Single beat 3D echocardiography for the assessment of right ventricular dimension and function after endurance exercise: Intraindividual comparison with magnetic resonance imaging
Single beat 3D echocardiography for the assessment of right ventricular dimension and function after endurance exercise: Intraindividual comparison with magnetic resonance imaging
Sebastian Schattke 0 3
Moritz Wagner 2
Robert Hättasch 0 3
Sabrina Schroeckh 1
Tahir Durmus 2
Ingolf Schimke 0 3
Wasiem Sanad 0 3
Sebastian Spethmann 0 3
Jürgen Scharhag 4
Gert Baumann 0 3
Adrian C Borges
Fabian Knebel 0 3
0 Charité - Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charité Campus Mitte , Charitéplatz 1, 10117 Berlin , Germany
1 Klinik für Dermatologie, Venerologie und Allergologie , Charité Campus Mitte, Berlin , Germany
2 Institut für Radiologie , Charité Campus Mitte, Berlin , Germany
3 Charité - Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charité Campus Mitte , Charitéplatz 1, 10117 Berlin , Germany
4 Innere Medizin III , Universitätsklinikum
Background: Our study compares new single beat 3D echocardiography (sb3DE) to cardiovascular magnetic resonance imaging (CMR) for the measurement of right ventricular (RV) dimension and function immediately after a 30 km run. This is to validate sb3DE against the “gold standard” CMR and to bring new insights into acute changes of RV dimension and function after endurance exercise. Methods: 21 non-elite male marathon runners were examined by sb3DE (Siemens ACUSON SC2000, matrix transducer 4Z1c, volume rates 10-29/s), CMR (Siemens Magnetom Avanto, 1,5 Tesla) and blood tests before and immediately after each athlete ran 30 km. The runners were not allowed to rehydrate after the race. The order of sb3DE and CMR examination was randomized. Results: Sb3DE for the acquisition of RV dimension and function was feasible in all subjects. The decrease in mean body weight and the significant increase in hematocrit indicated dehydration. RV dimensions measured by CMR were consistently larger than measured by sb3DE. Neither sb3DE nor CMR showed a significant difference in the RV ejection fraction before and after exercise. CMR demonstrated a significant decrease in RV dimensions. Measured by sb3DE, this decrease of RV volumes was not significant. Conclusion: First, both methods agree well in the acquisition of systolic RV function. The dimensions of the RV measured by CMR are larger than measured by sb3DE. After exercise, the RV volumes decrease significantly when measured by CMR compared to baseline. Second, endurance exercise seems not to induce acute RV dysfunction in athletes without rehydration.
Single beat 3D echocardiography; Magnetic resonance imaging; Endurance exercise; Right ventricle
Extreme exercise might lead to right ventricular (RV)
dysfunction and an elevated risk of arrhythmias in some
]. To acquire RV data cardiovascular
magnetic resonance imaging (CMR) and echocardiography
have been proven valuable tools.
Acquisition of RV echocardiographic data has been
conventionally proven difficult due to its anterior
position in the chest, a complex geometry and
morphology with prominent trabeculations. Over the years
several parameters have been developed to determine
RV function by 2D echocardiography, e.g. Tricuspid
Annular Plane Systolic Excursion (TAPSE), Tei-Index,
systolic pulmonary arterial pressure (sPAP), strain and
speckle tracking or even simple “eyeballing”. It is,
however, highly dependent on a standardized
acquisition since a slight drift in angle of view results in a
significant change of measurements [
]. Therefore the
modality of choice for evaluating right ventricular
chamber size and function is still considered to be
cardiovascular magnetic resonance imaging. Recent
advances in transducer and computing technology
make single beat 3D echocardiography (sb3DE)
possible. It might be an alternative that is less cost
intensive than CMR and can be used on patients with
pacemaker or an implantable cardioverter-defibrillator
(ICD). Since it is single beat (shorter acquisition time)
it is also applicable in patients with arrhythmias or
breathing disorders. It is however very dependent on
good image quality and a fairly wide ultrasound sector
angle to include the entire right ventricle. Previous
studies have shown that even though volumes
acquired with sb3DE are generally smaller than
acquired with CMR there is a fair correlation in the
measured ejection fraction [
Several studies have already assessed changes of RV
function and dimension after endurance exercise. Most
of these studies used a one-time event like an official
marathon race or even an ultra-endurance competition
to acquire data. In such a setting CMR measurements
are delayed due to logistical limitations. In most studies,
CMR was performed within one or two days post-race
and after rehydration.
