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 technique in the assessment of aortic atherosclerotic thrombi and ulcers

We present two cases in whom live/real time three‐dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two‐dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.     

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 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.     

Morphologic features of carcinoid heart disease as assessed by three-dimensional transesophageal echocardiography

Background: Carcinoid heart disease (CHD) is a rare cause of valvular heart disease and carries a poor prognosis. CHD has a unique morphology and echocardiographic features that predominantly involve right‐sided valvular structures. The diagnosis of CHD is usually made by two‐dimensional transthoracic echocardiography (TTE). With the superior spatial resolution of real time three‐dimensional transesophageal echocardiography (3DTEE), structural changes that occur in patients with CHD‐associated valvular heart disease can be examined in greater detail. We undertook this study to examine the incremental value of 3DTEE in the diagnosis of CHD. Methods: A total of four patients with CHD underwent TTE, transesophageal echocardiography (TEE), and 3DTEE as part of their routine clinical evaluation. Results: TTE and TEE for all four patients revealed thickened, fibrosed, retracted, and malcoapted tricuspid leaflets with wide‐open tricuspid valve regurgitation. 3DTEE en face imaging of the tricuspid valve demonstrated the characteristic morphologic features of CHD more clearly in all four patients. Conclusions: 3DTEE provides substantial incremental value over TTE in the assessment of characteristic CHD pathology and thus enhances the echocardiographic diagnosis of CHD. (Echocardiography 2010;27:1098‐1105)     

The Incremental Value of RT Three‐Dimensional TEE in the Evaluation of Prosthetic Mitral Valve Ring Thrombosis Complicated with Thromboembolism

Purpose: Although nonobstructive prosthetic valve thrombosis (PVT) does not develop hemodynamic compromise, it carries potential risk for thromboembolism. Real time three‐dimensional transesophageal echocardiography (RT‐3DTEE), has emerged as a complementary tool in depicting “en face” views of prosthesis compared with two‐dimensional transesophageal echocardiography (2DTEE). We aimed to evaluate the utility of RT‐3DTEE in assessment of mitral ring‐located thrombosis. Method: We present 3 cases of mechanical mitral valve thrombosis complicated by thromboembolism, who were all examined and followed‐up by 2D transthoracic echocardiography (TTE), 2DTEE, and RT‐3DTEE. Result: The consequencies of thromboembolism in the patients were coronary embolism, transient ischemic attack, and ischemic stroke, respectively. They were all inadequately anticoagulated at the time of admission. 2DTTE and TEE examination was unsatisfactory; RT‐3DTEE depicted nonobstructive mitral ring thrombosis in each of the patients. The patients were followed up under effective anticoagulation and antiplatelet therapy. RT‐3DTEE was able to demonstrate the evolution of thrombus size in each of the patients. Conclusion: Nonobstructive ring‐located PVT which poses risk for thromboembolism, may be diagnosed with certainty and imaged with clarity utilizing RT‐3DTEE.     

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.     

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.     

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto‐ostial left main coronary artery PCI, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.     

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.     

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic aneurysm and dissection

We compared findings from intraoperative live/real time three-dimensional transesophageal echocardiography (3DTEE) and two-dimensional transesophageal echocardiography (2DTEE) with surgery in 67 patients having aortic aneurysm and/or aortic dissection. Of these, 20 patients had aortic aneurysm without dissection, 21 aortic aneurysm and dissection, and 26 aortic dissection without aneurysm. 3DTEE diagnosed the type and location of aneurysm correctly in all patients unlike 2DTEE, which missed an aneurysm in one case. There were four cases of aortic aneurysm rupture. Three of them were diagnosed by 3DTEE but only one by 2DTEE, and one missed by both techniques. The mouth of saccular aneurysm, site of aortic aneurysm rupture, and communication sites between perfusing and nonperfusing lumens of aortic dissection could be viewed en face only with 3DTEE, enabling comprehensive measurements of their area and dimensions as well as increasing the confidence level of their diagnosis. In all patients with aortic dissection, 3DTEE enabled a more confident diagnosis of dissection because the dissection flap when viewed en face presented as a sheet of tissue rather than a linear echo seen on 2DTEE which can be confused with an artifact. 2DTEE missed dissection in one patient. In six cases the dissection flap involved the right coronary artery orifice by 3DTEE and surgery. These were missed by 2DTEE. Aortic regurgitation severity was more comprehensively assessed by 3DTEE than 2DTEE. Aneurysm size by 3DTEE correlated well with 2DTEE and surgery/computed tomography scan. In conclusion, 3DTEE provides incremental information over 2DTEE in patients with aortic aneurysm and dissection.     

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 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.     

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.     

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.     

Does three‐dimensional transesophageal echocardiography provide incremental value in percutaneous closure of ascending aortic pseudoaneurysm?

Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two‐ and three‐dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre‐ and postclosure settings.     

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 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.     

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.