Incremental Value of Live/Real Time Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Technique in the Assessment of Primary Cardiac Malignant Fibrous Histiocytoma

We describe a case of primary cardiac malignant fibrous histiocytoma where live/real time three‐dimensional transesophageal echocardiography added incremental value to the two‐dimensional modalities. Specifically, the three‐dimensional technique allowed us to delineate the true extent and infiltration of the tumor, to identify characteristics of the tumor mass suggestive of its malignant nature, and to quantitatively assess the total tumor burden.     

Added Value of Real Time Three‐Dimensional Echocardiography in the Diagnosis of an Apical Right Ventricular Metastasis from Malignant Melanoma

In a man presenting to the emergency room with dyspnea and atypical chest pain irradiated among the scapulae, with new‐onset diffuse negative T‐waves on the ECG, the first clinical and diagnostic hypothesis was pulmonary embolism (PE). However, computed tomography (CT) performed in emergency was negative for PE, showing instead a marked defect in right ventricle (RV) filling. For this reason, echocardiography was performed to better investigate the nature of the space‐occupying lesion, and several echocardiographic modalities were used (two‐dimensional transthoracic and transesophageal echocardiography and three‐dimensional [3D] transthoracic echocardiography). They revealed the presence of a mass attached to the apex of the RV, partially obstructing the inflow and outflow tracts. Cardiac magnetic resonance imaging was also performed, confirming the findings of 3D echocardiography. After that, several other diagnostic imaging techniques were used for disease staging, since the patient had a history of surgical excision of a malignant melanoma of the skin several years before. Whole‐body CT, soft tissue echography and positron emission tomography revealed the widespread diffusion of the primary tumor to distant organs. For this reason, we suspected that the RV mass could also be an intracardiac metastasis from malignant melanoma, and did not perform biopsy given the bad clinical conditions and the worse prognosis of the patient. However, he was entered in an experimental therapeutic protocol with Vemurafenib because he showed B‐RAF gene mutation at molecular gene analysis.     

Incremental Value of Live/Real Time Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Modality in the Assessment of Cardiac Lymphoma

We describe a case of cardiac lymphoma where live/real time three‐dimensional transesophageal echocardiography provided additional information compared to two‐dimensional transesophageal echocardiography regarding the extent of tumor infiltration. In addition, it gave a quantitative assessment of the tumor burden by providing its volume.     

Intraoperative Evaluation of Right Ventricular Outflow Tract Myxoma by Real Time Three‐Dimensional Transesophageal Echocardiography

Cardiac myxoma arising form right ventricular outflow tract (RVOT) is extremely rare, but could cause major clinical sequelae and pose considerable diagnostic and therapeutic challenges. Here, we report the intraoperative application of real time three‐dimensional transesophageal echocardiography (RT3DTEE) in the assessment of a patient with a RVOT myxoma. RT3DTEE clearly assess the characteristics of the mass, such as the size, shape, attachment points, and composition. With the intraoperative guidance of RT3DTEE, the patient underwent successful removal of the mass.     

Incremental Value of Live/Real Time Three‐Dimensional over Two‐Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left‐sided (LASP) or right‐sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three‐dimensional transesophageal echocardiography (3DTEE) and who had a two‐dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.     

The Value of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment of Valvular Vegetations

We studied 13 patients with valvular vegetations who underwent intraoperative live/real time three‐dimensional transesophageal echocardiography (3DTEE) and real time two‐dimensional transesophageal echocardiography (2DTEE). The 3DTEE provided incremental value on top of 2DTEE in its ability to accurately identify and localize vegetations and in identifying complications of infective endocarditis such as abscesses, perforations, and ruptured chordae. By using 3DTEE, we were able to measure vegetation volumes, perforation areas, and estimate the area of the valve that is involved in the infective process. These preliminary results suggest the superiority of 3DTEE over 2DTEE in the evaluation of valvular vegetations and provide incremental knowledge that is useful to the cardiac surgeons. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Utilizing Three‐Dimensional Echocardiography in Cardioscopic Left Ventricular Myxoma Resection

A 31‐year‐old female presented with right‐sided stroke symptoms. She was found to have a left ventricular (LV) mass on transthoracic echocardiogram. Subsequent transesophageal echocardiogram (TEE) with concurrent three‐dimensional (3D) imaging revealed a 2‐cm mobile mass, suspicious for a myxoma, attached to the anteroseptal LV wall. Given the size and location of the mass seen on the 3D images, the cardiothoracic surgeons chose to avoid resection via aortotomy or ventriculotomy and instead performed video‐assisted cardioscopic resection of the LV mass via left atriotomy. The mass was successfully removed, and pathology confirmed that it was a myxoma.     

