3D TOE Research Articles

Uncommon incidental 3D TOE findings: RA-LA clots within a PFO

The chest X-ray was normal. The 12 lead ECg showed sinus tachycardia with evidence of right ventricular (RV) strain and T wave inversion in V1-3. arterial blood gases (aBg) demonstrated hypoxia with so2 88.7%. The Ddimer was significantly raised; mild Troponin I rise as well as the inflammatory markers were found raised. The patient underwent CT pulmonary angiogram (CTpa) which showed large bilateral proximal pulmonary emboli and evidence of early right heart strain. Doppler ultrasound of left leg veins revealed partially occluded left distal superficial femoral vein (sFV) by a thrombus.

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

119 DEFINING PATENT FORAMEN OVALE MORPHOLOGY USING THREE-DIMENSIONAL TRANSOESOPHAGEAL ECHOCARDIOGRAPHY AND RELATIONSHIP TO SHUNT SIZE

Background Three dimensional transoesophageal echocardiography (3D TOE) has allowed better understanding of atrial septal anatomy and patent foramen ovale (PFO) morphology. Anatomical variations seen in patients undergoing transcatheter device closure may influence device choice and procedural success. Currently there is no standardised approach to 3D TOE imaging of a PFO. The aim of this study was to utilise a 3D imaging protocol to describe/quantify PFO morphological features of clinically important PFO9s and relate our findings to shunt size. Methods We examined 3D TOE images of the atrial septum in consecutive patients with otherwise structurally normal hearts undergoing TOE assessment prior to PFO closure. Datasets were obtained using Philips iE33 and then analysed offline (QLab 3DQ, Philips Healthcare). Linear measurements recorded included: tunnel dimensions, fossa ovalis dimensions, and septal sway. Other characteristics assessed included left atrial opening morphology, right atrial anatomy and presence of an atrial septal aneurysm (>10 mm septal excursion from the midline). Morphological features were categorised as either simple or complex. Complex defects were those with one or more of the following: long tunnel length (>8 mm), multiple openings into the left atrium, atrial septal aneurysm, hybrid defect (additional small defect(s) in fossa ovalis), thick secundum septum (>8 mm), Eustachian ridge (ER), Eustachian valve or Chiari network. The size of right-to-left shunt either at rest or with Valslava manoeuvre was assessed by transthoracic contrast echocardiography and graded according to the number of bubbles seen in a single still frame in the left atrium as: small-to-moderate ( 50 bubbles). Results 3D datasets were available for analysis in 73 patients. Mean age of the population was 47±12.7 years. and 62% were male. The most frequent indication for PFO closure was stroke (48%). Linear dimensions recorded from 3D datasets are presented (table). Left atrial opening was categorised as high, opening onto the left atrial roof, in 18% of patients and presence of multiple left atrial openings was observed in 8%. Atrial septal aneurysm was present in 12%. A prominent Eustachean ridge was seen in 78% patients and was positioned high on fossa ovalis in 32% cases. The majority of patients (88%) had one or more complex morphological features. There was no clear association observed between shunt size and size of PFO. Conclusions 3D transoesophageal echocardiography allows a practical, qualitative, and quantitative assessment of PFO morphology. In our cohort of patients a variety of complex anatomical features are demonstrated. Shunt size did not correlate with PFO dimensions.

Left ventricular volume and ejection fraction assessment with transoesophageal echocardiography: 2D vs 3D imaging

Developments in transducer technology have enabled the use of three-dimensional transoesophageal echocardiography (3D TOE) in the operating theatre. Transthoracic echocardiography (TTE) 3D left ventricular (LV) volumes and ejection fraction (EF) agree better with magnetic resonance imaging (MRI) measurements, with less intra- and inter-observer variability compared with 2D. This has not been validated with 3D TOE. The aim of this study was to assess the bias, limits of agreement, and reproducibility of 3D TOE and 2D TOE LV volumes and EF in cardiac surgical patients. Sixty-three patients having cardiac surgery with TOE were evaluated. LV volumes and EF were calculated using modified Simpson's method on 2D mid-oesophageal four- and two-chamber views, xPlane, and from a 3D full-volume data set. Intra- and inter-observer variability were assessed in a subset of 17 patients. Real-time 3D TOE volume and EF assessment was possible in 59 of the 63 patients. Median end-diastolic volumes (EDVs) as measured by 2D, xPlane, and 3D techniques were 98.5, 94, and 97 ml. Median ESVs were 38.5, 40 and 35.6 ml. Median EFs were 58, 54 and 62.2%. There were no significant pairwise differences between these measurements. The limits of agreement for all comparisons were wide, and there were no statistically significant differences between the three methods in intra- or inter-observer variability. The intraoperative use of 3D TOE to estimate LV volumes and EF has small bias compared with 2D assessments, wide limits of agreement, and no clear advantages compared with standard 2D TOE imaging in terms of LV volume and EF assessment.

