Three‐dimensional transesophageal echocardiography incremental value in a rare case of a bileaflet tricuspid valve

Detailed assessment of the tricuspid valve using two‐dimensional echocardiography is always challenging, as only two of three leaflets can be seen at a time. Three‐dimensional echocardiography can provide the enface view of the tricuspid valve that allows simultaneous visualization of all of the three leaflets. In a 42‐year‐old male patient scheduled for pulmonary endarterectomy, 3DTEE showed that the tricuspid valve is bileaflet, with one septal and another lateral leaflet. There were two commissures, one of them is anteriorly positioned and the other one is posterior. Our findings were confirmed intra‐operatively by direct surgical visualization of the tricuspid valve.     

Preoperative assessment of mitral valve prolapse and chordae rupture using real time three-dimensional transesophageal echocardiography

Background: Mitral valve (MV) repair provides a better outcome in patients with significant mitral regurgitation than MV replacement. Valve repair requires a thorough understanding of MV morphology. Recently developed real time three‐dimensional transesophageal echocardiography (RT3D TEE) can provide online acquisition and accurate information of cardiac structures. The study aim was to evaluate the feasibility and accuracy of using RT3D TEE to assess mitral valve prolapse (MVP) and chordae rupture for surgical planning purposes. Methods: Fifty‐six consecutive patients with moderate to severe mitral regurgitation due to MVP received two‐dimensional (2D) TEE and RT3D TEE the day before operation. The accuracy of the assessment of MVP and chordae rupture by RT3D TEE was determined and compared with assessment by 2D TEE using surgical inspection as the gold standard. Results: The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 2D TEE in detection of MVP were 87%, 96%, 93%, 88%, and 95%, respectively, whereas those of RT3D TEE were 100%, 99%, 99%, 98%, and 100%, respectively (P < 0.05 for all comparisons). The receiver operating characteristic (ROC) curve areas for assessment of anterior leaflet and posterior leaflet segment involvement using RT3D TEE (ROC areas 0.96 and 0.99) were higher than for those using 2D TEE (ROC areas 0.86 and 0.94). Interobserver agreement for RT3D TEE (κ= 0.97, 95% confidence interval [CI] 0.92–1.00) was significantly greater than for 2D TEE (κ= 0.89, 95% CI 0.81–0.93) (P < 0.05). Conclusion: RT3D TEE is a feasible, accurate and reproducible method for evaluating MVP and chordae rupture in the clinical setting. (Echocardiography 2011;28:1003‐1010)     

Effect of performing real time three-dimensional transesophageal echocardiography in addition to two-dimensional transesophageal echocardiography on operator diagnostic confidence

Background: This study evaluates the effects of performing real time three‐dimensional transesophageal echocardiography in addition to conventional two‐dimensional transesophageal echocardiography on diagnostic confidence. Methods: Operator diagnostic confidence in addressing clinical questions posed by the referral was scored using a five‐point scale for two‐dimensional transesophageal echocardiography alone and the combination of two‐dimensional and real time three‐dimensional transesophageal echocardiography in 136 consecutive patients undergoing examination in an academic hospital. Results: Mean diagnostic confidence score was higher for the combined studies compared to two‐dimensional transesophageal echocardiography alone (4.5 vs. 4.1, P < 0.001)). The addition of real time three‐dimensional transesophageal echocardiography increased diagnostic confidence score in 45 (33.1%) patients, and the percentage of studies with total diagnostic confidence rose from 40.4% with two‐dimensional transesophageal echocardiography alone to 65.4% after performing real time three‐dimensional transesophageal echocardiography. Type of clinical indication was associated with improved score by the combined exams (P < 0.004). The addition of real time three‐dimensional transesophageal echocardiography was most likely to improve diagnostic confidence score in studies performed to assess valve disease (56.1%) and least likely in examinations performed for intracardiac infection (14.9%). The location (anterior or posterior) of the primary cardiac pathology was not associated with improved score by the combined studies (P = 0.498). Conclusions: The addition of real time three‐dimensional transesophageal echocardiography to two‐dimensional transesophageal echocardiography increases diagnostic confidence in examinations routinely performed in an academic practice. Further studies of the impact of real time three‐dimensional transesophageal echocardiography on patient management, outcomes and displacement of or need for downstream testing are warranted. (Echocardiography 2011;28:235‐242)     

Incremental role of three-dimensional transesophageal echocardiography in the assessment of mitral-aortic intervalvular fibrosa abscess

We report a case of an elderly patient in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided definitive diagnosis of mitral-aortic intervalvular fibrosa abscess. This could not be done by two-dimensional transthoracic echocardiography (2DTTE) and two-dimensional transesophageal echocardiography (2DTEE). 3DTEE was also helpful in ruling out associated mitral valve endocarditis, which was initially suspected by 2DTEE leading to a mitral valve sparing surgery. Thus, 3DTEE provided incremental information over 2DTTE and 2DTEE in this patient.     

