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Estimation of Left Ventricular Volume by
One-Plane Cineangiography
By DAVID G. GREENE, M.D., RAYMOND CARLISLE, M.B., M.R.C.P.,
COLIN GRANT, M.B.,
AND
IVAN L. BUNNELL, M.D.
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SUMMARY
One-plane cineangiographic measurement of left ventricular volume uses angiocardiograms taken in the right anterior oblique view. Its basic assumption is that the third
(unvisualized) dimension, depth from septum to free wall, is of the same magnitude
and behaves in the same way as the visualized short axis. Examination of this assumption with biplane x-ray equipment revealed that the unmeasured length averages 7%
less and varies directly with the length of the measured short axis. Volumes measured
correlate well with consecutive studies using serial biplane x-rays and are systematically
somewhat larger than volumes obtained in autopsy specimens injected with barium
sulfate paste. The method is tolerant of variations in positioning of the patient, is convenient, yields repeatable analyses from one experienced observer to another, allows 60
volume measurements per second so that rapid cardiac events can be studied, and the
small doses of x-rays and contrast medium permit several observations at one catheterization session. This means that effects of drugs and other interventions can be studied
by the informative techniques of semi-continuous volume measurement and pressurevolume analysis.
ADDITIONAL INDEXING WORDS:
Left ventricular function
Isoproterenol
Biplane angiography
Angiotensin
for measuring left ventricular volume in man.17
It is an elaboration of a method applied for
the same purpose in dogs.18 Its validity has
been examined in five ways: by comparison
with the established biplane angiocardiographic method, by study of observer variation, by biplane examination of the short
axes of the ventricular ellipsoid, by study of
postmortem hearts filled with contrast medium, and by a comparison of length measurements with area measurements. An important advantage of the one-plane cine
method described herein is that multiple
studies become feasible at a single clinical
catheterization session, so that various drugs
and maneuvers can be assessed in regard to
their effect on ventricular function.
LEFT ventricular volume can be measured
by the somewhat cumbersome technique
of biplane angiocardiography'-7 and can be
estimated conveniently by the often misleading8-13 indicator washout techniques.14 Both
groups of methods have produced a growing
appreciation of the importance of volume studies in evaluating left ventricular function, and
of the frequent disparity between left ventricular end-diastolic pressure and end-diastolic
volume.'5, 16 This report describes and validates a convenient cineangiographic method
From the Department of Medicine, State University
of New York at Buffalo, and the Buffalo General
Hospital, Buffalo, New York.
This study was supported in part by Grant 2 ROI
HE-07539-04 from the National Heart Institute, and
in part by grants from the New York State Heart
Assembly and the Wyoming County Heart Associa-
Methods
Angiocardiograms were performed in patients
with valvular heart disease and in a few subjects
with substantially normal circulation usually studied because of a systolic murmur. Cineangiograms
in the right anterior oblique projection were made
tion.
Part of this paper has been included in a thesis
submitted by one author (R. C.) for the M. D. degree
from the University of Cambridge, England.
Circulation, Volume XXXV, January 1967
61
62
6EREENEN ET AL.
at 60 frames per second as 25 to 50 ml of 76%
nmethylgliucamine diatrizoate (Ren-iografin) were
in-ijected inlto the left atritum tlhrough a transseptal catheter. In 18 subjects these were followedl
in 15 to 30 miniutes by biplane 30 by 30-cm
angiocardiograms withi injection of 40 to 80 ml
of the satme miiaterial into the left atrium. Asidle
from rotatinig the patien-t froml- one projectioni to
the otlher and sliding the x-ray table to a invew
position, there were no changes in the experimental conditions between the two con-lsecuitve
sets of measurements of left ventricular volume.
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Volumes were calculated from the biplane films
by a slightly modified Arvidssoni teclhniiqtue as
described previously.7
Left venitricular volume wvas caleculated fr omii
the one-plane cine picturles uisinig the ellipsoidtype model developed by Arvidssoin for his b)iplane technique. In the biplaine method the lonig
axis of the veIntr icle, L, and two mututially perpen-dicular slhort axes at its midpoint, NI aind N,
are measuiired, and the volulme is calceulatecd firon]
the formula for the voltime of an ellipsoid,
v
7T LMN
6
where V is equial to left ventricular voliumie.
