally, the computer algorithm automatically defined and traced
the endocardial border in all frames of the cardiac cycle. ‘Casts’
of the LV endocardium were then automatically obtained from
which LV volumes vs. time curves were derived. From these
curves, LVEDV, LVESV, and LVEF were computed.
Inter- and intra-observer variabilities
Intra-observer variability was determined by having one observer
repeating the measurements of 2DSTE- and RT3DE-derived LVEDV,
LVESV, and LVEF in 35 randomly selected subjects 1 month later.
Inter-observer measurement variability was determined by having
a second observer measuring these variables in the same 35 sub-
jects. Intra- and inter-observer variability values were then calcu-
lated as the absolute difference between the corresponding two
measurements in per cent of their mean.
Statistical analysis
All values were expressed as mean + SD. Agreement between 2DSTE
and other modalities was evaluated by linear regression analysis
with Pearson’s correlation coefficient. In addition, Bland-Altman
analysis was used to determine the bias and limits of agreement
between the corresponding measurements. The significance of
inter-technique biases was tested using paired t-tests. A value of
P , 0.05 was considered significant.
T. Nishikage et al.
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Results
Protocol 1
2DSTE images obtained in all study subjects were suitable
for analysis and allowed the measurements of LV volumes
and LVEF. Significant correlation was noted between 2DSTE
and CMR for LV volumes (Figure 2), with no statistically
significant difference between them. Although good corre-
lation for LVEF was also noted, 2DSTE significantly underes-
timated LVEF with a mean difference of 5.2% (P , 0.005)
with 95% limits of agreement at +15%.
Protocol 2
Both 2DSTE in the apical four-chamber view and RT3DE data
sets were successfully acquired in all subjects. Patient
characteristics are shown in Table 1. The frame rate in the
2D apical four-chamber views was 70 + 10 frames/s
(range, 39–98) in contrast to 18 + 2 frames/s (range,
13–27) in the full-volume RT3DE data sets. Two-dimensional
speckle tracking analysis algorithm resulted in an average
LVEDV of 101 + 48 mL (range, 48–295 mL), LVESV of 59 +
45 mL (range, 19–238 mL), and LVEF of 46 + 13% (range,
10–66%). Using the speckle tracking algorithm, poor tracking
of the apical ROI, lateral wall ROI, and ROI at multiple
locations were observed in four, two and two cases, respect-
ively. LV volume vs. time curves showed drift in the LV
volume curves in an additional three cases. The time
2DSTE for LV function 85

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Figure 2 Linear regression analysis of 2DSTE measurement of LVEDV, LVESV, and LVEF against CMR as a gold standard (upper panels) and
Bland-Altman plots (lower panels) in 20 subjects. Dotted line in the upper panel depicts identity. Faded horizontal lines in the lower
panels denote the mean differences between 2DSTE and CMR measurements, whereas the faded lines represent the limits of agreement
(2SD around the mean inter-technique difference). CMR, cardiac magnetic resonance; 2DSTE, 2-dimensional speckle tracking
echocardiography.

required for analysis, including endocardial initialization,

adjustments of ROI, and computation of LV volume and
Table 1 Clinical characteristic of study subjects (n ¼ 181)
LVEF, was usually ,2 min. Manual tracing of standard 2D
Age (years) 61 + 14
apical four-chamber view resulted in LVEDV of 100 + 48 mL
Male (%) 143 (79%) (range, 44–304 mL), LVESV of 52 + 47 mL (range,
Height 163 + 9 cm 12–260 mL), and LVEF of 54 + 17% (range, 2–79%). RT3DE
Weight 61 + 11 kg surface detection algorithm yielded LVEDV of 109 + 47 mL
Clinical diagnosis (range, 46–293 ml), LVESV of 56 + 46 mL (range,
CAD 57 13–237 mL), and LVEF of 54 + 17% (range, 9–78%).
