3D TEE Research Articles

Case Report: Caseous Calcification of the Mitral Annulus in an 88-Year-Old Woman

The caseous calcification of the mitral annulus (CCMA) is a rare variant of the mitral annulus calcification (MAC), with prevalence of 0.067% in general population. It is usually an asymptomatic condition but rarely it can cause severe mitral valve dysfunction, embolization, and conduction abnormalities. Transthoracic echocardiography (TTE) is a useful diagnostic tool. However, it can be necessary a multi-modality imaging approach for a differential diagnosis among other intra-cardiac masses. We are presenting a case of CCMA in an 88-year-old woman admitted to our department for acute decompensation of chronic heart failure. TTE has shown pathognomonic findings of CCMA. Tridimensional trans-esophageal echocardiography (3D TEE) gave a better characterization of the CCMA, avoiding further diagnostic procedures.

P1407 Three dimensional echocardiography in cardiac myxomas

Abstract The majority of cardiac myxomas (75–80%) are located within the left atrium, characteristically originating from the mid-portion of the atrial septum by a narrow stalk; The detection of such a feature has paramount importance for the diagnosis of myxoma ; in fact other anatomical findings as sessile implantation or other locations may be common to other cadiac tumors. Two dimensional (2D) transthoracic (TT) and transesophageal(TE) echocardiography E and cardiac magnetic resonance imaging (MRI) are mainstay in the diagnosis; It has been reported that Three dimensional(3D) E and in particular the 2D orthogonal cross sectional planes generated by electronically sectioning the 3D volume, could correctly identify the attachment and the peduncle sometimes missed by other imaging modality and therefore lead to a correct diagnosis. Purpose of our study was to assess the usefulness of 3DE in the detection of the mainstay anatomical features of the cardiac myxomas; We retrospectively reviewed all the case of the myxomas with pathology confirmation that underwent 2D TEE, 3D TEE and MRI in the past 5 years in order to assess the ability of the techniques in identifying the following anatomical features: site of attachment (mid atrial septum, other locations ) , modality of attachment (pedunculated or sessile); Every study was reviewed by an expert reader. Our study group is comprised by 7 patients, 6 female, mean age 48.8 ±9.7 with 12 myxomas ; 8 located in the left atrium 3 in the right atrium ; In 6 case was the first diagnosis , in one patient was a recurrence. 9 mixomas were in the left atrium , 3 in the right atrium. & were pedunculated, 5 sessile. There was an agreement in detecting the anatomical features except in two patients in a one patients the attachment by a peduncle in the atrial septum close to the opening of the left upper pulmonary vein was seen only by 3DE ; in a second patient a small myxoma close to the left atrial appendage was detected only by TEE ; Until now few reports have described the uselfuness of three dimensional echocardiography in detecting the anatomical features of cardiac myxomas. Even though MRI is the only technique able to detect perfusion of a mass otherwise it is not able to distinguish among different tumors; therefore the visualization of the anatomical features may lead a more correct diagnosis that can help in a better therapeutical and surgical plan. In our study 3DE was the only technique able to correctly depict the mainstay anatomical features of cardiac myxomas. It was possible in particular by using the 2D cross sectional planes generated by electronically sectioning the 3D volume in a case of a small peduncle attached in an uncommon location of the interatrial septum. All the techniques are reliable in assessing the anatomical features of myxomas however 3DE could have an additional value in particular in not common location and will compliment 2D imaging in cardiac myxoma diagnosis

P336 Echocardiography guiding without floroscopy transcatheter ASD closure: Single center experience in indonesia

