3D Transesophageal Echocardiography Research Articles

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study

The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods. A prospective observational study. A tertiary referral center and a university level teaching hospital. The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions. Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71). Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Prosthetic Heart Valves Thrombosis with Infectious Endocarditis - A Practical Review

Abstract Simultaneous or sequential combination of prosthetic valve (PV) thrombosis and infectious endocarditis is a rare clinical finding. The management of these patients involves a complex multidisciplinary strategy using clinical judgment and imaging techniques. Transesophageal echocardiography (TEE) and especially 3D transesophageal echocardiography is essential. Moreover, positron emission tomography with fluorodeoxyglucose (F18-FDG PET/CT) can be a valuable tool to diagnose and manage these complicated clinical scenarios. We present the case of a 65-year-old patient who was admitted in our clinic for paroxysmal nocturnal dyspnea and chills for one week. He had multiple surgical interventions for rheumatic mitral valve disease (percutaneous mitral valvuloplasty in 2008, and mitral valve replacement and tricuspid annuloplasty in October 2019). At admission, the diagnosis of prosthetic valve thrombosis was established taking into account the clinical context (low INR values for the last two months), the patient symptoms and the echocardiographic findings. IV unfractionated heparin was administered. One week after admission the patient’s clinical status further deteriorated. TEE reevaluation showed partial thrombus regression with elements suggestive for concomitant infectious endocarditis. The diagnosis key is the clinical evolution and repeated TEE evaluations. In our case, they enabled the probable diagnosis of a sequential association of thrombosis and infectious endocarditis on mechanical PV. The therapeutic approach requires a high clinical suspicion and a prompt management, emergent surgery being the only lifesaving strategy in unstable patients with obstructive mechanical pathology.

The development of a flexible heart model for simulation-based training.

Simulation-based training has shown to be effective in training new surgical skills. The objective of this study is to develop a flexible 3-dimensional (3D)-printed heart model that can serve as a foundation for the simulation of multiple cardiovascular procedures. Using a pre-existing digital heart model, 3D transoesophageal echocardiography scans and a thoracic CT scan, a full volume new heart model was developed. The valves were removed from this model, and the internal structures were remodelled to make way for insertable patient-specific structures. Groves at the location of the coronaries were created using extrusion tools in a computer-modelling program. The heart was hollowed to create a more flexible model. A suitable material and thickness was determined using prior test prints. An aortic root and valve was built by segmenting the root from a thoracic CT scan and a valve from a transoesophageal echocardiogram. Segmentations were smoothed, small holes in the valves were filled and surrounding structures were removed to make the objects suitable for 3D printing. A hollow 3D-printed heart model with the wall thicknesses of 1.5 mm and spaces to insert coronary arteries, valves and aortic roots in various sizes was successfully printed in flexible material. A flexible 3D-printed model of the heart was developed onto which patient-specific cardiac structures can be attached to simulate multiple procedures. This model can be used as a platform for surgical simulation of various cardiovascular procedures.

Abstract 16289: Deformation of Tricuspid Annulus After Tricuspid Ring Annuloplasty: A Three-dimensional Transesophageal Echocardiography Study

Background: Tricuspid ring annuloplasty (TAP) is usually performed for patients with mild or greater functional tricuspid regurgitation (TR) at the time of left-sided valve surgery. However, there were limited data regarding the shape of tricuspid annulus after TAP. The aim of this study was using three-dimensional (3D) transesophageal echocardiography to investigate the impact of the ring annuloplasty on the tricuspid annulus after TAP. Methods: 3D tricuspid valve was retrospectively analyzed in 20 patients who underwent concomitant left-sided heart surgery and TAP for functional TR. 3D data of tricuspid valve were acquired before TAP, immediate after surgery (intraoperative), and before discharge (15±5 days after TAP). TAP was performed by one surgeon using a Carpentier-Edwards Physio Tricuspid annuloplasty ring. The ring size was determined by measuring the distance from anteroseptal to posteroseptal commissures. 3D tricuspid annular area was measured. The area protruded outside the annuloplasty ring was obtained by subtracting the ring area from the annular area (Figure). Results: All 20 patients underwent successfully TAP with less than mild residual TR. Annuloplasty rings size 28mm, 30mm, 32mm, and 34mm were used in 6 (30%), 4 (20%), 5 (25%), and 5 (25%) patients, respectively. Median annular area decreased from 1074 (interquartile rage 893-1276) mm 2 before TAP to 591 (519-706) mm 2 immediate after TAP, but showed significant increase to 645 (501-766) mm 2 at the time of discharge (P<0.001). Percent area protruded outside the annuloplasty ring was 14% immediate after TAP and increased to 24% before discharge (P<0.001). Before discharge, there were 9 patients with more than mild residual TR (2 had moderate TR). Percent area protruded outside the annuloplasty ring was associated with mild or more residual TR at the discharge. Conclusion: Tricuspid annular shape after TAP was not always round. Deformation of tricuspid annulus may be associated with residual TR.

