Journal of Pediatric Cardiology and Cardiac Surgery 3(1): 14‒19 (2019)

Original Article

Computed Tomography and Magnetic Resonance Imaging Can
Replace Cardiac Catheterization for Measuring Ventricular
Volume in Patients with Congenital Heart Disease
Hideharu Oka, MD1), Masaya Sugimoto, MD, PhD1)*, Aya Kajihama, MD1),
Kouichi Nakau, MD1), Sadahiro Nakagawa2),and Hiroshi Azuma, MD, PhD1)
1) Department of Pediatrics, Asahikawa Medical University, Hokkaido, Japan

2) Section of Radiological Technology, Department of Medical Technology, Asahikawa Medical University Hospital,

Hokkaido, Japan* Current Aﬃliation: Sugimoto Pediatric Clinic, Hokkaido, Japan

Background: Measuring ventricular volume accurately is important. We attempted to estimate the feasibilityof computed tomography (CT) and magnetic resonance imaging (MRI) for measuring ventricular volume inpatients with congenital heart disease (CHD).
Methods: Four diﬀerent cardiac models of CHD: hearts with atrial septal defects, ventricular septal defects,
tetralogy of Fallot, and single left ventricle were used. Each model was created using a three-dimensional printer.
The ventricular volume of each model was measured using cardiac catheterization (Cath), CT, and MRI.
Results: The mean percentages and standard deviations of ventricular volume that were measured with Cath, CT,
and MRI were 94% (±11%), 137% (±8%), and 111% (±8%), respectively. The value of the CT group was significantly higher than that of the Cath and MRI groups (p<0.01). We also found that the variance of the measured
values was small for MRI and CT. The corrected measured value of CT and MRI especially had less error thanthat of Cath (Cath: 103% [±16%], CT: 100% [±6%], MRI: 101% [±7%]).
Conclusions: CT and MRI may replace Cath to evaluate the ventricular volume of children and adults with CHD.

Keywords: congenital heart disease, cardiac catheterization, magnetic resonance imaging, computed
tomography, three-dimensional printerBackgroundTo accurately understand the pathology of congenital heart disease (CHD), several parameters need to
be used. Ventricular volume is especially essential forunderstanding the disease accurately and predicting
the patientʼs prognosis. Since ventricular volume canserve as one of the determinants of surgical intervention, accurate measurement is vitally important. Cardiac
catheterization (Cath), computed tomography (CT), andmagnetic resonance imaging (MRI) have been used toevaluate the ventricular volume of patients with CHD.
These reference values were measured in the 1970s using
a cast that was created from a necropsied body; the samemeasurements have been used for many years.1‒5) However, to the best of our knowledge, few reports have compared the accuracy of Cath, CT, and MRI in measuring
ventricular volume. Based on the current standards ofthese measurement methods, it is unknown how accurately ventricular volume can be measured. Therefore,
we prepared four diﬀerent models of CHD using a 3D
printer; measured the ventricular volume of each model

Received: May 2, 2018; Accepted: November 6, 2018
Corresponding author: Hideharu Oka, MD, Department of Pediatrics, Asahikawa Medical University, 2‒1‒1‒1 Midorigaoka Higashi,
Asahikawa 078‒8510, Japan
E-mail: oka5p@asahikawa-med.ac.jp
ORCiD: Hideharu Oka (https://orcid.org/0000-0001-8701-826X)
doi: 10.24509/jpccs.190103© 2019 Japanese Society of Pediatric Cardiology and Cardiac Surgery

15

using Cath, CT, and MRI; and compared the accuracy ofthe measured value of each modality.