Abstract Background Transcathether closure of Atrial Septal Defect (ASD) has become the first choice for most cases of secundum type of ASD worldwide with very good successful rate and low complication rate. However, the risk of radiation exposure to both patient and operator has gain increasing awareness due to its long term side effect. There is very limited data on transcathether ASD closure using only echocardiography without fluoroscopy. Purpose This study sought to evaluate feasibility, safety and effectiveness of transcatheter closure of atrial septal defects using echocardiography only without fluoroscopy in tertiary heart center in Jakarta Indonesia Methods We collected data from July 2018 to May 2019 of patients with secundum ASD underwent transcathether ASD closure using only echocardiography without fluoroscopy in tertiary heart center in Jakarta-Indonesia. All cooperative patient weighed > 25 kg has underwent pre-procedural 2D/3D TEE evaluation to evaluate suitability for device closure. Patient who do not fulfill above criteria will be evaluated at cath lab just before proceduel and will be excluded if TEE evaluation revealed not suitable for device closure. 2D TEE was used during transcathether closure guiding. In direct closure delivery sheath was guided into left upper pulmonary vein, right upper pulmonary vein, or in left atriumfor deployment. For patient suspected had coexsisting pulmonary hypertension, non flouoscopic right heart catheterization was done. Position of catheter was also confirmed by pressure waveform monitoring. Results There were 67 patients with attempted zero fluoroscopy technique, of which 97% (67 patients) were successful. In failed group, one patient had poor TEE window, and one patient had LA isomerism so transjugular approach was used and we had difficulty to guide interventionist to maneuver the cathether. To these groups, transcathether closure was switched to fluoroscopy methods and device susccesfully implanted in both cases. Of the success group, There were 12 male and 53 female, age ranging from 2-62 yo (median 29 yo). Median size of the defect was 20 mm (min-max : 9-33 mm), with median size device implanted was 26 (min-max: 12-42 mm). There were 14 patients underwent pre right heart catetherization before procedure with pulmonary resistance index dan PVR/SVR ratio acceptable for closure in all patients. There is difference in mean procedure duration in groups with direct closure vs pre-closure right heart cathetherization, though not reach statistically significant difference (38 + 17 min vs 55 + 29 min, p = 0.06). In majority of cases, delivery sheath was position in left upper pulmonary vein (69%, 45 patients). Residual shunt, occlusion device shedding or displacement, and pericardial effusion were not observed during or after the the procedure. Conclusion Percutaneous transcatheter ASD closure completely guided by TEE is a feasible and safe procedure.

87 A gynaecological cause of right heart failure

Abstract Introduction A 68-year-old lady complained of pelvic pain associated with progressive abdominal distension over few months. Physical examination revealed ascites, smooth hepatomegaly and lower limb edema. CT scan of abdomen and pelvis showed a 4 cm x 5 cm right ovarian mass without other intraabdominal lesion. Surgical excision of the ovarian mass was performed with clear resection margin. The ascitic fluid was negative for malignant cells. However, the patient had persistent ascites and lower limb edema after surgery. The gynaecologist suspected that she might have cardiac problems. Procedure Transthoracic echocardiogram was performed. The right atrium and ventricle were markedly enlarged. The tricuspid valve leaflets appeared retracted and sclerotic, with failed coaptation during systole (Figure A), severe tricuspid regurgitation (Figure B) and marked dilatation of inferior vena cava without respiratory variation. The pulmomary valve was not well visualized on 2D images. Continuous wave Doppler across pulmonary valve demonstrated short pressure half time 66 msec and premature termination of diastolic flow (Figure C), suggestive of severe pulmonary regurgitation. There was no intracardiac shunt. Left sided valves were unremarkable. Additional tranesophageal echocardiogram allowed better assessment of pulmonary valve, which revealed one of the cusps to be thickened, retracted and immobile on real time 3D images (Figure D, arrow). Discussion The ovarian mass was confirmed to be a carcinoid tumour. Due to its direct drainage into systemic venous circulation the vasoactive substances (serotonin, prostaglandin etc) reach the right heart directly without being metabolized by liver, resulting in plaque like deposit of fibrous tissue on the endocardium and valve surfaces, leading to classical appearance of thickened, retracted and immobile leaflet and subsequent valvular regurgitation or, less commonly, stenosis. Left-sided valve disease is less common, and may occur in cases of bronchial carcinoid or in presence of atrial right to left shunt (e.g. PFO). Urinary 5-hydroxyindoleacetic acid (5-HIAA) is a useful non-invasive diagnostic test. Carcinoid heart disease usually does not regress even the tumour is treated, and valve replacement is the only definitive curative treatment. This lady received tricuspid and pulmonary valve replacement with subsequent symptom resolution and chest X-ray showed marked reduction of cardiomegaly (Figure E). Conclusion A baseline echocardiogram is recommended for assessment valvular involvement in patient with carcinoid tumour, as the cardiac symptoms may be mistaken to be related to regional spread of tumour. Pulmonary valve is very often the "forgotten" valve in many Echo studies. However, it is crucial to have detailed assessment (with aids by 3D images or TEE) due to its implication to the surgical treatment planning. Abstract 87 Figure.