Abstract 13429: Echocardiographic Predictors of Mitral Transvalvular Gradients After Mitraclip Insertion

Introduction: The MitraClip procedure is a non-surgical alternative for patients with severe mitral regurgitation and high surgical risk. However, the MitraClip may lead to a reduction in the mitral valve orifice area (MVOA) and elevated transmitral mean gradients (TMG). The objectives of this study are to assess the value of baseline MVOA by different imaging methods and explore the value of MVOA indexed for left ventricular (LV) forward stroke volume (SV) to predict postprocedural TMG. Methods: Preprocedural echo images were retrospectively reviewed in 76 consecutive patients. MVOA from 2D transthoracic (MVOA TTE ), 2D transgastric (MVOA TG ) and 3D transesophageal (MVOA 3D ) echocardiography were measured and then indexed by the SV measured by Doppler in the LV outflow tract (MVOA/SV) . Postprocedural TMG was measured at one month and survival rate at one year. Results: Patients with postprocedural TMG >5 mmHg (18/76, 24%) had significantly smaller preprocedural MVOA 3D (3.9±0.9 vs 5.2±1.3 cm 2 , p<0.01) and MVOA TTE (4.9±1.1 vs 5.9±1.5 cm 2 , p=0.02). No significant difference was found for MVOA TG (5.5±1.4 vs 5.9±1.4 cm 2 , p=0.2). Best threshold values for MVOA 3D and MVOA TTE to predict postprocedural TMG >5 mmHg were respectively 3.9 cm 2 (AUC=0.80, IC95%: 0.67-0.94, p<0.01; sensitivity (Se) 62%, specificity (Sp) 87%) and 4,6 cm 2 (AUC=0.69, IC95%: 0.54-0.83, p=0.02; Se 50%, Sp 84%). MVOA/SV from each echocardiographic modality were smaller in patients with postprocedural TMG >5 mmHg (3D: 80 [62-95] vs 113 [99-129] cm 2 /L; TTE: 92 [81-105] vs 130 [100-166] cm 2 /L; TG: 104 [83-123] vs 135 [104-166] cm 2 /L; p<0.01 for all). MVOA/SV 3D was overall the best predictor of postprocedural TMG >5 mmHg, with an optimal threshold of 96 cm 2 /L (AUC=0.86, IC95%: 0.76-0.97, p<0.001; Se 84%, Sp 81%). Patients with MVOA 3D <3.9 cm 2 and MVOA/SV 3D <96 cm 2 /L tend to be at higher risk for mortality at one-year follow-up (69% vs 84%, p=0.14 and 67% vs 87%, p=0.11 respectively). Conclusion: Unlike preprocedural MVOAs assessed by 3D echocardiography, preprocedural MVOAs measured by 2D echocardiographic modalities were poor predictors of high TMG after MitraClip. Preprocedural MVOA 3D <3.9 cm 2 and MVOA/SV 3D <96 cm 2 /L were found to be the best cut-off values to predict postprocedural TMG >5 mmHg.

Abstract 15424: Tricuspid Valve Geometry and Right Heart Remodeling: Insights Into the Mechanism of Atrial Functional Tricuspid Regurgitation

Introduction: Functional tricuspid regurgitation (TR) caused by chronic atrial fibrillation with structurally normal tricuspid valve (TV) leaflets, normal right ventricular (RV) function, and dilated right atrium (RA), is considered as a new clinical entity, atrial functional TR (AF-TR). We sought to investigate TV geometry and right heart remodeling in AF-TR compared with ventricular functional TR with sinus rhythm (VF-TR). Methods: Transesophageal 3D echocardiography datasets of the TV and the RV were acquired in 51 symptomatic severe TR. 3D RV endocardial surfaces were reconstructed throughout the cardiac cycle and then postprocessed using semiautomated integration and segmentation software to calculate position of papillary muscle (PM) tips (Figure). Results: Compared with VF-TR, AF-TR had more dilated and posteriorly displaced annulus and less leaflet tethering angles with more prominent right atrium and smaller RV end-systolic volume. On the XY (annular) plane, the center of annulus was getting closer towards the anterior and posterior PM tips and was going away from the medial PM tip caused by prominent annular dilatation in AF-TR. On the Z axis, the position of each PM tip in AF-TR was not so much displaced apically as that in VF-TR. Multiple linear regression analyses revealed that right atrial volume and right atrial/RV end-systolic volume ratio were determinants of annular area and orientation in AF-TR, respectively (both P <0.001). Additionally, the posteromedial directed component of posterior PM tip position and the apically directed component of the position of all 3 PM tips were independently associated with TV tethering angles of each leaflet in AF-TR (all P <0.02). In subgroup analysis, massive to torrential AF-TR had a larger RV volume with more apically displaced PM tips than severe AF-TR. Conclusion: Right heart remodeling and its association with TV geometry differ between AF-TR and VF-TR, which offers distinctive therapeutic implications.