Methods
Commercially available 3D cardiac models of CHD(one for atrial septal defect [ASD], one for ventricularseptal defect [VSD], and one for tetralogy of Fallot[TOF]) were used for this study. The model was madeby the Cross Medical Corporation (Kyoto, Japan) basedon CT images of children with ASD, VSD, and TOF. The
CT images were further reconstructed into a 3D modelby the CrossMedical Corporation. Then, a 3D cardiac
model was created with soft urethane, using stereolithography and the vacuum casting technique. The cardiac phase of the 3D model was the end-diastolic phase.
A 3D cardiac model of the single left ventricle (SLV)
was specifically prepared based on the CT images ofa patient who underwent Fontan surgery (Fig. 1). The
patient was a 3-year-old boy with SLV, VSD, and coarctation of the aorta after undergoing the Fontan procedure.
He was followed up at our hospital. We utilized digital
data of a contrast CT examination that was performed at
our hospital to create a 3D model of his heart. Informed
consent for using the data was obtained from thepatientʼs parents.
To accurately measure the ventricular volumes ofeach model (seven ventricles), the valves of each ventricle were closed with glue and VSD patch closure was
performed. Then, a 10-fold diluted contrast medium
was injected into each ventricle through the tube. A
cardio-angiography apparatus was used to capture thecontrast agent in each ventricle. The amount of the contrast medium that filled the ventricle was defined as theabsolute volume. The ventricular volume was measured
with Cath, CT, and MRI using the same liquid. Then,these measured values were compared with the absolutevolume.
During Cath, ventricular imaging was performed
from two directions: the postero-anterior and left lateral
directions (Fig. 2a). Then, the ventricular volume wasmeasured using Cardio Agent analysis software (Toshiba
Medical Systems Corporation, Tochigi, Japan), where
the left ventricular volume was measured using thearea-length method and the right ventricular volume
was measured using the Graham method. The imagesof the left and right ventricular chamber were traced inplaces where the shading is clear.
To measure the ventricular volume with CT, we useda CT device (GE Healthcare Japan Corporation, Tokyo,
Japan). A 2.5-mm slice was taken to obtain the 3D constructed image (Fig. 2b). To reduce artifacts during theCT imaging, a 10-fold diluted contrast medium wasused. The ventricular volume was computed using the
CT analysis software VINCENT (Fujifilm Corporation,

Fig. 2a The image of cardiac catheterization
Fig. 1 Cardiac model
A cardiac model of single left ventricle after Fontan
procedure.

The postero-anterior view of left ventricular angiography in ASD model. The dotted line shows thetraced line. ASD: atrial septal defect© 2019 Japanese Society of Pediatric Cardiology and Cardiac Surgery

16Tokyo, Japan). As a specific measurement method, theauthors corrected all cross sections that were automatically traced in the ventricular lumen of the cardiac
model, the cross-sectional area was automatically constructed in 3D, and the ventricular volume was measured.
To measure the ventricular volume with MRI, we used
an MRI machine (1.5 Tesla, Philips Electronics Japan
Corporation, Tokyo, Japan). A 3-mm slice was takenusing the spin echo method. The image of an obtained
short-axis cross section was measured using Ziostation
MRI analysis software (Ziosoft Corporation, Tokyo,
Japan), and the ventricular volume was measured (Fig.
2c). The specific measurement method was the same asthat in CT.
All seven measurements were performed three times
by the same observer, and the mean value was adopted
as the measured volume. The measured volumes werealso expressed as a percentage of their corresponding
absolute volume. To ensure the reproducibility of our
methods, we examined intraobserver and interobserver
diﬀerences in the measured volumes. There was goodcorrelation between intraobserver and interobserver
values (r=0.991 and r=0.947, respectively).
The correction coeﬃcient (k) was determined as follows: k=absolute volume÷measured volume. The average of seven diﬀerent k values that were derived fromthe measurements of the volume of seven ventricles was
designated as Kaverage. The corrected measured volume

or corrected percentage was obtained as follows: themeasured volume×the Kaverage or percentage of absolutevolume×the Kaverage.
Each measured volume, which is expressed as thepercentage of the absolute volume, was used to compare
the accuracy among the three measuring methods. The
diﬀerences among groups were assessed using two-tailed
repeated ANOVA. Software was used for statisticalanalyses (ystat 2013; Igaku Tosho Press, Co. Ltd., Tokyo,
Japan). Values of p<0.01 were inferred as significant.
Post-hoc testing was conducted using a Dunnett test
(two-tailed test).

Results
Both the absolute volume and its corresponding measured volume that was obtained using the Cath, CT, and
MRI methods are summarized in Table 1. The absolutevolumes of the right ventricle for the ASD, VSD, andTOF models were 20, 10, and 35 mL, respectively. The
absolute volume of the left ventricle was 7, 8.5, and37 mL, respectively. The absolute volume of the SLV (asthe left ventricular volume) was 15 mL.
In the Cath method, the measured volumes of the rightventricle for the ASD, VSD, and TOF models were 17.3
(86%), 8.1 (81%), and 37 mL (106%), respectively. The
measurements of the left ventricular volume were 8.4(121%), 10.5 (124%), and 47.1 mL (127%), respectively.
The measured volume of the SLV (as the left ventricularvolume) was 16.7 mL (111%). The mean percentage andstandard deviation of the ventricular volume that wasmeasured using Cath was 94% (±11%).

