Three-dimensional echocardiography assessment of carcinoid valvular heart disease: Images of each and all

A 54-year-old male was found to have neuroendocrine carcinoma with hepatic metastasis. Two-dimensional (2D) transthoracic echocardiography (TTE) demonstrated dilated right ventricle and right atrium, and severe tricuspid and pulmonary regurgitation. Three-dimensional (3D) TTE en-face views showed thickened, retracted, and fixed tricuspid valve and pulmonic valve which remained widely open throughout the cardiac cycle. 3D TTE, particularly en-face views, demonstrates incremental value over 2D TTE by providing precise valvular anatomic details comparable to surgical findings. 3D TTE also offers a unique opportunity to assess all four valves simultaneously with en-face views to delineate their relationships with surrounding structures.     

'Coumadin ridge' in the left atrium demonstrated on three dimensional transthoracic echocardiography.

An echogenic band like structure was seen in the left atrium on two dimensional transthoracic echocardiography (2D TTE). Full volume three dimensional (3D) TTE and colour Doppler established the surrounding anatomical landmarks, and demonstrated the absence of obstruction related to this band. 3D TTE confirmed that this band like structure was consistent with the ridge between the left atrial appendage and left superior pulmonary vein ('warfarin/coumadin ridge').     

Prominent crista terminalis and Eustachian ridge in the right atrium: Two dimensional (2D) and three dimensional (3D) imaging.

The crista terminalis and Eustachian ridge are normal anatomical structures within the right atrium that are not normally looked for or visualised in the standard views obtained while performing a transthoracic echocardiogram (TTE). In this case report, the prominent terminal ridge (a normal anatomical variant) appeared as a "mass" in the right atrium that needed to be differentiated from a pathological cardiac mass. Identification of physiological structures in the right atrium on TTE using additional 3D imaging can avoid unnecessary additional tests that are both more invasive and expensive such as transesophageal echocardiography or MRIs.     

Live three-dimensional transthoracic echocardiographic assessment of ventricular noncompaction

We present eight adult patients with noncompaction (four with isolated left ventricular noncompaction and four with combined left and right ventricular noncompaction) in whom live three-dimensional transthoracic echocardiography (3D TTE) demonstrated multiple, prominent myocardial trabeculations, deep intertrabecular recesses communicating with the ventricular cavity, and a typical honeycombing appearance. In the four patients with combined right and left ventricular noncompaction, very extensive trabeculations in the right ventricle were identified, much more than in normal or hypertrophied right ventricles. Five of the eight patients were not definitively identified to have noncompaction on two-dimensional (2D) TTE, but the diagnosis was made with 3D TTE. These cases demonstrate the potential usefulness of 3D TTE as a supplement to 2D TTE in the assessment of noncompaction.     

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.     

Quantification of tricuspid regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area

We evaluated tricuspid regurgitation (TR) by multiple echocardiographic techniques in 93 consecutive patients who underwent standard two-dimensional (2D) and live three-dimensional (3D) transthoracic echocardiography (TTE). TR vena contracta (VC) area was obtained by 3D TTE by systematic and sequential cropping of the acquired 3D TTE dataset. Assessment of VC area by 3D TTE was compared to 2D TTE measurements of the ratio of TR regurgitant jet area to right atrial area (RJA/RAA), RJA alone, VC width, and calculated VC area. VC area from 3D TTE closely correlated with RJA/RAA and RJA alone as determined from 2D TTE measurements. Live 3D TTE color Doppler measurements of VC area can be used for quantitative assessment of TR and offer incremental value for quantification of particularly severe regurgitant lesions.     

Live three-dimensional transthoracic echocardiographic demonstration of septal perforator coronary artery-left ventricle fistulas following myectomy

We present an adult patient with hypertrophic cardiomyopathy status post septal myectomy in whom live three-dimensional transthoracic echocardiography (3D TTE) demonstrated two septal perforator coronary arteries opening directly into the left-ventricular outflow tract. Only one of these fistulas could be demonstrated by two-dimensional transthoracic echocardiography (2D TTE). Our case demonstrates the potential usefulness of 3D TTE as a supplement to 2D TTE in the assessment of septal coronary artery-left ventricle fistulas.     

A case of severe mitral regurgitation due to an unusually long aberrant chorda tendinea straddling the anterior mitral leaflet

We present a case of a 27-year-old female with severe mitral regurgitation caused by a single long aberrant chorda tendinea. This chorda extended from the base of the right coronary cusp of the aortic valve, through the A2 scallop of the mitral valve, and attached to the dome of the left atrium. Initial transthoracic echocardiogram (TTE) demonstrated a mildly redundant anterior mitral leaflet with thickened leaflet tip and moderate eccentric, posteriorly directed mitral regurgitation. Repeat TTE revealed a chord-like structure attached to the midportion of the anterior mitral leaflet and extending to the left ventricular outflow tract. Transesophageal echocardiography (TEE) suggested two aberrant chordae tendineae tethering the A2 scallop on both the left atrial and left ventricular side. Patient underwent surgical resection of the aberrant chorda. During the excision of the chorda the structural integrity of the A2 scallop was compromised, necessitating mitral valve repair with excellent results.     

