Impact of image quality on reliability of the measurements of left ventricular systolic function and global longitudinal strain in 2D echocardiography

Background: Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) play important roles in diagnosis and management of cardiac diseases. However, the issue of the accuracy and reliability of LVEF and GLS remains to be solved. Image quality is one of the most important factors affecting measurement variability. The aim of this study was to investigate whether improved image quality could reduce observer variability. Methods: Two sets of three apical images were acquired using relatively old- and new-generation ultrasound imaging systems (Vivid 7 and Vivid E95) in 308 subjects. Image quality was assessed by endocardial border delineation index (EBDI) using a 3-point scoring system. Three observers measured the LVEF and GLS, and these values and inter-observer variability were investigated. Results: Image quality was significantly better with Vivid E95 (EBDI: 26.8±5.9) than that with Vivid 7 (22.8±6.3, P<0.0001). Regarding the inter-observer variability of LVEF, the r-value, bias, 95% limit of agreement and intra-class correlation coefficient for Vivid 7 were comparable to those for Vivid E95. The % variabilities were significantly lower for Vivid E95 (5.3-6.5%) than those for Vivid 7 (6.5-7.5%). Regarding GLS, all observer variability parameters were better for Vivid E95 than for Vivid 7. Improvements in image quality yielded benefits to both LVEF and GLS measurement reliability. Multivariate analysis showed that image quality was indeed an important factor of observer variability in the measurement of LVEF and GLS. Conclusions: The new-generation ultrasound imaging system offers improved image quality and reduces inter-observer variability in the measurement of LVEF and GLS.