Three-dimensional echocardiographic features of unicuspid aortic valve stenosis correlate with surgical findings

A unicuspid aortic valve (UAV) is a rare congenital defect that may manifest clinically as severe aortic stenosis or regurgitation in the third to fifth decade of life. This report describes two cases of UAV stenosis in adult patients diagnosed by transesophageal echocardiography (TEE). The utility of three-dimensional TEE in confirming valve morphology and its relevance to transcatheter valve replacement are discussed.     

Diagnosis of Congenital Unicuspid Aortic Valve in Adult Population: The Value and Limitation of Transesophageal Echocardiography

Background: This study aimed to assess the accuracy of two‐dimensional echocardiography (echo) in diagnosing unicuspid aortic valve (UAV) and to determine echo features that could improve the diagnosis. Method: We reviewed transthoracic/transesophageal echoes (TTE/TEE) from our hospital database for adult patients who had aortic valve surgery with a preoperative echo diagnosis of UAV or equivocal diagnosis of bicuspid aortic valve (BAV) BAV/UAV. Morphological characteristics of AV and ascending aortic dimensions were evaluated. Results: Nineteen patients were identified, 13 (11 Male, 2 Female, mean age 47 ± 10 years) had surgically confirmed diagnosis of UAV, six had BAV. The incidence of UAV was 2.6%. For diagnosing UAV, the sensitivity and specificity of TTE was 27% and 50% and those of TEE was 75% and 86%, respectively. For TTE, positive predictive value (PPV) was 60% and negative predictive value (NPV) was 20%. By TEE, PPV was 90% and the NPV was 67%. In UAV patients, 85% had severe aortic stenosis (mean gradient 45 ± 16 mmHg, AVA: 0.9 ± 0.2 cm²). 46% had ascending aorta aneurysm (mean aortic root, sinutubular junction, ascending aorta dimensions: 36 ± 3 mm, 31 ± 4 mm and 41 ± 8 mm). Patients with ascending aortic aneurysm were younger (41 ± 11 years vs. 52 ± 5 years, P < 0.05) All UAV were unicommissural with a posteriorly positioned commissural attachment, 69% were heavily calcified. Diagnostic accuracy was limited by quality of images, severity, and distribution of calcification. Conclusion: TEE is the diagnostic modality of choice in UAV. Identifying several echo features may improve its diagnostic accuracy. (Echocardiography 2010;27:1107‐1112)     

3D Transesophageal Echocardiographic Guidance and Monitoring of Percutaneous Aortic Valve Replacement

We describe a preliminary clinical experience with 3D transesophageal echocardiography (3D TEE) in an 84-year-old man with severe aortic stenosis and multiple comorbidity, who underwent percutaneous aortic valve implantation. Although 3D TEE monitoring is not a standard procedure during aortic valve replacement procedure (PAVR), when used in combination with conventional 2D-TEE contributes to improving adequate patient selection and provides more accurate information to the interventional cardiologist during positioning, deployment, and early function of the prosthesis. (Echocardiography 2010;27:84-86)     

Utility of three-dimensional transesophageal echocardiography in the diagnosis of valvular perforations

Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is a relatively new imaging modality that is increasingly being used to characterize a variety of cardiac pathologic features. In the present study, we reviewed the 2-dimensional (2D) and 3D TEE images from our echocardiographic database to identify patients with valve perforations. A review of the 2D TEE images resulted in the identification of 11 valvular perforations (6 aortic valves, 4 mitral valves, and 1 tricuspid valve). A review of the 3D TEE images allowed for the identification of 15 valve perforations (7 aortic valves, 7 mitral valves, and 1 tricuspid valve), including 4 perforations that could not be diagnosed using 2D imaging alone. In conclusion, 3D TEE imaging provided added benefit to traditional 2D TEE imaging because of its ability to provide en face visualization of the cardiac valves, allowing improved identification and precise anatomic localization of the perforation.     

