3-dimensional Transesophageal Echocardiography Research Articles

Mass in the Left Atrial Appendage: A Therapeutic Dilemma

This is a case of a persistent mobile mass in the left atrial appendage in which 3-dimensional transesophageal echocardiography provided excellent definition of the contour of the mass and helped in comparison during follow-up. The mass was incidentally found before atrial fibrillation ablation and initially thought to be a thrombus. As it persisted almost unchanged despite adequate anticoagulation, a tumour such as a fibroelastoma became the leading possibility, presenting us with a management dilemma. Ablation was cancelled, and, because the mass was stable with no embolic sequelae, a conservative approach was adopted. The patient was discharged on long-term anticoagulation.

Left Atrium Reverse Remodeling in Patients With Mitral Valve Stenosis After Percutaneous Valvuloplasty: A 2- and 3-Dimensional Echocardiographic Study

Introduction and objectivesThe left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3-dimensional transthoracic echocardiography. MethodsWe carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 [11.5]) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemodynamic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction. ResultsThe 3-dimensional parameters of the mitral valve stenosis patients before and 72h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm2; 1.8 (0.2) cm2 (P<.001); 1.7 (0.2) cm2 (P<.001); b) left atrium maximum volumes: 49.9 (12) mL/m2; 42 (11.4) mL/m2 (P<.001); 40.3 (10.2) mL/m2 (P<.001), and c) left atrium emptying fraction: 30.1 (9.4%); 40.6 (7.4%) (P<.001); 44.1 (8%) (P<.001), respectively. ConclusionsIn symptomatic mitral valve stenosis patients who underwent percutaneous balloon valvuloplasty analysis by 2- and 3-dimensional echocardiography, improvements in left atrium reverse remodeling and left atrium emptying fraction were observed 72h and 12 months after the procedure.

Remodelado inverso de aurícula izquierda en pacientes con estenosis de válvula mitral tras valvuloplastia percutánea: estudio ecocardiográfico bidimensional y tridimensional

Introduction and objectivesThe left atrium is clinically relevant in patients with mitral valve stenosis. The objective of this study was to analyze the effects of percutaneous balloon valvuloplasty on left atrium volumes and the left atrium emptying fraction in symptomatic mitral valve stenosis patients using 2-dimensional and real-time 3 -dimensional transthoracic echocardiography. MethodsWe carried out a prospective study of 28 consecutive symptomatic mitral valve stenosis patients, aged 22-72 (39 [11.5]) years, 24/28 (85.6%) women, who underwent to percutaneous balloon valvuloplasty between March 2009 and May 2011. Patients underwent 2- and 3-dimensional transthoracic and transesophageal echocardiography (atrial fibrillation) and invasive mitral valve area measurement. Echocardiographic analysis was performed before, 72 h after and 12 months after percutaneous balloon valvuloplasty. The following parameters were analyzed: a) mitral valve area (2-dimensional planimetry, pressure half-time, 3-dimensional echocardiography, invasive hemodynamic measurement); b) indexed left atrium maximum and indexed minimum volumes, and c) left atrium emptying fraction. ResultsThe 3-dimensional parameters of the mitral valve stenosis patients before and 72 h and 12 months after percutaneous balloon valvuloplasty were as follows: a) mitral valve area: 0.9 (0.1) cm2; 1.8 (0.2) cm2 (P<.001); 1.7 (0.2) cm2 (P<.001); b) left atrium maximum volumes: 49.9 (12) mL/m2; 42 (11.4) mL/m2 (P<.001); 40.3 (10.2) mL/m2 (P<.001), and c) left atrium emptying fraction: 30.1 (9.4%); 40.6 (7.4%) (P<.001); 44.1 (8%) (P<.001), respectively. ConclusionsIn symptomatic mitral valve stenosis patients who underwent percutaneous balloon valvuloplasty analysis by 2- and 3-dimensional echocardiography, improvements in left atrium reverse remodeling and left atrium emptying fraction were observed 72 h and 12 months after the procedure.Full English text available from:www.revespcardiol.org/en

