The value of a simplified approach to end-systolic volume measurement for assessment of left ventricular contractile reserve during stress-echocardiography

  • Marco A. R. Torres
  • Thais F. Texeira
  • Ana C. Camarozano
  • Clarissa C. A. Bellagamba
  • Natalia M. Quevedo
  • Altair I. Heidemann Junior
  • Carolina Bertoluci
  • Tonino Bombardini
  • Michele De Nes
  • Quirino Ciampi
  • Eugenio PicanoEmail author
  • the Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging
Original Paper


The peak stress/rest ratio of left ventricular (LV) elastance, or LV force, is a load-independent index of left ventricular contractile reserve (LVCR) with stress echo (SE). To assess the accuracy of LVCR calculated during SE with approaches of different complexity. Two-hundred-forty patients were referred to SE for known or suspected coronary artery disease or heart failure and, of those, 200 patients, age 61 ± 15, 99 females, with interpretable volumetric SE were enrolled. All readers had passed the upstream quality control reading for regional wall motion abnormality (RWMA) and end-systolic volume (ESV) measurement. The employed stress was dipyridamole (0.84 mg, 6 min) in 86 (43%) and dobutamine (up to 40 mcg/kg/min) in 114 (57%) patients. All underwent SE with evaluation of RWMA and simultaneous LVCR assessment with stress/rest ratio of LV force (systolic blood pressure by cuff sphygmomanometer/ESV). ESV was calculated in each patient by two of three methods: biplane Simpson rule (S, in 100 patients), single plane area-length (AL, apical four-chamber area and length, in 100 patients), and Teichholz rule (T, from parasternal long axis and/or short axis view, in 200 patients). RMWA were observed in 54 patients. Success rate for ESV measurement was 76% (100/131) for S, 92% (100/109) for AL, and 100% (240/240) for T. There were 100 paired measurements (rest and stress) with S versus T, and 100 with AL versus T. The analysis time was the shortest for T (33 ± 8 s at rest, 34 ± 7 s at stress), intermediate for AL (70 ± 22 s at rest 67 ± 21 s at stress), and the longest for S (136 ± 24 at rest 129 ± 27 s at stress, p < 0.05 vs. T and AL). ESV absolute values were moderately correlated: T versus S (r rest = 0.746, p < 0.01, n = 100; r stress = 0.794, p < 0.01, n = 100); T vs. AL (r = 0.603 p < 0.01, n = 100, at rest and r = 0.820 p < 0.01 n = 100 at peak stress). LVCR values were tightly correlated independently of the method employed: T versus S (r = 0.899, p < 0.01, n = 100), and T versus AL (r = 0.845, p < 0.01, n = 100). LVCR can be accurately determined with all three methods used to extract the raw values of ESV necessary to generate the calculation of Force. Although S is known to be more precise in determining absolute ESV values, the relative (rest-stress) changes can be assessed, with comparable accuracy, with simpler and more feasible T and AL methods, characterized by higher success rate, shorter imaging and analysis time.


Left ventricular contractility Echocardiography Stress 



Area-length method


Coronary artery disease


Ejection fraction


End-systolic volume


Heart failure


Left ventricle


Left ventricular contractile reserve


Regional wall motion abnormalities


Simpson method


Stress echocardiography


Teichholz method


Transthoracic echocardiography


Wall motion score index



Ageing project of Italian national Research Council (GAE P001328).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.


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Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Marco A. R. Torres
    • 1
  • Thais F. Texeira
    • 1
  • Ana C. Camarozano
    • 2
  • Clarissa C. A. Bellagamba
    • 1
  • Natalia M. Quevedo
    • 2
  • Altair I. Heidemann Junior
    • 1
  • Carolina Bertoluci
    • 1
  • Tonino Bombardini
    • 3
  • Michele De Nes
    • 3
  • Quirino Ciampi
    • 4
  • Eugenio Picano
    • 3
    Email author
  • the Stress Echo 2020 study group of the Italian Society of Cardiovascular Imaging
  1. 1.Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do SulPorto AlegreBrazil
  2. 2.Hospital de Clinicas UFPR, Medicine Department, Federal University of ParanàCuritibaBrazil
  3. 3.Biomedicine DepartmentInstitute of Clinical Physiology, CNRPisaItaly
  4. 4.Cardiology DivisionFatebenefratelli HospitalBeneventoItaly

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