P1798 Determinants of increased mitral mean diastolic gradient after transcatheter edge-to-edge mitral valve repair

Abstract Background Transcatheter edge-to-edge mitral valve repair (TMVR; MitraClip, Abbott Vascular) is clinically approved for treatment of severe, symptomatic mitral regurgitation (MR) in high or prohibitive surgical risk patients. Iatrogenic mitral stenosis is a known complication of TMVR, but determinants of increased post-procedure mean diastolic gradient are not well defined. Purpose We aimed to investigate the determinants of increased mitral mean diastolic gradient after TMVR. Methods We retrospectively reviewed 59 patients. 2D and 3D TEE data sets acquired before and immediately after procedure were analyzed. 4D Cardio-View and 4D MV-Assessment (TomTec, Germany) were used for the analysis of the 3D volume data set. Quantitative mitral valve analysis was done at the end of systole. Increased mitral mean diastolic gradient after TMVR was correlated with pre-procedure 2D and 3D echocardiographic data. Results 34 patients had primary MR, 25 patients had mixed/secondary MR. Baseline mean mitral diastolic gradient was 2.0 ± 0.9mmHg and increased to 3.9 ± 1.8mmHg post-TMVR and the mean 3D planimetric mitral valve area decreased from 5.3 ± 1.5cm2 to 2.6 ± 1.0cm2. Implantation of multiple clips was performed less frequently in patients with smaller baseline mitral valve area; 8% vs 47% in the lowest quartile vs all others (p = 0.006). 12(20%) of patients had a mean diastolic gradient >5mmHg post-TMVR and 15(25%) of patients had a post-TMVR mitral valve area <2.0 cm2. There was no significant difference in post-procedure heart rate between patients with mean diastolic gradient ≤5mmHg vs >5mmHg (p = 0.08). Patient characteristics according to post-TMVR mean diastolic gradient are shown in the Table. Post-TMVR mean diastolic gradient >5mmHg was more common in patients with increased pre-procedure mean diastolic gradient(p = 0.006), post-TMVR mitral valve area <2.0 cm2(40% vs 14%, p = 0.03), and ≥moderate residual mitral regurgitation(38% vs 11%, p = 0.02). Post-TMVR mitral valve area <2.0cm2 was present in 50% vs 19% of patients with vs without a mean gradient >5mmHg(p = 0.04). Conclusions Elevated post-TMVR mean diastolic gradient is multifactorial and related to mitral stenosis, but residual mitral regurgitation also appears to be an important contributor to increased gradients in some patients. Larger cohorts are likely needed to assess the concurrent impact of mitral annular calcification, leaflet calcification, and other variables on post-TMVR mean gradient. Abstract P1798 Figure. 2D and 3D Echocardiographic Parameters

P1592 Papillary- annular continuum is a dynamic component of obstruction in outflow tract of left ventricle in patients with hypertrophic cardiomyopathy

