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Updated: Jun 6, 2025
Evaluation of Left Ventricular Structure and Function using 3D Echocardiography
Published on: October 28, 2020
Impact of experience on visual and Simpson's biplane echocardiographic assessment of left ventricular ejection
S Akil1, J Castaings1,2, P Thind2
1Division of Laboratory Medicine, Department of Clinical Physiology, Karolinska Institute, Huddinge, Sweden.
Background:
In clinical routine, health care professionals with various levels of experience assess left ventricular ejection fraction (LVEF) by echocardiography. The aim was to investigate to what extent visual and Simpson's biplane assessment of LVEF, using two-dimensional (2D) transthoracic echocardiography (TTE), is affected by the evaluator's experience.
Methods:
Ultrasound images of 140 patients were assessed, visually and with Simpson's biplane method, by six evaluators divided into three groups based on echocardiographic experience level (beginner, intermediate and expert). The evaluators were blinded to each other's LVEF assessments. Bland-Altman analyses (bias±SD) were performed to assess agreement. P-values < 0.05 with the performed paired t-test were considered statistically significant.
Results:
Level of agreement in LVEF was good between evaluators within the expert group: visual = LVEFexpert 1 vs LVEFexpert 2: -0.4 ± 6.4 (p = 0.46); Simpson's biplane = LVEFexpert 1 vs LVEFexpert 2: 0.96 ± 7.0 (p = 0.11), somewhat lower within the intermediate group: visual = LVEFintermediate 1 vs LVEFintermediate 2: -1.2 ± 4.4 (p = 0.004); Simpson's biplane = LVEFintermediate 1 vs LVEF intermediate 2: -3.3 ± 5.0 (p < 0.001) and lowest for beginners: visual = LVEFbeginner 1 vs LVEFbeginner 2: 2.3 ± 9.8 (p = 0.007), Simpson's biplane = LVEFbeginner 1 vs LVEF beginner 2: -1.8 ± 8.7 (p = 0.02). The agreement between LVEFexpert and LVEFs by the two other groups was: visual = LVEFexpert vs LVEFbeginner: 1.5 ± 6.0 (p = 0.005); LVEFintermediate: -3.0 ± 4.4 (p < 0.001) and Simpson's biplane = LVEFexpert vs LVEFbeginner: 3.2 ± 6.3 (p < 0.001); LVEFintermediate: -2.2 ± 4.7 (p < 0.001).
Conclusions:
The evaluator's level of experience affects visual and Simpson's biplane assessment of LVEF by 2D-TTE, with highest variability being among beginners. Furthermore, a second opinion is recommended when assessing reduced LVEF even for evaluators with intermediate and expert experience.
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