Non-Invasive Pressure-Volume Analysis by Three-Dimensional Echocardiography: A Novel Powerful Method for Evaluating Left Ventricular Function

Lars-Egil R Hammersboen; Espen Boe; Jürgen Duchenne; John M Aalen; Hans Henrik Odland; Manuel Villegas-Martinez; Vetle C Frostelid; Faraz H Khan; Ole Jakob Sletten; Marit Witsoe; Helge Skulstad; Filip Rega; Olivier Gheysens; Jens-Uwe Voigt; Otto A Smiseth; Marie Stugaard; Espen W Remme

doi:10.1016/j.echo.2025.05.008

Non-Invasive Pressure-Volume Analysis by Three-Dimensional Echocardiography: A Novel Powerful Method for Evaluating Left Ventricular Function

J Am Soc Echocardiogr. 2025 May 22:S0894-7317(25)00268-8. doi: 10.1016/j.echo.2025.05.008. Online ahead of print.

Authors

Lars-Egil R Hammersboen¹, Espen Boe², Jürgen Duchenne³, John M Aalen², Hans Henrik Odland⁴, Manuel Villegas-Martinez⁵, Vetle C Frostelid⁵, Faraz H Khan⁶, Ole Jakob Sletten¹, Marit Witsoe¹, Helge Skulstad¹, Filip Rega⁷, Olivier Gheysens⁸, Jens-Uwe Voigt³, Otto A Smiseth², Marie Stugaard⁹, Espen W Remme¹⁰

Affiliations

¹ Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Division of Cardiovascular and Pulmonary Diseases, Cardiology Department, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Clinical Medicine, University of Oslo, Oslo, Norway.
² Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Division of Cardiovascular and Pulmonary Diseases, Cardiology Department, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
³ Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Research Group Cardiology & Organ Systems, UHasselt, Diepenbeek, Belgium; Department of Cardiology, Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium.
⁴ Department of Cardiology and Paediatric Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
⁵ The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
⁶ Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
⁷ Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
⁸ Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, and Institute of Experimental and Clinical Research, UCLouvain, Brussels, Brussels.
⁹ Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Clinical Medicine, University of Oslo, Oslo, Norway; Vestre Viken Hospital Trust, Ringerike, Norway.
¹⁰ Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Division of Cardiovascular and Pulmonary Diseases, Cardiology Department, Oslo University Hospital, Rikshospitalet, Oslo, Norway; The Intervention Center, Oslo University Hospital, Rikshospitalet, Oslo, Norway. Electronic address: espen.remme@medisin.uio.no.

PMID: 40412539
DOI: 10.1016/j.echo.2025.05.008

Abstract

Background: Pressure-volume (PV) analysis is the gold standard for evaluating left ventricular (LV) function but is rarely used clinically due to its invasiveness. We validated a non-invasive method for PV analysis by 3D echocardiography against invasive reference measurements and a novel index of LV efficiency against LV efficiency derived from metabolism by positron emission tomography-computed tomography (PET/CT).

Methods: In 22 canines, LV volume was measured invasively using piezoelectric crystals and LV pressure by micromanometer. Echocardiography and peak pressure were used to obtain 3D LV volume traces and LV pressure trace estimates. Stroke work, single-beat contractility indices, arterial elastance and an index of LV efficiency were derived from echocardiography and compared with their invasively measured counterparts at baseline and different interventions. In 12 sheep, the LV efficiency index was compared with efficiency calculated as stroke work divided by total LV glucose metabolism from PET/CT. The sheep underwent 8 weeks of rapid dyssynchronous pacing to induce heart failure (HF). Recordings were performed during synchronous and dyssynchronous electrical activation, at baseline, and after 8 weeks pacing-induced HF.

Results: In canines, there was a very good correlation and agreement between non-invasive and invasive measurements of LV stroke work (r=0.98, P<0.0001; difference 237±212 mmHg×ml, mean±SD). The non-invasive and invasive efficiency indices also showed very good agreement (r=0.95, P<0.0001; difference 0.4±3.4%). The changes in LV function by the different interventions resulted in similar changes in the non-invasive and invasive PV indices (both P<0.005). In sheep, the efficiency index showed similar decline compared to efficiency by PET/CT after induction of HF and after switching from synchronous to dyssynchronous electrical activation (r=0.67, P<0.001 for all interventions).

Conclusions: Non-invasive PV analysis by 3D echocardiography is feasible and accurate, making PV-loop parameters for evaluating LV function accessible for clinical use. Further studies should explore the clinical utility of this method.

Keywords: Echocardiography; arterial elastance; pressure-volume analysis; ventricular contractility; ventricular efficiency.