3-dimensional Transesophageal Echocardiography Research Articles

The first four cases of successful NeoChord procedure in mainland China.

Transapical off-pump NeoChord procedure is a novel minimally invasive surgical repair of degenerative mitral regurgitation (MR). Here, we report the first four cases of NeoChord procedure in patients with mitral valve prolapse in mainland China. Four patients, aged 86, 84, 80 and 60 years, with severe MR due to posterior middle scallop prolapse (P2), underwent transapical off-pump artificial chordae implantation on April 9 and 10, 2019. The procedure was performed by left mini-thoracotomy under general anaesthesia and guided by 2D and 3D dimensional transoesophageal echocardiography (TEE). Mitral valve repair via NeoChord procedure was successfully performed with implantation of 3 artificial chordae in the first patient and 3, 2, and 3 artificial chordae in the following patients, respectively. Intraoperative TEE and pre-discharge transthoracic echocardiography (TTE) showed only mild to moderate MR of these four patients and no postoperative complications were noted. There were no changes of TTE finding between one-month follow-up and pre-discharge. The successful NeoChord procedures in four Chinese indicate that the valve repair using the NeoChord system for Chinese population is feasible.

A preliminary study for the feasibility and accuracy of three-dimensional printing mitral annulus models based on echocardiographic data

Objective To evaluate the feasibility of three-dimensional (3D) printing of mitral annulus with transesophageal echocardiographic volume images as the data source, and to assess the accuracy of the 3D printing mitral annulus models based on three dimensional transesophageal echocardiography (3D-TEE) images preliminarily. Methods A retrospective study was performed in 25 patients with mild or slight mitral regurgitation and 10 patients with moderate to severe mitral regurgitation. All the subjects were underwent 3D-TEE. The 3D-TEE volume images of mitral annulus at the end diastole were post-processed by Mimics software to create images of the mitral annulus in standard tessellation language format. The STL file was output to the 3D printer and the 3D printing models of mitral annulus were obtained. The mitral annulus size parameters including the diameter between anterior and posterior, the diameter between anterolaterior and posteromedial, sphericity index and mitral annulus circumference were measured from 3D printing models and 3D-TEE images, respectively. From which the absolute difference of the measurements between 3D printing models and the 3D-TEE images were calculated. Results All of the 3D-TEE images were successfully post-processed, and the corresponding 3D printing models were acquired by high-precision 3D printer. It showed no significant difference in all the mitral annulus size parameters between 3D printing models and 3D-TEE images (all P>0.05). Morever, the size parameters were concordant well between the two methods, all of the data points fell within the limits of agreement. It showed little absolute difference in value of the mitral annulus size parameters between the 3D printing mitral annulus models and the 3D-TEE images. Conclusions It is technically feasible to print 3D models of mitral annulus using 3D-TEE images as the data source. 3D printing mitral annulus models based on transesophageal echocardiographic volume images have high precision. Key words: Echocardiography, transesophageal; 3D printing technology; Mitral annulus; Feasibility; Accuracy

Role of real time-three dimensional transesophageal echocardiography in left atrial appendage closure with LACBES® devices.

Catheter-based left atrial appendage closure (LAAC) has recently become an innovative strategy for preventing embolic events in patients with nonvalvular atrial fibrillation (AF). There is limited information on optimal sizing for LAAC with the recently developed LACBES® device. The aim of the present study was to assess the role of real time-three dimensional transesophageal echocardiography (RT-3D TEE) for LACBES® device selection during LAAC. A total of 22 patients with nonvalvular AF and indications for LAAC were enrolled in the study. All patients underwent LAAC with LACBES® devices. TEE was performed in all patients 3 days prior to the procedure, during the procedure, and 3 months and 1 year following the procedure. Interatrial septal puncture, exchange of the sheath and release of the device were performed under the guidance of RT-3D TEE. The LAA ostium and landing zone dimensions measured by RT-3D TEE were better correlated with the device size used for occlusion (r=0.60, P=0.003) than those measured with two dimensional TEE or LAA contrast angiography. There were no clinically significant residual shunts, pericardial effusion or tamponade following occlusion. All patients had the device well-seated and presented no evidence of closure-associated complications during the follow-up. No cases of peri-procedural stroke or mortality were observed during a mean follow-up period of 12 months. In conclusion, RT-3D TEE is a reliable and effective imaging modality to guide LAAC using LACBES® devices in patients with nonvalvular AF at high risk of cardioembolic events.