The goals of this study were
1. to validate the new method of sb3DE of the RV
against CMR and
2. to examine the immediate effect of endurance
exercise on RV function.
In this study we examined amateur athletes
immediately after a run of 30 km with CMR and sb3DE, in a
randomized order and compared the results. No more
than two runners ran at a time to ensure immediate
measurement after exercise.
Over a hundred male non-elite runners resident in the
Berlin-area were asked to take part in this study.
Inclusion criteria were a regular training routine and at least
one finished marathon race in the past. Exclusion
criteria were signs and symptoms of coronary heart
disease, chronic cardiovascular disorders (atrial fibrillation,
pacemaker, bypass surgery, prosthetic valves, congenital
heart disease), allergy to gadolinium chelates or a
known kidney disease.
The number of participants was limited in advance.
The first 22 athletes were screened and provided
baseline characteristics and medical and training history.
Written informed consent was obtained from each
participant. The institutional ethics committee approved the
study protocol. The study complied with the Declaration
Each runner underwent baseline echocardiography,
CMR and gave a blood sample one to three weeks prior
to the 30 km run. The runners were asked to refrain
from their regular training for four days before baseline
testing to avoid elevated biomarkers or altered
There were neither pace nor fluid restrictions during
the run. However, rehydration was prohibited after the
race until completion of echocardiography and CMR
After the run echocardiography and CMR were
performed in a randomized order (CMR before
echocardiography in eleven cases) and a blood sample was taken.
Standard transthoracic echocardiography was performed
by an experienced cardiologist according to the
guidelines of the American Society of Echocardiography [
on a Siemens ACUSON SC2000 echocardiography
system (Siemens AG, Healthcare Sector, Erlangen,
Germany, 4V1c 1,25-4,5 MHz transducer).
Sb3DE was performed using the same
echocardiography system (4Z1c Instantaneous Full Volume
transducer, 1,5-3,5 MHz). The runners lay in left decubitus
position. A single beat scan was acquired from an apical
4-chamber transducer position in harmonic mode if
needed for better border definition or fundamental
mode during a single end-expiratory breath-hold. Depth
and angle of the ultrasound sector were set to only
visualize the right ventricle. Before each acquisition,
images were optimized for endocardial border detection.
At least two data sets were acquired per athlete to
ensure optimal data quality. The volume rates were 10
to 29 frames per second. The data sets were stored
digitally and were exported to a terminal workstation for
Data analysis was performed on a SC2000 workplace
1.5 (Siemens AG, Erlangen, Germany) running the Right
Ventricular Analysis Application. This application
requires manual tracing of the endocardial borders on a
short-axis, apical 4-chamber and coronal view in
end-systole and end-diastole. The detection of the ventricular
surface throughout the cardiac cycle is then automated
and represented in a dynamic 3D model (Figure 1).
Cardiac magnetic resonance imaging was performed on a
1,5 Tesla MR system (Siemens Magnetom Avanto,
Erlangen, Germany). Right ventricular volumes and function
were evaluated on axial cine steady state free precession
(SSFP) images (5 mm slice thickness)[
]. Calculation of
RV end-diastolic volume (EDV), end-systolic volume
(ESV), stroke volume (SV), and ejection fraction (EF) was
performed using dedicated software (ARGUS, Siemens
Medical Solutions, Erlangen, Germany) via manual
tracking of RV endocardial borders in different slices and
calculation of RV volumes using the Simpson method
(Figure 2). RV trabeculations were included in the
calculation of the ventricular volume [
The body surface area for the determination of cardiac
index (CI) was calculated separately at the two time
points (before and after the run) [
For hematologic parameters, EDTA plasma was
collected and measured immediately.
Results are expressed as mean value ± standard deviation,
number (percentage) or coefficient (interval -1, +1). The
Wilcoxon signed-rank test was used to compare repeated
or related measurements (e.g. CMR RV EF baseline and
post-run or CMR RV EF baseline and sb3DE RV EF
baseline). Bland-Altman plots and the intraclass correlation
coefficient (ICC) (two-way, mixed, average measure,
according to Shrout [
]) were either used to describe
the agreement of the two imaging modalities or for the
assessment of conformity among observers. The limits of
agreement for the Bland-Altman plot were specified as
average difference ± two standard deviations of the
For the calculation of intraobserver variability CMR
and sb3DE volume analysis were repeated for four
runners after three months. Three members of our group
performing analysis of two data sets calculated
echocardiography interobserver variability. They were blinded to
each other’s results.
