Live/Real Time Three-Dimensional Transthoracic Echocardiographic Assessment of Bicuspid Aortic Valve Morphology

We describe the usefulness of three-dimensional transthoracic echocardiography (3D TTE) in the assessment of bicuspid aortic valve morphology in an adult patient with no stenosis but severe aortic regurgitation .     

Role of Live/Real Time Three-Dimensional Transthoracic Echocardiography in Pericardial Disease

Despite the high sensitivity of two-dimensional transthoracic echocardiography (2DTTE) in diagnosing pericardial effusion, it has limitations in assessing its size and extent and in evaluating other pericardial pathologies. There are only limited reports so far, but live/real time three-dimensional transthoracic Echocardiography (3DTTE) has shown promise and potential advantages over 2DTTE in certain clinical situations. With its ability to crop and view cardiac structures from any desired angulation it offers incremental value in assessing the anatomy of the pericardium including echo densities within the effusion, fibrinous bands, and loculated effusions. It offers significant supplemental information over 2DTTE in clinical scenarios like post cardiac surgery follow up of hemopericardium, quantification of the effusion, evaluation of pericardial masses including granuloma, differentiating pericardial effusion from ascites and pleural effusion and in studying the extent of the disease in constrictive pericarditis. However, comprehensive studies are needed to further define its role in daily clinical practice. (Echocardiography 2012;29:98-102)     

Visualization of Secundum Atrial Septal Defect Using Transthoracic Three-Dimensional Echocardiography in Children

Background: The objective of this study was to evaluate the efficacy of quantitative measurements of secundum atrial septal defect (ASD) with dynamic transthoracic three-dimensional (3–D) echocardiography. Methods: Twenty-six patients (age, 13 months to 14 years; mean age, 37 months) with secundum ASDs underwent 3-D echocardiographic imaging generated from transthoracic echocardiographic interrogation before surgery. Four specific cut planes were defined: four-chamber view, transverse view, en face view from right and left atrial side. The images obtained from 16 patients clearly demonstrated all four defined cut planes for the quantitative measurement. Results: The defect sizing determined by the 3-D images correlated well with surgical findings. These images may be interactively manipulated to optimize visualization of the defect to allow the cardiologist to perform transcatheter occlusion. A significant correlation was demonstrated to the limbic band tissue assessment by four-chamber and transverse views. Unusual atrial structures such as muscle bands and the fore-shortening of the en face view might induce biased measurements. Conclusions: The transthoracic approach was successful in capturing sufficient data to create 3-D images, which can provide an accurate assessment of secundum ASD. The possibility of underestimation should always be taken into account with the en face view. Multiple cut planes were essential to ensure correct sizing for adequate selection of the occluder.     

Embolization of Atrial Septal Occluder Device into the Pulmonary Artery: A Rare Complication and Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography

Percutaneous closure of atrial septal defects (ASD) in adults has emerged as an alternative to surgery. We report a rare complication of an atrial septal occluder device embolization into the pulmonary artery which was detected by fluoroscopy and echocardiography. The potential usefulness of live/real time three-dimensional transthoracic echocardiography in the management of patients undergoing percutaneous ASD occlusion is described.     

Live/Real Time Three-Dimensional Transthoracic Echocardiographic Assessment of Transposition of the Great Arteries in the Adult

We studied 11 adult patients with dextro-transposition and 5 adult patients with levo-transposition (corrected transposition) of the great arteries with real time two-dimensional (2DTTE) and live/real time three-dimensional transthoracic echocardiography (3DTTE). All patients with dextro-transposition underwent a Mustard or Senning procedure during infancy. Incremental findings provided by 3DTTE and not delineated by 2DTTE were (a) comprehensive examination of all three leaflets of the tricuspid valve including the detection and measurement of anatomic defects in the leaflets and the assessment of systolic noncoaptation and segmental prolapse; (b) en face viewing and measurement of vena contracta areas of the valvular regurgitation jets and the assessment of regurgitant volumes; (c) en face viewing of the intra-atrial baffle and localization and measurement of baffle defects as well as the measurement of vena contractas of the baffle leaks; (d) recognition of a bicuspid pulmonary valve; and (e) the quantitative assessment of left ventricular outflow tract obstruction. 3DTTE appears to be a useful noninvasive modality which could supplement 2DTTE in the comprehensive assessment of adult patients with transposition of the great arteries.     