Delineation of anatomy of the ruptured sinus of Valsalva with three-dimensional echocardiography: the advantage of the added dimension

The rupture of sinus of Valsalva is a rare complication of infective endocarditis. Three-dimensional (3D) echocardiography represents an important adjunctive tool to demonstrate the ruptured sinus of Valsalva with better delineation of its characteristics. We present an adult patient with rupture of right sinus of Valsalva aneurysm due to infective endocarditis of the aortic valve, in whom the two-dimensional (2D) transthoracic echocardiogram erroneously localized the site of rupture into the right atrium. Whereas, 3D transthoracic echocardiogram accurately delineated the site of rupture into the right ventricle and it was confirmed on subsequent cardiac catheterization and angiogram. In addition, 3D echocardiography clearly showed the size and shape of the defect, which helped in successful transcatheter closure of the defect with amplatzer duct occluder device.     

Live/real time three-dimensional transthoracic echocardiographic assessment of Ebstein's anomaly

We describe our experience in using live/real time three-dimensional transthoracic echocardiography (3D TTE) in the assessment of five adult patients with Ebstein's anomaly. The technique was found useful in assessing the distribution and extent of tethering of each of the three leaflets of the tricuspid valve (TV) to the underlying right ventricular walls and the ventricular septum. The characteristic bubble-like appearance resulting from bulging of the non-tethered areas of the TV leaflets was also well visualized in three dimensions and their size measured. Thus, an estimate of the nontethered or free segments of all three leaflets of the TV could be obtained using this technique. This has important implications when considering these patients for surgical repair of the TV. Visualization of all three leaflets of the TV and their extent of tethering by 3D TTE also made it easier to identify the boundaries of the functioning right ventricular chamber potentially providing a more reliable assessment of its volumes and ejection fraction. Cropping of color Doppler 3D TTE data sets provided en face viewing of the TV regurgitation vena contracta permitting accurate assessment of its shape and size. This has the potential to provide a more accurate quantitative estimation of TV regurgitation severity as compared to two-dimensional color Doppler. In conclusion, live/real time 3D TTE appears useful in supplementing two-dimensional echocardiography in more comprehensively assessing the morphologic features of Ebstein's anomaly.     

Atypical Abnormal Pulmonary Vein Drainage with Atrial Septal Defect: Surgical Treatment

Sinus venosus atrial septal defect (SV‐ASD) usually coexists with partial anomalous pulmonary vein connection (PAPVC). It is a difficult diagnosis in transthoracic echocardiography (TTE) due to eccentric position of defects. We present a rare case of atypical anatomical variation in PAPVC, which was never described before. Two right pulmonary veins drained into superior vena cava, which overrode SV‐ASD and interatrial septum, a third pulmonary vein into the right atrium. Complete diagnosis could not be set after TTE, nor transesophageal echocardiography, whereas angio‐CT was finally conclusive. This diagnostic approach allowed the surgical planning.     

Left and right atrial volume by freehand three-dimensional echocardiography: in vivo validation using magnetic resonance imaging.

INTRODUCTION: Measurement of left and right atrial size is important for the management of arrhythmias, valvular and congenital heart disease. We have demonstrated that freehand three-dimensional (3D) echocardiography is more accurate and reproducible than two-dimensional (2D) echocardiography for measurement of left ventricular mass and volume. However, no prior study has validated the accuracy of freehand 3D for the determination of left or right atrial volume. METHODS: End-systolic (maximum) left and right atrial volumes were determined in 21 volunteer patients and normal subjects by one, two, and freehand 3D transthoracic echocardiography and compared to volumes obtained by gradient recalled magnetic resonance imaging. Three-dimensional echocardiographic determination of atrial volume was obtained using an acoustic spatial locator, a line-of-intersection display, and a surface reconstruction algorithm. Two-dimensional echocardiographic atrial volumes were obtained from apical biplane images of the left atrium and an apical single plane image of the right atrium using a summation of disks method. One-dimensional (ID) estimates of left atrial volume were determined by cubing the M-mode ID antero-posterior dimension obtained on the parasternal long axis view. RESULTS: An excellent correlation was Obtained between freedhand 3D echocardiography and magnetic resonce imaging (MRI) for the left atrium (r = 0.90, SEE=9.6 ml) and for the right atrium (r = 0.91, SEE = 8.8 ml) with a small bias (left atrium 5.25 ml, right atrium 12.06 ml) and narrow limits of agreement (left atrium 22.14 ml, right atrium 25.54 ml). Two-dimensional echocardiography correlated less well (left atrium r = 0.87, SEE = 10.23 ml, right atrium r = 0.79, SEE = 19.74 ml), and had a higher bias (left atrium 14.46 ml, right atrium 8.99 ml) and larger limits of agreement (left atrium 24.37 ml, right atrium 41.16 ml). One-dimensional estimates of left atrial volume correlated poorly with magnetic resonance determined left atrial volume (r = 0.80, SEE = 6.61 ml) and had unacceptably high bias (45.09 ml) and limits of agreement (35.52 ml). Interobserver variability was lowest for 3D echocardiography (left atrium 7.2 ml, 11%, right atrium 8.7 ml, 16%). CONCLUSIONS: Freehand 3D echocardiography using the line of intersection display for guidance of image positioning and a polyhedral surface reconstruction algorithm is a valid, accurate, reproducible method for determining left and right atrial volume in humans that is comparable to magnetic resonance imaging and is superior to current ID and 2D echocardiographic techniques.     