Acute changes in mitral valve geometry after MitraClip procedure assessed by 3D transoesophageal echocardiography

Abstract Background MitraClip procedure is a treatment option in patients with symptomatic mitral regurgitation (MR) and prohibitive surgical risk. Echocardiographic evaluation of mitral valve (MV) is of paramount importance for the correct identification of patient eligibility and procedural success. Our aim is to assess the acute effect of device implantation on mitral annular geometric parameters still little explored with the use of three-dimensional (3D) transoesophageal echocardiography (TEE) and to investigate its relationship with residual MR at discharge. Methods 67 consecutive patients (mean age78.7±7.2 yrs, 41 males) undergoing percutaneous MV repair with MitraClip in our Centre were enrolled. Patients eligibility was evaluated according to the EVEREST criteria and current guidelines. Four groups were identified on the base of MR aetiology: 22 were degenerative (DMR), 19 ischemic functional (IFMR), 19 non-ischemic functional (NIFMR) and 7 atrial functional (AFMR). 3D TEE was performed before and immediately after clip deployment with MV anatomical quantification by PHILIPS® QLAB MVQ and GE® 4D-AUTO-MVQ software. Results Severe MR (4+) was found in 17 pts, and moderate-severe MR (3+) in 50 pts. Thirteen cases were unsuccessful because of unchanged or residual MR>2+. Immediately after device positioning, almost all the evaluated parameters showed a significant modification within each group with a reduction of anterior-posterior (AP-D) and bi-commissural (CC-D) MV diameters, MV annulus area and perimeter and an increase in tenting volume, tenting height and posterior mitral leaflet angle (PML α). Anterior mitral leaflet angle (AML α), sphericity index and aorto-mitral angle remained unchanged. We observed no significant difference in the sub-analysis between degenerative and all functional MR groups, although a different trend of parameters variation could be evidenced. Post-procedural tenting height with cut off of 5.5 mm was a predictor of procedural success (see fig.), while at univariate analysis basal AP-D in DMR group and sphericity index, PMLα and annulus height at baseline in the FMR group were all significantly correlated to the entity of MR reduction at discharge. Conclusions Percutaneous edge-to-edge repair with MitraClip acutely changes the MV annular geometry in degenerative and both ventricular and atrial functional MR, with a different trend within each group. Post-procedural tenting height correlates with significant MR reduction at discharge, a promising marker that could be used in clinical practice for identification of MitraClip procedure success. Funding Acknowledgement Type of funding source: None

Anatomical changes in tricuspid annulus and tricuspid regurgitation reduction after Cardioband implantation

Abstract Introduction Isolated tricuspid regurgitation (TR) is an entity of high prevalence and associated with poor prognosis. Traditionally, treatment options have been limited because high surgery mortality. In this context, new percutaneous therapeutic options have appeared. The objective of this study is to describe the anatomical changes in tricuspid annulus (TA) and the immediate response in the TR severity after implantation of the Cardioband tricuspid system as well as the safety of the procedure. Methods Patients undergoing Cardioband implantation in our center where included. The diameter and area of the TA were measured by 2D and 3D transesophageal echocardiography (TEE) before and immediate after the implantation. TR severity was evaluated by the vena contracta width (VC) in 0 and 90 degrees by 2D TEE. Results Six patients (81.3 (79–85) years, 66.3% females) were included. The etiology of TR was dilatation of the ring in two cases, secondary to left valvulopathy in three cases and secondary to type III pulmonary hypertension in other case. Four patients presented basal severe TR, and two patients massive TR. A significant reduction in TA diameters (reduction TA diameter 0°: 10.6 mm; 90°: 12.2 mm) and 3D TA area (4.5 mm2) was observed immediately after the procedure as well as a reduction in the VC width (reduction VC 0°: 4.8 mm; 90°: 3.9 mm). Table 1 shows the measurements before and after the procedure. The success of the procedure was 84% (Five patients reduced one-degree TR severity, and one reduced two degrees TR severity). One patient was partial success because the complete implant of all anchors could not be performed. There was 0% intraprocedural mortality or major complications. There were two minor complications, one related to vascular access and the other related to an intra-atrial thrombus, both resolved. Conclusions The new percutaneous techniques to treat TR are a reality, and preliminary results seem to indicate that they are a safe and effective alternative, reducing the size of the ring and the severity of valvulopathy. Further studies and longer clinical follow-up will lead to the generalization of these new techniques. Funding Acknowledgement Type of funding source: None

Transcatheter echo guided mitral valve repair with neochord implantation for posterior leaflet disease

