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 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)     

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)     

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.     

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)     

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)     

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.     

Real Time Three‐Dimensional Transthoracic Echocardiography Evaluation in a Patient with Congenital Pulmonary Vein Stenosis

Although real time three‐dimensional transthoracic echocardiography (RD‐3DTTE) has been used in children with complex congenital heart diseases, the benefit of RD‐3DTTE as a vision of the pulmonary veins still requires further evaluation. We present here, a 3‐year‐old girl with a stenosis of the left upper pulmonary vein (LUPV). Excellent images were obtained rapidly by RD‐3DTTE that successfully visualized the narrowing at the junction of the LUPV. The result was demonstrated by MRI, cardiac catheterization, and operation. RD‐3DTTE is a feasible and promising technique in evaluating pulmonary veins in children. (Echocardiography 2010;27:E109‐E111)     

Identification of Left Ventricular “Rigid Body Rotation” by Three‐Dimensional Speckle‐Tracking Echocardiography in a Patient with Noncompaction of the Left Ventricle: A Case from the MAGYAR‐Path Study

Noncompaction of the left ventricular myocardium (LVNC) is a new clinical entity firstly described by Engberding and Bender in 1984. LVNC is characterized by the presence of numerous prominent trabeculations and deep intertrabecular recesses within the left ventricle. Recently, it has been demonstrated by two‐dimensional (2D) speckle‐tracking echocardiography (STE), that left ventricular (LV) basal and LV apical rotations are in the same direction resulting in the near absence of LV twist in LVNC patients, which was called as “LV solid/rigid body rotation.” Three‐dimensional (3D)‐STE has just been introduced, and found to be an accurate method for the evaluation of LV rotation mechanics. The aim of this report was to confirm LV “rigid body rotation” in an LVNC patient by 3D‐STE.     

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.     

Double‐Chambered Right Ventricle with Ventricular Septal Defect and Subaortic Membrane— Three‐Dimensional Echocardiographic Evaluation

Double‐chambered right ventricle (DCRV) is a rare congenital anomaly in which the right ventricle is divided into two compartments with varying pressures due to an anomalous muscle bundle. Here, we describe a case of an adolescent male with DCRV with associated ventricular septal defect and subaortic membrane. Two‐dimensional and three‐dimensional transthoracic echocardiography with color flow clearly outlined all the three cardiac anomalies as well as their relationship with each other. The diagnosis was confirmed by cardiac catheterization. The patient underwent successful surgical resection of the anomalous muscle bundle along with repair of the associated anomalies.     

Real Time Three‐Dimensional Transthoracic Echocardiography of Ruptured Left Sinus of Valsalva Aneurysm to Left Ventricle

Aneurysms arising from the sinus of Valsalva are a rare cardiac defect that can present with various signs and symptoms, and if not diagnosed and treated rapidly can lead to fatal outcomes. Unruptured aneurysms are usually asymptomatic and found incidentally during diagnostic studies. More commonly, aneurysm of sinus of Valsalva is detected after the occurrence of rupture. Echocardiography has become the investigative tool of choice for this condition, not only for diagnosis but also for quantification of severity. We hereby report a rare case of a 15‐year‐old patient presenting with complaints of effort dyspnea and palpitations. Two‐dimensional transthoracic echocardiography (TTE) showed aneurysmal dilatation of left sinus of Valsalva which had ruptured into the left ventricle. Also, there was an intimal flap within the sinus of Valsalva aneurysm. The anatomical relationship between the aorta, aneurysm, and the left ventricle as well as the intimal flap within the aneurysm was clearly delineated with the help of three‐dimensional TTE. After confirmation of the diagnosis with multidetector computed tomography, patient underwent successful surgical repair of the defect.