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)     

Incremental value of live/real time three‐dimensional transthoracic echocardiography over the two‐dimensional technique in assessing carcinoid heart disease involving the aortic valve

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three‐dimensional transthoracic echocardiography provided incremental value over two‐dimensional transthoracic echocardiography in assessing involvement of the aortic valve.     

Incremental value of live/real time three‐dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two‐dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two‐dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two‐dimensional views only, and a greater breadth of information is instead available through the use of three‐dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three‐dimensional transesophageal echocardiography offered incremental benefits over two‐dimensional imaging alone.     

Two‐ and Three‐Dimensional Transthoracic Echocardiography in the Assessment of Acquired Ascending Aortic Aneurysm to Pulmonary Artery Fistula

Aorta to pulmonary artery fistula is an uncommon and potentially fatal condition. This case is of a 48‐year‐old Caucasian male with congestive heart failure and multiple aortic valve replacement surgeries who presented with an acquired ascending aortic aneurysm to pulmonary artery fistula diagnosed using two‐dimensional transthoracic echocardiography via nonstandard imaging windows. Three‐dimensional transthoracic echocardiography using live/real time three‐dimensional color Doppler was used to assess the size of the opening of the fistula, providing additional value. This patient was surgically managed and is doing well 8 months postoperation.     

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.     

Live/Real Time Three‐Dimensional Transthoracic Echocardiography in the Evaluation of Post Traumatic Acquired Thoracic Aortic Coarctation

We report a young patient with post traumatic acquired thoracic aortic coarctation in whom three‐dimensional transthoracic echocardiography (3DTTE) demonstrated incremental value over two‐dimensional transthoracic echocardiography (2DTTE). 3DTTE showed (1) en face views of the obstruction site that showed a markedly narrowed, roughly circular orifice measuring 0.33 cm² in area, (2) echogenic tissue encroaching on the graft lumen consistent with fibrosis/thrombus, and (3) no graft protrusion into the aortic lumen, only hypermobility of the medial portion of the graft. These important findings were not detected by 2DTTE. (Echocardiography 2010;27:470‐472)     

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.     

Use of echocardiography as an essential tool for targeted transcatheter biopsy of cardiac masses

Echocardiography has emerged as an essential tool to guide targeted, transcatheter biopsy of cardiac masses. Options for imaging include transthoracic or transesophageal echocardiography and intracardiac echocardiography, with appropriate use being dictated by specific patient characteristics and institutional experience. The authors present a case of three‐dimensional (3‐D) transesophageal echocardiography‐guided transcatheter biopsy of a right ventricular mass and review the current use of echocardiography to guide these procedures.     

Incremental Value of Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Technique in the Assessment of a Thrombus in Transit through a Patent Foramen Ovale

We report a case of a right atrial thrombus traversing a patent foramen ovale into the left atrium, where three‐dimensional transesophageal echocardiography provided considerable incremental value over two‐dimensional transesophageal echocardiography in its assessment. As well as allowing us to better spatially characterize the thrombus, three‐dimensional transesophageal echocardiography provided a more quantitative assessment through estimation of total thrombus burden.     

Incremental Value of Live/Real Time Three‐Dimensional Transthoracic Echocardiography over Two‐Dimensional Echocardiography in Hypertrophic Cardiomyopathy with Mid‐Ventricular Obstruction and Apical Aneurysm

We describe a case of hypertrophic cardiomyopathy with mid‐left ventricular obstruction and apical aneurysm containing thrombi where live/real time three‐dimensional transthoracic echocardiography provided incremental value over two‐dimensional echocardiography in assessing the findings.     

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.     

Live/Real Time Three‐Dimensional Transthoracic Echocardiographic Assessment of Inferior Vena Cava and Hepatic Vein Thrombosis in Sickle Cell Disease

We describe the value of live/real time three‐dimensional transthoracic echocardiography (3DTTE) over two‐dimensional transthoracic echocardiography (2DTTE) in the assessment of inferior vena cava (IVC) and hepatic vein (HV) obstruction in a patient with sickle cell disease. 3DTTE provided additional information when compared to 2DTTE by (1) identifying the obstructing lesion as a likely thrombus, (2) by providing assessment of anatomical severity of IVC lumen obstruction since the thrombus could be visualized en face also, and (3) identifying an area of increased mobility of a portion of the thrombus suggesting greater risk of embolization. (Echocardiography 2010;27:594‐596)     

Incremental role of three-dimensional transesophageal echocardiography in the assessment of mitral-aortic intervalvular fibrosa abscess

We report a case of an elderly patient in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided definitive diagnosis of mitral-aortic intervalvular fibrosa abscess. This could not be done by two-dimensional transthoracic echocardiography (2DTTE) and two-dimensional transesophageal echocardiography (2DTEE). 3DTEE was also helpful in ruling out associated mitral valve endocarditis, which was initially suspected by 2DTEE leading to a mitral valve sparing surgery. Thus, 3DTEE provided incremental information over 2DTTE and 2DTEE in this patient.     