Reply to the Editor

We thank Dr Bozok and colleagues for their useful comments and suggestions to reduce paravalvular leak after transapical aortic valve implantation. In our study based on data from the Italian Registry of Trans-Apical Aortic Valve Implantation,1D’Onofrio A. Rubino P. Fusari M. Salvador L. Musumeci F. Rinaldi M. et al.Clinical and hemodynamic outcomes of “all-comers” undergoing transapical aortic valve implantation: results from the Italian Registry of Trans-Apical Aortic Valve Implantation (I-TA).J Thorac Cardiovasc Surg. 2011; 142: 768-775Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar the incidence of paravalvular leak (trivial and mild) was 38%, and this is consistent with the incidence reported by other series.2Unbehaun A. Pasic M. Dreysse S. Drews T. Kukucka M. Mladenow A. et al.Transapical aortic valve implantation: incidence and predictors of paravalvular leakage and transvalvular regurgitation in a series of 358 patients.J Am Coll Cardiol. 2012; 59: 211-221Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Reducing the incidence of paravalvular leak is of outmost importance to improve patient outcomes. In fact, it has been demonstrated that the presence of paravalvular aortic regurgitation after transcatheter aortic valve implantation is associated with an increased rate of late mortality and that the effect of aortic regurgitation on mortality is proportional to the severity of the regurgitation. Furthermore, even mild aortic regurgitation is associated with an increased rate of late deaths.3Kodali S.K. Williams M.R. Smith C.R. Svensson L.G. Webb J.G. Makkar R.R. et al.Two-year outcomes after transcatheter or surgical aortic-valve replacement.N Engl J Med. 2012; 366: 1686-1695Crossref PubMed Scopus (1896) Google Scholar Overexpansion of the Sapien valve after deployment might be useful, but it is controversial and should be performed carefully. Many complications can occur after this procedure, including not only coronary ostia occlusion, but also rupture of the aortic annulus and injury to the prosthetic valve leaflets. Furthermore, in our experience, overexpansion of the Sapien valve after deployment is often associated with a small (or none) reduction of the degree of paravalvular regurgitation. We agree with Dr Bozok that asymmetry of the calcium distribution over the leaflets and annulus is a major determinant of paravalvular regurgitation; however, other important causes should be also carefully considered such as correct sizing and correct positioning. Correct sizing needs an experienced multidisciplinary and multimodal (2-dimensional and 3-dimensional transthoracic and transesophageal echocardiography, multidetector computerized tomography scan) evaluation of the annulus dimensions and shape (the annulus is often oval and not circular) and a semiquantitative evaluation of the amount of calcium on the annulus and the leaflets. In fact, for the intermediate annulus diameters, the choice of a larger or a smaller valve depends on the amount of calcium. A larger valve in an extremely calcified annulus can cause rupture of the aortoventricular junction with consequent massive hemorrhage. However, a small valve in a poorly calcified annulus can lead to paravalvular regurgitation or, more dramatically, device embolization. Correct positioning requires experience and a strong synergic cooperation among all the components of the transcatheter aortic valve implantation team. The definition of valve malpositioning includes not only a valve positioned too high or too low, but also a problem of alignment between the valve and longitudinal axis of the aortic annulus. An asymmetric “diagonal” landing of the prosthesis on the annulus might lead to paravalvular regurgitation and to an abnormal stress on the leaflets with a greater potential risk of early structural dysfunction. In conclusion, we believe that even if valve overexpansion might be carefully considered to reduce paravalvular leak, the transcatheter aortic valve implantation results can be increased mainly by improving patient selection, annulus sizing, valve positioning, and cooperation among members, as well as the experience of the transcatheter aortic valve implantation team. Can the success of transcatheter aortic valve implantation be increased?The Journal of Thoracic and Cardiovascular SurgeryVol. 144Issue 2PreviewWe congratulate the authors on their study.1 After application of a size 26 Sapien valve to one third of the patients, the postoperative effective orifice area was noted to be 1.67 cm2 and the geometric size was 2.5 cm2 in the size 21 Sapien valve. This suggests that the balloon should be inflated more. Instead of “hinge-to-hinge” or “virtual ring” calculations, we suggest that an experienced cardiac surgeon can decide which leaflet should be dilated to what degree, while inflating the valve using computed tomography or echocardiography, because the Sapien valve is located at the leaflet and not at the annulus. Full-Text PDF

