Download Assessment of Left Ventricular Mass by Cardiovascular Magnetic

Assessment of Left Ventricular Mass by Cardiovascular
Magnetic Resonance
Saul G. Myerson, Nicholas G. Bellenger, Dudley J. Pennell
Abstract—Left ventricular hypertrophy is associated with significant excess mortality and morbidity. The study and
treatment of this condition, in particular the prognostic implications of changes in left ventricular mass, require an
accurate, safe, and reproducible method of measurement. Cardiovascular magnetic resonance is a suitable tool for this
purpose, and this review assesses the technique in comparison with others and examines the clinical and research
implications of the improved reproducibility. (Hypertension. 2002;39:750-755.)
Key Words: myocardium 䡲 hypertrophy 䡲 magnetic resonance imaging
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T
he importance of left ventricular hypertrophy (LVH) in
medicine is not widely appreciated. The Framingham
Study, among others, showed that increased left ventricular
(LV) mass is associated with a significant excess of cardiovascular mortality and morbidity.1 This is independent of the
presence of coronary artery disease2 or hypertension,1 with a
tripling of the mortality rate in subjects with1–3 and without2
either of these. The risks of coronary, peripheral, or cerebrovascular disease are also raised, even among normotensive
subjects with LVH.1,4,5
The accurate measurement of LV mass has in the past been
difficult, partly because of the oblique angle at which the
heart lies within the chest, its continuous movement, and the
lack of a technique for imaging the whole left ventricle. Initial
measurements with ECG data were surrogate markers for LV
mass, with values affected by positioning of the leads,
orientation of the heart, and obesity.6 – 8 Nevertheless, criteria
were developed for identifying LVH with ECG9,10 that
correlated to an extent with true LVH but were insensitive
and nonspecific (specificity, 6% to 56%).11–13 Imaging techniques have now supplanted the ECG, and we review these
with particular reference to cardiovascular magnetic resonance (CMR).
geometric shape for both M-mode and 2D echo may lead to
error, particularly as variations in ventricular geometry affect
calculated LV mass.19 The landmark trials, such as Framingham,1 overcame the deficiencies in accuracy and reproducibility of echo with large numbers of subjects.
M-mode is the commonest echocardiographic method for
measuring LV mass, the images being easier to obtain and the
calculations straightforward. Although validated against postmortem mainly normal hearts,20,21 it suffers most from the
assumption of geometric shape, and this variability is reflected in the poor accuracy of the technique, with standard
errors of the estimate (SEE) of 29 to 97 g (95% confidence
interval [CI], 57 to 190 g).20 –23 Interstudy reproducibility is
also poor, with SDs of the difference between successive
measurements of 22 to 40 g (95% CI, 45 to 78 g).21,24 –27 The
importance of operator skill is underlined by the large
interobserver variability of a similar degree (SEE, 28 to 41 g;
95% CI, 55 to 80 g).21,24,25
2D echo has advantages over M-mode echo, as measurement is made of the ventricular length and minor axis in 2
planes. It still, however, assumes a prolate ellipsoid shape of
the left ventricle and, to an extent, uniform wall thickness and
is thus prone to similar inaccuracies as M-mode echo. The
accuracy (SEE, 31 to 39 g)22,23 and reproducibility28 –30 are
moderately improved over those of M-mode, although the
increased difficulty in obtaining suitable quality images for
evaluation may limit the ability to determine LV mass.
3D echo removes the assumption of shape and wall
thickness. It has been shown to be more accurate than 2D or
M-mode echo22,31 and is comparable to CMR,32,33 with
reasonable reproducibility (95% CI, ⫾45 g),34 particularly
with the newer transesophageal 3D echo (95% CI, ⫾12.8
g).35 The technique requires skill and time; however, and a
number of subjects may not have suitable acoustic windows.
Echocardiography
Echocardiography (echo) was a distinct advance for LV mass
measurement over the ECG, with direct visualization of the
myocardium and real-time imaging, and many important
studies examining the prognostic effects of LVH have used
this method.1,2,14 However, obtaining good quality images is
dependent on a skilled operator, patient position and anatomy, obesity, and angle of the transducer beam,15,16 and
images of sufficient quality for LV mass measurement may
not be obtained in up to one third of cases.16 –18 The assumed
Received July 23, 2001; first decision August 4, 2001; revision accepted December 12, 2001.