Abstract Background/Introduction Transapical off-pump mitral valve repair with NeoChord implantation (TOP-MINI) has become applied for patients presenting with severe mitral regurgitation (MR) due to posterior leaflet (PML) prolapse or flail. The procedure is performed under real-time 2D- and 3D-transesophageal echocardiography for both implantation and neochordae tension adjustment allowing real-time monitoring of hemodynamic recovery. Purpose This prospective study sought to evaluate acute safety and efficacy of this innovative, minimally invasive, transcatheter mitral valve repair approach. Methods 33 symptomatic patients patients with severe MR secondary to PML flail/prolapse (March 2017-Dec 2019) were included. Patients were stratified on the basis of the preoperative 3D transesophageal echocardiography assessment of MV morphology: type A, isolated central PML prolapse/flail (25 patients); type B, posterior multisegment prolapse/flail (3 patients); type C and D, anterior or bileaflet prolapse/flail or paracommissural prolapse/flail or any type of disease with the presence of significant leaflet/annular calcifications (5 patients). Type A was considered the more favorable morphology. Results Median age was 67.7±13.4 y. Median EuroSCORE-II 2.7%±1.91. Procedural success was achieved in 28 patients (84,9%). 5 patients, 2 type A and 3 type D, underwent conversion to open surgery for immediate failure. The median number of chords implanted was 3.1±0.6. 1 high-risk patient considered inoperable because of severe comorbidities and extensive annular calcifications died before discharge. Postoperative length of stay was 4.25±1 days. At 12.3±4.9 months median follow-up, MR≤moderate was present in 25 (90%). Overall 1-year survival was 100%. Freedom from reintervention was 97% for overall population. Transthoracic echocardiography at 1 year revealed ventricular reverse remodeling, with a significant decrease in indexed left ventricular end- end-systolic volumes (25.3±6.4 to 21.6±8.2 mL/m2, P<0.001). 92.9% were in New York Heart Association class I. Conclusions TOP-MINI procedure is a feasible, low-risk technique that allows safely repair degenerative mitral valve failure secondary to prolapse/flail valvular and its efficacy is maintained up to 1-year. Funding Acknowledgement Type of funding source: None

Standalone totally thoracoscopic left appendage exclusion for stroke prevention and absolute contraindication to anticoagulation: a referral centre experience

Abstract Introduction Left atrial appendage is the source of more than 90% of thrombi in patients with atrial fibrillation (AF). ESC guidelines state as class IIB indication left appendage exclusion in patients with contraindication to oral anticoagulation. Here we give our contribute to the issue of safety and efficacy of standalone totally thoracoscopic left appendage exclusion (TT-LAE) for stroke prevention in patients with contraindication to oral anticoagulant or at risk of life threatening hemorrhage on antiplatelet therapy: a large single Centre experience. Materials and methods 60 patients with non valvular AF and contraindication to oral anticoagulation (25 cerebral hemorrhages,8 GI bleeding, 18 non cerebral/Gi bleeding requiring multiple transfusions, 2 myelodysplastic syndrome, 7 anatomy unsuitable for percutaneous closure, 75%male, patients age ranged 53–87 years,mean CHAD-VASC 6.4,mean HASBLED range 4.7, type of AF permanent 76.6%, 23.4% longstanding persistent), underwent stand alone totally thoracoscopic appendage exclusion. All patinets enrolled after Heart Team evaluation, were screened preoperatively with 3D CT scan, transesophageal echocardiography, spirometry and cerebrovascuar doppler ultrasound. Intraoperative appendage exclusion were guided and confirmed by transesophageal echo. All patients were not on anticoagulation nor antiplatelet therapy at the time of surgery, at discharge and at control visit. Follow up (range 35–1 months) included outpatient visit and CT scan or TEE at 3–6-12 month in all patients to document LAA exclusion. Perioperative mortality and early and late morbidity in addition to freedom from neurological events at follow up were analyzed by chart evaluation and full outpatient neurological examination including including the Questionnaire for Verifying Stroke Free Status (QVSFS) as validated screening tool. Results Mean duration of surgery “skin to skin” was 52.4 minutes; all patients were extubated shortly after the procedure. There were no deaths nor need for blood transfusion or pulmonary procedure related morbidities, only three casea of pericarditis treated with colchicine till complete resolution was documented. On CT or TEE follow up 100% of patients had complete exclusion of the left appendage with minimal residual stumps and no dislodgement of the clip detected. Freedom from neurological events in all patients was documented in absence of anticoagulation or antiplatelet regime from the time of surgery to the time of the follow up visit and questionnaire filling. Conclusion Standalone totally thoracoscopic left appendage clipping is a safe and effective procedure for stroke prevention in patients with permanent and longstanding persistent atrial fibrillation with contraindication to oral anticoagulation. Longer follow up and an European registry are needed to, possibly, confirm this preliminary results. Funding Acknowledgement Type of funding source: None

Assessment of D-Shaped Annulus of Mitral Valve in Patients with Severe MR Using Semi-Automated 4-Dimensional Analysis: Implications for Transcatheter Interventions.