Assessment of papillary fibroelastomas with live three-dimensional transthoracic echocardiography

Seven consecutive patients presenting with typical echocardiographic features of papillary fibroelastoma requiring surgery were studied. All patients underwent standard two-dimensional (2D) transthoracic echocardiography (TTE) followed by live three-dimensional (live 3D) echocardiography with data set storage allowing analysis with systematic cropping of the acquired 3D data and volume measurement of the lesions. Assessment of papillary fibroelastoma by 2D and live 3D TTE was compared to operative findings. The feasibility of live 3D echocardiography in this setting was 100%. The quality of images was considered as optimal in three patients, good in three patients, and poor in one patient. A typical speckled appearance of the tumor was observed in three patients presenting with large tumors. The location of the tumor attachment was precisely defined in all but one patient, with a clear improvement in spatial assessment with live 3D TTE in three patients. Live 3D TTE also improved the operative planning in three patients. Live 3D TTE appears to be useful in the assessment of intracardiac tumors as small as papillary fibroelastomas, leading to a comprehensive approach of the lesion and facilitating the operative planning.     

Is It Time to Move on from Two-Dimensional Transesophageal to Three-Dimensional Transthoracic Echocardiography for Assessment of Left Atrial Appendage? Review of Existing Literature

Left atrial appendage (LAA) has unique anatomical and physiological properties, which make it a common site for thrombus formation in many cardiovascular and systemic diseases. Assessment of LAA for thrombus thus becomes important in many clinical situations and two-dimensional transesophageal echocardiography (2D TEE), which allows excellent quality images of LAA because of its close proximity to esophagus is routinely used for this purpose. However, it is a semiinvasive procedure, requires more time and involves some degree of patient discomfort. With some training and experience, two-dimensional transthoracic echocardiography (2D TTE) can visualize LAA in most patients with good acoustic windows. A disadvantage of both 2D TTE and 2D TEE is that they provide only a thin slice or section of cardiac structures at any given time limiting their utility in comprehensively assessing the LAA for thrombus. On the other hand, live/real time three-dimensional (3D) TTE overcomes this limitation of both 2D TTE and 2D TEE because of its ability to encompass whole of the LAA in three-dimensions in the acquired data set, which can then be cropped and sectioned systematically at any desired angulation to more definitively look for clot. 3D TTE is also useful in differentiating a clot from pectinate muscles in the LAA, which can mimic a thrombus resulting in patient mismanagement. In addition, 3D TTE is helpful in sectioning a clot for lysis, which has implications in clot resolution. We reviewed the existing literature comparing the relative advantages and disadvantages of 3D TTE versus 2D TEE and found that in patients with good acoustic windows 3D TTE had similar efficacy for detecting LAA thrombus. (Echocardiography 2012;29:112-116)     

Morphologic features of carcinoid heart disease as assessed by three-dimensional transesophageal echocardiography

Background: Carcinoid heart disease (CHD) is a rare cause of valvular heart disease and carries a poor prognosis. CHD has a unique morphology and echocardiographic features that predominantly involve right‐sided valvular structures. The diagnosis of CHD is usually made by two‐dimensional transthoracic echocardiography (TTE). With the superior spatial resolution of real time three‐dimensional transesophageal echocardiography (3DTEE), structural changes that occur in patients with CHD‐associated valvular heart disease can be examined in greater detail. We undertook this study to examine the incremental value of 3DTEE in the diagnosis of CHD. Methods: A total of four patients with CHD underwent TTE, transesophageal echocardiography (TEE), and 3DTEE as part of their routine clinical evaluation. Results: TTE and TEE for all four patients revealed thickened, fibrosed, retracted, and malcoapted tricuspid leaflets with wide‐open tricuspid valve regurgitation. 3DTEE en face imaging of the tricuspid valve demonstrated the characteristic morphologic features of CHD more clearly in all four patients. Conclusions: 3DTEE provides substantial incremental value over TTE in the assessment of characteristic CHD pathology and thus enhances the echocardiographic diagnosis of CHD. (Echocardiography 2010;27:1098‐1105)     