Real-Time Three-Dimensional Transesophageal Echocardiography

Successful surgical repair of a regurgitant mitral valve (MV) is dependent on a comprehensive assessment of its complex anatomy. Although there is limited evidence of the feasibility and accuracy of intraoperative real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in MV surgery, its use is increasing worldwide. We designed this prospective observational study of patients with mitral regurgitation to test initial findings on the accuracy of RT3DTEE images in the diagnosis of MV prolapse and chordal rupture relative to 2D imaging and to assess the potential of RT3DTEE for visualizing leaflet clefts. TEE-certified anesthesiologists examined 62 consecutive patients undergoing MV surgery by acquiring a full standard set of 2D TEE sections and 3D zoom recordings. Offline, 2D and 3D images were presented independently and in randomized order to 2 expert interpreters. Accuracy was determined using the surgical findings as the "gold standard." Surgical inspection identified 52 cases of MV prolapse (MVP). RT3DTEE correlated stronger with the surgical findings than 2D TEE for detection and localization of MVP (difference in proportions=33.9%, P<0.001) and chordal rupture (difference in proportions=25.8%, P<0.001). The superiority of RT3DTEE was significant for scallops A2, P1, P2 in MVP and A2, P2 in chordal rupture (all P<0.05). In 22 patients, leaflet clefts were also surgically repaired, and RT3DTEE was feasible in accessing them (κ=0.65, confidence interval [0.44, 0.81]). Although 2D TEE is currently the standard tool for intraoperative imaging in MV surgery, RT3DTEE improves the visualization of MV pathology and increases the accuracy of interpretation by facilitating spatial orientation. Further investigations, particularly those aimed at establishing its cost effectiveness, are indicated.

Multimodality Imaging of a Gerbode Defect

A 76-year-old woman with a history of aortic valve replacement was referred for echocardiography for routine postoperative evaluation. Transthoracic echocardiogram revealed evidence of an intracardiac shunt between the left ventricle (LV) and the right atrium (RA) (Figure 1A). Figure 1. Illustration of LV-RA shunt by ( A ) 2-dimensional transthoracic echocardgiography, ( B ) 2-dimensional transesophageal echocardiography, and ( C ) 3-dimensional transesophageal echocardiography. LV indicates left ventricle; RA, right atrium; RV, right ventricle; LA, left atrium; TV, tricuspid valve. A transesophageal echocardiogram confirmed the presence of an LV to RA shunt consistent with a Gerbode defect (Figure 1B and 1C). To …

Direct Measurement of Multiple Vena Contracta Areas for Assessing the Severity of Mitral Regurgitation Using 3D TEE

The aim of this study was to determine whether direct measurement of multiple-jet vena contracta (VC) areas by real-time 3-dimensional (3D) transesophageal echocardiography is an accurate method for measuring the severity of mitral regurgitation (MR) in patients with multiple MR jets. Because of the conflicting requirements of Doppler and imaging physics, measuring VC using 2-dimensional (2D) echocardiography is a difficult procedure for assessing MR severity. A real-time 3D echocardiographic measurement of the VC area has been validated in a single jet of MR, but the applicability of this method for multiple jets is unknown. Two-dimensional and 3D transesophageal echocardiography was performed in 60 patients with multiple functional MR jets. MR severity was assessed quantitatively using the effective regurgitant orifice area derived from 3D left ventricular volume and thermodilution data (EROAstd). Manual tracings of multiple 3D VC areas in a cross-sectional plane through the VC were obtained, and the sum of the areas was compared using EROAstd. Similarly, 2D measurement of VC diameter was obtained from a 2D transesophageal echocardiographic view to optimize the largest legion size in each jet. All VC diameters were summed and compared with EROAstd. The correlation of the sum of the multiple 3D VC areas with EROAstd (r = 0.90, p < 0.01) was higher than that of the sum of the multiple 2D VC diameters (r = 0.56, p < 0.01), particularly with MR degrees greater than mild (r = 0.80, p < 0.01 vs. r = 0.05, p = 0.81) and in cases of 3 or more regurgitant jets (r = 0.91, p < 0.01 vs. r = 0.46, p = 0.05). Direct measurement of multiple VC areas using 3D transesophageal echocardiography allows for assessing MR severity in patients with multiple jets, particularly for MR degrees greater than mild and in cases of more than 2 jets, for which geometric assumptions may be challenging.