Fig. 2b The image of CT
The CT image of left ventricle in ASD model. This
image is constructed in three dimensions by the CT
analysis software VINCENT (Fujiﬁlm Corporation,
Tokyo, Japan). ASD: atrial septal defectJ Pediatr Cardiol Card Surg Vol. 3, No. 1 (2019)

Fig. 2c The image of MRI
The MRI image of left and right ventricles in ASD
model (arrow head). The dotted line shows thetraced line. ASD: atrial septal defect17

Table 1 Absolute volume and measured volume of 4 diﬀerent models
Absolute
volume
1
2
3
4
5
6
7

ASD RV (mL)
ASD LV (mL)VSD RV (mL)
VSD LV (mL)TOF RV (mL)TOF LV (mL)
SLV (mL)

20
7
10
8.5
35
37
15

Cardiac catheterization(Area length)

Cardiac catheterization(Graham)17.3±0.3 (86%)

8.4±0.2 (121%)8.1±0.3 (81%)
10.5±0.3 (124%)
37.0±0.8 (106%)47.1±0.8 (127%)16.7±0.5 (111%)

CT

MRI

29.5±1.5 (147%)
9.8±1.5 (140%)13.9±2.0 (139%)11.3±1.2 (133%)51.1±6.4 (146%)47.2±1.0 (128%)19.0±1.5 (126%)24.8±0.5 (128%)8.2±0.0 (117%)10.5±0.2 (105%)9.3±0.3 (110%)39.7±0.9 (114%)38.7±0.3 (105%)15.3±0.2 (102%)

All parameters are expressed as mean±SD. Parenthesis: measured volume was expressed as a percentage of absolute volume.
ASD, atrial septal defects; VSD, ventricular septal defects; TOF, tetolalogy of Fallot; SLV, single left ventricles

Fig. 3 The measured volume of seven ventricles
obtained by three diﬀerent methods

Fig. 4 The corrected measured volume of seven ventricles obtained by three diﬀerent methods

The values of each ventricle measured by cardiac
catheterization, CT, MRI were expressed as percentage of absolute volume of corresponding ventricle
and plotted on the graph. The vertical axis shows
the percentage of absolute volume. The measured
volumes were expressed as a percentage of theircorresponding absolute volume. ASD, atrial septal
defects; VSD, ventricular septal defects; TOF, tetolalogy of Fallot; SLV, single left ventricles

The values of each ventricle measured by cardiac
catheterization, CT, MRI were corrected by multiplying them by Kaverage, then, expressed as percentage
of absolute volume of corresponding ventricle andplotted on the graph. ASD, atrial septal defects; VSD,
ventricular septal defects; TOF, tetolalogy of Fallot;
SLV, single left ventricles

In the CT method, the measured volume of the rightventricle in the ASD, VSD, and TOF models was 29.5
(147%), 13.9 (139%), and 51.1 mL (146%), respectively.
The measurements of the left ventricular volume were
9.8 (140%), 11.3 (133%), and 47.2 mL (128%), respectively. The measured volume of the SLV (as the left
ventricular volume) was 19.0 mL (126%). The mean
percentage of the ventricular volume that was measured
using CT was 137% (±8%).
In the MRI method, the measured volume of the rightventricle in the ASD, VSD, and TOF models was 24.8
(128%), 10.5 (105%), and 39.7 mL (114%), respectively.
The measurements of the left ventricular volume were
8.2 (117%), 9.3 (110%), and 38.7 mL (105%), respec-tively. The measured volume of the SLV (as the left
ventricular volume) was 15.3 mL (102%). The mean
percentage of the ventricular volume that was measured
with MRI was 111% (±8%).
The values that were expressed as a percentage of thecorresponding absolute volume were plotted on a graph(Fig. 3). There was a significant diﬀerence (p<0.01)
among the three methods in the repeated ANOVA. The
mean percentage of the Cath group was closest to 100%.
However, regarding the data variability, the data of theCath group appeared to be more widely distributed thanthe data of the CT or MRI group. All values of both CT
and MRI groups were higher than 100%. Post hoc test
showed that the value obtained using CT was significantly higher (p<0.01) compared to that obtained using© 2019 Japanese Society of Pediatric Cardiology and Cardiac Surgery

18Cath or MRI.
The Kaverage of the Cath, CT, and MRI groups was 0.95,
0.73, and 0.91, respectively. Based on the Kaverage, thecorrected percentages were plotted on a graph (Fig. 4).
As expected, there was no significant diﬀerence among
the three groups. In addition, data obtained from CT or
MRI were more accurate than those from Cath (Cath:103% [±16%], CT: 100% [±6%], MRI: 101% [±7%]).