Comparative assessment of left atrial appendage by transesophageal and combined two- and three-dimensional transthoracic echocardiography

Objective: Our objective was to compare the utility of combined two‐dimensional (2D) transthoracic echocardiography (TTE) and three‐dimensional (3D) TTE versus 2D transesophageal echocardiography (TEE) in evaluation of the left atrium (LA) and LA appendage (LAA) for clot. Background: 2DTEE, usually performed to visualize the LAA, is semi‐invasive and not without risks. With improved technology the LAA has been increasingly visualized by 2DTTE and 3DTTE in many patients. Methods: We compared combined 2DTTE and 3DTTE with 2DTEE in evaluating the LA/LAA for a thrombus. Ninety‐two patients underwent 2DTTE, 3DTTE, and 2DTEE. An additional 20 patients, in whom TEE could not be performed, underwent 2DTTE and 3DTTE. Results: LA and LAA could be visualized in all patients. Of 92 patients studied, 74 had no thrombus and 7 had thrombus in the LAA by all modalities. Eleven patients, 9 with atrial fibrillation (AF), had a suspected thrombus by 2DTEE, but 3DTTE cropping clearly showed these to be prominent pectinate muscles which were seen in short axis on 2DTEE as rounded echo dense masses and therefore mimicked thrombi. These 9 patients with AF underwent successful cardioversion without any complications. Of the 20 patients in whom TEE could not be performed, 19 had no thrombus in the LA/LAA and 1 had a clot in the LAA. These 19 patients underwent successful cardioversion without complications. Conclusions: Our preliminary study suggests that combined 2DTTE and 3DTTE has comparable accuracy to TEE in evaluating the LA and LAA for thrombus. In some patients TEE, but not 3DTTE, may misdiagnose pectinate musculature as thrombus.     

Real time three-dimensional echocardiography and endovascular stenting

A 52-year-old male with HIV and chronic renal failure presented with 2-day history of fever and chills. He had recent superior vena cava (SVC) stent placement for SVC stenosis following multiple dialysis-catheter insertions. Patient's blood cultures grew methicillin-resistant staphylococcus aureus. Two-dimensional (2D) echocardiography showed no vegetations. With high clinical suspicion, 2D transesophageal echocardiogram (TEE) was obtained and confi rmed no endocarditis and patent stent at SVC right atrial junction; however, entire stent was not visualized. Simultaneous three-dimensional TEE provided superior views of SVC stent in cross-sectional and longitudinal planes, clearly demonstrating patent stent without vegetations, stenosis, migration, or thrombosis.     

Incremental value of three-dimensional over two-dimensional transesophageal echocardiography in the assessment of acute dysfunction of mechanical mitral valve prosthesis

We describe acute dysfunction of a bileaflet mechanical mitral valve prosthesis for the first time in a 57-year-old male. Unlike two-dimensional transesophageal echocardiography, three-dimensional imaging convincingly showed a large rounded echo density consistent with a papillary muscle in contact with one of the leaflets showing only partial opening during systole.     

The ability of live three-dimensional transesophageal echocardiography to evaluate the attachment site of intracardiac tumors

In this study, a case of a right ventricular myxoma and a case of a right ventricular hemangioma are used to demonstrate the ability of live three-dimensional transesophageal echocardiography (3DTEE) to assess the site of tumor attachment. Because 3DTEE has the ability to visualize desired structures in multiple planes, we defined the attached portion of the tumors and measured the en face view dimensions. In addition, the improved ability of 3DTEE to evaluate tissue characteristics allowed differentiation of the heterogeneous myxoma and highly vascular hemangioma. On the contrary, because two-dimensional (2D) TEE only allows structures to be viewed in a 2D plane, the attachment site can be located but complete delineation and measurement of area is not possible. As surgical options become less invasive, accurate attachment site location and size will become more important to ensure complete excision.     

Successful intraoperative identification of an anomalous origin of the left coronary artery from the pulmonary artery using real time three-dimensional transesophageal echocardiography

Anomalous origin of the left coronary artery (LCA) from the pulmonary artery (ALCAPA) is a rare congenital defect that presents only infrequently in adults. An adult diagnosed with ALCAPA, heart failure, and mitral regurgitation underwent surgical ligation of the anomalous origin of the LCA from the pulmonary artery (PA) and coronary artery bypass grafting (CABG). The anomalous origin in the PA and proximal segment of the left anterior descending artery (LAD) was successfully delineated via real time, three-dimensional transesophageal echocardiography during surgery. This modality allows for fast assessment and novel views of complex cardiac abnormalities and can aid in perioperative monitoring.     