The Most Accurate Method for Measurement of Mitral Valve Area in Mitral Stenosis by Direct Planimetery Three Dimensional Transesophageal Echocardiography (3D TEE)

DEAR EDITOR,Three-dimensional (3D) transesophageal echocardiography (TEE) is a powerful tool for assessment of mitral valve area with multiplanar reconstruction (MPR) or direct planimetery in patients with rheumatic mitral valve stenosis. Two dimensional transthorasic echocardiography (2D TTE) is a well-known conventional method in these patients which is used routinely. This method is less accurate than 3D TEE because mitral valve is saddle shaped and 2D images cannot image this valve correctly [1-7]. Exact method for 3D mitral valve area measurement is not determined yet and MPR was used as an accurate method. Direct planimetery by 3D TEE emerged as a novel method to evaluate mitral valve area with least variability [8].

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

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

3D-TEE for Measurement of the Aortic Annulus: a Review of the Literature and Step-By-Step Approach to an Essential Skill

The purpose of this paper is to review the measurement of the virtual aortic annulus using 3-dimensional (3D) transesophageal echocardiography (TEE). New software developments have allowed increased utility of 3D-TEE for aortic annulus analysis. 3D-TEE remains an alternative to multidetector row computed tomography (MDCT) for measurement of the aortic annulus prior to transcatheter aortic valve replacement (TAVR), but has been hampered by lack of semi-automated or automated technology. Automated software programs for 3D-TEE analysis of the aortic annulus are increasingly being developed to increase the ability for a wide array of users to perform pre-TAVR annulus analysis.

Quantitative analysis of mitral valve morphology in atrial functional mitral regurgitation using real-time 3-dimensional echocardiography atrial functional mitral regurgitation

BackgroundAtrial fibrillation (AF) can result in atrial functional mitral regurgitation (MR), but the mechanism remains controversial. Few data about the relationship between the 3-dimensional morphology of the MV and the degree of MR in AF exist.MethodsReal-time 3-dimensional transesophageal echocardiography (3D-TEE) of the MV was acquired in 168 patients with AF (57.7% persistent AF), including 25 (14.9%) patients with moderate to severe MR (the MR+ group) and 25 patients without AF as controls. The 3-dimensional geometry of the MV apparatus was acquired using dedicated quantification software.ResultsCompared with the group of patients with no or mild MR (the MR- group) and the controls, the MR+ group had a larger left atrium (LA), a more dilated mitral annulus (MA), a reduced annular height to commissural width ratio (AHCWR), indicating flattening of the annular saddle shape, and greater leaflet surfaces and tethering. MR severity was correlated with the MA area (r2 = 0.43, P < 0.01) and the annulus circumference (r2 = 0.38, P < 0.01). A logistic regression analysis indicated that the MA area (OR: 1.02, 95% CI: 1.01–1.03, P < 0.01), AHCWR (OR: 0.24, 95% CI: 0.14–0.35, P = 0.04) and MV tenting volume (OR: 3.24, 95% CI: 1.16–9.08, P = 0.03) were independent predictors of MR severity in AF patients.ConclusionsThe mechanisms of “atrial functional MR” are complex and include dilation of the MA, flattening of the annular saddle shape and greater leaflet tethering.

The Mechanism of Mitral Regurgitant Jets Identified by 3-Dimensional Transesophageal Echocardiography.

This study is a case report, which presents a case of severe mitral regurgitation in a 77-year-old man. Two-dimensional transesophageal echocardiography (TEE), regurgitant jets directed anteriorly in early systole and centrally to laterally in late systole were seen, while three-dimensional TEE showed a flail posterior middle scallop not only angulated centrally, but also laterally, which provided insight into the mechanism of mitral regurgitant jet direction. This case demonstrates the clinical usefulness of 3-dimensional TEE for identifying the mechanism of mitral regurgitant jets.The institution where the figures and the videos were recorded: Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada.