The development of transcatheter mitral valve replacement therapies requires accurate post-processing analysis tools to provide D-shaped mitral annulus dimensions from 3-dimensional (3D) data. The agreement between two semi-automated, software packages to process 3D transesophageal echocardiography (TEE) data for the measurement of the mitral valve annulus dimensions was evaluated. 3DTEE data of patients with moderate–severe mitral regurgitation (MR) were postprocessed with semi-automated, vendor-independent (VI) software and vendor-specific (VS) software. Both post-processing software provided key measurements for the selection of transcatheter valve prosthesis size: annulus area, annulus circumference and the septal-to-lateral distance of the annulus. The intertrigonal distance was provided only by the VS software. The inter- and intra-observer agreements were assessed with Bland–Altman analysis. Of 105 patients (63.8 ± 11 years, 66% male) with MR, 28 had secondary MR, 45 fibroelastic deficiency, and 32 Barlow’s disease. Using VS software, the dimensions for the overall population were 16.1 ± 4.6 cm2 for annulus area, for circumference 14.4 ± 1.9 cm, intertrigonal distance 3.4 ± 0.5 cm and septal-to-lateral distance 3.8 ± 0.6 cm. Similar dimensions were obtained using VI software: 15.7 ± 4.6 cm2 for annulus area, 14.5 ± 2.0 cm for circumference, and 4.1 ± 0.6 cm for septal-to-lateral distance. The inter- and intra-observer agreement for both software programs was excellent. In conclusion, current post-processing software programs for 3DTEE data of the mitral valve annulus provide good reproducibility of key measurements to select the transcatheter prosthesis size.

Intraoperative Three-dimensional Imaging of Ventricular Septal Defects in Children Using Epicardial Echocardiography: A Novel Approach

To assess the feasibility and accuracy of intraoperative three-dimensional (3D) epicardial en face images of ventricular septal defects (VSD) in children using the 3D transesophageal echocardiography (TEE) probe as an epicardial probe. This was a prospective nonrandomized blinded observational study. The study was conducted at a single tertiary cardiac care center. Fifty pediatric patients, weighing between 5.0 kg and 20 kg, who were scheduled for elective surgical closure of their VSDs, prospectively were recruited for this study. Epicardial 3D images were acquired using the full-volume mode. VSD location and size were determined from the 3D data sets using multiplanar reconstruction mode (QLAB 9) by a blinded investigator. The accuracy in terms of location and size was compared with surgical findings. In 50 study subjects, 54 VSDs were located by epicardial 3D echocardiography (3DE): 12 perimembranous, 17 inlet, eight muscular, 15 malaligned, and two outlet. Average image acquisition time was 4.96 (±1.47) minutes. Average image reconstruction time was 6.18 (±1.93) minutes. Good en face views of the VSD could be rendered in all patients (100% feasibility). The highest image quality was for perimembranous and malaligned VSDs. The location of VSD by 3DE corresponded precisely with surgical findings (100% accuracy). With linear regression analysis, excellent correlation was observed between the diameters measured by surgery and that measured by 3DE from the right ventricle side (r2 = 0.97, p < 0.001). The authors' study demonstrated that diagnostic quality 3D en face images of VSD can be obtained intraoperatively using 3D epicardial echocardiography. The short acquisition and reconstruction times make this technique clinically applicable.

Insufficient Mitral Leaflet Remodeling in Relation to Annular Dilation and Risk of Residual Mitral Regurgitation After MitraClip Implantation

ObjectivesThe purpose of this study was to determine whether the mitral valve (MV) total leaflet area (TLA)-to-mitral annular area (MAA) (TLA/MAA) ratio measured using 3-dimensional (3D) transesophageal echocardiography (TEE) was associated with residual mitral regurgitation (MR) after MitraClip implantation in patients with secondary MR. BackgroundThe factors influencing the results of MitraClip implantation for secondary MR are controversial. This study hypothesized that insufficient remodeling of the mitral leaflets relative to the annular dilation may be associated with significant MR after MitraClip implantation. MethodsThis study included patients with secondary MR treated with MitraClips. Using 3D TEE dataset, the TLA in diastole and MAA in systole were measured with dedicated software. ResultsIn a total cohort of 119 patients (mean age 74 ± 9 years; 61% male), significant residual MR (≥2+) was present in 43 patients (36%). In patients with significant residual MR, MAA was greater than in patients without residual MR (10.7 ± 2.4 cm2 vs. 9.0 ± 2.1 cm2; p < 0.001) whereas no significant difference was observed in TLA (12.2 ± 2.6 cm2 vs. 12.0 ± 2.9 cm2; p = 0.836). TLA/MAA ratio was lower in patients with significant residual MR as compared to their counterparts (1.14 ± 0.15 vs. 1.34 ± 0.16; p < 0.001), suggesting insufficient leaflet remodeling relative to annular dilation. On receiver-operating characteristic curve analysis, the TLA/MAA ratio had better discriminative power to identify patients who will have significant residual MR compared to MAA alone (area under the curve [AUC]: 0.830 vs. 0.723; p = 0.049). ConclusionsIn patients with secondary MR, insufficient mitral leaflet remodeling relative to the annulus dilation, as reflected by a lower TLA/MAA ratio, is associated with significant residual MR after MitraClip implantation.

Three-Dimensional Echocardiographic Method for the Visualization and Assessment of Specific Parameters of the Pulmonary Veins.