From the Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, United Kingdom.
Correspondence to Prof Dudley Pennell, Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney St, par London SW3 6NP,
United Kingdom. E-mail [email protected]
© 2002 American Heart Association, Inc.
Hypertension is available at http://www.hypertensionaha.org
750
Myerson et al
LV Mass With Cardiovascular MR
751
There are currently relatively few units worldwide practicing
the technique on a regular basis, and the transesophageal
route may not be acceptable to some subjects.
Electron-Beam Computed Tomography
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The fast imaging time of electron beam computed tomography (EBCT), when coupled with blood-pool contrast agents,
has facilitated 3D cardiac imaging precise enough to measure
LV mass. The technique is similar to 3D echo and CMR in
that multiple contiguous image planes are summed to measure myocardial volume, employing Simpson’s rule. When
multiplied by the density of myocardial tissue (1.05 g/cm3),
the LV mass is obtained. The ability to acquire many slices in
a single breath-hold is also an advantage. There is good
reported accuracy36,37 (SEE, 16 g in humans) and reproducibility,38 although human validation studies are limited. The
disadvantages are the exposure to ionizing radiation and need
for an intravenous contrast agent to delineate the cardiac
blood pool. In addition, the image slices are not true short
axes but an approximation, because of the limitations of
available image planes, which decrease accuracy because of
partial volume effects.
Cardiovascular Magnetic Resonance
3D techniques such as EBCT and 3D echo are clearly better
than 1D or 2D methods with assumptions about ventricular
shape. CMR shares this advantage without the ionizing
radiation or need for contrast agents with EBCT and without
the problems of acoustic windows for echo. The free choice
of imaging planes and good tissue visualization mean that
virtually all images are of sufficient quality for LV mass
determination.
CMR Technique
For the most accurate measurements, the image stack should
be parallel to the true LV short axis, minimizing partial
volume errors (Figure). The short axis is identified by first
piloting the vertical long axis (VLA) plane from transaxial
images, passing through the center of the mitral valve and
apex of the LV. A horizontal long axis (HLA) plane is then
obtained perpendicular to the VLA, again passing through the
center of the mitral valve and apex. From the HLA, a stack of
short-axis images is obtained, covering the length of the LV.
ECG-gated cine CMR is acquired to measure LV mass at a
single time point within the cardiac cycle (the standard is
end-diastole). In addition, acquiring each image slice within a
single breath-hold removes respiratory artifact. Usually 10
slices will cover the ventricle, and with a 10-second breathhold per slice, this can be achieved in ⬍10 minutes. With the
newest scanners, cine stack can be obtained in a single
breath-hold, reducing the time taken for a scan to ⬇8
seconds.39 The image stack can also provide volume information by summing the endocardial area on each slice to
derive left (and right) ventricular volumes. The cine nature of
the images allows end-diastolic and end-systolic volume to be
measured and thus also stroke volume, as well as regional
ventricular function.
Diagrammatic representation of the LV with typical CMR short
axis images obtained.
Accuracy and Reproducibility
The accuracy of CMR measurements of LV mass has been
validated using postmortem hearts, imaged ex vivo for
humans26,40 or in vivo for animal studies41– 46 (Table 1). These
show good agreement between the CMR-obtained and true
LV masses, with SD of the difference of ⬇8 g (95% CI, ⬇15
g) in human studies and 10 g (95% CI, ⬇19 g) in canine
studies. The gold-standard validation of comparing in vivo
images with subsequent postmortem weights has not been
performed in humans, and this important comparison remains
to be done.
The reproducibility of LV mass measurements is of importance for assessing changes over time, both for individuals
and research studies. This encompasses interstudy (ie, testretest reliability) and inter- and intraobserver variability in
values. Again these are very good for CMR (Table
2),26,27,40,47–53 with interstudy variability having a mean
weighted SD of the difference of 7.8 g (95% CI,
15.3 g).26,27,47,48 Mean weighted intra- and interobserver
variabilities are 4.8 and 9.0 g, respectively.47,53 By comparison, the mean weighted interstudy SD of the difference for
M-mode, 2D, and 3D echo is 27.7,21,24 –28 19.2,28,30 and
19.2 g,34,35 respectively.
