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Precision and reproducibility of semi-automated late gadolinium enhancement quantification techniques in patients with hypertrophic cardiomyopathy


The presence and extent of hyper-enhancement (HE) on Late Gadolinium Enhancement (LGE) has been associated with adverse events in patients with Hypertrophic Cardiomyopathy (HCM). Signal-threshold techniques are routinely employed for quantification; however, the precision and reproducibility of these versus a gold standard remains uncertain. Full Width Half of Maximum (FWHM) techniques are suggested to provide greater reproducibility than Signal Threshold versus Reference Mean (STRM) techniques, however the precision of these approaches versus manual assignment of optimal signal intensity(SI) thresholds has not been studied. We compare all known semi-automated LGE-quantification techniques for precision and reproducibility among patients with HCM.


Seventy-six patients with HCM (51 male, age 54 ± 13) were studied. Endocardial and epidcardial borders were manually traced. Total HE volume was quantified using 6 semi-automated techniques and compared to expert manual adjustment of the signal intensity threshold. Techniques tested included STRM-based thresholds of > 2, 3, 5 and 6 SD above mean SI of reference myocardium, the FWHM technique, and the Otsu-auto-threshold (OAT) technique. The SI threshold applied for each slice and total HE volume were recorded. Bland-Altman analysis and intra-class correlation coefficients (ICC) were reported for each semi-automated technique versus expert, manually adjusted HE segmentation. Intra- and inter-observer reproducibility assessments were performed.


Fifty-two patients showed HE on a total of 201 slices. Total HE volumes by manual segmentation were reproducible (mean difference between observers = 0.06 g, within observer = 1.35 g). For precision, the STRM > 3SD technique showed the greatest agreement with the manual segmentation (ICC = 0.95, mean difference and 95% limits of agreement = 3.7 ± 12.1 g) while STRM > 6SD, > 5SD and FWHM techniques systematically underestimated total HE volume (Figure 1). STRM > 2SD and OAT techniques over-estimated HE volume. Slice-based analysis similarly showed the STRM > 3SD threshold to most closely approximate manually adjusted SI thresholds (ICC = 0.91). For reproducibility, the FWHM method showed the greatest intra- and inter-observer reproducibility for total HE volume (mean difference = 0.3 g and 0.7 g, respectively). Reproducibility values for STRM-based thresholds improved with increasing SI threshold. The intra- and inter-observer reproducibility of the 3SD threshold demonstrated an acceptable mean difference of 1.14 g and 1.14 g, respectively.

Figure 1
figure 1

The mean difference of the total enhanced mass between each semi-automated technique and manual segmentation.


FWHM segmentation provides superior reproducibility, however systematically under-estimates total HE volume compared to manual segmentation in patients with HCM. The STRM > 3SD technique provides the greatest precision while retaining acceptable reproducibility and may therefore be the preferred approach for HE quantification in this population.


Canada Foundation for Innovation.

Figure 2
figure 2

Manual segmentation and semi-automated quantification of hyper-enhancement. STRM > 3SD technique shows the greatest agreement with the manual segmentation.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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Mikami, Y., Kolman, L., Joncas, S.X. et al. Precision and reproducibility of semi-automated late gadolinium enhancement quantification techniques in patients with hypertrophic cardiomyopathy. J Cardiovasc Magn Reson 16 (Suppl 1), P340 (2014).

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