3D Transesophageal Echocardiography Research Articles

Mapping of the myxomatous mitral valve: The three-dimensional extension of mitral annular disjunction in surgically repaired mitral prolapse.

This study aimed to describe the heterogeneous extension of mitral annular disjunction (MAD) and assess the hypotesis that different phenotypes of disjunction are not associated with increased surgical challenges. Mitral regurgitation (MR) is the most common end-stage scenario of degenerative mitral valve disease (DMVD). Few data exist on the three-dimensional extension and geometry of MAD, as well as for its role in valvular dynamic and coaptation. A total of 85 consecutive subjects, who underwent elective mitral valve repair (MVR) for MMVD at our Institution between November 2019 and October 2021, were studied retrospectively. The extension and geometry of MAD was assessed using the digitally stored volumetric datasets of real-time 3D transesophageal echocardiography (TEE). Annular phenotypes and surgical repair techniques were analyzed. Mitral annular disjunction was diagnosed in 50 out of 85 patients (59%) with Barlow disease (BD). A detailed analysis of MAD extension was conducted on 33 patients. Two pattern of disjunction were identified: a bimodal shape was highlighted in 21 patients, while a more uniform distribution of the disjuncted annulus was observed in 12 patients. The bimodal pattern was characterized by lower disjunction distance (DD) at the 140°-220° arch (3.6 ± 2.2 mm), while a more regular DD was measured in the remaining patients. All patients successfully underwent MVR. Triangular leaflet resection was performed in 58% of the cases, neochordae implantation in 9%, and notably a 27% received an isolated annuloplasty. Rather than a binary feature, MAD should be taken into account in its complex and heterogeneous morphology, where two major phenotypes can be identified. Despite its anatomical complexity, MAD was not associated with an increased surgical challenge; conversely a peculiar subgroup of patient was successfully treated with an isolated annuloplasty.

Prevalence and Hemodynamic Consequences of Mitral Valve Abnormalities in Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common congenital heart disease in adults. Concomitant mitral valve disease in patients with ASD could have significant hemodynamic effects whit a great impact on managing this congenital defect. Objectives: This study evaluated the prevalence of mitral valve abnormalities and the hemodynamic burden associated with different types of ASD. Methods: This retrospective study reanalyzed 1,006 consecutive patients referred to Rajaie Heart Center in Tehran from March 2019 to February 2022. We evaluated adult patients with the diagnosis of a shunt at the atrial level. Diagnoses were made with 2D and 3D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). 3D analysis was performed with 3D zoom, mitral valve navigation (MVN), and full-volume and multi-planar reconstruction (MPR) modalities. We performed statistical analysis by SPSS version 22.0. The qualitative data were expressed as frequency and percentage. Data were compared between subgroups via Mann-Whitney U/Kruskal-Wallis tests for the interval variables, Pearson's chi-square test for nominal variables, and chi-square for trends test for ordinal variables. Results: The distribution of different ASD types was ostium secundum in 88.8% of cases, primum ASD in 0.9%, SVC-type sinus venosus ASD in 9%, IVC-type sinus venosus in 0.4%, and unroofed coronary sinus in 0.9%. We found mitral valve abnormalities in 21.1% of cases, and the most common mitral valve abnormality were prolaptic lesions (17.4%). Conclusions: Age, ASD size, estimated Systolic Pulmonary Artery Pressure (SPAP), and severity of mitral regurgitation (MR) were markedly higher were markedly higher among patients with MV anomalies, more over left ventricular ejection fraction (LVEF) was significantly lower among this group (P-value < 0.05).

Level of agreement between three-dimensional transthoracic and transesophageal echocardiography for mitral annulus evaluation: A feasibility and comparison study.

