Clinical Investigation
Right Ventricular Size and Function
Accuracy and Interobserver Concordance of Echocardiographic Assessment of Right Ventricular Size and Systolic Function: A Quality Control Exercise

https://doi.org/10.1016/j.echo.2012.03.018Get rights and content

Background

Accurate assessment of right ventricular (RV) size (RVS) and RV systolic function (RVSF) is vital in the management of various conditions, but their assessment is challenging using echocardiography. The aim of this study was to determine the accuracy and interobserver concordance of qualitative and quantitative RV echocardiography.

Methods

Fifteen readers evaluated RV function in 12 patients (360 readings) who underwent echocardiography and cardiac magnetic resonance for RV assessment. Readers qualitatively estimated RVS and RVSF as normal, mild, moderate, or severe and then reassessed quantitatively by adding RV dimensions, fractional area change, S′, tricuspid annular plane systolic excursion, and RV index of myocardial performance. Cardiac magnetic resonance was used as the reference standard for grading RVS and RVSF.

Results

Quantitative measurements increased accuracy and interreader agreement compared to qualitative assessment alone, especially in normal categories. Readers’ accuracy for diagnosing normal and severe RVS increased from 38% to 78% (P = .001) and from 70% to 97% (P = .018), and readers’ accuracy for diagnosing normal and mild RVSF increased from 52% to 84% (P < .001) and from 36% to 56% (P = .001). Interreader agreement for classification of the subjects as normal or abnormal improved from a κ value of 0.40 to 0.77 (fair to good agreement) for RVS and from 0.43 to 0.66 (moderate to good agreement) for RVSF.

Conclusions

Visual estimation of RVS and RVSF is inaccurate and has wide interobserver variability. Quantitation improves accuracy and reliability, especially in distinction of normal and abnormal. The reliability of mild and moderate grades remains inadequate, and further guidance is needed for the classification of abnormal categories.

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Patients

Studies from 12 patients (mean age, 52 ± 19 years; six women) undergoing RV assessment with both echocardiography and CMR imaging performed within 24 hours were selected retrospectively. Five patients had grade 3 or 4+ tricuspid regurgitation, two had grade 3 or 4+ pulmonary regurgitation, three had undergone right-sided valvular repair, one presented for shunt evaluation, and one presented for for evaluation of possible constriction. The institutional review board approved this study.

Echocardiography

Accuracy

The readers’ overall accuracy for diagnosing normal, mild, moderate, and severe RVS and normal, mild, and moderate RVSF is shown in Table 1, Table 2. With only visual scoring, readers had poor accuracy in characterizing RVS as normal, mild, and even moderate. Over a quarter of normal cases were reported as moderate or severe RVS. Visual scoring had 70% accuracy for diagnosis of severe RVS, with 27% of severe cases interpreted as moderate. The addition of quantification correctly classified 78%

Discussion

The main findings of this study are that (1) visual estimation of RVS and RVSF is inaccurate, with significant interrater variability; (2) the addition of quantification improved accuracy and reduced interrater variability (especially in the differentiation of normal and abnormal cases; and (3) the reliability of grading the abnormal cases in mild and moderate categories remains inadequate.

Conclusions

Visual assessment of RVS and RVSF is inaccurate and shows considerable variability. The addition of quantitative assessment yields improved accuracy and decreased variability, especially in relation to defining the normality of the right ventricle. The reliability of grading mild and moderate abnormalities remains inadequate, and further guidance is needed for the classification of abnormal categories.

References (25)

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