Clinical Implications
The greater accuracy and reproducibility of 3D techniques,
such as CMR, has important implications for clinical practice
and research. The improved reproducibility means that in
group studies, much smaller sample sizes can be used to
detect the same change in LV mass. Alternatively, using the
same sample size, smaller degrees of change can be identified. A comparison between CMR and echo of the sample
752
Hypertension
March 2002
TABLE 1.
Accuracy of CMR-Determined LV Mass in Human and Animal Studies
No.
SDD
95% CI
Mean
Difference
Mean %
Difference
Notes
6
8.9 g
⫾17.5 g
0.7 g
4.0%
Human
Katz et al40
10
7.4 g
⫾14.5 g
10.2 g
5.3%
Human
Human studies
(mean values)
16
8.0 g
⫾15.7 g
McDonald et al41
10
1.8 g
⫾3.5 g
4.4 g
5.2%
Shapiro et al42
10
6.7 g*
⫾13.1 g
8
8.7 g*
⫾17.1 g
Caputo et al43
13
13.7 g*
⫾26.9 g
Keller et al44
Study
Bottini et al26
Canine
Canine normal
Canine post-MI
10.0%
Canine normal ⫹
LVH
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10
3.5 g
⫾6.9 g
Maddahi et al45
8
4.9 g*
⫾9.6 g
Canine; in vivo
9
3.4 g*
⫾6.7 g
Canine; dead (in-situ)
Florentine et al46
11
13.1 g*
⫾25.7 g
Canine ⫹ feline
Canine studies
(mean values)
79
7.0 g
⫾13.7 g
6.8 g
13.3%
Canine
Values are compared to postmortem derived LV mass. Mean values are weighted for sample size. SDD indicates
standard deviation of the difference between the 2 measurements; CI, confidence interval (1.96 ⫻ SDD); and MI,
myocardial infarction.
*SE of the estimate from regression equation.
sizes needed to detect a statistically significant change in
mean LV mass of 10 g are shown in Table 3. The numbers
needed with CMR are ⬇8% of those with M-mode and 17%
of those with 2D echo, with considerable savings in cost and
study duration. CMR has already been used in clinical trials
to identify very small differences in LV mass between
groups: 9 to 11 g/m2 with 15 to 20 subjects per group54,55 and
7 g with groups of 30 to 40 subjects each.56
For individual patients, the 95% CI for serial studies using
M-mode echo of ⫾45 to 78 g21,24 –27 means that serial LV
TABLE 2.
mass measurements cannot detect a change of less than this
amount with any certainty. Given that most therapeutic
interventions are likely to effect a change that is smaller than
this, M-mode echo would not be an ideal method for serial
changes. 2D echo has improved reproducibility, which results
in better confidence intervals (⫾39 g),30 and these are ⫾13 to
45 g for 3D echo, depending on the route used (transesophageal versus transthoracic).34,35 CMR has 95% CIs of ⫾12 to
22 g,26,27,47,48 and this or another 3D technique should be used
for individual changes in LV mass.
Reproducibility of CMR-Derived LV Mass Measurements from Human Studies
Study
No.
Interstudy
Intraobserver
Interobserver
Notes
15
6.4 g (2.8%)
3.0 g (1.6%)
5.1 g (2.4%)
Normal subjects
15
6.4 g (3.0%)
5.9 g (2.7%)
7.7 g (3.1%)
4
8.2 g
Normal subjects
Germain et al27
20
11.2 g (6.7%)
Normal subjects
Grothues et al48
20
4.2 g (2.3%)
Normal subjects
20
9.6 g (3.8%)
Heart failure
20
8.4 g (2.8%)
LVH
Bellenger et al
47
Bottini et al26
Semelka et al
Heart failure
49
11
5.2%
4.4%
Normal subjects
Semelka et al50
11
4.7–6.1%
3.4%
DCM
8
3.5–4.8%
5.5%
LVH
12
4.4%
4.2%
Normal subjects
Bogaert et al51
Matheijssen et al52
4.1%
8
3.6%
3.6%
MI
Yamaoka et al53
10
5.8 g
17.8 g
Normal, LVH, and DCM
Katz et al40
10
Mean weighted
values
7.8 g (n⫽114)
6.1%
7.2%
4.8 g
(n⫽40)
9.0 g
(n⫽40)
Values are standard deviations of the difference between successive scans (g) or % variability. Mean values are for studies with
absolute values, weighted by sample size. DCM indicates dilated cardiomyopathy; MI, myocardial infarction.