HHD 21 A significant correlation was found between
Cardiomyopathy 42 2DSTE and RT3DE measurements for LVEDV (r ¼ 0.95), LVESV
VHD 6 (r ¼ 0.97), and LVEF (r ¼ 0.92) (Figure 3). Compared with
LBBB 4
RT3DE, 2DSTE underestimated LVEDV, and slightly, but signifi-
Congenital heart 1
disease
cantly overestimated LVESV, resulting in a significant underes-
Others 33 timation of LVEF. Bland-Altman analysis of LVEF using both
Normal volunteer 17 methods showed a mean difference of 8 with 95% limits of
Risk factor agreement at +14%. The subgroup analysis showed
HT 98 that good correlation (LVEDV: r ¼ 0.93, LVESV: r ¼ 0.93,
DM 37 LVEF: r ¼ 0.80) was still preserved in 42 patients who had
HL 59 globally reduced LV systolic function (28 + 11% of mean LVEF
Real time 3D echocardiographic data by RT3DE, range, 9–44%) or in 29 patients with regional wall
LVEDV 108.8 + 46.9 ml (range: 46 to 293 ml) motion abnormalities (LVEDV: r ¼ 0.83, LVESV: r ¼ 0.90,
LVESV 56.3 + 46.2 ml (range: 13 to 237 ml)
LVEF: r ¼ 0.89).
LVEF 53.6 + 17.1% (range: 9 to 78%)
A significant correlation was also noted between the RT3DE
CAD, coronary artery disease; DM, diabetes mellitus; HHD, hyperten- and 2D manual tracing methods for LVEDV (r ¼ 0.93), LVESV
sive heart disease; HL, hyperlipidemia; HT, hypertension; LBBB, left (r ¼ 0.96), and LVEF (r ¼ 0.92) (Figure 4). Although manual
bundle branch block; LVEF, left ventricular ejection fraction; LVED(S)V, 2D tracing method significantly underestimated LV volume
left ventricular end-diastolic (systolic) volume.
measurements, no differences of LVEF were noted between
86
Figure 3 Linear regression analysis of 2DSTE measurement of LVEDV, LVESV, and LVEF against RT3DE as a gold standard (upper panels) and
Bland-Altman plots (lower panels) in 181 subjects in the same format as in Figure 2.
the two methods. Bland-Altman analysis of LVEF showed a
mean difference of 0.1% with 95% limits of agreement at
+13%.
Intra- and inter-observer variabilities
Intra-observer variability in the measured LV volume and
LVEF using 2DSTE was 6.7 + 7.8 and 5.9 + 5.8%, respect-
ively. Inter-observer variability in the measured LV volume
and LVEF using 2DSTE was 9.4 + 8.0 and 7.7 + 5.6%,
respectively.
Intra-observer variability in the measured LV volume and
LVEF using RT3DE was 7.7 + 6.7 and 13.7 + 12.3%. Inter-
observer variability in the measured LV volume and LVEF
using RT3DE was 8.3 + 7.6 and 20.1 + 14.0%, respectively.
Discussion
This study demonstrated that (i) 2DSTE evaluation of both LV
volumes and LVEF correlated well with CMR, and (ii)
although good correlation was noted between 2DSTE and
RT3DE for LV volumes and LVEF, a small yet significant under-
estimation of LVEDV and LVEF was noted with 2D speckle
tracking method. Despite these small differences, a
shorter analysis time coupled with low observer variabilities
makes this method potentially clinically useful.
Two-dimensional speckle tracking analysis was developed
as a tool to measure regional LV function, using myocardial
strain, strain rate, and torsion.14–19 The general principle
of this technique relies on the tracking of natural acoustic
T. Nishikage et al.
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markers (speckles) in the myocardium from frame to
frame throughout the cardiac cycle using a sum of absolute
differences algorithm.15,17 Tracking a specific speckle detail
during serial frames allows measurements of temporal and
spatial displacement of speckle targets, from which 2D
strain and strain rate in the left ventricle can be calculated
globally and regionally. The accuracy of 2D speckle tracking
and its clinical utility for the assessment of regional LV func-
tion was demonstrated in several studies.14,20,21 Impor-
tantly, unlike tissue Doppler-derived strain and strain rate,
speckle tracking is angle independent. Moreover, regional
LV function can be assessed in all myocardial segments.
The results of this study showed that this new method may
also be useful for the evaluation of global LV function.
Speckle tracking of the endocardial border is easier com-
pared with tracking of the epicardium, because the acoustic
mismatch between the endocardium and blood pool is large,
resulting in more accurate tracking of the blood tissue
interface.
Previous studies
As the quantitative assessment of LV function using manual
tracing method is relatively tedious and observer depen-
dent, automated approaches have attracted interest in
the past. Acoustic quantification (AQ) is an automated
border detection technique that has been used for the
quantitative assessment of LV volume and function.22,23
However, AQ requires adequate visualization of the endo-
cardial border to accomplish accurate tracking. Gain
2DSTE for LV function
Figure 4 Linear regression analysis and Bland-Altman analysis between RT3DE and 2D manual tracing method shown in the same format as in
Figure 2.
setting heavily affects accurate tracking of the blood–tissue
interface resulting in substantial measurement variability.