Mitral annulus assessment is of utmost importance for the management of patients with mitral valve (MV) abnormalities, as it helps to determine the decision for surgical or transcatheter treatment. Three-dimensional (3D) transesophageal echocardiography (TOE) has been the only reliable echocardiographic method for the evaluation of the mitral annulus by now. However, newer transthoracic echocardiography (TTE) 3D probes have enabled to provide accurate measurements as well and become a valuable tool when TOE is contraindicated. The aim of this study is to assess the feasibility of 3D TTE analysis of mitral annulus and the level of agreement with 3D TOE measurements. A total of 121 consecutive patients were assessed with 3D TTE and TOE. All mitral annulus parameters were retrospectively analyzed with the dedicated 4D autoMVQ application. Bland-Altman analysis and intraclass correlation coefficient were used for the comparison and agreement between the two methods. Half of our patients had normal mitral valves and served as control group, while the other half had various mitral valve pathologies. AutoMVQ analysis was not feasible in 11 out of 121 TTE examinations (91% feasibility) and in 4 out of 121 TOE examinations (96% feasibility). Mitral annular area and perimeter were slightly larger in TTE than those measured by TOE (12.7±3.6vs. 12.4±3.2 cm2 for area and 12.7±1.7vs. 12.5±1.6cm for perimeter), however still showing strong correlation (r=.942 and r=.922, respectively). The majority of mitral valve measurements (anterior-posterior, medial-lateral and commissural diameter, aorto-mitral angle and anterior leaflet length) were similar among the two methods with strong correlation (r>.80). Inter-trigonal distance, posterior leaflet length and tenting height showed weaker agreement between TTE and TOE (r=.687, r=.687, r=.634, respectively). Mitral annular dimensions (by 3D area) were found to be significantly larger in patients with MV pathology (13.5±3.5vs. 11±2.3 cm2 ), atrial fibrillation (14.4±3vs. 11.4±2.8 cm2 ), left ventricular (13.8±3.1vs. 11.7±3.1cm2 ) and left atrial dilatation (13±3.3vs. 10.6±2.3cm2 ) compared to the individuals in the control group (p<.001 for all comparisons). Assessment of the MV with 3D TTE with dedicated MVQ software is feasible and accurate, showing strong correlation and agreement with TOE measurements.

Real-time 3D echocardiographic transilluminated imaging combined with artificially intelligent left atrial appendage measurement for atrial fibrillation interventional procedures.

Aims: This study investigated the feasibility and accuracy of real-time three-dimensional (3D) echocardiographic transilluminated imaging (TrueVue Glass) in left atrial appendage (LAA) anatomical morphology and artificial intelligence (AI)-assisted 3D automated LAA measurement (3D Auto LAA) software in the preoperative evaluation of LAA occlusion (LAAO) in patients with atrial fibrillation (AF). Method and results: Thirty-seven patients with AF were selected. Two-dimensional (2D) and real-time 3D transesophageal echocardiography (RT3D-TEE) were performed preoperatively, using conventional 3D, the new 3D TrueVue Glass mode, and cardiac computed tomography angiography (CCTA) to assess and type the morphology of LAA. Physiological parameters were measured using traditional 2D and 3D manual (3D Manual LAA), 3D Auto LAA, and CCTA. TrueVue Glass for LAA outer contour display was compared with CCTA. Comparisons were based on correlation and consistency in measuring the maximum diameter (LZ max), minimum diameter (LZ min), area (LZ area), and circumference (LZ cir) of LAA landing zone (LZ). Times and variabilities were compared. The concordance rate for external shape of LAA was 97.14% between TrueVue Glass and CCTA. 3D Auto LAA and 3D Manual LAA have a stronger correlation and higher consistency in all parameters. 3D Auto LAA showed higher intra- and interobserver reproducibility and allowed quicker analysis (p < 0.05). LAAO was performed in 35 patients (94.59%), and none of which had serious adverse events. Conclusion: TrueVue Glass is the first non-invasive and radiation-free visualization of the overall external contour of LAA and its adjacent structures. 3D Auto LAA simplifies the measurement, making the preoperative assessment more efficient and convenient while ensuring the accuracy and reproducibility. A combination of the two is feasible for accurate and rapid assessment of LAA anatomy and physiology in AF patients and has practical application in LAAO.

Abstract 13131: Three-Dimensional Echocardiography Left Atrial Appendage Dimensions is a Reflect of Cardiac Rhythm at Mid-Term Follow-Up in Atrial Fibrillation Patients

