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.     

Real Time Three‐Dimensional Transesophageal Echocardiography Demonstration of Membranous Septal Aneurysm Causing Severe Right Ventricular Outflow Tract Obstruction

In addition to infundibular muscular hypertrophy and anomalous muscle bundles in the right ventricular body, large membranous septal aneurysms (MSA), sinus of valsalva aneurysms, and aneurysms derived from the embryonic venous valve protruding through the tricuspid valve can cause right ventricular outflow obstruction in a patient with ventricular septal defect. Here we describe an adult with a small perimembranous ventricular septal defect complicated by a large MSA causing severe right ventricular outflow obstruction evaluated with real time three dimensional transesophageal echocardiography and cardiac catheterisation. The patient underwent surgical correction of the abnormality and is asymptomatic on follow up.     

Two‐ and Three‐Dimensional Speckle Tracking Echocardiography: Clinical Applications and Future Directions

Two‐dimensional speckle tracking echocardiography (2D STE) is a novel technique of cardiac imaging for quantifying complex cardiac motion based on frame‐to‐frame tracking of ultrasonic speckles in gray scale 2D images. Two‐dimensional STE is a relatively angle independent technology that can measure global and regional strain, strain rate, displacement, and velocity in longitudinal, radial, and circumferential directions. It can also quantify rotational movements such as rotation, twist, and torsion of the myocardium. Two‐dimensional STE has been validated against hemodynamics, tissue Doppler, tagged magnetic resonance imaging, and sonomicrometry studies. Two‐dimensional STE has been found clinically useful in the assessment of cardiac systolic and diastolic function as well as providing new insights in deciphering cardiac physiology and mechanics in cardiomyopathies, and identifying early subclinical changes in various pathologies. A large number of studies have evaluated the role of 2D STE in predicting response to cardiac resynchronization therapy in patients with severe heart failure. However, the clinical utility of 2D STE in the above mentioned conditions remains controversial because of conflicting reports from different studies. Emerging areas of application include prediction of rejection in heart transplant patients, early detection of cardiotoxicity in patients receiving chemotherapy for cancer, and effect of intracoronary injection of bone marrow stem cells on left ventricular function in patients with acute myocardial infarction. The emerging technique of three‐dimensional STE may further extend its clinical usefulness.     

New Approach for Rotational Dyssynchrony Using Three‐Dimensional Speckle Tracking Echocardiography

Left ventricular (LV) twist can be evaluated using two‐dimensional speckle tracking echocardiography (2DSTE) by analyzing difference between apical and basal rotation. However, it is unable to evaluate global rotational dyssynchrony because it cannot assess mid‐wall rotation. Recently developed three‐dimensional STE (3DSTE) can investigate LV global rotational dyssynchrony. In this study, we investigated the role of torsion on the long‐term effects of cardiac resynchronization therapy (CRT) using 3DSTE. We evaluated 43 patients by 3DSTE: 12 CRT responders, 14 CRT nonresponders, and 17 healthy normal controls. Regional torsion and rotation were assessed using 3DSTE across 16 segments during CRT‐off (native conduction) and CRT‐on. The following parameters were calculated: global peak twist, Δ global peak twist (difference between CRT‐on and CRT‐off), and torsion delay index. The torsion delay index was considered to be the rotational energy lost by rotational dyssynchrony. Global peak twist did not show significant differences between the responders and nonresponders during CRT‐off (4.0 ± 3.4° vs. 2.8 ± 2.3°, P = 0.295), but it significantly improved in responders compared to nonresponders after CRT‐on (5.4 ± 3.5° vs. 2.6 ± 2.6°, P = 0.029). The torsion delay index during CRT‐off was significantly higher in responders compared to nonresponders and normal controls (18.5 ± 11.3 vs. 8.6 ± 3.8 and 7.8 ± 5.5, P = 0.010 and P = 0.004, respectively). The torsion delay index during CRT‐off significantly correlated with the Δ global peak twist (r = 0.503, P = 0.009). Improvement in LV global peak twist, which is one of the mechanisms for the long‐term effects of CRT correlated with the torsion delay index during native conduction that can only be calculated by 3DSTE.     

