Iatrogenic coronary pseudoaneurysm diagnosed by three-dimensional transesophageal echocardiography.

The Role of Three-Dimensional Transesophageal Echocardiography in Better Understanding the Mechanism of Percutaneous Atrial Septal Device Failure

We present a case of isolated prolapse of the tricuspid anterior leaflet in an asymptomatic 34-year-old man who was referred to our hospital for a routine check up. We performed two-and three-dimensional transoesophageal echocardiography (TEE). We found three-dimensional TEE a useful, non-invasive tool that can provide additional information to two-dimensional echocardiography in the assessment of tricuspid valve prolapse.

Real-Time Three-Dimensional Transesophageal Echocardiography in Patients with Secundum Atrial Septal Defects: Outcomes following Transcatheter Closure

Three-Dimensional Transesophageal Echocardiography of Atrial Septal Defect: A Qualitative and Quantitative Anatomic Study

The Double-Orifice Left Atrial Appendage: Multimodality and Virtual Transillumination Imaging

Atrial septal defect (ASD) size measurement is of paramount importance for the successful deployment of a transcatheter septal occluder. The stretched balloon diameter (SBD) has long been regarded as the gold standard for selection of the size of any device. Three-dimensional (3-D) transesophageal echocardiography (TEE) can visualize the overall structure of the atrial septum, therefore rendering an accurate size of the ASD. In this study we aimed to validate the accuracy of ASD size measurement by 3-D TEE and to elucidate the reason for the difference between balloon sizing and 3-D measurement. Forty-one consecutive patients were enrolled in this protocol for ASD device closure using the Amplatzer septal occluder. Thirty-nine patients were diagnosed by 2-D transthoracic echocardiography as secundum ASD and 2 patients were diagnosed as patent foramen ovale. Two measurements of the balloon size were sequentially obtained by 2-D TEE after the balloon was fully inflated in the left atrium. First, no residual shunt across the septum could be seen while the balloon was pulled back against the septum. This measurement was called the balloon occlusive diameter (BOD). Second, with balloon deflation, a slight deformity of the balloon was seen just prior to its popping through the septum. This measurement was called the stretched balloon diameter (SBD). Three-dimensional TEE was performed in all patients at the beginning of the procedure before device deployment and within 15 minutes after device release. Three-dimensional TEE provided superior views of the ASDs, showing the spatial relationship between the ASD and the neighboring structures. For maximal ASD size measurement, balloon sizing was larger than 3-D TEE examination, whereas 2-D was smaller than the other two methods. The best correlation was found between 3-D TEE measurements and the BOD (r = 0.98, p < 0.0001). Three-dimensional TEE provides en face view of ASD; thus, it can accurately measure the size of ASD. Three-dimensional TEE measurement of ASD can be used instead of balloon sizing for the selection of transcatheter ASD occluder size.

Utility of Three-Dimensional and Four-Dimensional Transesophageal Echocardiography in Decision-Making in a Patient with Iatrogenic Left Ventricle–to–Right Atrium Shunt (Gerbode Defect)

To examine the feasibility of transcatheter closure of multiple atrial septal defects using two Amplatzer devices simultaneously and to describe the importance and the role of two- and three-dimensional transoesophageal echocardiography in the selection and closure of such defects. Twenty-two patients with more than one atrial septal defect underwent an attempt at transcatheter closure of their atrial septal defects at a mean+/-SD age of 30. 8+/-18.6 years (range 3.7-65.9 years) and mean weight of 56.6+/-25.5 kg (range 12.9-99 kg) using two Amplatzer devices implanted simultaneously via two separate delivery systems. During catheterization, two dimensional transoesophageal echocardiography was performed in all but one patient, during and after transcatheter closure, while three dimensional transoesophageal echocardiography was performed in six patients before and after transcatheter closure. Forty-four devices were deployed in all patients to close 45 defects (one patient with three defects closed by two devices). Two dimensional transoesophageal echocardiography was helpful in selection and in guiding correct deployment of the devices. The mean size of the larger defect, as measured by transoesophageal echocardiography was 12.8+/-5.9 mm and the mean size of the smaller defect was 6.6+/-3.0 mm. The mean size of the larger devices was 15+/-7.5 mm, and 8.4+/-3.7 mm for the smaller. Three dimensional transoesophageal echocardiography provided superior imaging and demonstrated the number, shape and the surrounding structures of the atrial septal defects in one single view. The median fluoroscopy time was 28.7 min. Device embolization with successful catheter retrieval occurred in one patient. Forty-four devices were evaluated by colour Doppler transoesophageal echocardiography immediately after the catheterization with a successful closure rate of 97.7%. On follow-up colour Doppler transthoracic echocardiography demonstrated successful closure in 97.5% at 3 months. The use of more than one Amplatzer septal occluder to close multiple atrial septal defects is safe and effective. The use of two- and three-dimensional transoesophageal echocardiography provided useful information for transcatheter closure of multiple atrial septal defects using two devices. Three-dimensional transoesophageal echocardiography enhanced our ability to image and understand the spatial relationship of the atrial septal defect anatomy.