The dimensions of the pulmonary veins are important parameters when planning pulmonary vein isolation (PVI), especially with the cryoballoon ablation technique. Acknowledging the dimensions and anatomical variations of the pulmonary veins (PVs) may improve the outcome of the intervention. Conventional 2D transoesophageal echocardiography can only provide limited data about the dimensions of the PVs; however, 3D echocardiography can further evaluate relevant diameters and areas of the PVs, as well as their spatial relationship to surrounding structures. In previous literature data, parameters influencing the success rate of PVI have already been identified. These are the left lateral ridge, the intervenous ridge, the ostial area of the PVs and the ovality index of the ostium. Proper imaging of the PVs by 3D echocardiography is a technically challenging method. One crucial step is the collection of images. Three individual transducer positions are necessary to visualize the important structures; these are the left lateral ridge, the ostium of the PVs and the intervenous ridge of the left and right PVs. Next, 3D images are acquired and saved as digital loops. These datasets are cropped, which result in the en face views displaying spatial relationships. This step can also be employed to determine the anatomical variations of the PVs. Finally, multiplanar reconstructions are created to measure each individual parameter of the PVs. Optimal quality and orientation of the acquired images are paramount for the appropriate assessment of PV anatomy. In the present work, we examined the 3D visibility of the PVs and the suitability of the above method in 80 patients. The aim was to provide a detailed outline of the essential steps and potential pitfalls of PV visualization and assessment with 3D echocardiography.

Aortic valve area calculation using 3D transesophageal echocardiography: Implications for aortic stenosis severity grading.

Aortic stenosis (AS) grading by 2D-transthoracic echocardiography (2D-TTE) aortic valve area (AVA) calculation is limited by left ventricular outflow tract (LVOT) area underestimation. The combination of Doppler parameters with 3D LVOT area obtained by multidetector computed tomography (MDCT) can improve AS grading, reconciling discordant 2D-TTE findings. This study aimed to systematically evaluate the role of 3D-transesophageal echocardiography (3D-TEE) in AS grading using MDCT as reference standard. 288 patients (81±6.3years, 52.4% female) with symptomatic AS underwent 2D-TTE, 3D-TEE, and MDCT for transcatheter aortic valve implantation. Doppler parameters were combined with 3D LVOT areas measured by manual and semi-automated software 3D-TEE and by MDCT to calculate AVA, reassessing AS severity. Both 3D-TEE modalities demonstrated good correlation with MDCT, with excellent intra-observer and inter-observer variability. Compared to MDCT, 3D-TEE measurements significantly underestimated AVA (PANOVA <.0001), although the difference was clinically acceptable. Compared to 2D-TTE, 3D-TEE manual and semi-automated software reclassified severe AS in 21.9% and 25.2% of cases, respectively (P<.0001), overcame grading parameters discordance in more than 40% of cases in patients with low-gradient AS (P<.0001) and reduced the proportion of low-flow states in nearly 75% of cases when combined to stroke volume index assessment (P<.0001). 3D-TEE imaging modalities showed a reduction in the proportion of patients with low-gradient and pathological AVA as defined by 2D-TTE, and improved AVA and mean pressure gradient agreement with current guidelines cutoff values. 3D-TEE AVA calculation is a reliable tool for AS grading with excellent reproducibility and good correlation with MDCT measurements.

Diagnostic Accuracy of Transillumination in Mitral Valve Prolapse: Side-by-Side Comparison of Standard Transthoracic Three-Dimensional Echocardiography against Surgical Findings