Quantification of mitral valve regurgitation with color flow Doppler using baseline shift

Vena contracta width (VCW) and effective regurgitant orifice area (EROA) are well established methods for evaluating mitral regurgitation using transesophageal echocardiography (TEE). For color-flow Doppler (CF) measurements Nyquist limit of 50-60 cm/s is recommended. Aim of the study was to investigate the effectiveness of a baseline shift of the Nyquist limit for these measurements. After a comprehensive 2-dimensional (2D) TEE examination, the mitral regurgitation jet was acquired with a Nyquist limit of 50 cm/s (NL50) along with a baseline shift to 37.5 cm/s (NL37.5) using CF. Moreover a real time 3-dimensional (RT 3D) color complete volume dataset was stored with a Nyquist limit of 50 cm/s (NL50) and 37.5 cm/s (NL37.5). Vena contracta width (VCW) as well as proximal isovelocity surface area (PISA) derived EROA were measured based on 2D TEE and compared to RT 3D echo measurements for vena contracta area (VCA) using planimetry method. Correlation between VCA 3D NL50 and VCW NL50 was 0.29 (p < 0.05) compared to 0.6 (p < 0.05) using NL37.5. Correlation between VCA 3D NL50 and EROA 2D NL50 was 0.46 (p < 0.05) vs. 0.6 (p < 0.05) EROA 2D NL37.5. Correlation between VCA 3D NL37.5 and VCW NL50 was 0.45 (p < 0.05) compared to 0.65 (p < 0.05) using VCW NL37.5. Correlation between VCA 3D NL37.5 and EROA 2D NL50 was 0.41 (p < 0.05) vs. 0.53 (p < 0.05) using EROA 2D NL37.5. Baseline shift of the NL to 37.5 cm/s improves the correlation for VCW and EROA when compared to RT 3D NL50 planimetry of the vena contracta area. Baseline shift in RT 3D to a NL of 37.5 cm/s shows similar results like NL50.

Recurrent Ischaemic Mitral Regurgitation Post Mitral Annuloplasty due to Suture Dehiscence Evaluated Using Real Time Three Dimensional Transoesophageal Echocardiography

Ischaemic mitral regurgitation after myocardial infarction results from geometric changes in left ventricular shape and displacement of papillary muscles with resultant tethering and incomplete leaflet coaptation of mitral leaflets. Post mitral valve repair, both valve apparatus related factors such as persistent leaflet tethering and progressive left ventricular adverse remodelling and procedure related factors such as ring dehiscence are important causes of recurrent mitral regurgitation after initial undersized mitral ring annuloplasty. Three-dimensional echocardiography is a novel clinical tool that has the potential to provide additional anatomical and functional information regarding the mechanism of recurrent mitral regurgitation post mitral valve repair that is complementary to standard two dimensional transoesophageal echocardiography thus helping guide the most appropriate subsequent therapeutic intervention.

Comparison of Accuracy of Mitral Valve Regurgitation Volume Determined by Three-Dimensional Transesophageal Echocardiography Versus Cardiac Magnetic Resonance Imaging

Direct planimetry of anatomic regurgitation orifice area (AROA) using 3-dimensional transesophageal echocardiography (TEE) has been described. This study sought to (1) compare mitral valve regurgitant volume (RV) derived by AROA using 3-dimensional TEE with RV obtained by cardiac magnetic resonance (CMR) imaging and (2) determine the impact of AROA and flow velocity changes throughout systole on the dynamic variation in mitral regurgitation. In 43 patients (71 ± 11 years old) with mild to severe mitral regurgitation, 3-dimensional TEE and CMR were performed. Mitral valve RV was determined based on (1) AROA at 5 subintervals of systole and analysis of the regurgitant continuous-wave Doppler signal at equal durations of systole, (2) effective regurgitation orifice area (EROA) using the proximal isovelocity surface area method, (3) CMR with subtraction of aortic outflow volume from left ventricular stroke volume. RV calculated by AROA tended to overestimate RV less than RV calculated by EROA compared to RV by CMR (average bias +20 ml, 95% confidence interval [CI] -41 to +81, vs +13 ml, 95% CI -22 to 47). In patients with RV >30 ml by CMR, overestimation of RV using the AROA method was less than using the EROA method (difference in means +18 ml, 95% CI 4 to 32, p <0.001). AROA determined by 3-dimensional TEE varied by only 18% among the 5 subintervals of systole, and the velocity time integral of the subinterval with the highest flow was 120% of the subinterval with the lowest flow. In conclusion, 3-dimensional TEE allows accurate analysis of mitral valve RV. In the clinically relevant group of patients with RV >30 ml as defined by CMR, the AROA method results in less overestimation of RV than the EROA method. Changes in AROA during systole contribute much less to dynamic variation in mitral regurgitation severity than changes in regurgitant flow velocity.

