Three-dimensional echocardiography (3DE) is a reliable and reproducible tool for assessing left ventricular (LV) function but remains sensitive to patient echogenicity. Contrast-enhanced 3DE (C3DE) has the potential to improve quantification in challenging patients. The aim of this study was to evaluate the impact of temporal resolution, spatial resolution, and image dynamic range on LV function assessed using C3DE compared with cardiac magnetic resonance imaging (MRI) in patients with poor echogenicity.

Forty-one patients with poor echogenicity who underwent two-dimensional echocardiography (2DE), 3DE, C3DE, and MRI were retrospectively investigated.

Before contrast injection, 24 patients had three or more nonvisible segments. Three cases of 2DE and 12 cases of 3DE were not suitable for quantification. LV end-diastolic volumes were systematically underestimated by 2DE (142 ± 58 mL), 3DE (146 ± 69 mL), and C3DE (172 ± 61 mL) compared with MRI (216 ± 85 mL) (P < .001). Similar results were found for LV end-systolic volumes (81 ± 65 mL for 2DE, 82 ± 69 mL for 3DE, and 102 ± 80 mL for C3DE vs 129 ± 94 mL for MRI; P < .001). C3DE provided the best agreement with MRI (Lin concordance correlation coefficients of 0.67, 0.93, and 0.99, respectively, for end-diastolic volume, end-systolic volume, and ejection fraction) as well as the best measurement reproducibility. Finally, ultrasound settings had no significant effect on LV volumes and ejection fraction measurements.

In these patients with poor ultrasound image quality, C3DE, regardless of instrument settings, outperformed 2DE and 3DE to assess LV volumes and ejection fraction and can thus be proposed as an acceptable alternative when MRI cannot be performed in this subgroup.