Live/Real Time Three‐Dimensional Transthoracic Echocardiographic Assessment of Pericardial Disease

We studied 19 patients with pericardial disease using two‐dimensional and three‐dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE a more comprehensive assessment of pericardial effusion can be made and both the parietal and visceral layers of the pericardium can be visualized en face and examined for pathologies and fibrin deposits. In our series of patients, 3DTTE was superior to 2DTTE in uncovering mass lesions involving the pericardium such as tuberculous granulomas and metastatic disease. Furthermore, it provided a better assessment of the nature of pericardial lesions, such as pericardial and mediastinal hematomas, pericardial cysts, and metastatic disease to the pericardium by sequential cropping of the 3D data sets and visualizing the interior of the lesions in a manner not possible with 2DTTE. It was also valuable in determining the extent of pericardial calcification in pericardial constriction and in measuring the size of pericardial masses. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of pericardial diseases and that it provides incremental knowledge to the echocardiographer. (ECHOCARDIOGRAPHY, Volume 26, November 2009)     

Complete Atrioventricular Septal Defect with Truncus Arteriosus and Interrupted Aortic Arch in the Fetus

Complete atrioventricular septal defect is generally diagnosed on the four‐chamber view of the fetal heart. This defect can be accompanied by additional outflow tract lesions, including truncus arteriosus. Although truncus arteriosus in isolation can be associated with interrupted aortic arch, we describe a fetal case with the rare association of all three diagnoses: complete atrioventricular septal defect with truncus arteriosus and interrupted aortic arch. This case points to the importance of evaluating the complete fetal heart even after one congenital cardiac abnormality is noted. The complexity of heart disease has implications for prenatal counseling and postnatal management.     

Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography in Diagnosing Acquired Left Ventricular-Right Atrial Communication Misdiagnosed as Severe Pulmonary Hypertension by Two-Dimensional Transthoracic Echocardiography

We describe an adult patient with an acquired left ventricular-right atrial communication that was misdiagnosed as severe pulmonary hypertension (PH) by two-dimensional (2D) transthoracic echocardiography, but accurately detected on three-dimensional (3D) transthoracic echocardiography. Open heart surgery confirmed the defect .     

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)     

Live/Real Time Three-Dimensional Transthoracic Echocardiographic Assessment of Aortic Dissection Rupture into Right Ventricular Outflow Tract: A Case Report and Review of the Literature

We present a case of chronic ascending thoracic aortic dissection with rupture into the right ventricular outflow tract (RVOT) diagnosed by two-dimensional transthoracic echocardiogram in which live/real time three-dimensional (3D) transthoracic echocardiogram provided incremental value by demonstrating: (a) a tortuous false lumen that encroached and ruptured into the RVOT, (b) exact location of the rupture site in relation to other surrounding structures in 3 dimensions (c) en face view of the rupture site facilitating assessment of its size and shape, and (d) localized compression of the main pulmonary artery (PA) by the false lumen. In addition, cropping of the 3D data set permitted visualization of the origin of the left main coronary in a rapid manner excluding involvement of this vessel with the dissection process. These findings have potential implications for surgical planning and were corroborated by a computed tomography angiogram. We summarize seven previously reported aortic dissection cases with rupture into the right ventricle .     

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)     

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.     

Transesophageal Real Time Three-Dimensional Echocardiography in Assessment of Partial Atrioventricular Septal Defect

We present a practical application of real time three-dimensional transesophageal echocardiography in a 67-year-old male patient with congenital heart disease.     