22 athletes were screened. One runner showing signs of
prior myocardial infarction (subendocardial delayed
enhancement) in baseline-CMR was excluded from the
study before the 30 km run. He was encouraged to
undergo further cardiac diagnostics.
21 athletes ran in May and June 2010. All finished the
30 km run without adverse events. The average running
time was 169,4 ± 17,4 minutes. The runners mean body
weight decreased from 75,5 kg ± 7,9 to 73,2 kg ± 8,0.
Table 1 shows the runners’ baseline characteristics.
All post-run measurements were completed in less
than 120 Minutes in all runners.
All subjects had sufficient image quality to perform
sb3DE RV analysis. CMR showed no significant
difference in the ejection fraction before and after the run,
while RVEDV and RVESV and RVSV decreased
significantly. (Table 2).
Sb3DE as well showed no significant difference in the
ejection fraction before and after the race. However,
although the mean values were lower, sb3DE did not show
a significant reduction of RVEDV, RVESV or RVSV.
Both methods, CMR and sb3DE, showed a significant
increase of the CI.
Inter- and intra-observer variabilities and intraclass
correlation coefficients are shown in Table 3.
Standard 2D echocardiography showed neither a
significant change in fractional area change (FAC) nor in
tricuspid annular plane systolic excursion (TAPSE). It
did, however, show a significant decrease of pulmonary
valve acceleration time (PVAT) and pulmonary valve
ejection time (PVET).
The volumes measured by sb3DE were significantly
smaller than those measured by CMR (Table 4).
However, there was no significant difference between the EF
determined by the two methods (Figure 3). Figure 4
shows Bland-Altman plots comparing RV ejection
fraction and dimensions measured by both methods.
Cellular blood components (erythrocytes, leukocytes,
thrombocytes, hematocrit) as well as sodium and
potassium showed a relative increase.
RV E’, cm/s
RV A’, cm/s
RV S’, cm/s
p (baseline vs.
This study is the first head-to-head comparison of
sb3DE and CMR in the analysis of RV dimension and
function immediately after endurance exercise in
welltrained athletes. We found no signs of RV dysfunction.
However, there was a decrease in RV volumes. This
decrease was significant in CMR, in sb3DE the mean
values tended to be lower after the run but a high
heterogeneity resulted in no significance.
Sb3DE was feasible in all subjects. Acquisition and RV
analysis is possible within minutes. Sb3DE can be
performed in tachycardic subjects after exercise. Data
analysis in sb3DE is dependent on good image quality.
While detection of the endocardial border was easily
possible in the apical 4-chamber view it often was a
challenge in short-axis and coronal views. To facilitate
contour delineation, the software gives reference points
based on the users previous input in former views. This,
although being a helpful feature, makes measurement
prone for sequence errors. Due to the RV anterior
position in the chest, the RV anterior wall and outflow tract
in the near field remains problematic in some subjects
despite good image quality. This is a reason for the
relatively high intra- and inter-observer-variability, which
might be more pronounced in patients with RV disease
or poor acoustic windows. An advantage of single beat
3D echocardiography is the lack of stitching artifacts
and prolonged breath-hold, which will lead to a better
acceptance of the method in routine echocardiography.
Previous studies have used stitched volumes. The
normal values for this method were published recently
]. Compared to these normal values, our subjects
had larger ventricles; this is most likely due to the fact
that we have examined well trained athletes . The
RVEF in our subjects is lower than the published
normal values [
]. Still, it is in normal range in all
subjects before and after endurance exercise. The intra- and
inter-observer-variability in our study is comparable
with published data [
Although CMR is considered as the gold standard
for RV volumetry and functional analysis [
] a clear
identification of the tricuspid or pulmonary valve or
the endocardial border is not always possible. Also,
border delineation is user-dependent (e.g. how much
trabeculation is included). In addition, relevant
restrictions and contraindications have to be considered. Its
use is limited in children, claustrophobic patients and
patients with pacemakers or similar implants.
Furthermore, it is relatively expensive and not easily available.
Image acquisition requires a sufficient patient
Both sb3DE and CMR have relatively low volume/
frame rates. Therefore, the definition of end-diastole
and end-systole can be missed. This is especially difficult
if the patient has a high heart rate (in our study the
highest post-run heart rate was 111/minute).