These drawbacks have limited its routine use in clinical
practice.
Current study
The results of Protocol 1 demonstrated that 2D speckle
tracking analysis allows reliable assessment of LV volumes
and LVEF when compared against CMR as a reference stan-
dard with relatively small bias and narrow limits of agree-
ment. Although sample size was relatively small, our
results contribute towards the validation of 2DSTE assess-
ment of LV volume and LVEF.
In Protocol 2, all subjects who were enrolled on the basis
of relatively good image quality were found suitable for
2DSTE analysis of LV volumes and LVEF. However, eight out
of 181 subjects had suboptimal speckle tracking, especially
in the apex and lateral wall. Additional three patients had
a drift in the LV volume curve, which occurred as a result
of obvious cardiac translation during data acquisition.
When compared against RT3DE, 2D manual tracing method
consistently underestimated both LVEDV and LVESV, a
finding which is in agreement with previous studies.5,8
Although LVEDV by 2DSTE was also underestimated, in this
study, compared with RT3DE, LVESV was slightly overesti-
mated compared with RT3DE, resulting in an 8% underesti-
mation of LVEF. In contrast to the 2D manual tracing and
RT3DE methods, in which manual editing can be performed
in both the end-diastolic as well as end-systolic frames,
87
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the speckle tracking software allows manual editing of the
ROI position only in the end-diastolic frame, which might
have contributed to this discrepancy.
In this study, LV volume and LVEF measurements obtained
by 2D speckle tracking method were calculated using single-
plane Simpson’s role (apical four-chamber view) which
necessitates mathematical geometric assumption. Previous
studies have shown that a minimum of three to six long-axis
cross sections is necessary for the accurate determination of
LV function.24,25 However, our subgroup analysis still showed
good correlation of LV volume and LVEF between 2DSTE and
RT3DE measurements in patients with globally reduced LV
systolic function and those with regional wall motion
abnormalities. Thus, this method could be applicable in
ischaemic patients with LV asynergy. Further studies are
required to test this hypothesis.
Two-dimensional speckle tracking of the LV endocardial
border provides LV volume vs. time curves throughout the
cardiac cycle. Since the frame rates of 2DSTE are four to
five times faster than those of full-volume RT3DE data
sets, more detailed LV volume analysis could be potentially
accomplished, including the analysis of diastolic function
using parameters such as filling rates and per cent filling
at specific time intervals of diastole.
Compared with previous studies, the inter-observer
variability in LV volumes and LVEF using 2DSTE was
smaller compared with those obtained with the 2D
manual tracing and RT3DE.5,8,12 This finding is another
advantage of 2DSTE compared with manual tracing for
assessing global LV function.
88
Study limitations
We assessed only 2D speckle tracking in the apical four-
chamber view and used single-plane Simpson’s formula for
the calculation of LV volume and LVEF, because this software
does not support the use of the bi-plane Simpson’s formula
in its current stage of development. The study subjects did
not constitute a consecutive series of subjects, and were
selected according to image quality. In the future, the
true feasibility of this method should be determined in a
large series of consecutive patients. The accuracy of
speckle tracking largely depends on image quality, and con-
sequently poor endocardial delineation should result in inac-
curate findings as a result of artificial error of endocardial
tracking. However, the same situation occurs with manual
tracing. Nevertheless, in this feasibility study, only 15
patients (,20%) were excluded because of inadequate
image quality. We did not enrol patients with poor image
quality, and therefore, subjects did not receive intravenous
contrast agents to enhance endocardial border. Further
studies are required to determine whether 2D speckle track-
ing would accurately track endocardial border on
contrast-enhanced images.
Conclusions
2DSTE measurements of global LV function resulted in a
small but significant underestimation of LVEDV and EF com-
pared with RT3DE. However, its accuracy, low observer
variability, and speed of analysis make 2DSTE an attractive
alternative for the assessment of LV function in the clinical
setting.
Conflict of interest: I.S.S., S.H.S. and S.H. are employees of Philips.
Funding
Dr. Takeuchi: Equipment was loaned and software was
donated from Philips in order to perform this work. Dr.
Lang: software was donated from Philips in order to
perform this work.
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