Comparison of magnetic resonance imaging of aortic valve stenosis and aortic root to multimodality imaging for selection of transcatheter aortic valve implantation candidates

The purpose of the present study was to compare the aortic valve area, aortic valve annulus, and aortic root dimensions measured using magnetic resonance imaging (MRI) with catheterization, transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE). An optimal prosthesis--aortic root match is an essential goal when evaluating patients for transcatheter aortic valve implantation. Comparisons between MRI and the other imaging techniques are rare and need validation. In 24 consecutive, high-risk, symptomatic patients with severe aortic stenosis, aortic valve area was prospectively determined using MRI and direct planimetry using three-dimensional TTE and calculated by catheterization using the Gorlin equation and by Doppler echocardiography using the continuity equation. Aortic valve annulus and the aortic root dimensions were prospectively measured using MRI, 2-dimensional TTE, and invasive aortography. In addition, aortic valve annulus was measured using TEE. No differences in aortic valve area were found among MRI, Doppler echocardiography, and 3-dimensional TTE compared with catheterization (p = NS). Invasive angiography underestimated aortic valve annulus compared with MRI (p <0.001), TEE (p <0.001), and 2-dimensional TTE (p <0.001). Two-dimensional TTE tended to underestimate the aortic valve annulus diameters compared to TEE and MRI. In contrast to 2-dimensional TTE, 3 patients had aortic valve annulus beyond the transcatheter aortic valve implantation range using TEE and MRI. In conclusion, MRI planimetry, Doppler, and 3-dimensional TTE provided an accurate estimate of the aortic valve area compared to catheterization. MRI and TEE provided similar and essential assessment of the aortic valve annulus dimensions, especially at the limits of the transcatheter aortic valve implantation range.     

Aortic Stenosis

Noninvasive assessment of aortic valve area by echocardiography has become the standard of practice over the past few years. The advent of transesophageal echocardiography (TEE) has provided a new method for the assessment of aortic valve area (AVA) using planimetry by two-dimensional imaging. Clear visualization of the anatomy of the valve, as well as accuracy of AVA assessment, makes TEE an invaluable tool for the evaluation of aortic valve stenosis. TEE is especially helpful in clinical settings when there is a discrepancy between the AVA obtained by transthoracic echocardiography and cardiac catheterization. TEE is particularly helpful in the assessment of the aortic valve during intraoperative echocardiography. This review discusses the techniques, imaging planes, and details for assessing AVA by TEE. The role of TEE in AVA assessment is described, with specific clinical case examples cited.     

A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral‐aortic intervalvular fibrosa

A 28‐year‐old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three‐dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26‐mm‐long pouch was seen in mitral‐aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.     

3D transesophageal echocardiography in TAVR

Recently, there has been an increasingly minimalistic approach to transcatheter aortic valve replacement (TAVR), with most procedures now performed under conscious sedation without real time transesophageal echocardiography (TEE) guidance. Proponents of echo should not feel discouraged by this; it is the initial insights that were gained with procedural TEE during the early years of TAVR that have allowed the procedure's gradual maturation and sophistication. Experienced centers that have promoted extensive TAVR TEE programs continue to maximize the benefits of echocardiography in both procedural planning and execution. Critical to this is the understanding of 3D TEE, allowing the annulus to be sized accurately, relevant neighboring anatomy defined, and complications flagged. This review will outline the current application of 3D TEE in TAVR and discuss challenges and opportunities for 3D echocardiography in this field.     

