In response to the article by Debrun et al. (Int. J. Cardiovascular Imaging 21,[239][240][241][242][243][244][245][246][247] In managing patients with left ventricular (LV) dysfunction, cardiologists have long sought quantification of LV function by various measures, including ejection fraction (EF), myocardial perfusion, wall motion score index, LV diastolic filling patterns, long axis function and even NYHA class. Furthermore in patients with coronary artery disease (CAD), it has been established that LV volume and LV EF are prognostic predictors of survival [1][2][3][4].Ejection fraction served for several decades as the sole measure of systolic function, attracting different imaging techniques to find ways of obtaining reproducible values. Despite its useful value in quantifying ventricular function, EF has its known limitations, particularly in patients with segmental ventricular dysfunction and in those with asynchronous wall movement. In these patients, reproducible values of EF are often scarcely obtainable even by the same technique, let alone comparative values between different imaging modalities that have a broad range of variability.The anatomical basis for such variability lies in the shape of the LV cavity and its changes during dynamic systole. The left ventricle is a threedimensional structure, and during systole significant shape changes occur even in normal subjects. In patients with CAD in particular, a broad scale of changes in LV segmental and global function occur during different phases of the cardiac cycle. With this in mind, the ideal way of standardising LV function would be a four-dimensional (4-D) approach, where timing is also considered as a fundamental variable.In this issue of the International Journal of Cardiovascular Imaging, Debrun et al. present an in vitro study comparing gated single photon emission computed tomography (SPECT) and 4-D echocardiographic measurement of left ventricular volumes and EF in a cardiac phantom. This study evaluates the measurement fidelity of an established nuclear medicine technique and an emerging real-time 3-D echocardiographic technique against known volumes in a gated dynamic cardiac phantom and torso model. LV end-systolic volumes (ESV) from 50-130 ml and LV end-diatolic volumes (EDV) from 120-200 ml were measured with a constant stroke volume (SV) of 70 ml, representing EF from 35% (LV dysfunction) to 58% (normal).In contrast to previous work in the literature comparing SPECT and 2-D echo, LV volumes were calculated in three dimensions for both the nuclear and ultrasound modalities in this study. Vourvouri and Roelandt [5] reported on the agreement between gated SPECT and 2-D echocardiography for measuring LV volumes. In vivo measurements using both modalities showed excellent correlation for LV volumes and good agreement for calculated EF in patients with chronic ischaemic LV dysfunction. Debrun and colleagues empirically validate the next logical advancement in cardiac imaging -real-time 3-D echocardiography against gated SPECT.There have...