Side-by-Side Comparison of Fluoroscopy, 2D and 3D TEE During Percutaneous Edge-to-Edge Mitral Valve Repair

catheter-based mitral valve clip repair is an effective procedure in selected patients with mitral regurgitation. Fluoroscopy and 2-dimensional transesophageal echocardiography (2D TEE) are the primary imaging modalities for guidance mitral-clip procedure. Real-time 3-dimensional transesophageal

Dehiscence of an Aortic Valved Conduit: A Three-dimensional Echocardiographic View

We present the case of a 47 year old patient with a history of bicuspid aortic valve disease, severe symptomatic stenosis and dilation of the ascending aorta who underwent an aortic root reconstruction using the Bentall procedure. Two years after surgery, asymptomatic until then, the patient experienced general discomfort with progressive dyspnea, orthopnea and atypical chest pain for 1 month. The evolution was slow, gradually evolving to dyspnea on minimal effort. An electrocardiogram (ECG) revealed diffuse subendocardial injury and increased biomarkers (troponin I 31.6 ng/mL; creatine kinase-MB 147 IU/L) and the patient was referred to our center for an emergency coronary angiogram. Our initial examination found the following: the patient was generally unstable, hypotensive (90/60 mmHg) and tachycardia, no fever, dyspnea at rest, grade 3/6 aortic systolic murmur radiating to the carotids, ECG showing ST depression in V3-V6 and leukocytosis (29 000/mL). A transthoracic echocardiogram was performed, revealing abnormal movement of the prosthetic ring (Pr) suggesting dehiscence with grade III/IV periprosthetic aortic regurgitation. The study was completed with a real-time 3-dimensional transoesophageal echocardiography. We observed complete prosthetic valve dehiscence (Fig. 1) and a periprosthetic cavity at the level of the aortic root, corresponding to a pseudoaneurysm (Ps) with an internal flow and systolic collapse of the prosthetic conduit (PC) (Fig. 2). Emergent surgery was performed, which confirmed the echocardiographic findings (Fig. 3). The aortic valve conduit was replaced. Blood cultures were positive for Enteroccus faecalis, and the patient therefore completed 6 weeks of antibiotic treatment with ampicillin and streptomycin. Postoperative progress was good with no complications. (*) Area of dehiscence Hospital Son Dureta-Echocardiology

Perfect Correspondence of Mitral Valve Perforation Using Real-Time 3-Dimensional Transesophageal Echocardiography

![Figure][1] [![Graphic][3] ][3] Critical information about the exact anatomic characteristics of the mitral valve can be obtained using real-time 3-dimensional transesophageal echocardiography (RT3D TEE), which could be used in planning an appropriate intervention strategy. The

The role of real-time 3-dimensional transesophageal echocardiography in depiction of the concealed base of the iceberg

The role of real-time 3-dimensional transesophageal echocardiography in depiction of the concealed base of the iceberg

Acute aortic dissection with ongoing right coronary artery and aortic valve involvement

Acute aortic dissection Acute myocardial infarction Right coronary artery Severe aortic regurgitation Three dimensional transesophageal echocardiography Computed tomography

Echocardiographic Evaluation of Iatrogenic Atrial Septal Defect After Catheter-Based Mitral Valve Clip Insertion

