Age-, Body Size-, and Sex-Specific Reference Values for Right Ventricular Volumes and Ejection Fraction by Three-Dimensional Echocardiography

Abstract

R ight ventricular (RV) volumes and ejection fraction (EF)are important determinants of survival in patients with myocardial infarction, 1 systolic heart failure, 2-4 congenital heart disease, 5 and pulmonary arterial hypertension.6 Clinical Perspective on p 710Cardiac magnetic resonance (CMR) is the current gold standard for quantitation of RV geometry and function, but its widespread use is limited by costs, time consumption, and contraindications, making it unsuitable for patient screening or monitoring on large scale.One of the major breakthroughs of transthoracic threedimensional echocardiography (3DE) is the ability to measure RV volumes and EF, otherwise not feasible by standard two-dimensional (2D) echocardiography. 7 However, recent recommendations for RV quantitation 8 indicated that limited normative data are currently available for 3DE and, despite significant differences by age and sex for RV geometry and function were identified by CMR, 9 no reliable age-or sexspecific reference values can be recommended at present for 3DE. Paralleling the findings obtained with CMR, 9 we hypothesized that RV volumes and EF measured by 3DEBackground-Right ventricular (RV) volumes and ejection fraction (EF) vary significantly with demographic and anthropometric factors and are associated with poor prognosis in several cardiovascular diseases. This multicenter study was designed to (1) establish the reference values for RV volumes and EF using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on RV anatomy; (3) develop normative equations. Methods and Results-RV volumes (end-diastolic volume and end-systolic volume), stroke volume, and EF were measured by 3D echocardiography in 540 healthy adult volunteers, prospectively enrolled, evenly distributed across age and sex. The relation of age, sex, and body size parameters was investigated using bivariate and multiple linear regression. Analysis was feasible in 507 (94%) subjects (260 women; age, 45±16 years; range, 18-90). Age, sex, height, and weight significantly influenced RV volumes and EF. Sex effect was significant (P<0.01), with RV volumes larger and EF smaller in men than in women. Older age was associated with lower volumes (end-diastolic volume, −5 mLdecade; endsystolic volume, −3 mL/decade; EF, −2 mL/decade) and higher EF (+1% per decade). Inclusion of body size parameters in the statistical models resulted in improved overall explained variance for volumes (end-diastolic volume, R 2 =0.43; end-systolic volume, R 2 =0.35; stroke volume, R 2 =0.30), while EF was unaffected. Ratiometric and allometric indexing for age, sex, and body size resulted in no significant residual correlation between RV measures and height or weight. Conclusions-The MethodsHealthy volunteers were prospectively enrolled in 3 Italian tertiary centers (C1, C2, C3) having a large expertise in 3DE for RV quantification (>400 studies/y per center for both clinical and research purposes). Participating centers were asked to provi...

Right Ventricular Volumes and Systolic Function by Cardiac Magnetic Resonance and the Impact of Sex, Age, and Obesity in a Longitudinally Followed Cohort Free of Pulmonary and Cardiovascular Disease

“…However, consistent with our findings, most prior studies show smaller RV sizes and CO with increasing age. 5,6,13,[18][19][20] The present study extends these early SSFP-based reports in that our study sample was an order of magnitude larger, with participants drawn from a meticulously phenotyped community-dwelling cohort.…”

Sex- and Method-Specific Reference Values for Right Ventricular Strain by 2-Dimensional Speckle-Tracking Echocardiography

“…2 For 3DE analysis, 4-and 6-beat full-volume RV, LV, and RA data sets were by guest on May 11, 2018 http://circimaging.ahajournals.org/ Downloaded from acquired during breath-hold from the apical approach, taking care to avoid any artifacts and include the entire structure in the acquisition. 14 …”

Use of novel echocardiographic techniques to assess right ventricular geometry and function

“…3DE measurements are closely correlated (but slightly underestimate) with RV volumes measured by CMR both in children and adults [18][19][20][21], and by volumetric thermodilution during cardiac catheterisation [22]. Normative data for 3DE RV volumes and ejection fraction (EF) including age-, body size-, and sex-specific reference values based on large cohort studies of healthy volunteers have recently become available (Table 2) [23,24]. Recent chamber quantification guidelines for the first time included recommendations for 3D analysis of the RV specifying RV end-diastolic volume of 87 mL/m 2 in men and 74 mL/m 2 in women, and RV end-systolic volume of 44 mL/m 2 in men and 36 mL/m 2 in women as the upper normal range limits (Table 3) [12].…”

“…The reference values of 3DE RVEF have recently been obtained on large cohorts of healthy volunteers (Table 2) [23,24], and reports on performance in disease conditions are accumulating [30]. Importantly, recent guidelines suggest that in laboratories with appropriate 3D platforms and experience 3DE-derived RVEF should be considered a method of choice for quantifying RV systolic function, with the abnormality threshold < 45% (Table 3) [12].…”