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)     

Semiautomatic Quantification of Left Ventricular Function by Two‐Dimensional Feature Tracking Imaging Echocardiography. A Comparison Study with Cardiac Magnetic Resonance Imaging

Objective: To evaluate the accuracy of a semiautomatic quantification of left ventricular (LV) volumes and ejection fraction (EF) using two‐dimensional (2D) feature tracking imaging (FTI). Methods: Thirty‐four consecutive subjects (11 patients with dilated cardiomyopathy, 13 with hypertrophic cardiomyopathy, and 10 subjects with no cardiac disease) underwent, on the same day, trans‐thoracic echocardiography (TTE) examination, FTI, and cardiac magnetic resonance imaging (MRI), as gold standard, in order to quantify LV volumes and EF. The echocardiographic quantification of LV volumes and EF was determined from four‐ and two‐chamber views using both standard TTE Biplane Simpson's method and a semiautomatic border detection based on FTI. Furthermore, the time for data analysis for each method was measured. Results: The time required for semiautomatic analysis of volumes and EF was significantly lower (P < 0.0001) by FTI (71 seconds) in comparison with standard biplane Simpson's method (93 seconds). LV volumes obtained by FTI were significant underestimated (P < 0.001) in comparison with MRI. Bland‐Altman analysis of EDV and ESV using FTI and cardiac MRI showed a low level of agreement for EDV (mean difference = 40.8; SD = 39) and ESV (mean difference = 38.1; SD = 42). On the contrary, no significant difference between FTI and MRI in assessing the LVEF was found; furthermore, a very low bias (2 ± 12) by Bland‐Altman analysis was found between FTI and cardiac MRI for the quantification of EF. Conclusion: Semiautomatic quantification of LV volumes using FTI allows an accurate, rapid, easy and reliable assessment of LV EF and a rough estimation of LV volumes. (Echocardiography 2010;27:791‐797)     

Real Time Three‐Dimensional Echocardiography for Quantification of Ventricular Volumes,Mass, and Function in Children with Congenital and Acquired Heart Diseases

Quantitative measurement of left ventricular (LV) volumes, mass, and function is one of the most common and important indications for echocardiography. These measurements are among the most powerful tools for diagnosis and prognosis of congenital and acquired heart diseases and for assessment of medical, percutaneous, and surgical interventions. Awareness is also growing of the importance of right ventricular (RV) volume, mass, and function in many cardiopulmonary diseases. Furthermore, there are challenges and opportunities to measure the volume, mass, and function of complex chambers such as the left atrium, right atrium, and the univentricular heart. As echocardiography continues to be the imaging modality of choice for these measurements, the strengths and limitations of M‐mode, two‐dimensional (2D), and recently three‐dimensional (3D) echocardiographic (3DE) methodologies for accurate and reproducible measurement of these indices have been extensively investigated for congenital and acquired heart diseases. Evidence suggests that 3DE provides improved accuracy and reproducibility over 2D methods for measurement of LV volume and function calculation in adults and in children. Data have accumulated on the utility of 3DE for measuring chamber volumes and function for the RV and for the single ventricle, which may become more widely used in clinical and research arenas in the future. Finally, new advanced modes of analysis such as 3D strain and synchrony analysis by 3DE are promising methodologies that warrant further investigation.     

Three‐Dimensional Speckle Tracking Echocardiography–Derived Left Atrial Strain Parameters Are Reduced in Patients with Atrial Fibrillation (Results from the MAGYAR‐Path Study)

Objective: Three‐dimensional (3D) speckle tracking echocardiography (3DSTE) is a novel imaging modality for assessing cardiac function. We aimed to analyze left atrial (LA) function using 3DSTE in patients with atrial fibrillation (AF). Methods: 3DSTE was performed in 20 patients prior to their pulmonary vein isolation for AF. Every patient underwent a complete two‐dimensional echocardiographic study at the same time. 3DSTE‐derived circumferential (CS), longitudinal (LS), radial (RS), 3D (3DS), and area strain (AS) values were measured in the basal (b), mid (m), and superior (s) regions of the LA. 3DSTE‐defined maximal (LA_max) and minimal LA volumes (LA_min) and LA total emptying fraction were calculated automatically. Eleven randomly selected age‐ and gender‐matched healthy volunteers served as controls. Results: Patients with AF had significantly larger LA_max and LA_min and reduced LS, RS and CS.3DS and AS were significantly lower throughout the LA in cases with AF (3DS?b, ?m, ?s [AF patients vs. controls]: ?18 ± 8% vs. ?29 ± 8%, P = 0.001; ?14 ± 6% vs. ?22 ± 7%, P = 0.002; ?10 ± 7% vs. ?20 ± 9%, P = 0.002; AS?b, ?m, ?s [AF patients vs. controls]: 35 ± 15% vs. 52 ± 13%, P = 0.004; 50 ± 21% vs. 72 ± 19%, P = 0.009; 31 ± 21% vs. 65 ± 27%, P < 0.0001, respectively). Conclusions: 3DSTE‐derived “uni‐dimensional” LS, RS, CS, as well as novel strain parameters (3DS, AS) are significantly reduced in patients with AF compared to matched controls. 3DS and AS might be new strain parameters providing further insights into the alterations of LA function in patients developing AF.     