Three‐Dimensional Echocardiography Enhances Diagnostic Accuracy of Supramitral Ring

Real time three‐dimensional echocardiography (RT3DE) allows for accurate morphological characterization of congenital heart disease and complements two‐dimensional (2D) echocardiography. Accurate evaluation of the mitral valve and supramitral ring prior to surgery aids the surgeon in successful resection of the ring and repair of associated mitral valve abnormalities. We report a case of congenital mitral valve stenosis from a supramitral ring in a young child using real time three‐dimensional transesophageal echocardiography.     

Incremental Value of Three‐Dimensional Transesophageal Echocardiography over Two‐Dimensional Transesophageal Echocardiography in the Assessment of Lambl's Excrescences and Nodules of Arantius on the Aortic Valve

In this retrospective study, we identified 7 cases where Lambl's excrescences were identified by two‐dimensional transesophageal echocardiography (2DTEE) and also had live/real time three‐dimensional transesophageal echocardiography (3DTEE) studies available for comparison. We subsequently assessed them for the presence of Lambl's excrescences (LE) and nodules of Arantius (NA) on the aortic valve. After their identification, we qualitatively and quantitatively organized our findings by number, cusp location, measurements, and orientation if applicable. A greater number of LE was found by 3DTEE than 2DTEE (19 vs. 11, respectively). In all 3DTEE studies, their cusp attachment site, their x‐, y‐, and z‐axis measurements, and orientation were clearly visualized and described. Only 3DTEE studies provided confident visualization of the cusp attachment sites. Similarly, a greater number of NA was found by 3DTEE than 2DTEE (21 vs. 5, respectively). The triad of NA was visualized in all 3DTEE studies and each was described using its x‐, y‐, and z‐ axis measurements. Only three 2DTEE studies provided reliable identification of the NA. In conclusion, we present further evidence of the incremental value of 3DTEE over 2DTEE in the qualitative and quantitative assessment of cardiac structures including LE and NA on the aortic valve.     

The Role of Three‐Dimensional Echocardiography in Interventricular Mass Evaluation

A young patient underwent a screening electrocardiogram (EKG) that suggested apical hypertrophic cardiomyopathy. Serial investigation with echocardiography showed a well‐defined hyperechogenic mass involving the interventricular septal. To better define the lesion extension three‐dimensional (3D) echocardiography was done and it demonstrated a mass invading the septal myocardium, involving the major part of the muscular portion. The findings were highly suggestive of a cardiac fibroma. A cardiac magetic resonance image (MRI) was also compatible with this diagnosis. In our case, 3D echo showed a high accuracy, proving to be a useful tool to determine the anatomy of the lesion, complementary to MRI, guiding best management strategy.     

Coexisting Bicuspid Aortic and Pulmonary Valves with Normally Related Great Vessels Diagnosed by Live/Real Time Three‐Dimensional Transesophageal Echocardiography

Coexistence of bicuspid aortic and pulmonary valves in the same patient is a very rare entity identified mainly during surgery and postmortem. To the best of our knowledge, only one case has been diagnosed by two‐dimensional echocardiography in a newborn with malposition of the great arteries but no images were presented. Here, we are reporting the first case of bicuspid pulmonary and aortic valves diagnosed by live/real time three‐dimensional transesophageal echocardiography in an adult with normally related great arteries.     

Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Findings in Caseous Mitral Annular Calcification

We describe a 77‐year‐old female with hypertrophic cardiomyopathy in whom live/real time three‐dimensional transesophageal echocardiography (3DTEE) provided incremental value over two‐dimensional transthoracic and transesophageal echocardiography (2DTTE, 2DTEE) and three‐dimensional transthoracic echocardiography (3DTTE) in making a more comprehensive assessment and a more confident diagnosis of caseous mitral annular calcification. 3DTEE revealed a portion of the mass to consist of small, multiple, highly echogenic discrete band‐like and punctate areas within a relatively much less echogenic stroma and surrounded by a well defined highly echogenic border. This appearance correlated with the pathological findings of calcific granules/strands located in a liquefied or semiliquefied interior providing a typical toothpaste like appearance. The highly echogenic outer border represented the residual outer portion or rim of the calcific mass which did not undergo liquefaction. These findings on 3DTEE which correlated with the toothpaste like appearance seen at surgery were not visualized on 2DTTE, 2DTEE, and 3DTTE. (Echocardiography 2010;27:1147‐1150)     

Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Assessment of the Spinal Cord

We present an adult patient in whom live/real time three‐dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of the spinal cord as compared to two‐dimensional transesophageal echocardiographic (2DTEE) findings published in the literature. It improved accurate identification and assessment of the anterior radiculomedullary spinal arteries which may have an important clinical application in monitoring for spinal cord ischemia during thoracic aortic surgery. Because the spinal cord and spinal canal could be examined using not only transverse but also coronal (frontal), sagittal, and oblique planes, 3DTEE further allowed for three‐dimensional measurements of the dimensions and volumetric analysis of the visualized spinal cord and spinal canal. These may have implications in the assessment of spinal cord edema due to trauma and other conditions which result in increase in the size and volume of the spinal cord.