Erroneous diagnosis of significant obstruction by Doppler in a patient with discrete subaortic membrane: correct diagnosis by 3D-transthoracic echocardiography

We report an adult with a discrete subaortic membrane in whom two-dimensional transthoracic Doppler echocardiography demonstrated peak and mean gradients of 64 and 33 mmHg, respectively in the left ventricular outflow tract (LVOT) and a calculated orifice area by continuity equation of 1.14 cm(2) consistent with significant obstruction. However, by direct en face visualization of the LVOT at the level of the membrane by live/real time three-dimensional transthoracic echocardiography (3D TTE), a larger orifice measuring 2.29 cm(2) was seen and was indicative of no significant obstruction. This finding was confirmed at cardiac catheterization, which showed insignificant obstruction.     

Live three-dimensional transthoracic echocardiographic assessment of left atrial tumors

This preliminary study demonstrates the superiority of live three-dimensional transthoracic echocardiography (3D TTE) over two-dimensional (2D) TTE in the assessment of left atrial (LA) tumors in four patients studied by us (three myxomas, one hemangioma, all subsequently pathologically proven). Because of the unique ability of live 3D TTE to systematically section and view the contents of an intracardiac mass, LA myxomas in the three patients studied could be more confidently diagnosed by noting isolated echolucent areas consistent with hemorrhage/necrosis in the tumor mass. On the other hand, a definite echolucent area was found by 2D TTE in only two of the three patients with myxoma. In the fourth patient with a hemangioma, live 3D TTE showed much more extensive and closely packed echolucencies with little solid tissue as compared to a myxoma consistent with a highly vascularized tumor. In contrast, 2D TTE demonstrated only two isolated echolucencies in the tumor suggesting an erroneous diagnosis of myxoma.     

Images in geriatric cardiology. Usefulness of live three-dimensional transthoracic echocardiography in aortic valve stenosis evaluation

Aortic valve stenosis (AS) severity can be estimated by various modalities. Due to some of the limitations of the currently available methods, the usefulness of live three-dimensional transthoracic echocardiography (3D TTE) in the assessment of AS was explored. Live 3D TTE was able to visualize the aortic valve orifice in all 11 patients studied. Live 3D TTE correctly estimated the severity of AS in all 10 patients in whom AS severity could be evaluated at surgery. These included eight patients with severe AS and two with moderate AS. Two of these 10 patients with AS had associated hypertrophic cardiomyopathy and underwent myectomy at the time of aortic valve replacement. Aortic valve orifice area measurements by live 3D TTE correlated well with intraoperative three-dimensional transesophageal echocardiographic reconstruction measurements (r=0.85) but not as well with two-dimensional transesophageal echocardiography measurements (r=0.64). Live 3D TTE measurements of the aortic valve orifice area also did not correlate well with two-dimensional transthoracic echocardiography measurements (r=0.46) but the number of patients studied with two-dimensional transthoracic echocardiography was smaller (only seven) and four of these did not undergo two-dimensional transthoracic echocardiography at the authors' institution. Altogether, four patients with severe AS by live 3D TTE, and subsequently confirmed at surgery, were misdiagnosed as having moderate AS by two-dimensional transthoracic echocardiography. Because it is completely noninvasive and views the aortic valve in three dimensions, 3D TTE could be a useful complement to the existing modalities in the evaluation of AS severity.     

Live/Real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.     

Live/real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease

We present an adult with metastatic carcinoid disease affecting the heart, in whom live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over two-dimensional transthoracic echocardiography (2DTTE). Initial 2DTTE was able to demonstrate severe pulmonic and tricuspid regurgitation, but was unable to visualize the posterior leaflet of the tricuspid valve or the right (right anterior) leaflet of the pulmonic valve. Further analysis with 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of both the tricuspid and the pulmonary valves. En face viewing of tricuspid and pulmonary regurgitation vena contractas permitted more reliable quantification of regurgitation severity. In addition, localized, linear, echogenic areas consistent with carcinoid deposits were noted along the inner walls of the right atrium, atrial septum, and inferior vena cava. To the best of our knowledge, endocardial carcinoid deposits have never been reported by 2D or 3D echocardiography. En face viewing of these deposits by 3DTTE enabled measurement of their dimensions and areas. Subcostal examination also identified large circumscribed hepatic lesions consistent with metastatic disease. Neither the carcinoid deposits nor the metastatic lesions were detected by 2DTTE. This case demonstrates the usefulness of 3DTTE as a supplement to 2DTTE in more comprehensively assessing carcinoid involvement of the heart.