Imaging the heart failure patient–need for accurate measurements of left ventricular volumes and ejection fraction: the role of three-dimensional and contrast echocardiography

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Purpose of review

Left ventricular ejection fraction (LVEF) is a powerful prognostic marker in heart failure and plays a pivotal role in the allocation of many treatments that reduce morbidity and mortality. Although unenhanced two-dimensional echocardiography (2DE) is the most ubiquitous tool for the assessment of left ventricular (LV) size and systolic function, it does not provide reliable, reproducible and accurate measures. The purpose of this review is to critically appraise contrast echocardiography and three-dimensional echocardiography (3DE) for the assessment of LVEF and LV volumes.

Recent findings

Contrast echocardiography results in more accurate assessment of LVEF and LV volumes than unenhanced 2DE, significantly improving correlation with cardiac magnetic resonance, with comparable reproducibility. Contrast echocardiography reduces downstream testing, frequently alters patient management, and results in substantial cost savings. 3DE shows higher levels of agreement with cardiac magnetic resonance over unenhanced 2DE for LVEF and LV volumes, but requires adequate image quality, and consistently underestimates LV volumes due to limited spatial resolution.


The advent of contrast 2DE and 3DE has marked the dawn of significant improvements in the precision and reproducibility of echocardiography. Contrast 3DE improves LV assessment in patients with suboptimal images, but further work is needed to demonstrate incremental benefit over contrast echocardiography.

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