In the one-plane cin-e pietuire, L, the lonig axis
of the veintricle, andIM, a short axis at riglht
angles to it at its midpoinlt, ar-e bothi directly
measurlable. The asstumption is made that the
shiort axis wlhich is n-ot visible, N, perpendicular
to both L and iN, is equal to MX. The formula
then becomiies
V-
6 LM2.
6
Technique of Measurement of the Cine Film
This techniiqtue needs detailed description. The
iTnage of the opacified left ventricle on cinie
filrn in the right anterior oblique projection is
vieved under standard conditions, and the best
cycle is picked from the sequence of contractions. Appropriate reference is made to the simultaneotus graplhic records of electrocardiogram
aniid ventricular pressture to avoid premature contractions and post-extraisystolic beats. A reviexv of
-the sequence at cine speed allows an image of
the ven-tricle to be remembered so that individual
frames may be neasuried with more confidenice.
A coupledl fraame counlter is of help in identifying
frames.
The outline of the venl-tricle and adjacent atrial
border is traced oni a sheet of paper marked with
art identifying frame n-iumber. Wlhere indentations in the ventricular outline are caused by
papillary muiscles or trabeculations, these are igniored and the outline is drawn to include all
the opacified ai-eas. A typical frame anid the tracinig fron] it are showvni in figure 1.
Figure 1
Right anterior oblique cize frame of opacified left atriumnl anid left ventricle, left, and line
drawinig of the vetrtiicuilar outtlite, rigfht, wcith its lonig axis (L) and short axis (M). The
base of the longy axis is taken at the inUterisectioni of the left borders of the left atrial and
left ventricular shadowes, and its opposite enld is the farthest point of the apex. M is perpendicular to L at its midpoint and exteidis to the limit of the ventricullar shadow in
each directioni. Tl'he indenitation m7ade by the papillary mu.scle in the inferomedial margin
of the ventrictular shaldot is igtnoredl inl dralwing the ventricuilar otitline. The left ventrictular
catheter is for simultaneotus miieaisuiremiienrt of pressure. The left atrial catheter is for contrast
in-jection.
Circulation, Volumne XXXV, January 1967
LEFT VENTRICULAR VOLUME
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With left atrial injection the base of the left
ventricle and the aortic valve are obscured.
Therefore, the long axis of the ventricular cavity
is measured from its apex to the intersection of its
left anterior margin with the corresponding margin of the left atrium (or in a few patients, of the
aorta). This point is nearly as far from the apex
as the center of the aortic valve, which is obscured. In each subject a decision was made
whether to use one or the other intersection in
drawing the long axis and this was then used in
all studies on the subject. Figure 1 shows measurements made using the atrioventricular intersection. The long axis, L, is drawn from the intersection of the left ventricular margin and the
left atrial margin to the apex of the ventricle.
It is bisected, and the transverse diameter, M,
of the ventricle at the midpoint of its long diameter, L, is measured.
Both measurements must be corrected for magnification and distortion. Since there is "pincushion" distortion in the field as viewed through
the image amplifier, we allow for both distortion
and magnification by routinely photographing a
metal grid of 1-cm squares placed at the level
of the left ventricle (10 cm above the mattress
top). Pincushion distortion is spherical aberration of the electromagnetic lens system, with
more magnification at the periphery than in the
central field. It is so-called because of the appearance of the straight lines of the metal grid, which
appear to be curved convex to the center of the
field. When the film is subsequently projected,
the magnification of image and grid will be the
same. In the Tage Arno projector the magnification is about 1.5 at the center of the field and
1.6 at the periphery. Both magnification and
distortion are corrected with a single factor (f)
in the equation actually used:
V=KLM2
where
JT
6
.
1
Distortion in the image amplifier depends upon the distance of the line being measured from
the center of the picture. Radii and tangents are
affected slightly differently. A satisfactory compromise is achieved by using a factor dependent
upon the mean distance from the center of the
picture of the line being measured. One might
calculate the magnification and distortion factor, f, separately for each frame. In practice
the ventricle changes position in the field so little
that the factor changes only in the third decimal
place throughout the cycle. It is sufficient, therefore, to calculate f once for a frame in mid-systole
Circulation, Volume XXXV, January 1967
63
or mid-diastole and to use that value throughout
the cycle.
