3D Transoesophageal Echo Research Articles

Left Atrial Remodeling in Patients With Severe Rheumatic Mitral Stenosis and Sinus Rhythm Using Two-Dimensional and Three-Dimensional Speckle Tracking Echocardiography

In mitral stenosis (MS), the combination of an increase in left atrium (LA) pressure and atrial inflammatory response is accompanied by increase in interstitial fibrosis of the atrial wall with disorganization of atrial muscle bundles, LA dysfunction and subsequently LA dilatation. We aimed to assess the effect of severe rheumatic MS on LA volumes and mechanics. We enrolled 40 patients with pure severe rheumatic MS and sinus rhythm as a patient group and 30 healthy subjects as a control group. All patient and control groups underwent two-dimensional (2D) transthoracic echo to measure left ventricle (LV) dimensions, function, LA deformations, estimated systolic pulmonary artery pressure (EPAP), and left ventricle global longitudinal strain (LV GLS). Also LA volumes and mechanics (LA strain during LV systole (reservoir function) and LV diastole (early = conduit, and late = booster pump = atrial contraction)) were measured by three-dimensional (3D) transthoracic echo; mitral valve (MV) area was measured by 3D transesophageal echo (as routine pre-percutaneous MV commissurotomy using multiplanar reconstruction in mid-esophageal apical long-axis view from LA prospective). By 2D transthoracic echo, patient group revealed significantly lower all LA function vs. control group including LA strain during reservoir (24 ± 6 vs. 43 ± 3, P < 0.001), LA strain during conduit (-11 ± 3 vs. -25 ± 2, P < 0.001), and during booster pump (-13 ± 4 vs. -18 ± 1, P < 0.001). EPAP was significantly higher in patient group (48 ± 7 vs. 27 ± 4 in control group). LV GLS was significantly lower in patient group (-16±2% vs. -23±2% in control group). All 3D LA volumes were significantly higher in patient group than control group including maximum LA volume (LAVmax) (76 ± 18 vs. 50 ± 5, P < 0.001), indexed LA volume (LAVi) (44.6 ± 10.1 vs. 28.7 ± 3.7, P < 0.001), LV minimum volume (LAVmin) (51 ± 15 vs. 30 ± 4, P < 0.001), and LA volume pre atrial contraction (LAVpre A) (63 ± 15 vs. 41 ± 6, P < 0.001). Also, there was significantly decreased LA strain using 3D speckle tracking echo in patient group including systolic deformation of LA (reservoir function) (23 ± 6 vs. 41 ± 3, P < 0.001) and diastolic deformation, early diastole (conduit function) (-10 ± 2 vs. -24 ± 2, P < 0.001), and late diastole (booster pump function) (-13 ± 4 vs. -18 ± 1, P < 0.001). All LA function markedly reduced in pure severe rheumatic MS. The reduction of LA mechanics is directly related to the degree of reduction of the stenotic MV area. LV GLS significantly reduced in severe MS and its reduction is directly related to the degree of reduction of the stenotic MV area and the LAVi by 3D echo.

Echocardiography in the Assessment of Valve Regurgitation- Incremental Role of Three Dimensional Echocardiography.

Echocardiography (Echo) has a primary role in the evaluation of cardiac valve regurgitation. Echo valve regurgitation assessment includes multiple qualitative and quantitative methods which require adequate image quality, comprehensive echocardiographic images and precise measurements to obtain accurate assessment. For patient management, it is also important to investigate the mechanism of valve regurgitation. Severity and mechanism of valve regurgitation determine whether continued medical follow up is optimal or surgical or percutaneous valve repair, or replacement option should be necessary. Transthoracic Echo (TTE) is the gold standard most commonly used for the assessment of valve leaflet anatomy, valve motion and regurgitation severity to determine primary versus secondary causes of valve regurgitation, however transesophageal echo (TEE) provides high resolution imaging of valve leaflets and supporting apparatus and oftentimes determines mechanism of valve regurgitation particularly for mitral and tricuspid valves when TTE is unable to determine the mechanism. By providing surgical type views in a moving heart under normal hemodynamic conditions, 3D TEE has greatly improved assessment of mechanism and etiology of valve regurgitation. Besides, TEE also allows quantitation of valve regurgitation severity by Doppler methods as well as direct 3D planimetry of valve area and regurgitant orifice area. Doppler methods are pre and afterload dependent whereas direct 3D planimetry allows assessment of location and severity of valve regurgitation irrespective of ventricular loading conditions. Pre or intraoperative 3D TEE assessment can provide valuable information for surgical planning of valve repair or replacement. This review discusses various valvular pathologies causing regurgitation and the role of TTE and TEE in improving this assessment as shown by several case examples.