Use of real-time three-dimensional transesophageal echocardiography in type A aortic dissections: Advantages of 3D TEE illustrated in three cases

Stanford type A aortic dissections often present to the hospital requiring emergent surgical intervention. Initial diagnosis is usually made by computed tomography; however transesophageal echocardiography (TEE) can further characterize aortic dissections with specific advantages: It may be performed on an unstable patient, it can be used intra-operatively, and it has the ability to provide continuous real-time information. Three-dimensional (3D) TEE has become more accessible over recent years allowing it to serve as an additional tool in the operating room. We present a case series of three patients presenting with type A aortic dissections and the advantages of intra-operative 3D TEE to diagnose the extent of dissection in each case. Prior case reports have demonstrated the use of 3D TEE in type A aortic dissections to characterize the extent of dissection and involvement of neighboring structures. In our three cases described, 3D TEE provided additional understanding of spatial relationships between the dissection flap and neighboring structures such as the aortic valve and coronary orifices that were not fully appreciated with two-dimensional TEE, which affected surgical decisions in the operating room. This case series demonstrates the utility and benefit of real-time 3D TEE during intra-operative management of a type A aortic dissection.     

A unique case of “double‐orifice aortic valve”—comprehensive assessment by 2‐, 3‐dimensional,and color Doppler echocardiography

Transesophageal echocardiography (TEE) is a powerful imaging tool for the comprehensive assessment of valvular structure and function. TEE may be of added benefit when anatomy is difficult to delineate accurately by transthoracic echocardiography. In this article, we present 2‐, 3‐dimensional, and color Doppler TEE images from a male patient with aortic stenosis. A highly unusual and complex pattern of valvular calcification created a functionally “double‐orifice” valve. Such an abnormality may have implications for the accuracy of continuous‐wave Doppler echocardiography, which assumes a single orifice valve in native aortic valves.     

食管超声心动图在重危心脏病人诊断治疗中的价值

目的　为评价食管超声心动图 (TEE)在重危心脏病人诊断治疗中的价值 ,对 3 7例收住监护病房的重症心血管病人进行了经胸超声心动图 (TTE)和TEE检查 ,其中男 2 5例 ,女 1 2例 ,平均年龄57( 1 9～ 85)岁。入选对象包括怀疑夹层动脉瘤 2 3例、心脏瓣膜功能异常 9例、感染性心内膜炎 3例 ,心内分流 2例。结果　所有病人均可耐受TEE检查 ,无并发症发生 ,TEE较TTE可提供更高的阳性诊断结果 ,阳性率分别为 65 0 %和 3 8 0 % ,在怀疑夹层动脉瘤者中 ,TEE检出夹层撕裂膜 1 4例 ;而TTE仅检出 7例 ,且图象欠清 ,检出部位有限。在 4例人工机械瓣膜功能异常者中 ,TEE发现瓣膜部位血栓形成 3例。结论　在对心脏大血管疾病的诊断中 ,TEE阳性诊断率高于TTE ,尤其在怀疑夹层动脉瘤及人工机械瓣膜病变时 ,应行TEE检查。即使在重危病人 ,TEE也是一种安全有效的诊断手段。     

Impressive echocardiographic images of a rare pathology: Aneurysm of the mitral valve – Report of two cases and review of the literature

Aneurysm of the mitral valve (AMV) is rarely reported. The etiology of this unusual pathology is commonly attributed to aortic valve endocarditis (AVE) with aortic regurgitation (AR) or connective tissue disease. We present two recent cases of AMV with good correlation between pre-operative trans-esophageal echocardiography (TEE), intra-operative real-time 3-dimensional echocardiography (RT-3D-Echo) and surgical findings. The importance of diligent surveillance by TEE in patients with AVE for occurrence of AMV is emphasized. The literature on this topic is briefly reviewed.     