Transfemoral implantation of an Edwards SAPIEN valve in a tricuspid bioprosthesis without fluoroscopic landmarks

We describe the first report of an Edwards SAPIEN valve implanted in a tricuspid bioprosthesis from the femoral vein. We highlight the feasibility of this previously avoided approach and the techniques involved. A 61-year-old woman with multiple valve replacements for rheumatic heart disease presented with NHYA IV dyspnoea secondary to a severely stenosed tricuspid bioprosthesis. After failed aggressive medical therapy and surgical turn down, an Edwards SAPIEN XT valve was deployed in the tricuspid bioprosthesis via the right femoral vein. Adaptations to the standard transfemoral transcatheter aortic valve implantation (TAVI) technique included: (1) crossing the tricuspid bioprosthesis with a balloon floatation catheter; (2) temporary pacing wire in the coronary sinus rather than the right ventricle; (3) mounting of the SAPIEN XT valve in the reverse orientation to transfemoral TAVI; and (4) fine positioning of the final valve position pre-deployment by 3D transoesophageal echocardiography (3D TOE) alone due to complete radiolucency of the tricuspid bioprosthesis. The procedure was completed without complication and resulted in significant symptomatic improvement. Deployment of an Edwards SAPIEN valve in a tricuspid bioprosthesis via the femoral vein is feasible and, with careful adaptations to established TAVI techniques, can be performed without complications and with good clinical response.

Left Atrial Appendage Closure for Non-valvular Atrial Fibrillation

© C N igure 1. (A) The LAA closure device has a foam occluding surface (arrow) and an atrial surface woven from polytetrafluroethane (double arrow). B) The “fish-tail” appearance of the LAA (arrow) was demonstrated with reconstructed C-arm imaging, which is a novel use of this technology. C) The LAA (arrow) in the reconstructed image. (D) Imaging with 3D TOE was also utilised to characterise the LAA as this structure may have ariable geometry as well as for sizing and positioning the device prior to deployment. (E) Post-procedure fluoroscopy confirmed the device was ell-seated (arrow).

O-36 Complementary role of real time 3D TOE full volume data set during problem oriented 2D TOE

A complete intraoperative 2D TOE requires multiple standard views in order to perform various measurements necessary for quantification of cardiac chambers and valves. In Germany most centres only perform problem oriented intraoperative TOE examination which does not allow all required measurements to be done due to lack of time [1]. The present study investigated if all the measurements following the EACTA/EAE recommendations [2] could accurately be performed with the acquisition of one RT 3D TOE full volume (FV) data set compared to 2D standard views.

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography

AimsWe sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair.Methods and resultsIn 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height.ConclusionSuperimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

The Utility of 3D TOE in the Assessment of Crista Terminalis Mimicking a Right Atrial Mass

The Utility of 3D TOE in the Assessment of Crista Terminalis Mimicking a Right Atrial Mass

Three-Dimensional Quantitative Analysis of Rheumatic Mitral Valve in Childhood: Inter-Observer Variation

Background: Three-dimensional transoesophageal echocardiography (3D TOE) has potential to quantitate abnormalities of the mitral valve annulus and leaflets improving understanding of mitral valve dysfunction, and assisting surgical intervention. Reproducibility of available geometric indices is unknown.

Comparing Tissue Doppler Imaging with Speckle Tracking in Estimating Left Ventricular End Diastolic Pressure

and intraconduit thrombus, fibroelastomas, prosthetic valve anatomy and visualization of periprosthetic defects, atrial masses and atrial septal geometry. The additional information provided by biplane and RT 3D imaging was useful in guiding intervention and clinical decision making. Conclusions: Biplane 2D and RT 3D TOE imaging provides significant additional useful clinical information in approximately 30% cases referred. doi:10.1016/j.hlc.2009.05.054

3D TOE Assessment of PFO Anatomy: Surprising Results with Implications for Percutaneous Closure

3D TOE Assessment of PFO Anatomy: Surprising Results with Implications for Percutaneous Closure

Percutaneous transcatheter closure of atrial septal defects: initial single-centre experience and follow-up results. Initial experience with three-dimensional echocardiography.

Objective — Registry to report our single-centre experience in closing defects of the atrial septum.Methods — Between 1996 and 2001, transcatheter device closure of significant atrial septal defects was performed in 32 adults (mean age 45.1 years, range from 15 to 76 years), using different device types. Six patients had a patent foramen ovale (PFO) and 26 patients had a secundum atrial septal defect (ASD II). Defects were selected by means of two-dimensional transoesophageal echocardiography (2D TOE). For 12 defects additional three-dimensional transoesophageal echocardiography (3D TOE) was performed.Results — Mean balloon-stretched diameter was 19.3 mm (range from 11 to 24 mm). A device was successfully placed in all PFO patients (100%) without complications at follow-up. Successful immediate device placement occurred in 24 out of 26 ASD patients.Two immediate placement failures, 1 device embolisation and 1 device non-fixation, occurred and required urgent surgery. There was 1 patient with pericardial effusion after the intervention, requiring pericardiocentesis. Three late placement failures occurred: 2 device embolisations and 1 device dislocation. Clinical success after 3 to 6 months follow-up, defined as the absence of shunt or small shunt, was achieved in all 6 PFO patients and in 21 out of 23 ASD patients (1 device embolisation, requiring surgery, occurred before follow-up was completed).Two patients with significant shunt, 1 late device dislocation and 1 late device embolisation, underwent elective surgery. For patient selection, 3D TOE proved useful in the evaluation of large and/or complex defects.Conclusion — Transcatheter device closure of carefully selected atrial septal defects is an alternative to surgery. Although the results are promising, surgical back-up is often needed.