Real-time 3D, 2D trans esophageal echocardiography for the evaluation of rheumatic mitral stenosis initial single center experience

Abstract : Mitral stenosis (MS) is one form of heart disease of a valvular nature. Narrowing of the mitral valve orifice occurs in the Mitral stenosis. The most common cause of MS is rheumatism fever. Other uncommon causes of MS are calcification of the mitral valve leaflets, congenital heart disease, infective endocarditis, mitral annular calcification, endomyocardial fibroelastosis. The study aims to determine the consistency and viability of using 3dimensional transthoracic echocardiography 3DTEE planimetry (MVA 3D) for mitral valve area (MVA) dimensions in patients that have rheumatic mitral stenosis (RhMS). : A cross-sectional study with analytic elements. The data collection was carried out in the Shahid Al- Mihrab outpatient department. Forty-one patient patients underwent Transesophageal echo (TEE) to eliminate atrial thrombi in the left side, referring to our outpatient department for echocardiographic examination and evaluation of RhMS and suitability for percutaneous mitral valvoplasty (PTMV). The investigator and administrator arranged a self-restricted survey form to collect data from the members by straight meeting with participants. Forty-one patients had MS due to rheumatic heart disease (RhHD), where all (100%) assess MVA measurement by 3DTEE. It was significantly low if compare with mitral valve area by transthorasic echo planimetry (MVA TTE planimetry), mitral valve area by transthorasic echo (MVATTEPHT). However, mitral valve area by continuity equation by transthoracic echo (MVAconTTE) measurement was feasible in 5 patients only (12%), were no significant correlation between them. Mitral valve area by transesophageal echo,3dimension (MVA3DTEE) the best agreement with MVA2DTTE PLANEIMETRY was demonstrated (95 percent agreement limits and then with MVAPHTTTE (95 percent agreement limits. The mean ± SD of MVA3D TEE was 1.06 ± 0.79 cm2 in patients with minimal fusion, the mean ± SD of MVA3DTEE was 0.79±0.21 cm2, in patients with partial fusion, and the mean ± SD of MVA3D TEE was 0.69 ± 0.15 cm2 with complete fusion. There was a significant difference in the mean MVA3D TEE among the different degrees of fusions by 3D TEE (p=0.02). Three-dimensional (3D) TEE echocardiography has demonstrated accuracy for measuring MV area for both calcific also improved the “description” of valve anatomy, and provided an advantage for less experienced operators as a method for MV area measurements.

Three-Dimensional Echo and Three-Dimensional Transesophageal Echocardiography for Mitral Valve Disease

Three-dimensional (3D) echocardiography is one of the greatest technologies, which has a significant contribution in the field of valvular heart disease, especially after the development of real-time (RT) capability in transthoracic as well as transesophageal imaging during the past decade. RT 3D transesophageal echo has provided a simplified imaging tool for the anatomy of mitral valve (MV), including the MV annulus, leaflets, and subvalvular apparatus. Three scallops of anterior and posterior leaflets are easily recognized. This helps in localizing the MV abnormality, for example, MV prolapse and flail MV. This also helps in localizing the mitral regurgitation (MR). Even the quantification of MR has also seen a novel understanding of RT 3D planimetry of MR jet, which is possible by newer machines. Commissural inequality and calcification is well identified, and it helps in choosing the cases for percutaneous balloon mitral valvuloplasty. More recently, this technology with RT 3D transesophageal echocardiography has found a role in interventional procedure, for example, balloon mitral valvuloplasty, paravalvular leak closure, and edge-to-edge (MitraClip) repair of degenerative MV.

OC02 AUTOMATIC 3D-ECHO AORTIC ANNULUS MEASUREMENT FOR A PRECISE PREOPERATIVE TAVI PLANNING: IS IT ALREADY FEASIBLE?

Background and aim: Transcatheter aortic valve implantation is a wide-spreading technique. The advent of recent softwares based on 3D transoesophageal echo is updating the role of ultrasound in the preoperative prosthesis sizing because of its potentiality to provide precise measurements of the aortic annulus avoiding X-ray and contrast material. Aim of this study is to verify the reliability of echo measurements. Methods: We enrolled 15 patients with severe aortic stenosis and 5 with healthy aortic valve. All patients underwent ECG-gated angio CT-scan and 3D transoesophageal echocardiogram. We blindly compared the two sets of data focusing on annulus and sinuses dimensions. Results: Statistically significant differences were found in aortic annulus diastolic maximum diameter and perimeter. Although not significant, the small differences highlighted in systole would have led to the choice of a different prosthesis size in 33% of the patients in case of CoreValve Evolut R, in 40% in case of Sapien 3 and in 60% in case of Lotus valve. Conclusions: Although not significant, the small differences between echo and CT measurements, if at the extremities of different size range, lead to a different transcatheter prosthesis size choice with potential relevant clinical effect.