Incremental Value of Three‐Dimensional Transthoracic Echocardiography in the Assessment of Ruptured Aneurysm of Anterior Mitral Leaflet

The mitral valve aneurysm is a rare complication of infective endocarditis involving mitral or aortic valve. The perforation of the mitral valve aneurysm can lead to significant mitral regurgitation (MR) or thromboembolism, which can cause sudden hemodynamic deterioration. We describe here a case of healed infective endocarditis of the aortic valve with ruptured mitral valve aneurysm that led to severe MR. The aneurysm of the anterior mitral leaflet was diagnosed by two‐dimensional transthoracic echocardiography. In this case, three‐dimensional transthoracic echocardiography demonstrated the detailed morphology of mitral valve aneurysm which resulted in successful surgical repair of the aneurysm.     

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)     

Two‐ and Live/Real Time Three‐Dimensional Transthoracic Echocardiographic Assessment of Infective Endocarditis of a Valved Pulmonary Conduit

We describe the use of a nonstandard left infraclavicular approach in making the diagnosis of an infected valved conduit with two‐dimensional transthoracic echocardiography. The patient was an adult with tetralogy of Fallot and pulmonary atresia who had undergone multiple surgical repair procedures. The initial diagnosis of infective endocarditis was made by transesophageal echocardiography. Both techniques demonstrated a single, large vegetation in the conduit. Live/real time three‐dimensional transthoracic echocardiography, on the other hand, provided further information by demonstrating several additional vegetations in the conduit and more comprehensively assessed their size by enabling measurement of their azimuthal dimensions and volumes. The patient was treated with antibiotics with complete resolution of the vegetations.     

Perforated giant mycotic aneurysm of mitral valve in a drug‐addicted young man: Rare complication of infective endocarditis

Infective endocarditis (IE) affects patients at high clinical risk and may present as an acute and rapidly progressive, subacute or chronic infection. Transthoracic and transesophageal echocardiography represent the key diagnostic method in IE diagnosis. In particular, three‐dimensional transesophageal echocardiography represents the imaging technique that allows to establish with adequate accuracy dimensions, shape, and localization of endocarditis vegetations. In our case, we show a huge vermiform mycotic aneurysm in an immunodeficient young drug‐addicted man with severe mitral valve regurgitation and the additive value of three‐dimensional transesophageal echocardiography in this specific clinical setting.     

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)     

Two‐ and Three‐Dimensional Transthoracic Echocardiography in the Assessment of Aortic Arch Vasum Vasi to Pulmonary Artery Fistula

We report an elderly patient presenting with a stroke and also hemolytic anemia secondary to mitral and tricuspid valve repair 3 years earlier, in whom two‐dimensional transesophageal echocardiography (2DTEE) suspected a fistula into the pulmonary artery (APAF) from the posterior wall of the aortic arch. For further assessment, two‐dimensional transthoracic echocardiography (2DTTE) and live/real time three‐dimensional transthoracic echocardiography (3DTTE) were performed. 2DTTE showed findings similar to 2DTEE. Color Doppler guided continuous‐wave Doppler showed continuous flow throughout the cardiac cycle with systolic preponderance across the fistula with a small peak pressure gradient of 22 mmHg. Sequential systematic cropping of the 3D datasets obtained from 3DTTE confirmed that the flow signals originated from the posterior wall of the aortic arch and not the lumen. Thus, 3DTTE served to increase the confidence level that the fistula most likely originated from a vasum vasi in the wall of the aortic arch. To our knowledge, this type of fistula has not been reported previously. Fistulas from the aortic lumen to the pulmonary artery are also rare and so far only 24 cases have been reported in the literature. These are also reviewed by us.     

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of a primary pericardial hemangioma

Hemangiomas are rarely found in the heart and pericardial involvement is even more rare. We report a case of primary pericardial hemangioma, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Our case also highlights the importance of systematic cropping of the 3D datasets in making a diagnosis of pericardial hemangioma with a greater degree of certainty. In addition, we also provide a literature review of the features of cardiac/pericardial hemangiomas in a tabular form.