ArticleBMC cardiovascular disorders2026
Methodological discordance between apical four-chamber and biplane Simpson's method for left ventricular ejection fraction: a retrospective study of a credentialed echocardiographic dataset.
Article in BMC cardiovascular disorders, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundLeft ventricular ejection fraction (LVEF) remains central to heart failure phenotyping and device-based decision-making, yet the degree to which apical four-chamber (A4C) and biplane Simpson measurements diverge at clinically actionable thresholds is not well defined.
methodsWe analysed 1,022 unique algorithmically derived echocardiographic studies from 784 patients in the credentialed MIMIC-IV-ECHO-Ext-LVVOLUMES-A4C-ROI resource. Each study contained paired A4C and biplane volumetric labels derived from the same annotated DICOM sequence. Discordance was defined primarily at the HFrEF threshold (LVEF < 40%). Agreement was assessed with Bland-Altman analysis, and independent predictors were evaluated using multivariable logistic regression with cluster-robust standard errors.
resultsLVEF discordance at the HFrEF threshold occurred in 48 of 1,022 studies (4.7%, 95% CI 3.5-6.2%). At the ICD threshold (LVEF < 35%), discordance was present in 32 studies (3.1%). In the prespecified borderline zone (A4C LVEF 35-45%; n = 81), discordance rose to 30.9% (95% CI 21.9-41.6%). Mean bias was 0.11%, but the 95% limits of agreement were wide (- 13.5% to + 13.7%). LV end-diastolic volume was the only independent predictor of discordance (OR 1.61 per SD, 95% CI 1.27-2.05; p = 0.0001), and this association persisted after adjustment for acquisition variables.
conclusionsDiscordance between A4C and biplane Simpson LVEF is uncommon across an unselected cohort but becomes frequent near therapeutic cut-offs. LV dilatation is the dominant driver. These findings support continued preference for biplane quantification when the ventricle is enlarged or the measured LVEF falls near a treatment threshold.
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