Abstract The aim to study was to assess Strain of papillary muscles (PM) and their apical displacement with 3D mitral valve (MV) parameters with maximal size of gradient of obstruction in the left ventricle outflow tract (LVOFT) and the volume of mitral regurgitation (MR) in hypertrophic cardiomyopathy (HCMP) patients. Material and methods. 72 HCMP patients (aged of 56.9 ± 11.1 years and gradient in LVOFT 70.83 ± 14.83 mm Hg at rest) were investigated. 3D TEE of MV was performed in all patients with follow up reconstruction. Strain of anterolateral (AL) and posteromedial (PM) papillary muscles (PM) was assess by TTE. Results Strain of both PM was decreased in 45 (62.5)% patients. Positive Strain PM PM were found in 20 (27.8%) patients and AL PM -in 7 (9.7%) patients. Apical displacement of PM PM were registered in 19 (38.0%) pts and ALPM in 6 (12.0%) pts. Apical displacement of both papillary muscles was found in 10 (20.0%) patients. Pts with positive Strain of PM PM had remodeling fibrous ring of MV as compared to patients who had negative Strain of this PM (anteroposterior diameter - 1.97 ± 0.23 sm/m² vs 1.63 ± 0.20sm/m²; p = 0, 01; the perimeter of the ring - 6.92 ± 0.69 sm/m2 vs 6.09 ± 0.93sm/m2; p = 0.02; the area of the ring (3D) - 6.91 ± 1.23sm²/m² vs 5,14 ± 1.31 sm²/m²; p = 0.005). These patients had large areas of the MV leaflets (anterior 4.83 ± 1.03 sm²/m² vs 3.19 ± 0.81 sm² /m² ; p = 0.007; posterior - 4.39 ± 0.42 sm²/m² vs 3.39 ± 1.18 sm²2/m²; p = 0.004), the area of the tenting of leaflets (2.98 ± 1.64 sm²/m² vs 1.24 ± 0.61 sm²/m²; p = 0.04) and the fraction of the tenting (69, 04 ± 24.9% vs 41.27 ± 17.59; p = 0.03). Patients with positive Strain had a greater volume of mitral regurgitation (24.20 ± 11.91 ml vs 14.04 ± 7.58 ml p = 0.004) and the peak gradient in LVOFT was 88.90 ± 37.90 mm Hg vs 66.35 ± 27.00 mm Hg; p = 0.02). Thus, the parameters of 3D MV and strain of PM represent a fixed papillary – annular continuum causing a dynamic component of the obstruction in the LV OT and the volume of mitral regurgitation in patients with HCMP.

A novel three-dimensional echocardiographic method for device size selection in patients undergoing ASD trans-catheter closure

BackgroundProper device size selection is a crucial step for successful ASD device closure. The current gold standard for device size selection is balloon sizing. Balloon sizing can be tedious, time consuming and increase fluoroscopy and procedure times as well as risk of complications. We aimed to establish a simple and accurate method for device size selection using three-dimensional echocardiographic interrogation of the ASD.This is a prospective observational study conducted over a period of 12 months. All patients underwent 2D TTE, three-dimensional echocardiographic assessment of the IAS and transesophageal echocardiogram. Comparison between echocardiographic variables was done using independent sample t test. Linear correlation was established between three dimensional echocardiographic variables and respective variables of device size and 2D TTE and TEE measurements.ResultsThe study included 50 patients who underwent successful ASD device closure with properly sized device. There was no significant difference between 3D ASD maximum diameter and all diameters measured by TTE and TEE. There was a strong positive correlation between device size used for closure and both 3D measured ASD area (r = 0.907, P<0.0001) and 3D measured ASD circumference (r = 0.917, P<0.0001). Two regression equations were generated to determine proper device size where Device size = 10.8 + [3.95 x 3D ASD area] and Device size = [3.85 x 3D ASD circumference] -1.02ConclusionThree-dimensional echocardiogram can provide a simple and accurate method for device size selection in patients undergoing ASD device closure using either 3D derived ASD area or ASD circumference

Three-Dimensional Echocardiography for Transcatheter Aortic Valve Replacement Sizing: A Systematic Review and Meta-Analysis.