Introduction: Few studies have described the characteristics of the left atrial appendage (LAA) using three dimensional (3D) transesophageal echocardiography (TEE) in atrial fibrillation (AF). Hypothesis: We hypothesized that 3D characteristics of the LAA could further characterize patients in AF. Methods: We prospectively evaluated 156 patients hospitalized for AF with two-dimensional (2D) transthoracic and 3D TEE of the LAA within 24 hours of admission. 3D parameters were off-line analysed with Tomtec software (4D Cardio-View, Generic Volume, Philips) (Figure 1A). Patients were divided into two groups according to the cardiac rhythm at 2 years of follow up: restoration of sinus rhythm (SR group, 107 patients) or persistence of atrial fibrillation (AF group, 49 patients). Results: The mean age of the population was 66±11 years and 95 (61%) patients were male. At admission using 2D transthoracic echocardiography, AF group had in comparison with SR group higher left atrial end-systolic volume indexed (respectively 48.0 (38.7-57.0) versus 41.8 (35.0-51.5) ml/m 2 , p=0.0096), higher E velocity (respectively 0.90 (0.78-1.00) versus 0.76 (0.62-0.91) m/s, p= 0.0001) and higher pulmonary arterial pressure (respectively 31 (25-38) versus 28 (23-33) mmHg, p=0.0142). There were no significant differences in left ventricle ejection fraction and right atrial end-systolic volume indexed. At admission using 2D TEE, AF group had in comparison with SR group lower emptying flow velocity (29 (20-38) versus 38 (26-53) cm/s, p=0.002) and filling flow velocity (29 (20-39) versus 40 (29-56) cm/s, p=0.001) of the LAA. In 3D TEE, AF group had higher 3D end-systolic and end-diastolic LAA volumes (non-indexed and indexed) and no significant differences in LAA ostium in comparison with SR group (Figure 1B). Conclusions: 3D evaluation of the LAA reflects a degree of cardiac cavities remodeling in AF and seems to be associated with the evolution of cardiac rhythm at two-years follow-up.

Abstract 13506: Three-Dimensional Transoesophageal Echocardiography Characterization of Left Atrial Appendage Dimensions in Patients With Spontaneous Cardioversion of Atrial Fibrillation

Introduction: Few studies have described the clinical profile and natural history of patients with spontaneous cardioversion (SpCV) in atrial fibrillation (AF). Hypothesis: We hypothesized that patients with SpCV have a distinct morphological pattern in AF. Methods: We prospectively evaluated 262 patients hospitalized for AF using two-dimensional (2D) transthoracic (TTE) and three-dimensional (3D) transoesophageal echocardiography (TEE). 3D parameters were off-line analysed using Tomtec software (4D Cardio-View, Philips). Patients were divided into two groups according to the cardiac rhythm within 24 hours after admission: spontaneous cardioversion (SpCV group, 59 patients) and non-spontaneous cardioversion (noSpCV group, 203 patients). Results: Mean age of the population was 66±12 years and 166 (63%) patients were male. SpCV group had in comparison with noSpCV group lower CRP levels (respectively 3.3(3-5.5) versus 4(3-10) mg/L, p=0.0394), lower BNP levels (151(67-200) versus 269(129-424) pg/mL, p&lt;0.001) and lower HBA1c levels (5.5(5.3-5.7) versus 5.9(5.6-6.3) %, p&lt;0.0001). Using 2D TTE, SpCV group had in comparison with noSpCV group lower indexed left atrial end-systolic volume, lower indexed right atrial end-systolic volume, lower E velocity, and higher left ventricle ejection fraction (Table 1). Based on 2D and 3D TEE, SpCv group had in comparison with noSpCV group higher LAA emptying flow velocity and higher LAA filling flow velocity, lower 3D end-systolic and end-diastolic LAA volumes (both non-indexed and indexed) and lower 3D LAA ostium in comparison with noSpCV group (Table 1). Conclusions: Although SpCv of AF is a frequent situation incompletely studied, clinical and echocardiographic characteristics could be described. Further investigations are needed to determine the impact of such abnormalities on the prognosis in the SpCV group.

Abstract 14337: Cardiac Computed Tomography for Preoperative Assessment of Valve Morphology in Aortic Valve Repair

Introduction: A pre-operative assessment of aortic valve anatomy is important in valve repair for aortic regurgitation (AR). Although echocardiogram provides precise information, clear visualization of entire aortic valve and accurate quantification of valve geometry are limited even with 3D transesophageal echocardiography. In this study, usefulness of cardiac computed tomography (CT) in the evaluation of aortic valve pathology was investigated. Methods: A total of 119 patients who underwent surgical treatment for severe AR from May 2016 to July 2021 and had preoperative CT were studied. From the CT data set, volume rendering movie image was reconstructed to visualize valve anatomy. Effective height (EH) and geometric height (GH) were measured by CT in diastole and compared to intraoperative measurements. Results: The quality of CT image was satisfactory in 100 patients (84%), acceptable in 17 patients (14%) and suboptimal in 2 patients (2%). CT could visualize such detailed anatomy as shown in the Figure. EH in 41 patients and GH in 67 were measured by both CT and surgery. The measurements showed a correlation in EH (r=0.79, p&lt;0.0001) and in GH (r=0.74, p&lt;0.0001) with minimal bias of -1.6 mm in EH and 0.4 mm in GH and narrow limits of agreement from -5.9 to2.6 mm in EH and from -3.7 to 4.6 mm in GH. Inter- observer variabilities in CT measurement of EH and GH were 3.8±2.9% and 2.6±1.8%, with interclass correlation coefficients of 0.997 and 0.980, respectively. Conclusions: Reproducibility of CT measurement was excellent, while there was a little discrepancy between CT and surgical measurement. Not all cases underwent intraoperative measurement, and cases with structurally complexity tended to have surgical measurement. Some errors may be included in also intraoperative measurements. CT feasibly visualized aortic valve en-face view with showing the etiology of AR, which gave useful information to surgeons who perform aortic valve repair.