In patients with mitral valve prolapse (MVP) eligible for surgery, three-dimensional echocardiographic (3DE) imaging is routinely used for preoperative assessment. 1 Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2017; 38: 2739-2791 Crossref PubMed Scopus (2) Google Scholar ,2 Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin J.P. Fleisher L.A. et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017; 70: 252-289 Crossref PubMed Scopus (1731) Google Scholar Despite the worldwide use of transesophageal echocardiography in this context, transthoracic echocardiographic (TTE) imaging allows accurate noninvasive evaluation of mitral valve (MV) anatomy and pathology. 3 Gripari P. Mapelli M. Bellacosa I. Piazzese C. Milo M. Fusini L. et al. Transthoracic echocardiography in patients undergoing mitral valve repair: comparison of new transthoracic 3D techniques to 2D transoesophageal echocardiography in the localization of mitral valve prolapse. Int J Cardiovasc Imaging. 2018; 34: 1099-1107 Crossref PubMed Scopus (10) Google Scholar , 4 Tamborini G. Muratori M. Maltagliati A. Galli C.A. Naliato M. Zanobini M. et al. Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions. Eur J Echocardiogr. 2010; 11: 778-785 Crossref PubMed Scopus (43) Google Scholar , 5 Pepi M. Tamborini G. Maltagliati A. Galli C.A. Sisillo E. Salvi L. et al. Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol. 2006; 48: 2524-2530 Crossref PubMed Scopus (196) Google Scholar Transillumination (TI) is a new three-dimensional tool that improves the visualization of cardiac structures due to shadow effects achieved by the use of a virtual light source. 6 Genovese D. Addetia K. Kebed K. Kruse E. Yamat M. Narang A. et al. First clinical experience with 3-dimensional echocardiographic transillumination rendering. JACC Cardiovasc Imaging. 2019; 12: 1868-1871 Crossref PubMed Scopus (20) Google Scholar We aimed to compare the diagnostic accuracy of TTE TI side by side with standard 3DE (s3DE) display in patients undergoing surgery for MVP. Surgical valve inspection was used as a reference standard, even though surgery allows only static MV assessment. 3 Gripari P. Mapelli M. Bellacosa I. Piazzese C. Milo M. Fusini L. et al. Transthoracic echocardiography in patients undergoing mitral valve repair: comparison of new transthoracic 3D techniques to 2D transoesophageal echocardiography in the localization of mitral valve prolapse. Int J Cardiovasc Imaging. 2018; 34: 1099-1107 Crossref PubMed Scopus (10) Google Scholar , 4 Tamborini G. Muratori M. Maltagliati A. Galli C.A. Naliato M. Zanobini M. et al. Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions. Eur J Echocardiogr. 2010; 11: 778-785 Crossref PubMed Scopus (43) Google Scholar , 5 Pepi M. Tamborini G. Maltagliati A. Galli C.A. Sisillo E. Salvi L. et al. Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol. 2006; 48: 2524-2530 Crossref PubMed Scopus (196) Google Scholar

Reference value of perimeter-derived diameter assessed by three-dimensional transesophageal echocardiography in left atrial appendage occluder size selection.

The aim of this study was to investigate the utility of perimeter-derived diameter (PDD) measured by three-dimensional (3D) transesophageal echocardiography (TEE) in predicting the size of left atrial appendage (LAA) occluder. Left atrial appendage landing zone diameter (LZD) was measured by two-dimensional (2D) TEE, 3DTEE, and digital subtraction angiography (DSA) as LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD, LZD-DSAmax, respectively, before and during transcatheter LAA closure with Watchman devices in 100 patients. A difference of one or more device size intervals between the predicted size and the size actually implanted was defined as mismatching. Seventy-eight patients were followed up by TEE to obtain occluder compression ratio. The correlation between LZD and the final implanted occluder size was 0.559, 0.641, 0.754, 0.760, 0.782, and 0.848 for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively (P<.001). Matching ratio between the size predicted by retrospective measurements of LZD and the device size actually implanted was 65%, 57%, 66%, 63%, 70%, and 83% for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively. There was no significant difference in LZD value, matching ratio, and compression ratio between the patients with eccentric and noneccentric LAA landing zone (P>.05). Compression ratio of the mismatching subjects was higher than that in the matching subjects when evaluated by LZD-2Dmean, LZD-3Dmean, and LZD-PDD (P<.05). Landing zone diameter derived from LAA perimeter measured by preprocedure 3DTEE showed reference value for LAA occluder size selection, providing superior correlation and matching ratio with the final implanted size and indicating the adjustment of oversizing.

Resolution of strain abnormalities during extracorporeal rewarming from accidental hypothermic cardiac arrest: a case report

Introduction Three-dimensional left (LV) and right-ventricular (RV) assessment by transesophageal echocardiography (TEE) overcomes problems of 2D TEE such as incomplete coverage and mathematical assumptions of chamber geometry. Myocardial deformation parameters (strain) are reported to allow earlier detection of subclinical abnormalities and to improve prognostic accuracy compared to global assessment. Strain data describing functional recovery of the myocardium from severe hypothermic arrest are scarce. Methods A 55 year-old male victim of an avalanche accident arrived at the emergency department in asystole at 28°C core temperature under ongoing CPR (hypothermia stage IV). Reperfusion and rewarming was performed by percutaneous cannulation and minimized extracorporeal circulation (MiECC). Ventricular fibrillation ensued at 32°C and converted to sinus rhythm after defibrillation. At 33°C a full-volume loop (6 beats) was acquired for each ventricle, and tissue doppler interrogation was performed for assessment of diastolic function. Exams were repeated at 36°C. Images were analyzed for ventricular function and strain for all AHA segments. Results In hypothermia, LV ejection fraction (LVEF, 54%) and global circumferential strain (-35.9%) appeared normal but longitudinal strain was impaired (-13.5%). Basal myocardial segments showed hypo- and dyskinesia, while peak strain in more apical segments was preserved. This resulted in marked heterogeneity of strain curves. Diastology revealed restrictive LV dysfunction (III°). RV ejection fraction (RVEF, 45%) and global longitudinal strain were impaired (-15.2%). After normothermia had been reestablished, LVEF (68%) and strain had improved further (circumferential: -37.7%, longitudinal: -14.5%). Contractile function of LV segments had regained homogeneity among all segments. Time to peak systolic strain was shortened. Diastolic dysfunction had improved to pseudonormal (II°). RVEF (74%) and strain (-44.1%) also showed marked recovery. The figure shows numerical function changes for both ventricles and LV strain curves at 33°C and 36°C core temperature. Discussion In post-arrest core hypothermia at 33°C, LVEF may appear normal and RVEF only mildly impaired, whereas segmental LV and global RV strain analysis may reveal a still severely ab-nor¬mal myocardial systolic function. Such a discordant pattern in a hypothermic post-ischemic heart may show marked improvement when core temperature normalizes. Three-dimensional TEE in combination with myocardial strain analysis may be a useful adjunct for evaluating post-arrest recovery of cardiac function in victims of accidental hypothermic cardiac arrest.