BackgroundTranscatheter aortic valve replacement (TAVR) is the standard of care for many patients with severe symptomatic aortic stenosis and relies on accurate sizing of the aortic annulus. It has been suggested that 3‐dimensional transesophageal echocardiography (3D TEE) may be used instead of multidetector computed tomography (MDCT) for TAVR planning. This systematic review and meta‐analysis compared 3D TEE and MDCT for pre‐TAVR measurements.Methods and ResultsA systematic literature search was performed. The primary outcome was the correlation coefficient between 3D TEE– and MDCT‐measured annular area. Secondary outcomes were correlation coefficients for mean annular diameter, annular perimeter, and left ventricular outflow tract area; interobserver and intraobserver agreements; mean differences between 3D TEE and MDCT measurements; and pooled sensitivities, specificities, and receiver operating characteristic area under curve values of 3D TEE and MDCT for discriminating post‐TAVR paravalvular aortic regurgitation. A random effects model was used. Meta‐regression and leave‐one‐out analysis for the primary outcome were performed. Nineteen studies with a total of 1599 patients were included. Correlations between 3D TEE and MDCT annular area, annular perimeter, annular diameter, and left ventricular outflow tract area measurements were strong (0.86 [95% CI, 0.80–0.90]; 0.89 [CI, 0.82–0.93]; 0.80 [CI, 0.70–0.87]; and 0.78 [CI, 0.61–0.88], respectively). Mean differences between 3D TEE and MDCT between measurements were small and nonsignificant. Interobserver and intraobserver agreement and discriminatory abilities for paravalvular aortic regurgitation were good for both 3D TEE and MDCT.ConclusionsFor pre‐TAVR planning, 3D TEE is comparable to MDCT. In patients with renal dysfunction, 3D TEE may be potentially advantageous for TAVR measurements because of the lack of contrast exposure.

TCT-211 Static and Dynamic 3D TEE Automated Aortic Root Modeling Are Both Accurate and Useful to Size the Aortic Annulus in Patients Undergoing TAVR: Comparison to CT

TCT-211 Static and Dynamic 3D TEE Automated Aortic Root Modeling Are Both Accurate and Useful to Size the Aortic Annulus in Patients Undergoing TAVR: Comparison to CT

The value of three-dimensional echocardiography in the evaluation of cor triatrium sinister

Introduction Cor triatrium sinister is a very rare congenital heart disease in which the pulmonary veins enter a proximal accessory left atrial chamber that is separated from a distal true left atrial chamber by a fibromuscular membrane presenting one or more ostia. Its incidence in the adulthood is extremely rare. Adult patients are symptomatic in case the orifice across the membrane becomes obstructive mimicking a mitral stenosis. It has been reported that severe obstruction is present if maximum doppler velocity across the orifice is more than 2 m/s.1 However, in a review of case series no correlation could be found between the pressure gradient across the fenestration and the clinical symptoms.2 We report the case of a symptomatic adult female with obstructive cor triatrium in whom the intraoperative three-dimensional transesophageal echocardiography (3D TEE) revealed the severity of obstruction in contrast to the mild intraoperative pressure gradients. Methods A 34-year-old female was scheduled for surgical repair of a cor triatrium sinister. The symptoms of dyspnea had increased during the last months (NYHA III) which resulted in the echocardiographic diagnosis. The mean pressure gradient across the orifice was estimated 6 mmHg at rest and 18 mmHg at effort using modified Bernoulli equation. There were no associated cardiac abnormalities and no signs of pulmonary hypertension. The patient gave written consent to present her case. Results The induction of anesthesia was performed with the aim to keep hemodynamic stability. The intraoperative TEE confirmed the diagnosis. Color flow across the orifice showed an aspect of rather laminar flow. The mean pressure gradient across the sole orifice was 2 mmHg.Three-dimensional en face view of the membrane permitted offline analysis of the lesion in several orthogonal planes and measurement of the effective opening area of the orifice which was 1.45 cm2 (Fig 1). Discussion This case illustrates that pressure gradient across an obstructive cor triatrium may underestimate the true severity of the lesion as the blood flow may be low through the channel. Therefore, 3D echocardiography should be routinely performed in patients with cor triatrium in order to measure the exact maximal fenestration orifice area.