Abstract 13637: Advanced Multimodality Imaging of Atrial Baffle Leak After the Senning Operation

Description of Clinical Presentation We present a 40-year-old male with dextro-transposition of the great vessels and history of a Senning repair as an infant and a transvenous dual-chamber pacemaker at 7 years of age for sinus node dysfunction. Advanced imaging, including cardiac computed tomography (CT) and cardiac magnetic resonance (CMR), were performed as routine testing to evaluate the baffle and ventricular function. Diagnostic Testing and Their Most Important Findings: An ECG-gated cardiac CT demonstrated multiple defects between the systemic and pulmonary venous baffle (1A). CMR demonstrated a severely dilated right ventricle with moderately depressed systolic function, mild tricuspid valve insufficiency, and a moderately dilated, hyperdynamic left ventricle (LV). Advanced 4D flow confirmed a pulmonary to systemic blood flow ratio of 2.8:1, with large left-to-right shunt corresponding to the defects noted on CT (1B). There was no evidence of systemic or pulmonary venous baffle obstruction. 3D transesophageal echocardiography (echo) demonstrated multiple deficiencies in the septal/posterior atrial flap (1C). A stenotic, bicommissural pulmonary valve with moderate flow acceleration was also noted. 3D modelling from the CT/CMR data further clarified the location of the baffle leaks relative to pacemaker leads (1D). Cardiac catheterization confirmed these findings of large left-to-right shunt. Learning Points from this case: Atrial switch patients have a significant risk for baffle leaks, which can be challenging to identify. Advanced imaging including CT, CMR, 3D modeling, 3D echo, and cardiac catheterization are complimentary in the diagnosis of baffle leaks and can guide therapeutic options.

Left atrial function after standalone totally thoracoscopic left atrial appendage exclusion in atrial fibrillation patients with absolute contraindication to oral anticoagulation therapy.

Left atrial appendage (LAA) is a common source of thrombi in patients with atrial fibrillation (AF). The effect on left atrial (LA) function of the Totally Thoracoscopic (TT)-LAA exclusion with epicardial clip is currently unknown. This study aims at evaluating the effect of TT-LAA exclusion on LA function. Standalone TT-LAA exclusion with the clip device was performed in 26 patients with AF and contraindication to oral anticoagulation (OAC). A 3D CT scan, trans-esophageal echocardiography, spirometry and cerebrovascular doppler ultrasound were performed preoperatively. Clip positioning and LAA exclusion were guided and confirmed by intraoperative trans-esophageal echo. To evaluate LA function, standard transthoracic echocardiography and 2D strain of LA were performed before surgery, at discharge and at 3-month follow-up. The mean CHA2DS2-VASc and HASBLED scores were 4.6 and 2.4 respectively. There were no major complications during the procedure. At median follow-up of 10.3 months, 1 (3.8%) non-cardiovascular death, 1 (3.8%) stroke and 4 (15.4%) cardiovascular hospitalizations occurred. At 2D strain of LA, the reservoir function decreased significantly at discharge, compared to baseline and recovered at 3-months follow-up. Furthermore, NT-proBNP increased significantly after the procedure with a return to baseline after 3 months. Changes in E/A were persistent at 3 months. Our data in a small cohort suggest that TT-LAA exclusion with epicardial clip can be a safe procedure with regards to the atrial function. The LAA amputation impairs the reservoir LA function on the short term, that recovers over time.

Automatic alignment of standard views for transesophageal echocardiographic images.