Testing the Assumption that N Equals M
To test the assumption that the short axis not
measured, N, is equal to the measured short axis,
M, biplane films at six exposures per second were
made in the two oblique projections. These paired
pictures permitted measurement of N and M
simultaneously. Satisfactory measurements were
obtained in eight patients, and 19 or more consecutive frames were obtained in each study. Accordingly the middle 19 consecutive pairs of
frames were measured on each of the eight subjects, and these 152 values for M and N were
analyzed statistically.
Comparison of Calculated with Actual
Cavity Volume
To compare the calculated volume with actual
cavity volume, studies were made of bariumfilled ventricles in hearts post mortem. The mitral
valve orifices of seven fresh human hearts were
closed by suturing the free edges of the mitral
valves together. The left ventricular cavity was
filled with measured increments of a thixotropic
barium sulfate paste injected through a cannula
fixed in the aortic valve orifice. The specimens
were suspended in a position corresponding to that
of the living heart in the right anterior oblique
projection. Cine exposures were made after each
increment of barium sulfate paste was injected
into the left ventricular cavity.
A study was also made in the clinical angiocardiograms to compare length-width data with
planimetrically measured area to see whether these
alternative measurements contained similar information or not. The area of the shadow of the
left ventricle in the cine film was obtained by
planimetric integration of the projected image.
The product of length times width (lengthwidth product) of the left ventricle was also measured and compared with the area. End-systole
and end-diastole were studied in 15 subjcts
chosen to maximize the range of shapes and
sizes.
In addition to the validation studies, drugs
have been used to alter ventricular function.
After a control angiocardiogram, amyl nitrite (by
inhalation) or isoproterenol or angiotensin (each
by intravenous infusion) has been given. During
administration of each drug, left ventricular pressure was monitored. When a pressure change
occurred, a repeat cineangiogram was obtained.
The objective in each of the drug studies was
to produce a small change in ventricular parameters.
Results
The results are shown in figures 2 to 9.
64
GREENE ET AL.
Relationship of the One-Plane Volume to the
Biplane Large-Film Volume (Figure 2)
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In 18 patients the mean value for end-systolic volume over several cycles was determined by each technique, and similarly the
mean value for end-diastolic volume.
The points are distributed linearly along
the line of perfect agreement. The correlation
coefficient for the comparison of the two
methods is 0.988. The greatest disparity is a
few points at end-systole, particularly endsystolic points less than 200 ml, where the
cine volume is as small as 50% of the biplane volume, and points cluster below the
line of identity. A possible explanation of this
discrepancy is that, at six frames per second, it
is possible to miss the time when the ventricle
is smallest, while at 60 frames per second one
records the smallest volume with greater accuracy. Otherwise the data give no indication
of any systematic error. The lines connecting
the end-systolic and end-diastolic points of a
single case are in general parallel to the line
of identity, so that absolute errors tend to
cancel out in calculating stroke volume.
Observer Error
To test the influence of observor error two
observers independently measured and calcu-
i50-
M.C.
2 Sept 64
0
AA
A
A
-
A
First Observer
Second Observet
-
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W
IAA
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V)
LLJ
i:
0X
A
IA
100-
IA
i
50-
i!
A- A Ab
. __ .
:=A,
A_.
t
=s~~~~~~~~~~~~~~~~~~~~~~~~~~
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II
U
50
100
150
200
VOLUME ml.
Figure 3
Pressure-volume loop of a single ventricular contraction independently drawn by two observers. There
is stubstantial agreement between the two loops.
lated left ventricular volume, and correlated
it with left ventricular pressure. The two pres-
sure-volume loops were constructed, and then
drawn on the same plot (fig. 3). There is
disagreement on a few points, but the general shape is essentially similar. Other trials
of this sort have given similar good agreement. Repeated measurements of a single
dimension by one observer may differ by as
much as 0.5 cm.