Validation of Quantitative 3-Dimensional Transesophageal Echocardiography Mitral Valve Analysis Using Stereoscopic Display

The use of 3-dimensional (3D) transesophageal echocardiography (TEE) in perioperative evaluation of the mitral valve (MV) is increasing progressively, including the use of 3D MV models for quantitative analysis. However, the use of 3D MV models in clinical practice still is limited by the need for specific training and the long time required for analysis. A new stereoscopic visualization tool (EchoPixel True 3D) allows virtual examination of anatomic structures in the clinical setting, but its accuracy and feasibility for intraoperative use is unknown. The aim of this study was to assess the feasibility of 3D holographic display and evaluate 3D quantitative measurements on a volumetric MV image using the EchoPixel system compared with the 3D MV model generated by QLAB Mitral Valve Navigation (MVN) software. This was a retrospective comparative study. The study took place in a tertiary care center. A total of 40 patients, 20 with severe mitral regurgitation who underwent mitral valve repair and 20 controls with normal MV, were enrolled retrospectively. The 3D-TEE datasets of the MV were analyzed using a 3D MV model and stereoscopic display. The agreement of measurements, intraobserver and interobserver variability, and time for analysis were assessed. Fair agreement between the 2 software systems was found for annular circumference and area in pathologic valves, but good agreement was reported for prolapse height and linear annular diameters. A higher agreement for all annular parameters and prolapse height was seen in normal valves. Excellent intraobserver and interobserver reliability was proved for the same parameters; time for analysis between the 2 methods in pathologic valves was substantially equivalent, although longer in pathologic valves when compared with normal MV using both tools. EchoPixel proved to be reliable to display 3D TEE datasets and accurate for direct linear measurement of both MV annular sizes and prolapse height compared to QLAB MVN software; it also carries a low interobserver and intraobserver variability for most measurements.

P3418A detailed assessment of geometric height of normal aortic cusps by 3-dimensional transesophageal echocardiography: implications for aortic valve repair surgery

P3418A detailed assessment of geometric height of normal aortic cusps by 3-dimensional transesophageal echocardiography: implications for aortic valve repair surgery

Acoustic characterization of a miniature matrix transducer for pediatric 3D transesophageal echocardiography

This paper presents the design, fabrication and characterization of a miniature PZT-on-CMOS matrix transducer for real-time pediatric 3-dimensional (3D) transesophageal echocardiography (TEE). This 3D TEE probe consists of a 32 × 32 array of PZT elements integrated on top of an Application Specific Integrated Circuit (ASIC). We propose a partitioned transmit/receive array architecture wherein the 8 × 8 transmitter elements, located at the centre of the array, are directly wired out and the remaining receive elements are grouped into 96 sub-arrays of 3 × 3 elements. The echoes received by these sub-groups are locally processed by micro-beamformer circuits in the ASIC that allow pre-steering up to ±37°. The PZT-on-CMOS matrix transducer has been characterized acoustically and has a centre frequency of 5.8 MHz, -6 dB bandwidth of 67%, a transmit efficiency of 6 kPa/V at 30 mm, and a receive dynamic range of 85 dB with minimum and maximum detectable pressures of 5 Pa and 84 kPa respectively. The properties are very suitable for a miniature pediatric real-time 3D TEE probe.

Surgical Echocardiography of the MV: Focus on 3D.

The mitral valve remains a complex structure where multiple forms of pathology can be seen. Mitral regurgitation continues to be one of the most common valvular diseases in the industrialized world. While intraoperative 2-dimensional transesophageal echocardiography has been commonplace for some time, 3-dimensional technology has emerged and has shown great benefit for diagnosis and guidance during mitral valve surgery. In the hands of a trained sonographer, high-quality real-time images can easily be obtained and correlate well with gross anatomical findings. The use of multiple angled views and color Doppler within 3-dimensional transesophageal echocardiography has become a valuable asset in the understanding and interpretation of the mitral valve for surgical interventions.

Differences in Two- and Three-Dimensional Assessment of the Mitral Valve by Novices and Experts, Illustrated Using Anterior Mitral Valve Leaflet Length

In this measurement validation study, the authors evaluated agreement between 2-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE), measuring anterior mitral valve leaflet length by both novice and experienced echocardiographers. This was a retrospective, observational study. Single university hospital. Analyses on datasets from 44 patients. None. Fifty datasets from 44 patients with mitral regurgitation were analyzed by 4 observers (2 novices, 2 experts). All observers measured the anterior mitral valve leaflet length from end-systolic 2D TEE images from the midesophageal longitudinal axis view and 3D software-augmented TEE images. The overall mean anterior mitral valve leaflet length was significantly shorter with 3D versus 2D TEE measurements (24.6 ± 4.5 mm v 26.2 ± 5.3 mm; p < 0.001), with novices measuring shorter leaflets than experts for both techniques (p < 0.001 and p = 0.005, respectively). Bland-Altman plots of 3D and 2D TEE measurements showed mean biases (95% limits of agreement) of -1.6 mm (-9.0 to 5.9 mm), -1.8 mm (-9.6 to 6.0 mm), and -1.3 mm (-8.4 to 5.7 mm) for all observers, novices, and experts, respectively. For 2D measurements, interobserver reliability was very strong among experts and strong among novices (Pearson's r = 0.83 v 0.66; p = 0.055). For 3D measurements, interobserver reliability was strong in experts and moderate in novices (Pearson's r = 0.69 v 0.51; p = 0.168). For both novices and experts, 3D TEE measurements of the anterior mitral valve leaflet were significantly shorter than 2D measurements. Interobserver reliability was lowest for novices making 3D TEE measurements, indicating that reliable, quantitative evaluation of 3D TEE may require a greater amount of practice.