Left Atrial Appendage Morphology as a Determinant for Stroke Risk Assessment in Atrial Fibrillation Patients: Systematic Review and Meta-Analysis.

Atrial fibrillation (AF) is a leading source of emboli that precipitate cerebrovascular accident (CVA) which is correlated with left atrial appendage (LAA) morphology. We aimed to elaborate the relationship between CVA and LAA morphology in AF patients. Medline and EMBASE databases were thoroughly searched between 2010-2018 for studies that included atrial fibrillation patients and classified them into two groups based on CVA occurrence. Four different LAA morphologies (Chicken wing CW, Cauliflower, cactus and windsock) were determined in each group by 3D TEE, MDCT or CMRI. New Castle Ottawa Scale was used to appraise the quality of included studies. The risk of CVA before cardiac ablation and/or LAA intervention in CW patients was compared to each type of non-CW morphologies. The extracted data was statistically analyzed in the form of forest plot by measuring the risk ratio (RR) using REVMAN software. P value and I square were used to assess the heterogeneity between studies. PRISMA diagram was illustrated showing 789 imported studies for screening. Three duplicates were removed, and the rest were arbitrated by 2 reviewers yielding 12 included studies with 3486 patients including 1551 with CW, 442 with cauliflower, 732 with cactus 765 with windsock. The risk of CVA in CW patients was reduced by 41% relative to non-CW patients (Total RR=0.59 (0.52-0.68)). Likewise, the risk of CVA in CW patients was less by 46%, 35% and 31% compared to cauliflower (Total RR =0.54(0.46-0.64)), cactus (Total RR =0.65(0.55-0.77)) and windsock (Total RR =0.69(0.58-0.83)) patients respectively. Low levels of heterogeneity were achieved in all comparisons (I square <35% and p value > 0.1). Patients with non-CW morphologies (cauliflower, cactus and windsock) show a higher incidence of CVA than CW patients. For that reason, LAA appendage morphology could be useful for risk stratification of CVA in AF patients.

Photorealistic imaging of left atrial appendage occlusion/exclusion.

Recent improvements in 3D TEE post processing rendering techniques referred to as TrueVue (Philips Medical Systems, Andover, MA, USA). It allows for novel photorealistic imaging of cardiac structures including left atrial appendage (LAA) and its closure devices. Here we present TrueVue images of the LAA prior to and after LAA exclusion/occlusion using various percutaneous and surgical techniques. TrueVue may improve delineation of LAA anatomy prior to occlusion as well as visualization of occluder device position within the LAA.

Aortic annulus measurement with computed tomography angiography reduces aortic regurgitation after transfemoral aortic valve replacement compared to 3-D echocardiography: a single-centre experience.

Accurate assessment of the aortic annulus is crucial for successful transcatheter aortic valve replacement (TAVR), in particular to prevent paravalvular regurgitation (PVR). We compared aortic annular sizing using multidetector computed tomography (MDCT) and three-dimensional transoesophageal echocardiography (3-D TEE) to determine the predictive value of MDCT. All patients admitted for transfemoral TAVR [n = 227; 48.9% balloon expandable (Edwards Sapien 3); 51.1% self-expandable (Core Valve, Evolut R)] at our institution from January 2015 until December 2016 were analysed retrospectively. Aortic annular parameters were obtained either by MDCT or 3-D TEE. Additionally, we included a cohort of patients (n = 27) assessed by both MDCT and 3D TEE between October 2017 and April 2018 to enable intra-individual comparison of the two methods. Indications for TAVR were severe degenerative aortic stenosis (AS; 94.7%) or re-stenosis after surgical AVR (5.3%). 74.4% were classified as high-gradient AS. The mean age was 80 (37-94) years and 75.8% presented with NYHA III/IV. STS risk of mortality was intermediate (3.5 ± 2.3). MDCT and 3-D TEE were performed in 116 and 111 patients for aortic annulus sizing, respectively. Significantly larger implants were chosen in the CT group irrespective of prosthesis type or post-dilatation. Follow-up (median at 79days) revealed significantly less PVR in the MDCT compared to 3-D TEE group (absence of PVR in 59.3% and 40.7%, p = 0.016), without differences in mortality. Patients without PVR or mild PVR had a better clinical performance according to NYHA class (p = 0.016). MDCT is superior to 3-D TEE in terms of sizing accuracy and clinical outcomes. Reduction of PVR after TAVR with MDCT is likely due to valve annulus undersizing by TEE.