The Short Axes
500-
The relationship of M, the measured short
diameter, to N, the nonmeasurable short diameter (as measured in the special oblique bi-
400w
z
0
plane studies) is shown in figure 4, where the
data are plotted in relation to the calculated
regression line. The extreme values for the
ratio of N to M were 0.79 and 1.02, with a
mean of 0.93. The regression coefficient was
3000
*
Fg
D200
EODV
e
-j
0
E
0.993.
-j100-
The Postmortem Heart
0
0
100
200
300
400
500
600
LV VOLUME ml BIPLANE
Figure 2
End-systolic and end-diastolic volumes of the left
ventricle calculated from the cineangiogram (ordinate), and from biplane serial large films, taken 15
to 30 minutes later in 18 patients (abscissa). The
dotted line represents perfect agreement.
Known amounts of barium sulfate paste
were injected into postmortem hearts. The
volume calculated from cineangiograms of
these hearts suspended in the right anterior
oblique projection was compared with the
amount injected, as shown in figure 5. The
mean volumes calculated at each increment injected and the standard error of the mean are
Circulation, Volume XXXV, January 1967
LEFT VENTRICULAR VOLUME
65
0
z
8-
z
o
,
-J
"~~~~+
0
6-
4~
0
seA'~~~~~~~~~~
-4
4-
C)
xF
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ct
,o'
~REGRESSION
N=-.305+
0
EQUATION:
.993 M
2-
z
0I
i
,'
I
I
I
I
I
II
I
2
4
I
I
6
MINOR AXIS IN R.A.O.
I
a
1
I
8
PLANE,Mlcm
Figure 4
Relationship of the two perpendicular short
grams of the left ventricle. Different symbols
o 2
300Erz
Z
Length and Area Measurements
200-
T.
X7
w
J
100
are
plotted. Above 100 ml the calculated volumes
are 40 ml larger than the injected volumes,
and this deviation is virtually constant. Below
100 ml the overestimate of volume is proportionately less.
E
<z
simultaneous biplane oblique angioused for each of eight different patients.
axes on
-
o
T/
1)
X7
>
z
/14
....
11
..,.
1.I.-
0
I
P...
0
100
200
300
The relationship of the product of left ventricular length and width to the area of the
left ventricular shadow is shown in figure 6.
The correlation coefficient between the two
measurements was 0.975, showing that the
length-width product contains virtually all the
size information, and no material improvement would be obtained with a technique
VOLUME OF CONTRAST INJECTED ml
Figure 5
Volume of excised human left ventricles from right
anterior oblique cineangiograms (ordinate) compared
with injected volumes of barium sulfate paste (abCirculation, Volume XXXV, January 1967
scissa). The Lars indicate the standard error of the
observations. The numbers indicate number of observations at each volume. The dotted line represents
perfect agreement.
66
GREENE ET AL.
80
MxL
cm2 280 x
240-
x
z
60 -
x
tn
x
200-
Cx
40T
x
60-
.11.
x
x
vx
20
20x
xx
xx
80 -
x
0
X
40U c
:1
80
CORRELATION COEFFICIENT =0.975
l
r
I
I
I
'i
l
0
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40 80 120 160 200 240
AREA cm'
Figure 6
The product of the short axis and long axis of the
ventricle, M x L, compared with the planimetrically
measured area of the ventricular shadow. The linear
distribution ofC the relationship indicates that the
added information of the area measurement does not
change the estimate obtained from the simpler measurement.
based on the more laborious planimetric measurement.
Drugs
The effects of drugs on left ventricular function are illustrated in figures 7 to 9. Amyl
nitrite usually lowered systolic pressure in the
left ventricle, diminished end-systolic volume, and decreased end-diastolic volume and
pressure. Stroke work was reduced (fig. 7).
Angiotensin had opposite effects, increasing
systolic and diastolic pressures, and increasing end-systolic and end-diastolic volume.
Stroke work was unchanged (fig. 8). Both
these drugs are thought to work primarily
on the peripheral vascular bed, with reflex
changes in heart rate. Isoproterenol on the
other hand, with its inotropic effect on the
ventricle, usually decreased left ventricular
diastolic pressure, decreased end-systolic volume, increased end-diastolic volume, and resulted in an increase in stroke work (fig. 9).