Percutaneous Pulmonary Vein Stent Placement Guided by 2- and 3-Dimensional Transesophageal Echocardiography: A Case Report.

Percutaneous Pulmonary Vein Stent Placement Guided by 2- and 3-Dimensional Transesophageal Echocardiography: A Case Report.

OP-190 - Assessment of Bicuspid Aortic Valve Phenotypes and Associated Pathologies: A Transesophageal Echocardiographic Study

Objective We investigated the frequency of different bicuspid aortic valve disease (BAV) phenotypes,the associated valvular pathologies, and the aortopathy phenotypes, using 2-dimensional (2D) transthoracic, 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE. Methods A total of 154 patients with BAV were included. Five BAV phenotypes were detected. To better define valvular pathologies, binary classifications of BAV were used: BAV with antero-posterior commisural line (BAV-AP) and right-left commissural line (BAV-RL). Aortopathy phenotype was classified according to the involved tract(s). Results Of the patients, 53.2% had type 1, 16.2% type 2, 15.6% type 3, 1.3% type 4, and 13.6% had type 5 BAV. The prevalence of BAV-AP and BAV-RL was 68.2% and 31.8%, respectively. No difference was detected with respect to aortic regurgitation between BAV-AP and BAV-RL (p=0.9), but the BAVRL group had an increased propensity to have a stenotic aortic valve (p=0.003). The indexed aortic diameter was larger in BAV-AP cases than BAV-RL at the sinus of Valsalva (p=0.008). In patients with dilatation of the root and tubular portion, a predominance of BAV-AP versus BAV-RL was observed (85% vs 15%). A markedly low prevalence of the root phenotype (3.2%) was observed. In 90.1% of the patients, 2D TEE was sufficient to classify BAV phenotypes; further 3D imaging was needed in 9.9% of the cases. Conclusion There may be racial differences in the frequency of valvular and aortopathy phenotypes in patients with BAV. BAV phenotypes differ with respect to aortic stenosis and aortopathy phenotypes. TEE may have good diagnostic utility in differentiating BAV phenotypes.

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

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

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

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

Role of three dimensional transesophageal echocardiography in predicting mitral regurgitation after percutaneous balloon mitral valvuloplasty

BackgroundPercutaneous balloon mitral valvuloplasty (PBMV) can be complicated with significant mitral regurgitation (MR). We performed a pilot, prospective study to evaluate the role of three dimensional transesophageal echocardiography (3D-TEE) in the prediction of MR after PBMV through mitral valve quantification (MVQ). MethodsBetween October 2014 and October 2016, 37 patients with rheumatic, moderate-to-severe mitral stenosis, referred to the Cath lab of Bab Alshearia University hospitals for PBMV, were divided into two age and sex matched groups. Group I included 25 patients without significant MR following PBMV [vena contract area (VCA) <0.4cm2], while group II included 12 patients with significant MR after PBMV [VCA ≥0.4cm2]. Both groups were comparable in terms of TEE data, Wilkins score for favorability of PBMV and baseline hemodynamics. ResultsData from MVQ showed that both groups were comparable (p>0.05) in terms of MV annulus quantification (Anteroposterior diameter, annular sphericity, 3D area and height), MV scallops (A1, A2, A3, P1, P2 and P3) areas, as well as A1 and A2 tenting volumes. However, we recorded significant differences between the two groups as regard total MV, A2, P2 and P3 tenting volumes (p<0.05) and tenting height (p=0.03), as well as A2, A3 and P2 prolapse volumes (p<0.05). Moreover, our data showed a significant difference between both groups in terms of MV coaptation heights (p=0.01), but not in anterior coaptation length (p=0.13). ConclusionMitral valve quantification through 3D-TEE is a simple automated method, easily applicable to patients before PBMV. Moreover, MVQ-derived data, such as MV scallops' tenting and prolapse volumes, coaptation heights, and exposed and total A2 lengths may predict the possibility of significant MR after PBMV.