3D transesophageal echocardiography (TEE) has become an important modality for pre- and peri-operative imaging of valvular heart disease. TEE can give excellent visualization of valve morphology in 3D rendering. As a convention, 3D TEE images are reformatted in three standard views. We describe a method for automatic calculation of parameters needed to define the standard views from 3D TEE images using no manual input. An algorithm was designed to find the center of the mitral valve and the left ventricular outflow tract (OT). These parameters defined the three-chamber view. The problem was modeled as a state estimation problem in which a 3D model was deformed based on shape priors and edge detection using a Kalman filter. This algorithm is capable of running in real time after initialization. The algorithm was validated by comparing the automatic alignments of 106 TEE images against manually placed landmarks. The median error for determining the mitral valve center was 7.1mm, and the median error for determining the left ventricular OT orientation was 13.5deg. The algorithm is an accurate tool for automating the process of finding standard views for TEE images of the mitral valve.

3D mitral annulus echocardiography assessment in patients affected by degenerative mitral regurgitation who underwent mitral valve repair with flexible band.

Degenerative mitral valve (MV)regurgitation (DMR) shows significative mitral annulus (MA) alterations; mitral valve repair (MVR) seeks to restore annular geometry and function, and the current use of flexible band seams to respect most annular mobility reducing parietal stress. Parameters of MV geometry obtained by 3D transesophageal echocardiography (3D-TTE) analysis are crucial for surgical planning and postoperative success. The aim of this study was to assess, by means of a dedicated software, the variations of MA geometry and function in patients affected by DMR compared to controls and after MVR with flexible band. We enrolled 32 patients (cases) with severe DMR who underwent MVR using flexible band; we compare this group with 20 controls. The TEE with 3D MV images acquisition was performed in both groups and then analyzed in postprocessing by using a dedicated software. There were no anthropometrics differences between cases and controls, both presented normal left ventricular ejection fraction. DMR group showed a significant increase of annulus dimensional parameters (p = .001) and alteration of nonplanarity comparing to controls (p < .05). The annuloplasty with flexible band induces a considerable reduction of MV dimensions comparing to preoperative data and restores physiological mobility and nonplanarity. There were no statistical differences between postoperative DMR and controls data, except for nonplanarity parameters (p ~.05), maybe influenced by hemodynamic settings. MVR with annuloplasty using flexible band appears able to reinstate a more physiological anatomic conformation of the MA, without compromising its dynamic properties.

Spatiotemporal Complexity of Vena Contracta and Mitral Regurgitation Grading Using Three-Dimensional Echocardiographic Analysis

Spatiotemporal complexity of the color Doppler vena contracta challenging the assumption of a circular and constant orifice may lead to mitral regurgitation (MR) grading inconsistencies. Using 3D transesophageal echocardiography, we characterized spatiotemporal vena contracta complexity and its impact on MR severity grading. In 192 patients with suspected moderate or severe MR (100 primary MR [PMR]; 92 secondary MR [SMR]), we performed three-dimensional vena contracta area (VCA) quantification using single-frame (midsystolic or VCAmid, maximum or VCAmax) and multiframe (VCAmean) methods, as well as measures of orifice shape (shape index) and systolic variation of VCA. Vena contracta complexity and intermethod discrepancies were analyzed and correlated with functional class and pulmonary vein flow (PVF) patterns and with cardiac magnetic resonance (CMR) in a subset of cases (n=20). The vena contracta was noncircular (shape index > 1.5) in 90% of patients. Severe noncircularity (shape index > 3) was more prevalent in SMR than in PMR (32.4% vs 14.6%). Variations of the VCA were more prominent in SMR than in PMR. VCAmid showed a low grading agreement with VCAmax (62%) and high grading agreement with VCAmean (83.3%). Pulmonary vein flow systolic reversal was associated with MR severity by VCA in SMR but not in PMR. VCAmid and VCAmean showed a stronger association with systolic flow reversal than VCAmax (area under the curve, 0.88, 0.86, and 0.79, respectively). In the subset of patients with CMR quantification, severe MR by VCAmax was graded as nonsevere by CMR more frequently compared with VCAmid and VCAmean. Highly prevalent spatiotemporal vena contracta complexity features in MR challenge the assumption of a circular and constant orifice. VCAmid seems the best single-frame approximation to multiframe quantification, and VCAmax may lead to severity overestimation.

