Usefulness of live/real time three-dimensional transthoracic echocardiography in the identification of individual segment/scallop prolapse of the mitral valve

In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.     

Papillary fibroelastoma of the pulmonary valve: assessment by live/real time three-dimensional transthoracic echocardiography

The differential diagnosis of a cardiac valve mass includes fibroelastoma, myxoma, lipoma, Lambl's excrescences, thrombus, and vegetation. Fibroelastomas are extremely rare primary cardiac tumors. Their incidence is 0.00017-0.033% in autopsy series and 0.019% in clinical series identified on echocardiography. Although rare, fibroelastomas are the most common tumors affecting the cardiac valves with aortic, mitral, tricuspid, and pulmonary valves being involved in this order. In the current report we describe a case of pulmonary valve mass in which a confident prospective diagnosis of fibroelastoma could be made utilizing the technique of three-dimensional transthoracic echocardiography.     

Cor triatriatum sinister: assessment by live/real time three-dimensional transthoracic echocardiography

We report a 49-year-old morbidly obese female with a poor acoustic window in whom live/real time three-dimensional transthoracic echocardiography was able to make a confident diagnosis of cor triatriatum sinister. En face views of the membrane facilitated accurate assessment of the size and shape of the large nonobstructing opening in the membrane. Maximum dimensions of the opening were 3.06 × 1.03 cm and area was 2.3 cm².     

Incremental value of live/real time three-dimensional transthoracic echocardiography in the assessment of left ventricular thrombi

This is a case series on three adult patients who contain left ventricular (LV) thrombus and the incremental benefits of live/real time three-dimensional transthoracic echocardiography (3DTTE) in comparison to two-dimensional transthoracic echocardiography (2DTTE) in evaluating LV thrombi. These cases illustrate that 3DTTE is of additional benefit by demonstrating the following: (1) cropping of a single 3DTTE apical dataset may be enough to provide comprehensive assessment of the LV in a timely manner even without breath holding in a not fully cooperative patient (2) it identifies the exact point of attachment of the thrombus to the left ventricular wall, (3) helps to delineate the absence or presence of focal echolucent areas within thrombi indicative of the presence and extent of clot lysis, which may have potential therapeutic and prognostic implications, and (4) provides more accurate assessment of thrombus mobility which has prognostic indications.     

Live/real time three-dimensional transthoracic echocardiographic identification of quadricuspid aortic valve

We describe an adult in whom live/real time three-dimensional echocardiography was able to make a definite diagnosis of a quadricuspid aortic valve which was misdiagnosed as bicuspid by live two-dimensional transthoracic echocardiography (2DTTE).     

Usefulness of live three-dimensional transthoracic echocardiography in the characterization of atrial septal defects in adults

In this report we present 12 adult patients in whom surgical or percutaneous intervention was considered for repair of atrial septal defect (ASD). Location, size, and surrounding atrial anatomy of the ASD were assessed prior to intervention in all patients with standard and live three-dimensional transthoracic echocardiography (3D TTE). In the four patients in whom intraoperative three-dimensional transesophageal echocardiographic reconstruction (3D TEE) was done, 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with 3D TEE. In the seven patients who underwent transcatheter closure device insertion, live 3D TTE measurements of maximum dimension, maximum circumference, and maximum area of ASD agreed well with the sizing balloon. Additionally, since the sizing balloon measures a stretched diameter and area, a live 3D TTE stretched ASD diameter and area (derived from the actual live 3D TTE maximum circumference) were calculated and demonstrated improved agreement with the sizing balloon measurements. In all patients, > or =5 mm of atrial tissue was visualized surrounding the ASD. Further, with the addition of contrast enhancement, characterization of a small patent foramen ovale (<5 mm) was possible in one patient. Live 3D TTE accurately defined ASD location, size, and surrounding atrial anatomy in all patients studied by us. ASD characterization by live 3D TTE agreed well with 3D TEE and sizing balloon measurements.     

Live/real time three-dimensional transthoracic echocardiographic assessment of Ebstein's anomaly

We describe our experience in using live/real time three-dimensional transthoracic echocardiography (3D TTE) in the assessment of five adult patients with Ebstein's anomaly. The technique was found useful in assessing the distribution and extent of tethering of each of the three leaflets of the tricuspid valve (TV) to the underlying right ventricular walls and the ventricular septum. The characteristic bubble-like appearance resulting from bulging of the non-tethered areas of the TV leaflets was also well visualized in three dimensions and their size measured. Thus, an estimate of the nontethered or free segments of all three leaflets of the TV could be obtained using this technique. This has important implications when considering these patients for surgical repair of the TV. Visualization of all three leaflets of the TV and their extent of tethering by 3D TTE also made it easier to identify the boundaries of the functioning right ventricular chamber potentially providing a more reliable assessment of its volumes and ejection fraction. Cropping of color Doppler 3D TTE data sets provided en face viewing of the TV regurgitation vena contracta permitting accurate assessment of its shape and size. This has the potential to provide a more accurate quantitative estimation of TV regurgitation severity as compared to two-dimensional color Doppler. In conclusion, live/real time 3D TTE appears useful in supplementing two-dimensional echocardiography in more comprehensively assessing the morphologic features of Ebstein's anomaly.     