Comparison of real time two-dimensional with live/real time three-dimensional transesophageal echocardiography in the evaluation of mitral valve prolapse and chordae rupture

We compared live/real time three-dimensional transesophageal echocardiography (3D TEE) with real time two-dimensional transesophageal echocardiography (2D TEE) in the assessment of individual mitral valve (MV) segment/scallop prolapse and associated chordae rupture in 18 adult patients with a flail MV undergoing surgery for mitral regurgitation. 2D TEE was able to diagnose the prolapsing segment/scallop and associated chordae rupture correctly in only 9 of 18 patients when compared to surgery. In three of these, 2D TEE diagnosed an additional segment/scallop not confirmed at surgery. In the remaining nine patients, surgical findings were missed by 2D TEE. On the other hand with 3D TEE, the prolapsed segment/scallop and associated ruptured chords correlated exactly with the surgical findings in the operating room in 16 of 18 patients. The exceptions were two patients. In one, 3D TEE diagnosed prolapse and ruptured chordae of the A3 segment and P3 scallop, while the surgical finding was chordae rupture of the A3 segment but only prolapse without chordae rupture of the P3 scallop. In the other patient, 3D TEE diagnosed prolapse and chordae rupture of P1 scallop and prolapse without chordae rupture of the A1 and A2 segments, while at surgery chordae rupture involved A1, A2, and P1. This preliminary study demonstrates the superiority of 3D TEE over 2D TEE in the evaluation of individual MV segment/scallop prolapse and associated ruptured chordae.     

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic aneurysm and dissection

We compared findings from intraoperative live/real time three-dimensional transesophageal echocardiography (3DTEE) and two-dimensional transesophageal echocardiography (2DTEE) with surgery in 67 patients having aortic aneurysm and/or aortic dissection. Of these, 20 patients had aortic aneurysm without dissection, 21 aortic aneurysm and dissection, and 26 aortic dissection without aneurysm. 3DTEE diagnosed the type and location of aneurysm correctly in all patients unlike 2DTEE, which missed an aneurysm in one case. There were four cases of aortic aneurysm rupture. Three of them were diagnosed by 3DTEE but only one by 2DTEE, and one missed by both techniques. The mouth of saccular aneurysm, site of aortic aneurysm rupture, and communication sites between perfusing and nonperfusing lumens of aortic dissection could be viewed en face only with 3DTEE, enabling comprehensive measurements of their area and dimensions as well as increasing the confidence level of their diagnosis. In all patients with aortic dissection, 3DTEE enabled a more confident diagnosis of dissection because the dissection flap when viewed en face presented as a sheet of tissue rather than a linear echo seen on 2DTEE which can be confused with an artifact. 2DTEE missed dissection in one patient. In six cases the dissection flap involved the right coronary artery orifice by 3DTEE and surgery. These were missed by 2DTEE. Aortic regurgitation severity was more comprehensively assessed by 3DTEE than 2DTEE. Aneurysm size by 3DTEE correlated well with 2DTEE and surgery/computed tomography scan. In conclusion, 3DTEE provides incremental information over 2DTEE in patients with aortic aneurysm and dissection.     

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.     

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of sinus of valsalva aneurysm rupture

We present an adult patient with rupture of the right sinus of Valsalva aneurysm in whom the two-dimensional transesophageal echocardiogram failed to show the rupture. On the other hand, live/real time three-dimensional transesophageal echocardiography clearly delineated the site of rupture into the pericardium and mediastinum.     

Incremental value of live/real time three‐dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two‐dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two‐dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two‐dimensional views only, and a greater breadth of information is instead available through the use of three‐dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three‐dimensional transesophageal echocardiography offered incremental benefits over two‐dimensional imaging alone.     

Congenital submitral aneurysm with rupture into the left atrium: assessment by 2D and 3D transesophageal echocardiography

We describe two cases of congenital submitral aneurysms (SMAs) in which three-dimensional transesophageal echocardiography (3D TEE) proved useful to define the spatial extent of these aneurysms. In both cases, rupture into the left atrium was accurately delineated. 3D TEE was useful in case 1 as it depicted the precise site of rupture into the left atrium as well as pseudoprolapse of the P2 segment of the mitral valve. In case 2 it also localized the rupture into the left atrium in relation to the annulus to be adjacent to the anterolateral commissure. In addition, a cleft between the A1 and A2 scallops were identified and together with failure of the leaflets to coapt enabled the mechanisms contributing to the mitral regurgitation to be elucidated. Thus, imaging from the left atrial perspective using 3D TEE provided superior spatial anatomical delineation of the rupture and its relationship to the mitral valve, as well as accurate anatomical definition of the mitral leaflets. This information provides added benefit to the surgeon in planning a transatrial surgical repair of the SMAs. 3D TEE is superior to conventional 2D TEE in defining the spatial anatomy of SMAs as well as the mechanisms contributing to mitral regurgitation.