Routine use of 3-dimensional zoom modality with 2-dimensional transesophageal echocardiography to decide the candidacy for transcatheter device closure of atrial septal defect

Abstract Background 2-dimensional transesophageal echocardiography (2D-TEE) and balloon sizing are commonly used for assessment of Ostium secundum atrial septal defect (OS-ASD) prior to device closure but complications do occur. Therefore, assessment of accurate morphology and anatomy of the defect in three-dimensional plane is essential for transcatheter device closure to be successful, which the 2D TEE fails to reveal. Purpose 2D TEE has long been used to decide size of the device required for transcatheter closure of OS-ASD and the appropriate candidates. However, complications like inadequate closure, leaving behind residual defect or device embolization often come into picture. The reason behind this is complex anatomy of some defects in the three-dimensional plane. Purpose of this study was to see if the routine use of 3D zoom with 2D TEE can better help to select the appropriate patients for device closure than that by 2 TEE alone. Methods We enrolled 71 OS-ASD patients from October 2020 to December 2021. All the patients underwent transesophageal echocardiography (TEE). Assessment of quantitative (number, shape and size of defect and size of residual rims) and qualitative (aneurysm, malalignment, fenestration) parameters was done by both 2D and 3D zoom. The measurements by 2D and 3D TEE clips were done by different operators. Transcatheter device closure was done for the patients with defect morphology and residual rims amenable for the same, with acceptable pulmonary pressure. Patients found to be adequate for the device closure by 2D TEE, when further found to have an unfavorable morphology by 3D TEE, were referred for surgical management. Follow up transthoracic echo was done after 1 month. Results Of the 71 patients, 65% were females and mean age was 26.23±10.75 years. By 3D TEE, 66% had circular defect,19% had oval defect and 14% had complex defect. 2 patients had spiral defect. Malalignment of the septum was seen in 4 (5.6%) patients by 2D TEE whereas in 13 (18.3%) patients by 3D TEE. Septal aneurysm was seen in 1 (1.4%) by 2D TEE whereas in 3 (4.2%) patients by 3D TEE. Mean largest size obtained by 2D was 24.82±9 mm and that by 3D was 26.23±8.42. By 3D TEE, 37 patients had at least one rim deficient (&amp;lt;5 mm). 3D Maximal diameter strongly correlated with 2D Maximal diameter (correlation coefficient 0.860; p&amp;lt;0.01). 9 (12.6%) patients found adequate for the device closure by 2D TEE were further found to have an unfavorable morphology by 3D TEE. 38 (53.5%) patients underwent device closure and 20 (28.2%) patients underwent surgical patch closure. At 1 month follow up all the 38 patients had device in-situ and had no residual shunt. Conclusions In OS-ASD patients, routine use of 3D zoom modality can complement 2D TEE in deciding appropriate patients for transcatheter device closure and help prevent many unforeseeable complications. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Jawaharlal Institute of Postgraduate Medical Education and Research

Measurement error in echocardiographic assessment of aortic stenosis: an epidemiological consideration of research methodology and clinical practice

Abstract Background/Introduction Current international guidelines on treatment of valvular heart disease contain recommendations for aortic valve replacement based exclusively on abnormal echocardiographic parameters in asymptomatic patients with aortic stenosis (AS). To prevent misclassification and subsequent mistreatment of patients, these recommendations require accurate and unbiased measurements of hemodynamic parameters. Purpose To illustrate consideration and impact of measurement error in echocardiographic assessment of aortic stenosis in both the research and clinical setting. Methods First, a systematic review was performed to investigate the recognition of and correction for measurement error in clinical studies on the prognostic value of peak aortic jet velocity (Vmax), mean pressure gradient (MPG), and effective orifice area (EOA). Second, all potential erroneous sources in the calculation of those primary parameters were listed stratified to random or systematic measurement error, and subsequently their magnitude was quantified. Third, the impact of various types of measurement error on current thresholds for intervention was graphically illustrated in different clinical scenarios. Results The presence of measurement error was acknowledged in 44% of the 36 included studies, while none utilized methods to correct for it. Interobserver variability ranged between 0.9–8.3% for Vmax and MPG but was substantially higher for EOA (range 7.7–12.7%) implying lower reliability (Figure 1). Furthermore, the invalid assumption of a circular left ventricular outflow tract area resulted in a median underestimation in EOA of 22.5% compared to 3D-transesophageal echocardiography (3D-TEE), computed tomography (CT), and cardiovascular magnetic resonance (CMR) planimetry. Figure 2 illustrates the impact of this discrepancy on the classification of AS using one-sided t-tests to determine the areas under the curve; the proportion of patients with non-severe AS in a hypothetical cohort (based on values from the PARTNER 3 trial [1[) increased by 42%. Conclusion(s) Measurement error is underrecognized in studies of echocardiographic assessment of aortic stenosis. This review demonstrates that random and systematic measurement errors affect echocardiographic assessment, leading to potential misdiagnosis and subsequent mistreatment. Clinicians and scientists should be aware of the implications of measurement errors to enhance rightful clinical decision-making and assure research validity. Funding Acknowledgement Type of funding sources: None.

