Incremental Value of Three‐Dimensional Echocardiography over the Two‐Dimensional Technique in the Assessment of Combined Sinus of Valsalva Rupture into the Right Ventricle and Adjacent Perimembranous Ventricular Septal Defect

We describe the incremental value of live/real time three‐dimensional (3D) echocardiography over the 2D technique in the assessment of ruptured right sinus of Valsalva into the right ventricle associated with an adjacent perimembranous ventricular septal defect in an elderly patient.     

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 Transthoracic Echocardiography over Two‐Dimensional Echocardiography in Hypertrophic Cardiomyopathy with Mid‐Ventricular Obstruction and Apical Aneurysm

We describe a case of hypertrophic cardiomyopathy with mid‐left ventricular obstruction and apical aneurysm containing thrombi where live/real time three‐dimensional transthoracic echocardiography provided incremental value over two‐dimensional echocardiography in assessing the findings.     

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 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)     

Bad Company: Supracristal VSD Presenting with Ruptured Sinus of Valsalva Aneurysm. A Case Presentation with Echocardiographic Depiction and an Analysis of Contemporary Literature

Supracristal ventricular septal defect (SCVSD), a defect of the infundibular portion of the interventricular septum just below the right aortic cusp, occurs more frequently in Eastern Asian populations. SCVSD may be complicated by right sinus of Valsalva aneurysm (SoVA). We present the case of a 26‐year‐old male of Korean descent with a history of a childhood murmur who was referred to our institution for progressive heart failure symptoms. He was diagnosed with SCVSD and ruptured right SoVA based on history, physical exam, and echocardiography including three‐dimensional transesophageal echocardiography with reconstructed surgical views. The patient underwent SCVSD closure, SoVA excision, and valve‐sparing aortic root replacement. We reviewed the echocardiography literature regarding SCVSD and SoVA, and analyzed contemporary literature of SoVA and its relationship with SCVSD. We conclude that a higher prevalence of ruptured SoVA in Eastern Asians is likely related to a higher prevalence of underlying SCVSD in this population.     

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.     

Rupture of a Noncoronary Sinus of Valsalva Aneurysm into the Left Atrium: A Rare Cause of Acute Pulmonary Edema

A sinus of Valsalva aneurysm is a dilatation of the aortic wall caused by the lack of continuity between the middle layer of the aortic wall and the aortic valve. It has an incidence of <0.1%. The most common cause of a sinus of Valsalva aneurysms is congenital, although they may also be acquired. The most common complication is rupture into the right atrium or ventricle, with rupture into the left chambers occurring very rarely. We present a 40‐year‐old man admitted to the hospital with an acute onset of respiratory distress and pleuritic chest pain. Transthoracic echocardiography followed by transesophageal echocardiography showed rupture of a noncoronary aneurysm of Valsalva sinus into the left atrium. The jet from the fistula caused retrograde flow into the pulmonary veins.     

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)     

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)     

Two Different Presentations of Sinus of Valsalva Aneurysm

Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly that can be congenital or acquired. We report 2 cases of SVA. The first case involves a 59‐year‐old male presenting with frequent syncope. Echocardiogram revealed a large right SVA obstructing the right ventricular outflow tract (RVOT). The second case involves a 21‐year‐old female presenting with sudden onset chest pain and a continuous machinery murmur. Echocardiogram revealed a ruptured right SVA into the right atrium. Although advanced percutaneous techniques have been implemented in the correction of this anomaly, open‐heart surgery with or without aortic valve replacement remains the treatment of choice.     

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)