Atrial Septal Occluder Device Embolization to an Iliac Artery: A Case Highlighting the Utility of Three‐Dimensional Transesophageal Echocardiography during Percutaneous Closure

Percutaneous closure of secundum atrial defects has become an accepted treatment in part because it is minimally invasive and relatively low risk. Despite recent advances in implantation technique and device improvements, complications occur. Here, we report a case of device embolization during percutaneous repair of an atrial septal defect (ASD) with multiple fenestrations. We highlight the value of using live/real time three‐dimensional transesophageal echocardiography to help plan the percutaneous procedure and detect complications.     

Role of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Percutaneous Epicardial Closure of the Left Atrial Appendage

We are reporting the use of three‐dimensional transesophageal echocardiography as a supplement to two‐dimensional transesophageal echocardiography in the percutaneous suture closure of the left atrial appendage.     

Three‐Dimensional Echocardiography Guided Closure of Complex Multiple Atrial Septal Defects

Transcatheter closure of complex multiple atrial septal defects (ASDs) remains a challenge. We describe our clinical experience with staged device deployment in a patient with multiple ASDs using four Amplatzer septal occluder devices. Three‐dimensional transesophageal echocardiography imaging contributed not only to the therapeutic guidance of successful device deployment but also to the decision making for the staged device delivery approach in a case of morphologically complex multiple ASDs.     

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.     

Complex Atrial Septal Defect: Percutaneous Repair Guided by Three‐Dimensional Echocardiography

Three‐dimensional transesophageal echocardiography (3D TEE) has been used to guide the percutaneous repair of simple atrial septal defects (ASDs). There has been limited experience in using this imaging modality to guide complex ASD repair. In this report, we describe how 3D TEE was used to guide the repair of a complex, multifenestrated ASD. In a single view, 3D TEE provides a superior anatomic definition when compared to the traditional two‐dimensional echocardiography. We believe that this emerging technology will play a critical role as the number and complexity of percutaneous techniques treating structural heart disease continue to rise. (Echocardiography 2010;27:590‐593)     

Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment of Aortic Root Patch Dehiscence

We report a 66‐year‐old man who underwent partial reconstruction of the aortic root and presented with heart failure 2 months after the procedure. We used live/real time three‐dimensional transesophageal echocardiography (3DTEE) to detect the exact site of the dehiscence flap and extent of the leakage. This information could be valuable to surgeons.     

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.     

Incremental Value of Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Technique in Percutaneous Closure of Aortic Paraprosthetic Regurgitation

We describe 2 patients with significant aortic paraprosthetic regurgitation who underwent percutaneous closure where live/real time three‐dimensional transesophageal echocardiography provided incremental value over two‐dimensional transesophageal echocardiography.     

Usefulness of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in Evaluation of Prosthetic Valve Function

We studied 31 patients with prosthetic valves (PVs) using two‐dimensional and three‐dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides an incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE both leaflets of the St. Jude mechanical PV can be visualized simultaneously, thereby increasing the diagnostic confidence in excluding valvular abnormalities and overcoming the well‐known limitations of 2DTTE in the examination of PVs, which heavily relies on Doppler. Three‐dimensional transthorathic echocardiography provides a more comprehensive evaluation of PV regurgitation than 2DTTE with its ability to more precisely quantify PV regurgitation, in determining the mechanism causing regurgitation, and in localizing the regurgitant defect. Furthermore, 3DTTE is superior in identifying, quantifying, and localizing PV thrombi and vegetations, in addition to the unique feature of providing a look inside mass lesions by serial sectioning. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of PVs and that it provides incremental knowledge to the echocardiographer. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Usefulness of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in the Assessment of Descending Thoracic Aorta Graft Dehiscence

We report the usefulness of live/real time three‐dimensional transthoracic echocardiography to identify endovascular graft showing leakage not visualized using two‐dimensional transthoracic echocardiography. (Echocardiography 2010;27:722‐723)     

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 Ventricular Septal Volume and Mass before and after Myectomy in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most common genetically transmitted cardiomyopathy. In patients resistant to medical management, myectomy is the surgical procedure of choice to reduce the symptoms of left ventricular outflow obstruction. Two‐dimensional transesophageal echocardiography (2DTEE) has become part of the operative procedure by decreasing the incidence of postoperative complications. However, because of the three‐dimensional geometry of left ventricular outflow tract, it is unable to comprehensively assess the location and severity of the obstruction and to provide accurate guidance during myectomy. In this study, 10 patients with HCM underwent live/real time three‐dimensional transesophageal echocardiography (3DTEE) intra‐operatively to measure the volume of the resected septum. This volume correlated well with the volume of the resected septal muscle directly obtained using a graduating cylinder containing water (r = 0.9, P < 0.000). 3DTEE may be potentially used as an adjunct to guide the surgeon in performing an adequate myectomy with a lower incidence of residual obstruction and complications such as an iatrogenic ventricular septal defect.     

Real Time Three‐Dimensional Transesophageal Echocardiography Demonstration of Membranous Septal Aneurysm Causing Severe Right Ventricular Outflow Tract Obstruction

In addition to infundibular muscular hypertrophy and anomalous muscle bundles in the right ventricular body, large membranous septal aneurysms (MSA), sinus of valsalva aneurysms, and aneurysms derived from the embryonic venous valve protruding through the tricuspid valve can cause right ventricular outflow obstruction in a patient with ventricular septal defect. Here we describe an adult with a small perimembranous ventricular septal defect complicated by a large MSA causing severe right ventricular outflow obstruction evaluated with real time three dimensional transesophageal echocardiography and cardiac catheterisation. The patient underwent surgical correction of the abnormality and is asymptomatic on follow up.     

Real Time Three‐Dimensional Transesophageal Echocardiographic Evaluation of a Sinus Venosus Atrial Septal Defect

We present a case of a 65‐year‐old man who presented with atrial flutter and dilation of right heart was noted on transthoracic echocardiography. Transesophageal echocardiography revealed a large sinus venosus atrial septal defect close to superior vena cava and anomalous connection of right superior pulmonary vein. Additionally, real time three‐dimensional transesophageal echocardiography provided superior spatial details and demonstrated the size, location of the defect and its spatial relationship to the surrounding structures. Patient underwent successful surgical repair. (Echocardiography 2011;28:E82‐E84)     

Depicting of a Cleft Mitral Valve by Real Time Three‐Dimensional Transesophageal Echocardiography

We report the usefulness of real time three‐dimensional transesophageal echocardiography in comprehensive delineation of cleft mitral valve. This new technique may be a useful supplement to two‐dimensional and three‐dimensional transthoracic echocardiography in the assessment of this pathology. (Echocardiography 2010;27:356‐358)     

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)     

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.