Discussion
Left ventricular volumes as calculated from
one-plane cineangiograms agree well with the
r-
l00
120
Left Ventricular Volume, ml
140
I.
_
160
180
Figure 7
Representative pressure-volume ioop of the left ventricle at rest, and similar loop after inhalation of
amyl nitrite. With amyl nitrite, end-diastolic and
end-systolic volume and pressure are less, as is stroke
work. The patient had mitral stenosis and regurgi-
tation and aortic regurgitation.
biplane left ventricular volume data obtained
from the same patient under substantially unchanged conditions a few minutes later. One
source of systematic bias is that the cine
volume was usually determined first, and may
have influenced ventricular function during
the subsequent observation. We do not believe that a significant error was thus introduced for two reasons. In one patient the
o---
W.S.
Control
Angiotensin
3 Dec. 65
1201
I
Eeo
E 80-
crILI
uD
(n
w
4 0-
0_,
-
,|
80
120
160
VOLUME
200
240
ml.
Figure 8
Representative pressure-volume loop of the left ventricle, at rest (control), and after an intravenous
infusion of angiotensin. With angiotensin, end-diastolic
and end-systolic volume and pressure are greater, but
stroke work is unchanged. The patient had a calcified
mitral valve with stenosis and regurgitation.
Circulation, Volume XXXV, January 1967
LEFT VENTRICULAR VOLUME
Control
*-- * Isoproterenol
G.B. 2 Mar. 65
20-
E
E
80 -
w
40w
0r
0-
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.e
--r-
I
80
120
VOLUME
160
ml.
Figure 9
Representative pressure-volume loop of left ventricle
at rest (control), and after an intravenous infusion
of isoproterenol. With isoproterenol end-diastolic volume is larger. End-systolic volume and end-diastolic
and end-systolic pressures are less. The stroke work
is increased. The patient had mild mitral stenosis.
biplane determination
was
done first, and the
agreement was similar. Also these observa-
tions of left ventricular volume by one-plane
and biplane techniques were often preceded
by one or more other injections of contrasl
for diagnostic purposes, usually into the aorta
and left ventricle.
Precise measurement of the margin of the
opacified ventricular shadow in the stationary
projected cine frame is often more difficult
than direct measurement on a 30 by 30-cm
x-ray picture. That the problem can be overcome by practice is demonstrated by the
good agreement of two experienced observers
in constructing a pressure-volume loop from
the same data. Part of the success comes from
agreement on taking the widest extent of
opacification and part from reviewing questionable frames in motion. Borders are more
indistinct when seen in a still frame than when
seen in motion because the signal (the shadow
of the contrast) is reinforced, while the noise
(random effects of film grain, and so forth) is
largely cancelled.
Circulation, Volume XXXV, January 1967
67
The crucial assumption involved in calculating left ventricular volume from the right anterior oblique projection alone is that the
two mutually perpendicular short diameters
at the midpoint of the long axis of the ventricle are essentially equal. Direct measurement of these two diameters in simultaneous
biplane oblique films shows that this is reasonable. The diameter not measured, N, is on
the average 7% smaller than the measured
diameter, and for some purposes it may be
useful to make this correction. It should improve the agreement between calculated and
actual left ventricular volumes (fig. 5). We
have, however, chosen not to change the
formula in the present series.
In a larger chamber the mechanical forces
acting on the nonrigid myocardium are likely
to make the cross-section of the ventricle more
nearly round (cylindrical). M is more likely
to equal N in a large cavity, and less likely
to equal N in a small, contracted, irregular
cavity. In the latter, the percentage error
might become large, but the absolute error
(ml) would not be great. In the eight
subjects in whom M and N were directly
measured and compared, the values ranged
from less than 4 to more than 8 cm.
Estimates of left ventricular volume by the
one-plane cine technique and by the biplane
technique are both larger than the volumes of
barium sulfate paste injected into postmortem
specimens. The injected volume includes only
the fluid placed in the ventricular cavity,
while the angiograms outline the greatest extent of the ventricular cavity. This latter
measurement includes papillary muscles and
trabeculations. This discrepancy is some measure of the volume of these structures. If one's
objective is the study of ventricular muscle
function, the larger volume, including trabeculations and papillary muscles, is of more significance, since a circular band of muscle at
the ventricular waist is contracting on a noncompressible core which includes muscle as
well as liquid contents.