Impact of a one-day three-dimensional transesophageal echocardiography workshop on clinical practice at a single academic centre.

Transesophageal echocardiography (TEE) is a powerful diagnostic tool which has become an integral part in the management of cardiac surgery patients. We developed a one-day 3D TEE workshop specifically designed to meet the needs of perioperative cardiac anaesthesiologists. We hypothesized that participation in the workshop would increase the uptake of 3D TEE in routine perioperative practice. To examine the impact of one-day 3D TEE workshop on 3D TEE image acquisition and incorporation into routine perioperative practice. Tertiary care hospital. Prospective observational monocentric study. A convenience sample of 20 cardiac anesthesiologists (with an option to attend the one- day workshop midway through the study) from a single center consented to have their intraoperative TEE images collected during the course of the study reviewed for research purposes. Images acquired 6 months before, immediately after, and 6 months following the workshop and images were examined by a blinded, expert echocardiographer. Data collected for 16 participants (8 workshop attendees, 8 non-attendees) indicate that the TEE workshop increased the number of 3D TEE images, but not x images acquired immediately following the workshop (P=0.006). No difference was observed in number of 3D images at six months' post workshop. Workshop participants obtained more 3D and multi-plane images after the workshop and more 3D images at 6 months compared to those who did not attend the workshop. Our study suggests that a single day hands-on 3D TEE workshop may have had an impact on the implementation of intraoperative 3D TEE in experienced echocardiographers.

Taking Command of Three-Dimensional Stitching Artifacts: From an Annoyance to an Easy Tool for Navigating Three-Dimensional Transesophageal Echocardiography

Despite many recent advances in three-dimensional (3D) transesophageal echocardiography (TEE) imagining, the process of orienting 3D TEE images is nonintuitive and uses assumptions based on idealized anatomy. Correlating two-dimensional TEE cross-sectional images to 3D reconstructions remains an additional challenge. In this article, we suggest the repurposing of the stitching artifact generated in 2-beat electrocardiogram-gated 3D TEE as a means of exactly orienting 3D images within a patient's unique anatomy. We demonstrate the application of this strategy to assess a normal mitral valve to localize scallops of mitral valve prolapse and to visualize typical left atrial appendage two-dimensional cuts in a 3D space. By taking command of stitching artifacts, cardiac imagers can successfully navigate the complex structures of the heart for optimal, individualized echocardiographic views.

Usefulness of a novel sizing chart for left atrial appendage occlusion with the Amplatzer Amulet.

The present article aims to compare a novel sizing chart based on both maximum and minimum diameters (novel MATRIX) with the current sizing recommendationinstructions for use(IFU) based on the maximum diameter. Current IFUwith the Amulet device are still based on the maximum left atrial appendage (LAA) diameter, which might lead to inappropriate oversizing, especially in elliptic appendages. This was a retrospective analysis of patients undergoing LAA occlusion in two high-volume centers. Two hundred patients were included (100 patients with baseline cardiac computed tomography angiography[CCTA] and 100 with baseline 2D and 3D-transesophageal echocardiography[TEE]). The degree of concordance between the predicted device size recommendation and the actual device selection was the primary outcome. The novel MATRIX showed a higher level of concordance between the predicted and implanted device size, regardless of imaging modalities. CCTA showed the strongest, and 2D-TEE the weakest concordance between the predicted and implanted device for both MATRIX and IFU charts. The percentage of patients in whom the disagreement among the predicted and implanted device represented &gt;1 size was higher when using the IFU chart. In elliptical LAA anatomies, the differences favoring the use of MATRIX compared to the IFU in terms of predicted/implanted agreement were higher. Finally, no significant differences in clinical or imaging endpoints were observed between the two different sizing charts. Incorporating both the LAA maximum and minimum diameters, as opposed to just maximum diameter, appears to improve sizing accuracy. The proposed MATRIX sizing chart offered a higher level of concordance between predicted and implanted device compared to the current IFU.