Changes in dynamic mitral valve geometry during percutaneous edge-edge mitral valve repair with the MitraClip system.

The aim of this study was to quantify the acute dynamic changes of mitral valve (MV) geometry throughout the cardiac cycle-during percutaneous MV repair with the MitraClip system by 3-dimensional transesophageal echocardiography (3D TEE). The MV was imaged throughout the cardiac cycle (CC) before and after the MitraClip procedure using 3D TEE in 28 patients (mean age, 77 ± 8years) with functional mitral regurgitation (FMR). Dynamic changes in the MV annulus geometry and anatomical MV orifice area (AMVOA) were quantified using a novel semi-automated software. Percutaneous MV repair decreased anterior-posterior diameter by up to 9% (at 50% of CC; from 34.5 to 31.9mm; p < 0.001) throughout the CC and increased the diastolic lateral-medial diameter by up to 7% (at 60% of the CC; from 39.7 to 42.3mm; p < 0.001), whereas the annular circumference and area were not significantly affected. Annulus sphericity index was reduced up to 13% (at 50% of the CC; from 0.89 to 0.78, p < 0.001). The AMVOA also decreased during systole, the maximum decrease being from 0.6 to 0.2mm2 (at 0% of CC; p = 0.007), and during diastole the maximum decrease being from 4.6 to 1.6cm2 (at 50% of CC; p < 0.001). Percutaneous MV repair reduces the MR by an improved coaptation of MV leaflets joint with a simultaneous indirect reduction of anterior-posterior diameter. Further, the MitraClip procedure leads to a reduction of AMVOA of more than 60% during diastole.

Acute Effect of Mitral Valve Repair on Mitral Valve Geometry.

The aim of this study was to quantify acute mitral valve (MV) geometry dynamic changes throughout the cardiac cycle using three-dimensional transesophageal echocardiography (3D TEE) in patients undergoing surgical MV repair (MVR) with ring annuloplasty and optional neochord implantation. Twenty-nine patients (63 ± 10 years) with severe primary mitral regurgitation underwent surgical MVR using ring annuloplasty with or without neochord implantation. We recorded 3D TEE data throughout the cardiac cycle before and after MVR. Dynamic changes (4D) in the MV annulus geometry and anatomical MV orifice area (AMVOA) were measured using a novel semiautomated software (Auto Valve, Siemens Healthcare). MVR significantly reduces the anteroposterior diameter by up to 38% at end-systole (36.8-22.7 mm; p < 0.001) and the lateromedial diameter by up to 31% (42.7-30.3 mm; p < 0.001). Moreover, the annular circumference was reduced by up to 31% at end-systole (129.6-87.6 mm, p < 0.001), and the annular area was significantly decreased by up to 52% (12.8-5.7 cm2; p < 0.001). Finally, the AMVOA experienced the largest change, decreasing from 1.1 to 0.2 cm2 during systole (at midsystole; p < 0.001) and from 4.1 to 3.2 cm2 (p < 0.001) during diastole. MVR reduces the annular dimension and the AMVOA, contributing to mitral competency, but the use of annuloplasty rings reduces annular contractility after the procedure. Surgeons can use 4D imaging technology to assess MV function dynamically, detecting the acute morphological changes of the mitral annulus and leaflets before and after the procedure.