Cardiac Resynchronization Therapy as Rescue Therapy in End‐Stage Heart Failure: Illustration by Three‐Dimensional Speckle Tracking Strain Echocardiography

We report the case of a 73‐year‐old man admitted for refractory heart failure following implantation of a dual‐chamber pacemaker. Three‐dimensional (3D) echocardiography with speckle tracking area strain identified severe left ventricular (LV) dysfunction and LV dyssynchrony following right ventricular pacing. As the patient's clinical condition rapidly worsened despite optimal medical treatment, a cardiac resynchronization therapy (CRT) pacemaker was successfully implanted as rescue therapy. Symptoms rapidly regressed and echocardiographic assessment following CRT demonstrated an immediate improvement in LV systolic function, confirmed at 9‐month follow‐up with evidence of reverse remodeling. New imaging technologies such as 3D echocardiography with speckle tracking area strain may help to identify and follow up patients who will benefit from CRT as rescue therapy.     

Assessment of Interventricular Dyssynchrony by Real Time Three‐Dimensional Echocardiography: An In Vitro Study in a Porcine Model

Background: Loss of synchronous contraction between or within the right and left ventricle (RV, LV) leads to adverse ventricular function. We used real time three‐dimensional echocardiography (RT3DE) for evaluation of severity of interventricular dyssynchrony and function in a porcine heart model. Methods: Six fresh in vitro porcine hearts were used to create a controlled model of LV and RV dyssynchrony using two sets of pulsatile pumps. Synchronized and dyssynchronized pump settings were used with two different dyssynchronized settings: LV filled first and RV filled first. Results: There was good correlation between actual measurement and RT3DE for interventricular time difference (r = 0.95, P < 0.0001) and stroke volume (SV) for LV and RV (0.89, 0.85; P < 0.0001, respectively). RT3DE data showed a small but significant underestimation for actual volume (P < 0.05). The intra‐ and interobserver variabilities are 2.9 ± 1.5% and 3.1 ± 5.4% for LV and RV SVs, and 1.7 ± 2.4% and 2.2 ± 3.2% for time differences by RT3DE. There was significant difference in RV SV between synchrony and dyssynchrony when the RV filled first (P < 0.05), but not in other groups. The same pattern was found in RT3DE derived SVs (synchrony versus dyssynchrony with RV filled first, P < 0.05). Conclusions: There is no compromise in LV SV during interventricular dyssynchrony; but RV SV was significantly diminished when the RV filled first. RT3DE is a feasible, robust and reproducible method to identify interventricular dyssynchrony and to evaluate ventricular SVs. (Echocardiography 2010;27:709‐715)     

Emerging Role of Three‐Dimensional Speckle Tracking Strain for Accurate Quantification of Left Ventricular Dyssynchrony

A case was 53‐year‐old female with dilated‐phase hypertrophic cardiomyopathy. She was classified as New York Heart Association functional class III heart failure despite receiving optimal medical therapy. The electrocardiogram taken showed intraventricular conduction delay with a QRS width of 194 msec. The left ventricular (LV) end‐diastolic and systolic volumes, and ejection fraction (EF) were 101 mL, 68 mL, and 32%, respectively. The patient showed no significant mechanical LV dyssynchrony as evidenced by two‐dimensional (2D) speckle tracking radial strain, which is defined as the time difference between anterior‐septum and posterior wall, of 105 msec (<130 msec). Three‐dimensional (3D) speckle tracking radial strain was performed for more detailed LV mechanical dyssynchrony analysis. An especially important finding for 3D speckle tracking radial strain analysis was that the average time‐to‐peak strain of 5 septum segments at 3 different LV levels (basal‐anterior‐septum, basal‐septum, mid‐anterior‐septum, mid‐septum, apical‐septum) was significantly shorter than that of 5 posterolateral segments at 3 different LV levels (basal‐posterior, basal‐lateral, mid‐posterior, mid‐lateral, apical‐lateral). This time difference between septum and posterolateral wall was 216 msec (204 msec vs. 420 msec), which was considered to indicate significant LV mechanical dyssynchrony (≥130 msec). 12 months after cardiac resynchronization therapy (CRT), EF had improved to 47%, while end‐systolic and diastolic volumes had decreased to 88 mL and 47 mL, respectively, so that the patient was classified as a responder. In conclusions, a newly developed 3D speckle tracking strain can provide a comprehensive evaluation of “true” LV mechanical dyssynchrony from pyramidal 3D data sets acquired in the same beat, thus yielding more accurate information than previously possible with the 2D speckle tracking system.