AUTOMATED DETECTION OF MITRAL VALVE ANNULAR AND LEAFLET GEOMETRY: ECHOCARDIOGRAPHY AND CT COMPARISON

Background: Mitral valve (MV) interventions require accurate anatomic data, but existing methods are time-consuming. We compared novel automated MV detection based on machine learning using both 3D transesophageal echo (3DE TEE) and cardiac CT (CCT). Manual 2D TEE (2DE) measurements were also made

Clinical Application of 3-Dimensional Echocardiography in the USA

Three-dimensional (3D) echocardiography is one of the most promising methods for the diagnosis of cardiac disease. Left and right ventricular size and function are currently evaluated with 2D echocardiography. However, for unpredictable asymmetry of the chamber geometry, conventional 2D echocardiography cannot be used to accurately determine absolute chamber volumes and ejection fraction. As for valvular heart diseases, the 3D echo approach has proven to be the most unique, powerful, and convincing method for understanding the complicated anatomy of the valves and their dynamism. The method has been useful for surgical management, including robotic mitral valve repair. Moreover, this method has become indispensable for nonsurgical procedures such as edge-to-edge mitral valve repair. Color Doppler 3D echo has also been valuable to identify the location of the regurgitant orifice, and the severity and character of the valvular regurgitation. In addition, 3D echo is invaluable in the diagnosis and management of congenital heart disease and in certain other situations, such as evaluation of the aortic annulus for transcatheter aortic valve implantation or replacement. It is now clear that 3D echocardiography, especially with the continued development of real-time 3D transesophageal echo technology, will enhance the diagnosis and management of patients with heart diseases.

Quantitative analysis of mitral valve geometry by transthoracic three-dimensional echocardiography: accuracy, feasibility, reproducibility and reference values

Purpose: Quantitative analysis of mitral valve (MVQA) can discriminate among mechanisms causing valve insufficiency. However, MVQA has been performed only on data sets acquired using 3D transoesophageal echo (TOE). There are neither reference values for MV geometry assessed by transthoracic 3DE (3DTTE), nor data on its feasibility and reproducibility. Methods: 30 consecutive pts with indication for TOE constituted the validation group. In each pt, we acquired 2 MV data sets by both 3DTTE (31±6 vps) and 3DTOE (28±13 vps, p=NS) using Vivid E9 with 4V and 6VT-D probes (GE Healthcare, N). In the reference group, we studied 81 healthy volunteers (43±13 yrs, range 18-70; 33 men) in whom we acquired 3D TTE full-volume data sets of MV apparatus (32±2 vps). MV datasets were analyzed offline using a prototype software for 3DTTE (TomTec MV 2.0, Unterschleissheim, D). Intra- and inter-observer reproducibility was reported as intraclass correlation coefficients (ICC) in 15 subjects. Results: In the validation group, we found good correlations (r=0.86 to 0.69, p<0.001) and agreement (biases from -0.004 to 0.0 cm) with no significant differerences between MVQA parameters measured by 3DTOE and 3DTTE. In the reference group, 5 subjects were excluded due to poor MV tracking (feasibility 94%). Average analysis time of datasets (including manual editing) was 2'. Reference values for MVQA and their reproducibility are shown in Table. Leaflet tenting and annulus measures were positively correlated with body surface area (BSA, r=0.34-0.53, p<0.001), but not with age. No gender difference in MV parameters was detectable after indexation by BSA. View this table: Reference values for MV by 3D TTE Conclusion: MVQA by 3DTTE is accurate, highly feasible and reproducible. Our reference values may support the implementation of MVQA by 3DTTE in clinical practice.