Automatic 3D mitral valve leaflet segmentation and validation of quantitative measurement

3D transesophageal echocardiography (TEE) is widely used in the diagnosis of mitral valve disease and is also well suited for guiding cardiac interventions. The aim of this work is to achieve patient-specific 3D TEE mitral valve leaflet segmentation without any user interaction and to assess the feasibility of 3D quantitative measurements on automatic segmentation model. We suggested a novel pre-training strategy to better implement automatic segmentation. The strategy refers to classify the diastolic and systolic states of the mitral valve through a 3D convolutional neural network architecture, and then use the pretrained weights obtained from the classification task to initialize the parameters of the 3D segmentation deep learning framework. To determine the accuracy of geometric parameters of segmentation model, the measurements of the segmentation model were compared with those obtained by the clinical software. Statistical analysis was performed by using Intraclass Correlation Coefficient and Bland–Altman method. Fourteen 3D volumes were used to evaluate the segmentation performance. The results show a Dice Similarity Coefficient (DSC) of 0.877±0.027 and an Average Surface Distance (ASD) of 0.925±0.392 mm. Twenty-eight 3D volumes were used for the quantitative measurement. The statistical results show that the mitral annular parameters have a good agreement between segmentation model and clinical software except for the annular height. We developed a fully automatic methodology to segment the mitral valve leaflet from 3D TEE and demonstrated the feasibility of improving segmentation performance with the proposed pre-training strategy. The automatic segmentation model was proved to be reliable for performing quantitative measurements of mitral valve annulus dimensions. The results indicate that the precision of the automatic segmentation methodology could pave the way for application in quantification, modeling and surgical planning tools.

Usefulness of perioperative transesophageal echocardiography during pediatric cardiac surgery

Pediatric transesophageal echocardiography (TEE) probes allow perioperative evaluation during pediatric congenital heart disease (CHD) surgery. The aim of the study was to determine the usefulness of perioperative TEE for evaluation of residual lesions severity according to the type of repaired CHD. Retrospective review of patients who underwent a perioperative TEE study during open-heart surgery (excluding ostium secundum atrial septal defect closure) over 4 consecutive years in our center. Residual lesions were rated as mild, moderate or severe. Among 291 interventions (which may include multiple gestures) in 280 patients (pts), no complications related to TEE study occurred. Median weight was 8.1 kg (range 2–96) and size of probe (micro 2D TEE, mini-multi 2D TEE or 3D TEE) adapted to the weight. Twenty-one (7.2%) severe residual lesions required immediate reintervention. Eleven pts (9.7%) had severe residual stenosis and required immediate reintervention out of 113 right ventricular outflow tract obstruction (RVOTO) surgeries. Three pts (3.5%) required immediate reintervention for aortic regurgitation and two (2.3%) for mitral residual lesions out of 86 left heart surgeries. Two pts (1.1%) required immediate reintervention for severe residual VSD out of 188 ventricular shunt surgeries. Two pts (4.2%) required immediate reintervention for superior vena cava stenosis following Warden procedure out of 47 pretricuspid shunt surgeries. One immediate reintervention occurred after a “Cone surgery” for severe right ventricle dysfunction. Use of perioperative TEE is safe and provides accurate information of residual lesions leading to several immediate intervention. RVOTO, left valvular and shunt closure surgeries could most likely benefit of its use.

Fully Automated 3D Segmentation and Diffeomorphic Medial Modeling of the Left Ventricle Mitral Valve Complex in Ischemic Mitral Regurgitation.

There is an urgent unmet need to develop a fully-automated image-based left ventricle mitral valve analysis tool to support surgical decision making for ischemic mitral regurgitation patients. This requires an automated tool for segmentation and modeling of the left ventricle and mitral valve from immediate pre-operative 3D transesophageal echocardiography. Previous works have presented methods for semi-automatically segmenting and modeling the mitral valve, but do not include the left ventricle and do not avoid self-intersection of the mitral valve leaflets during shape modeling. In this study, we develop and validate a fully automated algorithm for segmentation and shape modeling of the left ventricular mitral valve complex from pre-operative 3D transesophageal echocardiography. We performed a 3-fold nested cross validation study on two datasets from separate institutions to evaluate automated segmentations generated by nnU-net with the expert manual segmentation which yielded average overall Dice scores of 0.82±0.03 (set A), 0.87±0.08 (set B) respectively. A deformable medial template was subsequently fitted to the segmentation to generate shape models. Comparison of shape models to the manual and automatically generated segmentations resulted in an average Dice score of 0.93-0.94 and 0.75-0.81 for the left ventricle and mitral valve, respectively. This is a substantial step towards automatically analyzing the left ventricle mitral valve complex in the operating room.