Influence of transesophageal echocardiography on intraoperative decision making for toronto stentless prosthetic valve implantation

BACKGROUND AND AIM OF THE STUDY: Intraoperative transesophageal echocardiography (TEE) is commonly used during aortic valve surgery. In aortic valve replacement (AVR), this permits measurement of the aortic annulus, study of the anatomy of aortic valve components, and prediction of prosthesis valve size. After cardiopulmonary bypass (CPB), echocardiography is valuable in checking prosthesis function. In this study, we evaluated the impact of intraoperative TEE on the decision-making process of aortic Toronto stentless prosthetic valve (TSPV) implantation. METHODS: Fifty-two consecutive patients undergoing elective AVR were collected prospectively. Multiplane TEE was performed before CPB to determine diameters of the aortic valve annulus and sinotubular junction. This was to evaluate the feasibility of TSPV implantation in the aortic position and to predict prosthesis size. Further TEE evaluation was carried out after CPB to assess prosthetic valve function. RESULTS: TEE allowed measurement of the aortic annulus and sinotubular junction, and enabled correct prediction of prosthesis size. Ultrasonic evaluation also revealed contraindications to TSPV implantation in five patients. In one case, color-Doppler examination led to immediate successful surgical correction of prosthetic incompetence. CONCLUSION: Intraoperative multiplane TEE examination is useful in the decision-making process in AVR with the TSPV by selecting patients suitable for the stentless valve, predicting prosthesis size, and checking prosthesis function.     

Impact of three-dimensional echocardiography in valvular heart disease

PURPOSE OF REVIEW: Recent advances in the field of three-dimensional (3D) echocardiography have allowed improved visualization of cardiac structures. These advances have also provided valuable insights into cardiac function. The purpose of this review is to describe the recent developments in 3D echocardiography in assessing valvular heart disease. RECENT FINDINGS: Application of 3D echocardiography to valvular heart disease has improved with advances made in both the hardware and software components of 3D ultrasound systems. The most significant advancement has been the development of a matrix transducer that is capable of rapid real-time 3D acquisition and rendering. There have been many studies evaluating 3D echocardiographic assessment of mitral valve disease, aortic valve disease, as well as congenital heart disease using both real-time 3D transthoracic echocardiography (TTE) as well as off-line reconstructed 3D images from transesophageal echocardiography (TEE) using post image processing. More recent studies have combined the structural 3D information with color Doppler 3D imaging, providing qualitative functional information. SUMMARY: Developments in the field of 3D ultrasound imaging have allowed better qualitative assessment of valvular structures. The addition of color flow Doppler to the 3D imaging has provided improved visualization of regurgitant lesions and holds great promise for improved quantitative assessment of such lesions. The ongoing miniaturization of transducers and improvements in hardware and software components of ultrasound systems will certainly enhance both the ease of image acquisition as well as image quality, which should result in more precise quantitation of valvular dysfunction. However, clinical benefits of 3D echocardiography are yet to be demonstrated in properly conducted clinical trials, which are needed for wider acceptance of this technique.     

Transesophageal echocardiographic findings of quadricuspid aortic valve.

We report a case of a 40-year-old man who had a quadricuspid aortic valve associated with aortic regurgitation. The anomaly was revealed by transesophageal echocardiography (TEE), and confirmed by cardiac surgery. TEE is a useful noninvasive method for identifying the quadricuspid aortic valve.     

The Role of Jet Eccentricity in Generating Disproportionately Elevated Transaortic Pressure Gradients in Patients with Aortic Stenosis

In patients with aortic stenosis (AS) and eccentric transaortic flow, greater pressure loss occurs as the jet collides with the aortic wall together with delayed and diminished pressure recovery. This leads to the elevated transaortic valve pressure gradients noted on both Doppler and cardiac catheterization. Such situations may present a diagnostic dilemma where traditional measures of stenosis severity indicate severe AS, while imaging modalities of the aortic valve geometric aortic valve area (GOA) suggest less than severe stenosis. In this study, we present a series of cases exemplifying this clinical dilemma and demonstrate how color M‐mode, 2D and 3D transthoracic (TTE) and transesophageal (TEE) echocardiography, cardiac computed tomography angiography (CTA), and magnetic resonance imaging (MRI), may be used to resolve such discrepancies.     