Aortic Root Geometry in Patients with Aortic Stenosis Assessed by Real-Time Three-Dimensional Transesophageal Echocardiography

To close the atrial septal defect (ASD) with the transcatheter method, correctly defining the defect and selecting the appropriate closure device size are the most critical steps for the procedure's success. Although ASD can be successfully closed under the guidance of three-dimensional (3D) transesophageal echocardiography (TEE) and two-dimensional (2D) TEE, measurement comparisons between different types of defects are still needed. Our study was designed retrospectively. Sixty-one patients who underwent transcatheter ASD closure with 2D TEE and 3D TEE between 2020 and 2024 were included. The patients were divided into three groups according to the defect shape: circular, oval, and complex; and the measurement results, perioperative process, and clinical outcomes were compared in each group. The average age of the patients was 35.05 ± 13.87 years, and 41 (67.2%) were women. The average follow-up period of the patients was 15.3 ± 9.18 months. No statistical significance was observed in the comparison of measurements obtained with 3D TEE and 2D TEE in the circular and oval defect groups. The differences between the minimum defect diameters of complex defects measured by 2D TEE and 3D TEE (p: 0.037), IVC rims (p < 0.001), aortic rims (p: 0.012), and the differences between implanted device dimensions and the maximum defect diameters measured by both methods were compared; statistical significance was observed (p: 0.025). In circular and non-complex oval defects, it has been observed that the size of the closure device selected with 2D TEE or 3D TEE is optimal, and the procedure is practical and feasible. While the closure of complex ASDs with 3D TEE provides reliable and optimal results, using only 2D TEE in complex ASDs may lead to selecting a smaller-sized device.

Quantification of Mitral Valve Anatomy by Three-Dimensional Transesophageal Echocardiography in Mitral Valve Prolapse Predicts Surgical Anatomy and the Complexity of Mitral Valve Repair

Background: Three-dimensional (3D) transesophageal echocardiography (TEE) provides high-resolution images of aortic valve area (AVA) in patients with bicuspid aortic stenosis (AS). However, the correlation with pressure gradient compared with conventional echocardiographic indices and prognostic implications of 3D TEE derived valve area (AVA 3DTEE ) has not been evaluated. Therefore, we assessed the disease severity and the prognostic value of AVA 3DTEE in patients with bicuspid AS. Methods: We retrospectively analyzed 105 patients with at least mild bicuspid AS (peak aortic velocity &gt;2.5m/sec) and LVEF ≥50% (mean transaortic pressure gradient 46±17 mm Hg) underwent transthoracic echocardiography, two-dimensional (2D) and 3D TEE between 2012 and 2019. AVA was measured using (i) the continuity equation (CE) obtained with transthoracic echocardiography, (ii) planimetric 2D TEE, and (iii) volumetric 3D TEE. Cardiac events were defined as surgical or transcatheter aortic valve replacement and/or aortic replacement, heart failure admission, or cardiac death. Results: AVA 3DTEE was larger than AVA CE (mean difference 0.21±0.03, P &lt;0.001), and smaller than AVA 2DTEE (mean difference 0.11±0.02, P &lt;0.001). AVA 3DTEE had an excellent correlation with mean transaortic pressure gradient (r=0.91, P &lt;0.001), whereas AVA 2DTEE and AVA CE showed lower correlations (r=0.81 and r=0.59, both P &lt;0.001). AVA 3DTEE significantly reduced the proportion of inconsistent AS grading, compared with AVA CE (6% versus 17%, P &lt;0.001). During a follow-up period (median, 853 days; range 513 to 1287 days), 101 surgical or transcatheter aortic valve replacement and/or aortic replacement, 6 heart failure admission, or 1 cardiac death occurred. AVA 3DTEE ≤1cm 2 was an independent predictor of cardiac events (adjusted hazard ratio (HR) 2.40, (1.41 to 4.09), P =0.001) and AVA 3DTEE of 1 cm 2 was the optimal cutoff value for predicting cardiovascular events with sensitivity of 71% and specificity of 100%. Conclusions: AVA measured by 3D TEE has a good correlation with mean transaortic pressure gradient and improved the hitherto inconsistent AS grading. AVA 3DTEE ≤1cm 2 is an important predictor for cardiac events of patients with bicuspid AS.

Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 120 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 50 patients, persistent AF: 70 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 116/120 patients (96.7 %). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.9 (cryo group), 4.0 (radiofrequency catheter ablation group)). At 42-month follow-up, 70.0 % of all patients were free from an arrhythmia recurrence (cryo group: 76.0 %, Carto group: 65.7 %). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 150 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 65 patients, persistent AF: 85 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 144/150 patients (96.0%). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.8 (cryo group), 4.0 (radiofrequency catheter ablation group)). At 48-month follow-up, 69.3% of all patients were free from an arrhythmia recurrence (cryo group: 75.4%, Carto group: 64.7%). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients. Funding Acknowledgement Type of funding source: None

Artifacts in Three-Dimensional Transesophageal Echocardiography