Myerson et al
TABLE 3. Comparison of Sample Sizes Needed to Detect a
Statistically Significant Change in Mean LV Mass of 10 g
Power (1-␤ Error)
CMR
2D Echo
M-Mode Echo
99%
23
136
283
95%
16
96
199
90%
13
78
162
80%
10
58
121
These assume a 2-tailed unpaired t test with 0.05 level of significance
(␣-error) and refer to the sample size in each group (2 parallel treatment
groups would need twice this number in total). We used the mean weighted
values of interstudy standard deviation of the difference for M-mode echo (27.7
g),21,24 –28 2D echo (19.2 g),28,30 and CMR (7.8 g).26,27,47,48
Limitations of CMR
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Patient factors can sometimes limit the usefulness of the
technique. Because of the enclosed nature of the CMR
scanner, some people find this too claustrophobic. In practice,
the incidence of this is ⬇3% to 5%, though light intravenous
anxiolysis with diazepam to can reduce this to 1%.57 Advances in equipment technology, with shorter and more open
magnets together with reduced time in the scanner from faster
imaging, will also improve conditions for these patients. The
same restrictions as for any MR scanner apply for patients
with cranial aneurysm clips, ocular metallic shards, and
pacemakers. The need for breath-holding to remove respiratory motion artifact can present problems for some patients
with severe cardiac or respiratory disease; for these patients,
“navigator” sequences can be used in which free breathing is
allowed and the diaphragm is continuously monitored, with
imaging adjusted for the diaphragm position.58 This has the
disadvantage of slightly increased imaging time, but image
quality is well maintained.
Currently, the availability of CMR scanners capable of
cardiac work and the skilled personnel needed to obtain
and interpret the images limits the widespread clinical use
of this technique, although many pharmacological studies
with CMR have already been performed. This is likely to
change in the near future, with nearly all new MR scanners
having the required hardware and the cardiac software.
Although the initial cost of the scanner is high, for research
purposes the savings from the reduced number of subjects
may offset this substantially. A single study takes ⬇15
minutes for postprocessing with standard techniques. Although this is longer than for echo, the new generation of
machines coupled with automated image processing will
greatly reduce these times and will allow a fast-throughput
service.
Conclusions
LVH is a potent risk factor for cardiovascular disease and is
associated with significant increases in morbidity and mortality, but traditionally little has been done to specifically
address this issue. This is because until recently, no reliable
and reproducible technique existed to quantify LV mass. We
now know that the measurement of LV mass is best accomplished with 3D techniques, and CMR has become the gold
standard. 3D echo and EBCT achieve an accuracy and
reproducibility close to those of CMR and are acceptable
LV Mass With Cardiovascular MR
753
alternatives, but problems preclude their regular use. Now
that good data exist in particular for the effectiveness of ACE
inhibitors in reducing LV mass,59 – 61 and the prognostic
benefits of LV mass reduction are becoming defined,62– 64
coupled with a reproducible and accurate measurement technique in CMR, it is likely that more clinical and research
attention will be paid to this condition. The fidelity of the
CMR technique may also lead to new understanding of the
precise mechanisms behind LVH,65 and why its effects on
mortality are so profound, even in the absence of coronary
artery disease and hypertension, although recent work implicates plaque disruption as an important issue.66
Acknowledgments
The British Heart Foundation provided funding for Dr Myerson (FS
97030). This work was also supported by the Coronary Artery
Disease Research Association (CORDA) and the Wellcome Trust.
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Assessment of Left Ventricular Mass by Cardiovascular Magnetic Resonance
Saul G. Myerson, Nicholas G. Bellenger and Dudley J. Pennell
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Hypertension. 2002;39:750-755
doi: 10.1161/hy0302.104674
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