Development of a software algorithm for comprehensive right ventricular strain analysis employing meshes derived from three-dimensional speckle-tracking echocardiography

Introduction Although right ventricular (RV) function assessment is important in cardiac surgical patients, dedicated software solutions to measure RV strain on three-dimensional (3D) speckle-tracking echocardiography-based (STE) meshes are lacking. Hence, a novel tool to do so was developed and tested for its feasibility in a clinical setting. Methods RV meshes were generated using dedicated 3D-STE software (4D RV-Function 2.0, Tomtec). A software algorithm was programmed in the Visualization Toolkit (www.vtk.org) to measure systolic peak strains of four regional longitudinal and circumferential contours on the mesh surface (see figure). Longitudinal strains were tracked using fixed-angle pathways (“fixed”) and compared with frame-to-frame angle definition (“variable”). The four circumferential strain layers were defined by strict long-axis segmentation in each frame (“constant”) and compared to “pinning” the planes to points along the anterior and posterior edge (“tilted”). For longitudinal strains, different strategies for the segmentation into basal and apical segments were tested. Global strain values were calculated by averaging the corresponding regional strains. Results 22 patients undergoing mitral valve surgery (MVS) received intraoperative 3D transesophageal echocardiography (TEE) before and after cardiopulmonary bypass. STE yielded 44 meshes for inclusion. 44 percutaneous mitral valve repair (PMVR) patients received 3D-TEE before and after PMVR and 88 meshes were generated. Altogether, 132 total meshes were included. Complete strain analysis was feasible in 126 meshes (95%). Visual validation of each mesh carried out by experienced investigators revealed that “fixed” longitudinal strain calculation resulted in more plausible contour tracking and shortening patterns compared to “variable” calculation, whereas peak longitudinal strain values did not differ (-0.04%, p=0.12). Baso-apical segmentation was best achieved by fixing the segment border in planes defined by neighboring mesh points in the end-diastolic frame. Regarding circumferential strains, “tilted” tracking was visually superior to “constant” segmentation in maintaining functionally matching surface units in the circumferential planes along the heart cycle. “Tilted” vs. “constant” tracking resulted in significantly different global strain values (1.5%, p Discussion RV strain analysis on meshes derived from transesophageal 3D-STE using a custom-made algorithm is feasible. In patients undergoing cardiac surgery, this approach might able be to detect subtle changes of RV function more sensitively than established parameters.

Atrial appendages’ mechanics assessed by 3D transoesophageal echocardiography as predictors of atrial fibrillation recurrence after pulmonary vein isolation

Although there are numerous studies reflecting predictors of atrial fibrillation (AF) recurrence (AFR) after pulmonary vein isolation (PVI), data on atrial appendages' mechanics is scarce. This study aimed to assess atrial appendages' mechanics by 2-dimensional (2D) and 3-dimenssional (3D) transoesphageal echocardiography (TEE) and to explore its value to predict AFR after PVI. Consecutive patients with paroxysmal AF undergoing first PVIwere analysed. 3D and 2D-TEE with tissue Doppler imaging (TDI) and strain analysis was obtained prior to the PVI, including: left atrial appendage (LAA) TDI and strain analysis, LAA ostium surface area, right atrial appendage's TDI velocity and superior vena cava (SVC) ostium surface area. The primary end-point was freedom from any documented recurrence of atrial arrhythmia lasting > 30 s. This single-centre, prospective study included 74 patients with paroxysmal AF (median age 59 years; 36% female; BMI 27.4 ± 4.1 kg/m2, LA volume index 32 ± 11 mL/m2). After a median follow-up of 14 (IQR 10-22) months, 21 (28%) patients had AFR. In a univariate and multivariate Cox-regression analysis LAA TDI velocity (HR 1.48, 95%CI 1.28-1.62, p < 0.001) and LAA ostium surface area(HR 1.58, 95%CI 1.06-1.81, p = 0.033) both independently predicted AFR after single PVI. RAA TDI velocity and SVC ostium surface area were not correlated to AFR. Paroxysmal AF patients with lower LAA TDI tissue velocity and LAA ostium surface area have higher risk of developing AFR after PVI. To our knowledge, this is the first study assessing atrial appendages' mechanics in predicting AFR after PVI.Clinical trial registration: www.drks.de(Identifier: DRKS00010495).