3D Transesophageal Echo in Percutaneous Correction of Paraprosthetic Regurgitation

About 210,000 valve replacement surgeries are performed annually worldwide. Paraprosthetic regurgitations are a complication that can happen, especially in mechanical prostheses and reoperations, reaching a prevalence of 10 to 15% in follow-up studies1. Surgical treatment remains the first choice, especially when there are significant symptoms and hemolysis. However, due to high perioperative mortality (6-14%)2,3, percutaneous techniques for correction of paraprosthetic regurgitation have been developed, although there are not yet specific occlusion devices. Real time three-dimensional transesophageal echocardiography (3DTEECHO) plays a fundamental role in the procedure since diagnosis, quantification of regurgitation, location and measurements of the regurgitant orifice, guiding in real-time the implantation of percutaneous prostheses. The initial experience of our service is four cases of occlusion of mitral paraprosthetic regurgitation percutaneously. Although we have not achieved complete resolution of regurgitation in three cases (two remained with moderate regurgitation and one with discreet regurgitation), it is worth noting that the procedures were conducted without complications and all patients improved functional class after implantation. In order to discuss the role of echocardiography this context, we describe a case where the complete occlusion of the paraprosthetic defect was achieved after implantation of the devices.

Abstract 18366: Cutoff of 1.0 cm 2 For Severe Aortic Stenosis? A Case for Redefining this Cutoff Based on Eccentricity of LVOT Geometry

Background: Current guidelines define severe aortic stenosis (AS) as aortic valve area (AVA) of &lt;1.0 cm 2 . This cutoff is based on the assumption of a circular left ventricular outflow tract (LVOT) cross sectional area (CSA) for the continuity equation (CE). However, patients with AS have chronic pressure load and may have remodeling of the LVOT geometry from circular to elliptical. An elliptical LVOT with a smaller dimension in the anterior-posterior plane would result in a lower calculated AVA. Many patients have discrepant indices of severe AS where AVA by CE is severe (&lt;1.0 cm 2 ) yet peak velocity (V2) and mean gradient (MG) are in the moderate or mild range. We hypothesized that discordance of AS severity by AVA versus V2 or MG may be due to inaccurate circular LVOT CSA assumption in patients with AS where chronic pressure load results in an elliptical LVOT geometry. Methods: We assessed LVOT geometry by direct planimetry using 3D transesophageal echo (TEE) and calculated an eccentricity index (ratio of two orthogonal linear measurements and also ratio of CSA direct planimetry/CSA by circular LVOT assumption) in 54 patients with severe AS undergoing TTE and TEE within one month of each other. We compared AVA by elliptical LVOT (AVA LVOT ) to conventional circular LVOT CE. We then applied a correction factor for AVA underestimation based on the measured LVOT eccentricity index in a separate cohort of 49 patients with discrepant AS indices (AVA &lt;1.0 cm 2 but MG &lt;30 mmHg). Results: LVOT shape was elliptical in 53 of 54 (98%) patients with a mean eccentricity index of 0.88 ± 0.06 by 3D TEE. The mean LVOT CSA assuming circular geometry underestimated the true CSA determined by direct planimetry by approximately 14% (3.25 vs. 3.71 cm 2 , p&lt;0.001). AVA LVOT was higher than AVA by conventional CE (0.71 vs. 0.61 cm 2 , p=0.003). After multiplying the LVOT CSA by correction factor of 1.14 (to account for 14% underestimation of LVOT area) in 49 patients with discrepant severe AS (mean AVA, V2 and MG of 0.88 cm 2 , 3.2 m/s and 23 mmHg, respectively), the mean AVA increased to 1.0 cm 2 . Conclusions: The LVOT geometry in patients with AS is predominantly elliptical with an eccentricity index of 0.88. The cutoff for severe AS valve area by conventional CE should be 0.8 cm 2 to adjust for elliptical LVOT geometry.

117 Tricuspid valve annular dynamics in normal vs dilated right hearts; a 3D TOE Study

BackgroundThe tricuspid valve annulus (TVA) is a complex three dimensional structure that is non-planar, and is incompletely understood. The dynamics of the normal TVA has not been described in any...

Recommendations for transoesophageal echocardiography: update 2010

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Should we be using 3D transesophageal echocardiography instead of 2D for the assessment of aortic annular diameter in transcatheter aortic valve implantation?

Objectives: Transcatheter aortic valve implantation is a relatively new procedure aimed at patients deemed too high risk for conventional aortic valve replacement. Accurate imaging of the aortic annulus is necessary for prosthetic valve sizing and we aimed to see if there was a difference between 2D and 3D transesophageal echo (TEE) regarding this measurement.