Three-Dimensional Echocardiographic Guidance of Right Heart Catheterization Decreases Radiation Exposure in Atrial Septal Defect Closures

Radiation reduction is desirable in children undergoing cardiac catheterization. Three-dimensional (3D) transesophageal echocardiographic (3D TEE) imaging obviates the need for mental reconstruction of 3D structures from two-dimensional images. Three-dimensional TEE imaging is used in atrial septal defect (ASD) closures. Three-dimensional TEE guidance of right heart catheterization (RHC) without fluoroscopy for ASD closures has not been demonstrated. The aim of this study was to evaluate the feasibility of 3D TEE guidance of RHC in ASD closures and radiation reduction compared with historical control subjects. Twenty-two patients underwent 3D TEE guidance of RHC and ASD closures and were compared with 44 control subjects. RHC time, total fluoroscopy time, radiation dose, and procedural time were compared. Fluoroscopy time during RHC was recorded in patients undergoing 3D TEE guidance. There was a 54% reduction in total fluoroscopy time and a 78% radiation reduction demonstrated with 3D TEE guidance of patients with ASDs compared with control subjects. Although there were no statistically significant differences in the RHC time compared with control subjects, the fluoroscopy time (mean, 0.06±0.23min) for RHC guidance using 3D TEE imaging was almost zero. There was decreased RHC time as we progressed through the learning curve of performing 3D TEE guidance of RHC (r=-0.63, P<.01). There were no statistically significant differences in total procedural time. Three-dimensional TEE guidance in RHC is feasible without the use of fluoroscopy and reduces radiation exposure in percutaneous ASD closures. Three-dimensional TEE guidance may be used in other interventional procedures in the future to further reduce radiation exposure and facilitate catheter interventions.

Diagnostic significance of three‐dimensional echocardiography in asymptomatic unicuspid aortic valve

Unicuspid aortic valve (UAV) is a rare congenital anomaly of aorta associated with a faster progress of valvular dysfunction, aortic dilatation and with necessity for more frequent controls and precise evaluation Asymptomatic 35 year old man had abnormal systolic diastolic murmur on aortic valve during routine examination. Initial diagnostic with transthoracic echocardiography (TTE) supposed bicuspid aortic valve, while three-dimensional transesophageal echocardiography (3D TEE) and multidetector computed tomography defined unicuspid, unicomissural aortic valve with moderate aortic stenosis and regurgitation. This case report confirmed that 3D TEE gives us opportunity for early, improved and precise diagnosis of UAV.

FUNCTIONAL MITRAL REGURGITATION WITHOUT SIGNIFICANT MITRAL VALVE TETHERING: A THREE-DIMENSIONAL TRANSESOPHAGEAL ECHOCARDIOGRAPHY STUDY

Functional mitral regurgitation (FMR) is considered to occur due to mitral valve (MV) tethering. However, patients with FMR without significant MV tethering were encountered in clinical setting. We sought to assess FMR without MV tethering using 3-dimensional transesophageal echocardiography (3D TEE

3D MITRAL VALVE QUANTITATION PREDICTS PROCEDURAL SUCCESS DURING TRANSCATHETER MITRAL VALVE REPAIR

We aimed to investigate whether quantitative 3D transesophageal echocardiography (3D TEE) predicts successful mitral regurgitation (MR) reduction in patients undergoing transcatheter edge-to-edge mitral valve repair (TMVR). Thirty-nine patients underwent 3D TEE during TMVR. Volumetric datasets were

ECHOCARDIOGRAPHIC ASSESSMENT OF LEFT VENTRICULAR OUTFLOW TRACT AFTER TRANSCATHETER MITRAL VALVE REPLACEMENT

Left ventricular outflow tract (LVOT) obstruction is considered to increase mortality in patients undergoing transcatheter mitral valve replacement (TMVR). We aimed to assess the impact of TMVR on LVOT using 3-dimensional transesophageal echocardiography (3D TEE). Echocardiography data in 21