In turning the patient into the right anterior
oblique projection, it is not easy to be certain
of the angle made by the long axis of the
68
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heart and the central x-ray beam. True measurement of the long axis depends upon this
angle being 900. Deviations from a true perpendicular affect the measurement as the
cosine of the angle of deviation, and for small
angles they are negligible. The long axis must
deviate by 25° in order to cause a 10% shortening in this measurement. The rounded shape
of the ventricular apex further diminishes this
error, since angulation shortens the shadow of
a blunt object less than that of a thin line.
The assumption that the ventricle is 10 cm
above the surface of the mattress is used in
correcting for magnification. This vertical
height is the approximate position for the average adult subject in the right anterior oblique
projection. If the mean level of the ventricle
varies 5 cm above or below, the maximal error
introduced will be + 9% or - 7%, respectively.
The rough ellipse of the left ventricular outline contains much more information about
ventricular dimensions than is utilized in making only two measurements, the length and
the width. One might anticipate that better
estimations could be obtained by using more
information, for example, the area. Dodge
and co-workers2 have improved their data
derived from use of the biplane technique by
using a short axis determined from planimetric
measurement of the area of the ventricular
shadow. The high correlation between the
product of the length and width of the ventricular shadow and its area in our data indicates that the simpler measurements are adequate indications of ventricular size.
The volume-time curve of the left ventricle
can be studied by comparing it with records
of such other simultaneous measurements as
the ordinary intraventricular pressure-time
curve. Such a display, however, is less immediately informative than the plot of intraventricular pressure against volume. This
four-sided loop shows clearly end-systolic volume, end-diastolic volume, stroke volume,
residual volume, systolic and diastolic pressures, and stroke work (the area of the loop).
Various valvular lesions lead to characteristic
deformities of the pressure-volume loop, as
have been described recently.7 The changes in
GREENE ET AL.
the loop under the influence of drugs are currently being explored (figs. 7 to 9). The area
of the pressure-volume loop equals the net
stroke work of the left ventricle. Since intraventricular rather than aortic pressure is used,
no assumptions are necessary concerning aortic
cross-sectional area of kinetic work. The pressure-volume figure is currently the best method
available clinically for measuring left ventricular stroke work and is indispensable where
valvular regurgitation invalidates the simpler
stroke work measurements.
The advantages of the one-plane cine
method over the biplane technique are several,
and include convenience, smaller dose of
contrast medium, smaller dose of radiation,
the potential for multiple serial observations,
and volume measurements 60 times per second instead of a maximum of 12 times per
second. Mechanically, it is easier to position
a patient for one-plane cineangiography and
to record in similar fashion the effect of a
drug. Good definition of the adult ventricle is
obtained with 30 to 40 ml of contrast injected
into the left atrium. Such doses are well tolerated and may be repeated after 5 minutes
without difficulty. The hypotension which usually follows such an injection into the left side
of the heart does not appear until after the volume data have been collected, and has disappeared well before 5 minutes have elapsed,
usually in 1 or 2 minutes. The use of an
image amplifier in one plane requires much
less radiation than biplane exposures by usual
radiographic techniques. The recording of 60
frames per second allows one to calculate volume changes at that rate, to estimate the rate
of ventricular ejection, and to fill in the pressure-volume loop in much greater detail. This
is particularly helpful at the beginning of ventricular ejection and at the beginning of ventricular filling, two points in the cardiac
cycle where volume is changing rapidly.
Addendum
Since this paper was submitted, Dodge and
co-workers'9 have described a method for determining left ventricular volume from angiocardiograms taken in a single anteroposterior
projection on large films.
Circulation, Volume XXXV, January 1967
LEFT VENTRICULAR VOLUME
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Estimation of Left Ventricular Volume by One-Plane Cineangiography
DAVID G. GREENE, RAYMOND CARLISLE, COLIN GRANT and IVAN L.
BUNNELL
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Circulation. 1967;35:61-69
doi: 10.1161/01.CIR.35.1.61
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