Abstract 5796: Real-Time 3D Transesophageal Echo Enhances the Diagnostic Capabilities of Patent Foramen Ovale in Patient’s with Cerebral Vascular Accidents

Real-time 3D transesophageal echo (RT3D TEE) is a novel technology whereby RT3D rendering of ultrasound images is performed resulting in unique views of cardiac structures. We have presented initial data reporting the incidence of optimal en face visualization of cardiac structures including the fossa ovalis (FO). We aimed to further characterize the FO. Therefore, our hypotheses were that the FO could be seen en face in full circumferential view (CV) in most patients and saline contrast RT3D TEE would enhance the accuracy of patent foramen ovale (PFO) diagnosis compared to contrast 2D TEE. Therefore, in an unselected series of 124 patients referred for TEE, we performed RT3D TEE with specific views of the FO using the Philips x7–2t RT3D TEE transducer. Images of the FO were acquired in the real-time 3D, 3D zoom, and full volume modes. Visualization of the FO was scored by 2 separate observers using the following scale: full CV of the FO &gt;1/2 CV &lt;1/2 CV no visualization. The visualization score was 1.44. The average maximal and minimal diameters of the FO during the cardiac cycle were 1.46±0.90 and 1.12±0.12cm and an average maximum area of 169±20mm2. The sensitivity of saline contrast RT3DTEE for PFO diagnosis was 100% with specificity of 96% due to 3 cases where PFO was seen only by RT3D TEE. RT3DTEE allows complete circumferential visualization of the FO in the majority of cases. Our determination of the size of the FO compares favorably with pathologic series Some cases of PFO can be expected to be detected only by RT3DTEE and therefore this technique should be performed when 2D TEE is negative for PFO but clinical suspicion remains high.

Quantification of mitral regurgitation orifice area by 3-dimensional echocardiography: comparison with effective regurgitant orifice area by PISA method and proximal regurgitant jet diameter

Background: The evaluation of mitral regurgitation (MR) by 3-dimensional (3D) echo has generally been performed by reconstruction of Doppler regurgitant jets but there are little data on measuring anatomic regurgitant orifice area (AROA) directly from 3D mitral valve (MV) reconstructions. Methods and results: Transoesophageal echo (TOE) 3D images were acquired from 38 unselected patients (age 59±11 years, ten in atrial fibrillation) with various degrees of MR. In all patients MV was reconstructed en face from the left atrium (LA) and the left ventricle (LV). AROA was measured by planimetry from 3D pictures and compared to the effective regurgitant orifice area (EROA) by proximal isovelocity surface area and proximal MR jet width from 2D echo. AROA was measured in 95% of patients from LA, 89% from LV and in 84% from both LA and LV. Good correlation was found between EROA and AROA measured from both LA ( r=0.97, P<0.0001) and LV ( r=0.87, P<0.0001). The mean difference between LA-AROA and EROA was −3.01±6.12 mm 2 and −7.18±13.84 mm 2 for LV-AROA ( P<0.01, respectively). An acceptable correlation was found between the proximal MR jet width and AROA from LA ( r=0.71, P<0.0001) and LV perspective ( r=0.68, P<0.0001). AROA≥25 mm 2 differentiated mild MR (graded 1–2) from moderately severe (graded 3–4) with 80–90% accuracy. Conclusions: 3D TOE provides important quantitative information on both the mechanism and the severity of MR in an unselected group of patients. AROA enables quantification of MR with excellent agreement with the accepted clinical method of proximal flow convergence.

Performance of a Fourier-based program for three-dimensional reconstruction of the mitral annulus on application to sparse, noisy data.

We investigated the accuracy of mitral annular reconstruction from noisy, sparse data typical of three-dimensional (3D) transthoracic echocardiograms. Our Fourier-based method for reconstructing the annulus from dense, accurate 3D transesophageal echo (TEE) data has been validated in vitro with four harmonics in the x, y, and z coordinates (4,4,4). Thirteen mitral annuli were reconstructed from 'complete' 3D TEE data using four harmonics (4,4,4) and used to measure area, eccentricity. height, perimeter, and interpeak and intervalley distances; these were the 'true values'. To simulate transthoracic echo data, the TEE data sets were reduced evenly and unevenly (randomly). The complete and reduced data sets were used to reconstruct the annuli using three sets of fitting parameters: (4,4,4), (1,1,3), and (1,1,4). The resulting size and shape measurements were compared with true values. Regardless of the fitting parameters used, area, 2D perimeter, and 3D perimeter measurements were more accurate using reconstructions from evenly-reduced than randomly-reduced data sets (p < 0.006), and depended significantly on both data density (p < 0.015 for all) and data distribution (p < 0.02 for all). Perimeter, height, and eccentricity of the reconstructed annuli were more accurately measured using four harmonics (4,4,4). Mitral annuli can be reconstructed from sparse, noisy data using the (4,4,4) fit if at least 25 points are obtained from evenly distributed imaging planes. These results suggest that detailed analysis of mitral annular size and shape can be made accurately from 3D transthoracic echocardiograms.