Real-time three-dimensional echocardiography is useful in the evaluation of patients with atrioventricular septal defects

OBJECTIVE: We sought to determine whether three-dimensional echocardiography (3DE) is useful in the evaluation of patients with atrioventricular septal defect (AVSD). BACKGROUND: Recent advances in 3DE have enhanced its practicality. We assessed whether 3DE provided new information compared to 2DE among patients with AVSD. METHODS: We retrospectively reviewed 52 3DE datasets from 51 patients (median age: 4.6 years, range 0-30 years; median BSA: 0.6 m2, range 0.2-1.9 m2) with any type of AVSD during a 1-year period. 3DE findings were compared to 2DE and surgical reports. For each study, AVSD was classified by 2DE as one of the following: unrepaired balanced defect, repaired balanced defect with residual lesions, repaired balanced defect without residual lesions, or unbalanced defect. 3DE was graded as (1) Additive: 3DE resulted in a new finding or changed diagnosis; (2) Useful: While useful, 3DE did not result in new findings or changed diagnosis; or (3) Not useful. RESULTS: 3DE on unrepaired balanced AVSD and repaired AVSD with residual lesions was more often additive/useful (33/36; 92%) than on repaired AVSD without residual lesions or unbalanced AVSD (9/16 (56%), P=0.009). 3DE was additive or useful in all three patients with unbalanced AVSD being considered for biventricular repair. Useful information obtained by 3DE included: precise characterization of mitral regurgitation and cleft leaflet, substrate for subaortic stenosis, valve anatomy, and presence and location of additional septal defects. CONCLUSION: 3DE provides useful and additive information in unrepaired balanced AVSD, repaired AVSD with residual lesions, and unbalanced AVSD under consideration for biventricular repair.     

Live/real time three-dimensional transthoracic echocardiographic visualization of Chiari network

We report the usefulness of live/real time three-dimensional transthoracic echocardiography in the visualization of Chiari network.     

Real time three-dimensional echocardiography in assessing ventricular septal defects: an echocardiographic-surgical correlative study

BACKGROUND: Two-dimensional echocardiography (2DE) enhanced by combining with color Doppler technology has significant limitations in providing precise quantitative information, geometric assumptions to calculate chamber volume, mass, and ejection fraction. Reconstructed three-dimensional echocardiographic (3DE) systems (from multiple cross-sectional echocardiographic scans) are still cumbersome and time-consuming. Real time 3DE (RT-3DE) with shorter imaging time than with 3D reconstruction techniques can obtain qualitative and quantitative information on heart disorders. Our purpose was to investigate the feasibility and potential value of RT-3DE as a means of accurately and quantitatively estimating the size of VSD to correlate with the surgical findings. MATERIALS AND METHODS: 38 patients with VSD were examined with RT-3DE. 3D image database was postprocessed using TomTec echo 3D workstation. The results were compared with the results measured by 2 DE and surgical findings. RT-3DE produced novel views of VSD and improved quantification of the size of the defect. The sizes obtained from 3DE have equivalent correlation with surgical findings as diameter measured by 2DE (r = 0.89 vs r = 0.90). Good agreement between blinded observers was achieved by little interobserver variability. CONCLUSION: RT-3DE offers intraoperative visualization of VSD to generate a "virtual sense of depth" without extending examining time. From an LV en face projection, the positions, sizes, and shapes of VSDs can be accurately determined to permit quantitative recording of VSD dynamics. It is a potentially valuable clinical tool to provide precise imaging for surgical and catheter-based closure of difficult perimembranous and singular or multiple muscular VSD.     

Live/Real time three-dimensional transthoracic echocardiographic assessment of aortopulmonary window

Aortopulmonary (AP) window is an extremely rare congenital anomaly involving a communication between the ascending aorta and pulmonary artery. Two-dimensional transthoracic echocardiography is traditionally used in the diagnosis but has limitations. We report the usefulness of three-dimensional transthoracic echocardiography in the assessment of AP window in two newborns studied by us.     

Assessment of surgically unroofed coronary sinus by live/real time three-dimensional transthoracic echocardiography

Both two-dimensional transthoracic echocardiography (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE) were attempted in a 25-year-old morbidly obese female with total anomalous pulmonary venous return (TAPVR) into the coronary sinus (CS) in whom surgical unroofing of CS with patch closure of CS ostium was performed in infancy to redirect pulmonary venous flow into the left atrium (LA). The patient had become increasingly symptomatic over the past 1 year because of severe left-to-right shunting due to dehiscence of the patch used to close the CS ostium. Despite a poor acoustic window, 3DTTE was able to identify a communication between the LA and CS which resulted from surgical unroofing of the CS as well as flow signals moving into the right atrium from the CS. These findings were not detected by 2DTTE.     