Discussion
Using a cardiac model that was created with a 3D
printer, we compared the absolute volume of the ventricle with the measured volume that was obtainedwith three diﬀerent methods. In patients with CHD,
expansion of the ventricular volume is often allowed
due to valve regurgitation, especially in the remote postoperative period. When it is diﬃcult to decide whether
reoperation should be performed, the ventricular volume should be considered, as this enables the surgeon
to arrive at a proper decision. Therefore, it is importantto accurately measure the volume of the ventricle. Cathis the most common method for measuring ventricularvolume, but it is an invasive method and can place a highburden on the patient if it is needed frequently. Therefore, CT and MRI are often used as substitute examinations for cardiac catheterization when evaluating
the cardiac function and ventricular volume of patientswith CHD. Patients with right ventricular volume overload due to pulmonary regurgitation after TOF repair
in the remote postoperative period are often evaluatedwith MRI to determine the optimal time of pulmonary
valve replacement.6) Although MRI has been regarded
as the gold standard of ventricular volumetry for CHD
patients, measurement with CT has also been carriedout in recent years.7, 8) However, the extent to which thevolume measured with CT or MRI deviates from theabsolute volume has not been studied for very long, andfew studies have addressed this issue. At present, thediﬀerences in the measurements using each modality do
not have any clinical significance, but we believe that it isimportant to use accurate figures.
The ventricular volumes measured using CT and
MRI were always higher than the absolute volumes. In
addition, the measured volume of the CT group was
significantly larger than the volumes of the Cath and
MRI groups (p<0.01) (Fig. 3). This may be due to an
artifact that was caused by the contrast medium. To
J Pediatr Cardiol Card Surg Vol. 3, No. 1 (2019)prevent artifacts from appearing on CT images during
the examination, we measured the ventricular volumeusing a diluted contrast medium. However, even the
diluted contrast agent was insuﬃcient to alleviate artifacts. Advances in imaging technology may resolve thisproblem in the future.
The ventricular volume that was measured using MRI
was also larger than the absolute volumes. There are two
reasons for this: 1) it is diﬃcult to trace the cross-sectional area finely with MRI and 2) the volume of the papillary muscles was not excluded because of the limited
performance of the analysis software that was used inthis study. Therefore, the measured ventricular volume
may be larger than the absolute volume. Recently, atechnique that is capable of semi-automatically removing the papillary muscles and measuring the volume
in a threshold-based segmentation algorithm has been
introduced.9) As a result, ventricular volume measured
using MRI is expected to further approximate the absolute volume.
On the other hand, the error variation of Cath in eachmodel was larger than that for CT and MRI (Fig. 3).
These values may have been derived from data that wereobtained with a two-dimensional analysis. The complicated morphology of the cardiac model may make themeasured volume more inaccurate. In the case of cardiac
Cath, the ventricular volume varies, depending on theangle and direction of the heart in the existing calculation formulas. In contrast to Cath, both CT and MRI
use data that are obtained by a 3D analysis. This may be
one reason for the dispersion of error being smaller in
CT and MRI than in Cath. In other words, the values
that are close to the absolute volumes could be obtainedby correcting measured values that were obtained using
CT and MRI. Therefore, we measured the average valueof the correction coeﬃcient (Kaverage), produced thecorrected measured value using Kaverage, and expressed
them as the percentage of the absolute volume (Fig. 4).
There were no significant diﬀerences among the groups.
In addition, the error variation of CT and MRI were
smaller than that of Cath. This indicated that the corrected measured volume that was obtained with both CT
and MRI well reflected the absolute volume. Therefore,
we concluded that CT or MRI could replace Cath forevaluating ventricular volume.
The limitation of this study is that the number ofcardiac models was small. Second, the Kaverage was not19reported for each modality. However, as we have shownin this study, it may be possible to calculate the correction coeﬃcient by utilizing many cardiac models andstudy its feasibility. Third, in reality, cardiac motion has
to be taken into account when measuring ventricularvolume. Therefore, the volume should be measured
using an ECG-gated method and respiratory-gatedmethods in CT or MRI. Fourth, all the cardiac models
used in this study are created on the basis of CT images.
Cardiac morphology, especially the inner surface ofventricles such as the chordae and trabeculations, may
be more complicated than that of the cardiac models. Additional consideration is needed to determine
whether similar results can be obtained with a large- or
small-volume cardiac model.
We found that the variance of the measured volume ofthe ventricular volume was small for MRI and CT compared with that obtained using cardiac Cath. We believethat if the ventricular volume can be accurately measured noninvasively, the quality of management during
the remote postoperative period will improve greatly.
CT and MRI can replace cardiac Cath for measuring
ventricular volume in patients with CHD.
Funding
This research did not receive specific grants from any
funding agency, or commercial or non-profit entities.
Conﬂicts of Interest
The authors have no conflicts of interest.
Ethical Approval
All procedures performed in studies involving humanparticipants were in accordance with the ethical standardsof the institutional and/or national research committee andwith the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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