Echocardiography Ejection fraction: Is it the same by different methods, comparative 4D echocardiography study

Background: Cardiovascular disease is the leading global cause of death, making accurate assessment of left ventricular ejection fraction(LVEF) essential. Echocardiography is widely used, including M-mode, biplane Simpson’s, wall motion score index(WMSI), global longitudinal strain(GLS), and 4D echocardiography, but conventional methods have limitations in accuracy and reproducibility. This study aimed to compare LVEF assessment by M-mode, Simpson’s biplane, GLS and WMSI against 4D echocardiography. Methods: This prospective cohort study was conducted from April 2024 to April 2025 and included 150 patients(mean age 44.59±15.37 years; 54% were females) were classified as normal(n=38), heart failure(n=34), ischemic heart disease(n=64), and valvular heart disease(n=14). All underwent echocardiography using GE Vivid E95. LVEF and volumes were measured by M-mode(Teichholz), biplane Simpson, WMSI(16-segment model), GLS, and 4D echocardiography with automated volumetric analysis. Results: Statistical significant differences were found in ESV and EDV across modalities(p<0.05), especially in heart failure(ESV p<0.0001) and ischemic groups(p<0.05), with M-mode showing higher values. LVEF, WMSI, and GLS showed highly sstatistical significant variation(p=0.0001), while stroke volume was not statistically significant(p=0.131). 4D echocardiography showed significant differences in EDV(p=0.001), ESV(p<0.0001), SV(p=0.004), CO(p=0.001), and LVEF(p<0.0001). LVEF differed across modalities overall(p<0.05), but not in normal(p=0.095) or valvular groups(p=0.061). Diagnostic accuracy vs 4D was highest for biplane Simpson(98.7%), followed by M-mode(96.7%) and WMSI(96.7%), while GLS was lowest(90%). Conclusion: 4D echocardiography was most accurate, especially in abnormal ventricular geometry; biplane Simpson was the best conventional method, closely matching 4D and suitable for routine use. GLS detected early subtle dysfunction even with normal ejection fraction, and WMSI effectively assessed ischemic severity.