Definitive diagnosis of descending thoracic aortic dissection by real time/live three-dimensional transthoracic echocardiography

We describe a patient with descending thoracic aortic dissection in whom three- dimensional transthoracic echocardiography was able to clearly visualize the dissection flap en face as a sheet of tissue, as well as demonstrate a large communication between the true and false lumen in three dimensions, enabling a definitive diagnosis of dissection.     

Real time three-dimensional transthoracic echocardiography for guiding Amplatzer septal occluder device deployment in patients with atrial septal defect

BACKGROUND: Transcatheter Amplatzer septal occluder (ASO) device closure of atrial septal defects (ASDs) has traditionally been guided by two-dimensional transesophageal echocardiography (2D-TEE) and intracardiac echocardiography (ICE) modalities. Real time three-dimensional transthoracic echocardiography (RT3D-TTE) provides rotating images to define ASD and adjacent structures with potential as an alternative to 2D-TEE or ICE for guiding the device closure of ASD. Our aim was to assess the feasibility and effectiveness of RT3D-TTE in parasternal four-chamber views to guide ASO device closure of ASD. METHODS AND RESULTS: From July 2004 to August 2005, 59 patients underwent transcatheter ASO device closure of ASD. The first 30 patients underwent 2D-TEE guidance under general anesthesia and the remaining 29 patients underwent RT3D-TTE guidance with local anesthesia. All interventions were successfully completed without complications. The clinical characteristics and transcatheter closure variables of RT3D-TTE and 2D-TEE were compared. Echocardiographic visualization of ASD and ASO deployment was found to be adequate when using either methods. Catheterization laboratory time (39.1 +/- 5.4 vs 78.8 +/- 14.1 minutes, P < 0.001) and interventional procedure length (7.6 +/- 4.2 vs 15.3 +/- 2.9 minutes, P < 0.001) were shortened by using RT3D-TTE as compared with 2DE-TEE. There was no difference in the rate of closure following either method, assessed after a 6-month follow-up. The maximal diameter measured by RT3D-TTE and 2D-TEE was correlated well with a balloon-stretched ASD size (y = 0.985x + 0.628, r = 0.924 vs y = 0.93x + 2.08, r = 0.885, respectively). CONCLUSION: RT3D-TTE may be a feasible, safe, and effective alternative to the standard practice of using 2D-TEE to guide ASO deployment.     

Added value of three‐dimensional transthoracic echocardiography in assessment of an adult patient with atrioventricular septal defect

Transthoracic echocardiography is the principal imaging modality for assessment of patients with atrioventricular septal defects. Three‐dimensional echocardiography streamlines and simplifies data acquisition offering a unique realistic en‐face display of heart valves and septal defects and enables accurate evaluation of the cardiac anatomy, dynamic, and function. We demonstrated an added value of three‐dimensional echocardiography in assessment of an adult patient with atrioventricular septal defect and its advantages over conventional echocardiography.     

Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique

Twenty-nine patients with different tricuspid valve (TV) pathologies were studied by both two-dimensional transthoracic (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE). A major contribution of 3DTTE over 2DTTE was the en face visualization of all three leaflets of the TV in all patients. This allowed accurate assessment of TV orifice area in patients with TV stenosis and carcinoid disease. Loss of TV leaflet tissue, defects in TV leaflets and size of TV systolic non-coaptation could also be delineated and resulted in identifying the mechanism of tricuspid regurgitation (TR) in patients with Ebstein's anomaly and rheumatic heart disease. Prolapse of TV leaflets could also be well visualized and enabled us to develop a schema for systematic assessment of individual segment prolapse which could help in surgical planning. The exact sites of chordae rupture in patients with flail TV as well as right ventricular papillary muscle rupture could be well seen by 3DTTE. 3DTTE also permitted sectioning of various TV masses for more specific diagnosis of their nature. In addition, color Doppler 3DTTE provided an estimate of quantitative evaluation of TR severity, since the exact shape and size of the vena contracta could be accurately assessed. In conclusion, our preliminary experience with 3DTTE has demonstrated substantial incremental value over 2DTTE in the assessment of various TV pathologies.     

Live/real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.     

Unusual bileaflet tricuspid valve by real time three-dimensional echocardiography

The right atrioventricular valve is formed by three leaflets as described by the classic anatomic studies. Two-dimensional transthoracic echocardiography (2DE) shows the tricuspid valve (TV) in its long axis. However, short-axis views of the TV leaflets are not generally obtained and therefore distinction between leaflets by 2DE is difficult. Real time three-dimensional echocardiography (RT3DE) overcomes this limitation of 2DE and facilitates obtaining short axis view (enface view) of the TV. In the current case study, en face view of the TV obtained by RT3DE was found to be formed of only two leaflets with two commissures. The surgical findings were consistent with that of RT3DE.