Live/Real Time Three-Dimensional Transesophageal Echocardiographic Evaluation of Mitral and Aortic Valve Prosthetic Paravalvular Regurgitation

Thirteen patients already scheduled for surgery for repair of prosthetic paravalvular regurgitation underwent intraoperative real time two-dimensional transesophageal echocardiography (2D TEE) and live/real time three-dimensional transesophageal echocardiography (3D TEE). In all patients, 3D TEE was able to provide more information regarding the location and size of the paravalvular defect as compared to 2D TEE. 3D TEE resulted in a more accurate localization of the defect and an estimation of the size of the defect that correlated much more closely with surgical findings when compared with 2D TEE. Our preliminary results demonstrate the superiority of 3D TEE over 2D TEE in the evaluation of paravalvular prosthetic regurgitation. 3D TEE not only provides an accurate assessment of the exact site of the leakage, but also gives a more accurate estimate of its size. This information could be valuable to surgeons who may encounter difficulty when localizing and estimating the size of paraprosthetic leaks while the heart is devoid of blood during surgery.     

Incremental Value of Live/Real Time Three-Dimensional Transthoracic Echocardiography in the Assessment of Right Ventricular Masses

This case series demonstrates the incremental value of three-dimensional transthoracic echocardiography (3D TTE) over two-dimensional transthoracic echocardiography (2D TTE) in the assessment of 11 patients with right ventricular (RV) masses or mass-like lesions (three cases of RV thrombus, one myxoma, one fibroma, one lipoma, one chordoma, and one sarcoma and three cases of RV noncompaction, which are considered to be mass-like in nature). 3D TTE was of incremental value in the assessment of these masses in that 3D TTE has the capacity to section the mass and view it from multiple angles, giving the examiner a more comprehensive assessment of the mass. This was particularly helpful in the cases of thrombi, as the presence of echolucencies indicated clot lysis. In addition, certainty in the number of thrombi present was an advantage of 3D TTE. Also, sectioning of cardiac tumors allowed more confidence in narrowing the differential diagnosis of the etiology of the mass. In addition, 3D TTE allowed us to identify precise location of the attachments of the masses as well as to determine whether there were mobile components to the mass. Another noteworthy advantage of 3D TTE was that the volumes of the masses could be calculated. Additionally, the findings by 3D TTE correlated well with pathologic examination of RV tumors, and some of the masses measured larger by 3D TTE than by 2D TTE, which was also validated in one case by surgery. As in the case of RV fibroma, another advantage was that 3D TTE actually identified more masses than 2D TTE. RV noncompaction was also well studied, and the assessment with 3D TTE helped to give a more definitive diagnosis in these patients.     

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)     

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.     

新型导丝在单纯经胸超声心动图引导下经皮房间隔缺损封堵术中的应用

目的:探索一种新型超声专用导丝在单纯经胸超声心动图(TTE)引导下封堵房间隔缺损的安全性和有效性。方法:于2017年11月至2017年12月在中国医学科学院阜外医院入选10例房间隔缺损患者,均采用一种新设计的导丝进行单纯TTE引导下房间隔缺损封堵术,这种新型导丝的特点是头端为梭形弹性结构,可以在超声心动图引导下精确定位。手术由3名在单纯超声心动图引导下行封堵手术不超过10例的医生完成。术后即刻通过TTE评价手术疗效。术后1个月、3个月和6个月门诊随访,复查TTE和心电图。结果:10例患者在TTE引导下应用新型导丝成功封堵房间隔缺损。10例患者中,男性4例,女性6例,平均年龄(45.2±13.5)岁,平均体重(65.5±8.8)kg,平均房间隔缺损直径(14.9±5.1)mm。平均手术时间为(20.2±8.9)min,导丝从进入股静脉至左心房所需的时间为(3.6±2.6)min。无导丝脱入右心房。患者在住院期间均无残余分流、外周血管损伤、三尖瓣损伤及心脏穿孔等并发症。随访至术后6个月,均无封堵器脱落、残余分流和心包积液等并发症。结论:新型超声专用导丝可以在超声心动图引导下精确定位,可安全、有效地引导经皮房间隔缺损封堵术。     

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.