Biplane EF vs Visual EF on Echocardiography
Biplane ejection fraction (using Simpson's biplane method of discs) is the guideline-recommended quantitative method for measuring LVEF, while visual estimation ("eyeballing") is a qualitative assessment that, despite being faster and universally applicable, shows greater inter-observer variability especially among less experienced operators 1.
Key Methodological Differences
Biplane Simpson's Method (Quantitative)
- Technique: Traces endocardial borders in apical 4-chamber and 2-chamber views, dividing the LV into discs to calculate volume without geometric assumptions 1
- Advantages:
- Guideline-recommended standard 1
- More reproducible between experienced operators
- Provides numerical value for documentation and serial comparison
- Limitations:
Visual Estimation (Qualitative)
- Technique: Gestalt assessment of LV contractility across multiple views
- Advantages:
- Limitations:
- Highly experience-dependent
- Greater inter-observer variability, particularly among beginners 5
- Lacks precise numerical documentation
Evidence on Accuracy and Agreement
The most recent 2025 study demonstrates that among experienced operators, visual estimation shows excellent agreement with formal TTE (ICC 0.97) and outperforms AI-based biplane methods (ICC 0.84) 6. Visual estimation achieved sensitivity 90.9%, specificity 97.8%, and kappa 0.96 for categorizing LV dysfunction severity 6.
However, experience matters critically. The 2025 study by Impact of Experience showed agreement between expert evaluators was good for both methods (visual: bias -0.4±6.4; biplane: bias 0.96±7.0), but deteriorated significantly among beginners (visual: bias 2.3±9.8; biplane: bias -1.8±8.7) 5.
Clinical Algorithm for Method Selection
Use biplane Simpson's when:
- Documenting baseline LVEF for serial monitoring (heart failure, chemotherapy)
- Image quality is adequate with clear endocardial borders
- Precise numerical values are needed for clinical decision-making
- The operator has intermediate-to-expert experience 1
Use visual estimation when:
- Emergency/perioperative settings requiring rapid assessment 2
- Image quality precludes adequate border tracing
- The operator is highly experienced (>expert level)
- Initial screening before formal quantification
Critical caveat: Even among intermediate and expert operators, obtain a second opinion when detecting reduced LVEF regardless of method used 5. The 2023 study in untrained perioperative echocardiographers showed visual estimation had acceptable accuracy (correlation 0.818) but wide limits of agreement (95% LOA: -26.6 to 26.5% depending on LVEF grade) 2.
Guideline Recommendations
The 2015 ASE/EACVI guidelines explicitly state that LV volumes and EF should be measured using biplane Simpson's method from apical 4- and 2-chamber views 1. The Teichholz and Quinones methods (linear dimension-based calculations) are no longer recommended 1. The 2017 EACVI standardization document reinforces that biplane Simpson's is the standard, with 3D echocardiography preferred when available 7.
Visual estimation is not mentioned as a guideline-recommended method, though research consistently shows it performs comparably to or better than algorithmic methods when performed by experienced operators 4, 3, 6.
Practical Considerations
- Beginners should avoid relying solely on visual estimation due to high variability (±9.8% for visual vs ±8.7% for biplane among beginners) 5
- Visual estimation performs best at extremes (hyperdynamic or severely reduced function) with 65.3% accuracy, but struggles with mid-range dysfunction 2
- When right ventricular pressure overload is present, biplane method of discs maintains better accuracy than other geometric models 8
- Report the method used in documentation, as inter-vendor variability exists even for quantitative measurements 7