The geometries and sizes of persistent iatrogenic atrial septal defects (IASDs) after transseptal puncture during catheter-based mitral valve clip insertion (MVCI) have not been detailed. In this study, 11 IASDs were investigated in 10 patients who underwent MVCI using a guide catheter (24Fr proximally and 22Fr at the atrial septum). The diameters of the long and short axes and the area at maximum and minimum during a cardiac cycle were measured after MVCI using real-time 3-dimensional (RT3D) transesophageal echocardiography (TEE). A circular shape was assumed on 2-dimensional TEE, resulting in an area calculation of π × (dimension/2)(2). The anatomic geometries of IASDs were visualized in a 3-dimensional en face view of the atrial septum. Furthermore, 1 month after MVCI, IASDs were evaluated using echocardiography. The IASDs had a variety of irregular geometries. The mean long-axis diameter was 1.0 ± 0.24 cm, the mean short-axis diameter was 0.51 ± 0.22 cm, and the mean area was 0.40 ± 0.24 cm(2) on RT3D TEE. The diameters and area changed significantly between the maximal and minimal values during the cardiac cycle. Importantly, 2-dimensional TEE underestimated the maximal diameters of IASDs (0.54 ± 0.17 vs 1.0 ± 0.24 cm by RT3D TEE, p <0.01) and the maximal areas of IASDs (0.25 ± 0.15 vs 0.40 ± 0.23 cm(2) by RT3D TEE, p <0.05). One month after MVCI, the smallest and the second smallest IASDs had closed, and the other 9 remained open. In conclusion, RT3D TEE is useful to assess the irregular geometries of IASDs created during MVCI.

Value of Real Time Three Dimensional Transesophageal Echocardiography in General Cardiology Practice

Value of Real Time Three Dimensional Transesophageal Echocardiography in General Cardiology Practice

Mitral Valve Repair for Double-Orifice Mitral Valve With Flail Leaflet: The Usefulness of Real-Time Three-Dimensional Transesophageal Echocardiography

We describe a 66-year-old man who required an operation for severe mitral regurgitation associated with a double-orifice mitral valve. Real-time 3-dimensional transesophageal echocardiography clearly demonstrated a double-orifice mitral valve with a central fibrous bridge. A flail posterior leaflet was observed on the anterolateral mitral valve orifice. Mitral valve repair using P1 triangular resection, anterolateral commissure plication, and ring annuloplasty with Duran band (Medtronic, Minneapolis, MN) was successfully performed. Postoperative real-time 3-dimensional transesophageal echocardiography demonstrated a double-orifice mitral valve without regurgitation or stenosis.

Comparison of Left Ventricular Outflow Geometry and Aortic Valve Area in Patients With Aortic Stenosis by 2-Dimensional Versus 3-Dimensional Echocardiography

The present study sought to elucidate the geometry of the left ventricular outflow tract (LVOT) in patients with aortic stenosis and its effect on the accuracy of the continuity equation-based aortic valve area (AVA) estimation. Real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) provides high-resolution images of LVOT in patients with aortic stenosis. Thus, AVA is derived reliably with the continuity equation. Forty patients with aortic stenosis who underwent 2-dimensional transthoracic echocardiography (2D-TTE), 2-dimensional transesophageal echocardiography (2D-TEE), and RT3D-TEE were studied. In 2D-TTE and 2D-TEE, the LVOT areas were calculated as π × (LVOT dimension/2)(2). In RT3D-TEE, the LVOT areas and ellipticity ([diameter of the anteroposterior axis]/[diameter of the medial-lateral axis]) were evaluated by planimetry. The AVA is then determined using planimetry and the continuity equation method. LVOT shape was found to be elliptical (ellipticity of 0.80 ± 0.08). Accordingly, the LVOT areas measured by 2D-TTE (median 3.7 cm(2), interquartile range 3.1 to 4.1) and 2D-TEE (median 3.7 cm(2), interquartile range 3.1 to 4.0) were smaller than those by 3D-TEE (median 4.6 cm(2), interquartile range 3.9 to 5.3; p <0.05 vs both 2D-TTE and 2D-TEE). RT3D-TEE yielded a larger continuity equation-based AVA (median 1.0 cm(2), interquartile range 0.79 to 1.3, p <0.05 vs both 2D-TTE and 2D-TEE) than 2D-TTE (median 0.77 cm(2), interquartile range 0.64 to 0.94) and 2D-TEE (median 0.76 cm(2), interquartile range 0.62 to 0.95). Additionally, the continuity equation-based AVA by RT3D-TEE was consistent with the planimetry method. In conclusion, RT3D-TEE might allow more accurate evaluation of the elliptical LVOT geometry and continuity equation-based AVA in patients with aortic stenosis than 2D-TTE and 2D-TEE.

Multimodality Imaging of Thrombus in Transit Crossing a Patent Foramen Ovale

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4] A 77-year-old woman presented with chest pain and dyspnea. Transthoracic echocardiography suggested a mobile, ill-defined right atrial mass. Real-time 3-dimensional transesophageal echocardiography demonstrated a large, highly