RV dimensions and function by sb3DE were in fair
correlation to CMR. As previously described, sb3DE
defines lower volumes than CMR [
]. This is
partly due to differences in data analysis since in sb3DE
the endocardial borders are traced and most of the
trabeculations are excluded while generally in CMR most
of the trabeculations were included into the calculation
of the cavity volume. In CMR analysis this is clinical
standard because it leads to a faster and more reliable
The discrepancy between volumetry in 3D
echocardiography and CMR is more pronounced in larger
]. RV 3D echocardiography was recently
validated against CMR in patients with congenital heart
]. Only 50-80% of the patients had a
sufficient acoustic window for 3D echocardiography. In our
study with ideal healthy subjects 100% could be
analyzed. The RV analysis algorithm is designed for normal
shaped RV and not congenital RV disease. Additionally,
several data sets were acquired per athlete to ensure
optimal data quality.
In sports cardiology, the issue of RV dysfunction after
endurance exercise is not solved. Most CMR studies had
a long delay of data acquisition after the race or did not
mention the time point of echocardiography and CMR
]. Neither CMR, nor sb3DE or standard
transthoracic echocardiography showed RV systolic
dysfunction in dehydrated subjects in our study. The changes of
pulmonary valve acceleration and ejection time are
within normal limits and probably due to the change in
heart rate. Thus they do not indicate the presence of
post-exercise pulmonary hypertension.
All other previously published studies that have
investigated RV function after exercise have measured after
rehydration and showed RV dysfunction [
Our laboratory results clearly underline the presence
of relevant dehydration.
Our study is limited by the fact that we have not
performed additional echocardiography and CMR after
rehydration. It therefore remains unclear if rehydration
through an increase in volume load leads to a change in
Both CMR and sb3DE are feasible in healthy athletes
with high and low heart rates.
The two modalities showed a good correlation of RV
function. Sb3DE obtained, however, smaller RV volumes
compared to CMR. In conclusion, it is a sufficient
alternative whenever it comes to image acquisition that
needs to be done fast, with less expenditure or with
patients that have contraindications for CMR.
In contrast to previous data, we could not detect RV
dysfunction after exercise in either method. We assume
that rehydration and volume load were important
factors, which needs further investigation.
CI: Cardiac index; CMR: Cardiovascular magnetic resonance imaging: EDTA:
Ethylenediaminetetraacetic acid; EDV: End-diastolic volume; EF: Ejection
fraction; ESV: End-systolic volume; FAC: Fractional area change; Hs-cTnT: High
sensitivity cardiac troponin T; ICC: Intraclass correlation coefficient; ICD:
Implantable cardioverter-defibrillator; IL-6: Interleukin 6; IOV:
Interobservervariability; NT-proBNP: N-terminal prohormone of brain natriuretic peptide;
PVAT: Pulmonary valve acceleration time; PVET: Pulmonary valve ejection
time; RV: Right ventricle: right ventricular; RVOT: Right ventricular outflow
tract; SAX: Short axis; Sb3DE: Single beat three dimensional
echocardiography; SCD: Sudden cardiac death; sPAP: systolic pulmonary
arterial pressure; SV: Stroke volume; TAPSE: Tricuspid annular plane systolic
We are grateful to the athletes who have participated in the study.
Furthermore we thank Michael Ilg and Birgit Bohn (Siemens) for the
technical support and Carina Schücke and Ursula Wagner for their great
help and the time they have invested in our study.
Heidelberg, Heidelberg, Germany. 5Imaging Science Institute, Charité
BerlinSiemens, Berlin, Germany. 6Klinik für Innere Medizin I, Kardiologie und
Diabetologie, HELIOS Klinikum Emil von Behring, Berlin, Germany.
SS, Conception and design of the study, analysis and interpretation of
echocardiographic data, revision of the manuscript. MW, Conception and
design of the study, analysis and interpretation of CMR data, revision of the
manuscript. RH, Conception and design of the study, analysis and
interpretation of CMR and echo data, drafting and revision of the
manuscript, SS, Conception and design of the study. TD, Conception and
design of the study, analysis and interpretation of CMR data, revision of the
manuscript. IS, Analysis and interpretation of hematologic data. WS,
Conception and design of the study, analysis and interpretation of
echocardiographic data, revision of the manuscript. SS Revision of the
manuscript. JS, Revision of the manuscript. AH, Conception and design of
the study. GM, Conception and design of the study. ACB, Conception and
design of the study. FK, Conception and design of the study, analysis and
interpretation of echocardiographic data, drafting and revision of the
manuscript. All authors read and approved the final Manuscript.
The authors declare that they have no competing interests.
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