Comparison of accuracy of aortic valve area assessment in aortic stenosis by real time three-dimensional echocardiography in biplane mode versus two-dimensional transthoracic and transesophageal echocardiography

Our aim was to validate the clinical feasibility of assessment of the area of the aortic valve orifice (AVA) by real time three-dimensional echocardiography (RT3DE) in biplane mode by planimetry and to compare it with the echo-Doppler methods more commonly used to evaluate valvular aortic stenosis (AS).RT3DE in biplane mode is a novel technique that allows operators to visualize the aortic valve orifice anatomy in any desired plane orientation. Its usefulness and accuracy have not previously been established.Using this technique, we studied a series of patients with AS and compared the results with those obtained by two-dimensional transesophageal echocardiography (TEE) planimetry and two-dimensional transthoracic echocardiography using the continuity equation (TTE-CE). RT3DE planimetries in biplane mode were measured by two independent observers. Bland-Altman analysis was used to compare these two methods.Forty-one patients with AS were enrolled in the study (15 women, 26 men, mean age 73.5 +/- 8.2 years). RT3DE planimetry was feasible in 92.7%. Average AVA determined by TTE-CE was 0.76 +/- 0.20 cm, by TEE planimetry 0.73 +/- 0.1 cm, and by RT3DE planimetry 0.76 +/- 0.20 cm(2). The average differences in AVA were-0.001 +/- 0.254 cm(2) and 0.03 +/- 0.155 cm(2) (RT3DE/TEE). The correlation coefficient for AVA (RT3DE/TTE-CE) was 0.82 and for AVA (RT3DE/TEE) it was 0.94, P < 0.0001. No significant intra- and interobserver variability was observed. In conclusion, RT3DE in biplane mode provides a feasible and reproducible method for measuring the area of the aortic valve orifice in aortic stenosis.     

Role of real-time three-dimensional transesophageal echocardiography in mitral valve repair

Background and objective Pre-operative assessment of mitral valve (MV) anatomy is essential to surgical design in patients undergoing MV repair.Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy,RT-3D TEE could increase the understanding of MV apparatus and individual scallop identification.We aimed to investigate the value of RT- 3DTEE in MV repair.Methods RT-3DTEE was performed in six patients with mitral valve prolapse (MVP) by using Philips 1E33 with X7-2t probe.Preoperative RT-3DTEE studies were compared with surgical findings in patients undergoing surgical mitral valve repair,and quantitative evaluation was performed by QLab 6.0 software before and after surgical mitral valve repair.Results RT- 3DTEE could display dynamic morphology of MV,the location of prolapse,and spatial relation to the surrounding tissue.It could provide surgical views of the valves and the valvular apparatus.These results were consistent with surgical findings.The quantitative evaluation before and after surgical MV repair indicated that anterolateral to posteromedial diameter of annulus,anterior to posterior diameter of annulus,perimeter of annulus,and area of annulus in projection plane were significantly smaller after operation compared with those before operation (P<0.05).The length of posterior leaflet,the area of anterior and posterior leaflet,the maximal prolapse height,the volume of leaflet prolapse and the length of coaptation in projection plane were significantly reduced after operation (P<0. 05).Conclusion RT-3DTEE is a unique new modality for rapid and accurate evaluation ofmitral valve prolapse and mitral valve repair.     

Prolapse of aortic intimal flap into the left ventricle: a rare cause of global myocardial ischemia in acute type A aortic dissection.

A 62-year-old woman experienced an acute type A aortic dissection complicated with profound shock caused by acute myocardial ischemia. Intraoperative transesophageal echocardiography (TEE) identified a circumferentially dissected intimal flap at 5.5 cm above the aortic valve, prolapsing into the left ventricle through the aortic valve during diastole and obstructing both coronary ostia. Acute aortic dissection must be kept in mind when presented with myocardial ischemia and TEE is the most useful method for detecting a prolapsing cylindrical intimal flap.