Acute intraoperative echocardiographic changes after transapical off-pump mitral valve repair with NeoChord implantation

ObjectivesOur aim is to investigate the acute intraoperative effects of the NeoChord repair procedure on mitral valve (MV) annular geometry and LV function and the impact of these changes on MR at 1-year follow-up. BackgroundRecently transapical off-pump mitral valve repair with NeoChord implantation has been demonstrated to be safe and effective in patients with degenerative mitral regurgitation (DMR). MethodsWe retrospectively analyzed baseline and early postoperative 3-dimensional transesophageal echocardiography of 66 patients who underwent NeoChord repair for isolated posterior leaflet MV disease using semiautomatic off-line analysis software. ResultsWe observed a significant acute reduction of indexed LV end diastolic volume (Δ% = 14, p < .001), LV ejection fraction (Δ = 5.7%, p = .002), indexed left atrial volume (Δ = 14.7%, p = .045), and pulmonary artery pressure (Δ = 2.1%, p = .026). Among MV geometric parameters, we observed a significant reduction of MV antero-posterior diameter (Δ = 7%, p < .001), sphericity index (Δ = 8%, p < .001), annulus circumference (Δ = 0.9%, p = .021), and annulus area (Δ = 2.7%, p = .018). At 1-year, 53 patients (85.5%) presented MR ≤ mild, while 9 patients (14.5%) had MR ≥ moderate. Reduction of AP diameter (OR = 0.14, CI −3.83; 0.08, p < .001), annulus circumference (OR = 0.27, CI −2.98; 0.37, p = .005), MV area (OR = 0.39, CI −2.46; 0.61, p = .04), aorto-mitral angle (OR = 0.38, CI −2.49; 0.54, p = .002) and iEDV (OR = 0.44, CI −2.44; 0.81, p = .001) were independent protective factors against recurrence of MR greater than mild at 1-year follow-up. ConclusionsTransapical NeoChord repair produces important acute intraoperative changes in MV anatomy in DMR patients. The acute changes observed were associated with procedure durability at 1-year FU.

Left atrial enlargement and clinical considerations in patients with or without a residual interatrial shunt after closure of the left atrial appendage with the WATCHMAN\u2122-device

BackgroundInterventional closure of the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation, high thromboembolic and bleeding risk or bleeding history is an alternative therapeutic strategy to oral anticoagulation. It is not known if the exclusion of the LAA from the blood circulation affects the left atrial volume (LAV) and consequently its prognostic value or the circulatory performance of the heart in humans.MethodsWe aimed to prospectively assess potential changes in baseline LAV, left ventricular ejection fraction (LVEF), NT-proBNP-level and the covered distance in the 6-min walk-test 6 weeks and 6 months after LAA closure with the WATCHMAN™ device. We used serial 3-dimensional transthoracic and transesophageal echocardiography to assess LAV, residual interatrial shunt and device performance in 58 consecutive patients with successful LAA closure.ResultsAccurate 3D–echocardiographic data for LAV measurements were evaluable for 51 (91%) patients. Maximum LAV (LAVmax) at baseline was 102.8 ± 30.8 ml and increased significantly to 107.7 ± 32.8 ml after 6 weeks (p < 0.01) and 113.5 ± 34.2 ml after 6 months (p < 0.01). Minimal LAV (LAVmin) increased from 76.9 ± 29.5 ml at baseline to 81.8 ± 30.2 ml after 45 days (p < 0.01) and 82.1 ± 33.3 ml after 6 months (p < 0.01). Similarly, their indexes to BSA (LAVImax and LAVImin) increased significantly, as well. Patients without a residual left-to-right interatrial shunt showed a significantly higher increase in LAVmax or LAVmin. Baseline LVEF, NT-proBNP-level or the distance covered at the 6-min walk test did not significantly change 6 weeks or 6 months after LAA closure.ConclusionsLAVmax and LAVmin increase significantly after interventional LAA closure. LA enlargement does not correlate with clinical progression of heart failure. Persistent left-to-right interatrial shunt counteracts the LA enlargement. A reduced LA compliance after exclusion of the LAA from the blood circulation with consecutive increase in LA pressure may be a potential cause of LA enlargement and warrants further investigation.Trial registrationGerman Clinical Trials Register ID: DRKS00010768; Registration Date 07.07.2016.