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)     

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.     

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 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.     

Utility of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment and Percutaneous Intervention of Bioprosthetic Pulmonary Valve Stenosis

Accurate echocardiographic evaluation of the pulmonary valve is technically difficult because of its close proximity to the left lung, which often limits decision making. Pulmonary valvotomy is the intervention of choice for symptomatic pulmonary valve stenosis, but fluoroscopy lacks appropriate real time anatomic detail. In this report, we present a case where direct imaging of the pulmonary valve with live/real time three‐dimensional transesophageal echocardiography (3DTEE) aided in accurate evaluation and was then used to help guide and monitor successful valvuloplasty of a stenotic pulmonary valve bioprosthesis. We demonstrate that even in cases where two‐dimensional (2D) evaluation of the pulmonary valve is difficult, the use of live/real time 3DTEE allows for accurate evaluation of bioprosthetic pulmonary valve structure and function, and enhances the precision and monitoring of percutaneous valvuloplasty.     

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.     

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.     

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.     

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 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.     

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)