Real-time 3-dimensional Echocardiography Research Articles

The role of new echocardiographic techniques in athlete's heart.

'Athlete's heart' is a common term for the various adaptive changes induced by intensive exercise. Exercise causes alterations of the heart in hemodynamic response to the increased systemic and pulmonary demand during exercise. The understanding of these adaptations is of high importance, since they may overlap with those caused by pathological conditions. Cardiac imaging assessment of the athlete's heart should begin with a complete echocardiographic examination. In recent years classical echocardiographic surveys have been joined by new developments: tissue Doppler imaging, strain rate echocardiography, and real-time 3-dimensional echocardiography. This review paper focuses on the importance of these new echocardiographic techniques in delineating the morphological characteristics and functional properties of the athlete's heart.

4-Dimensional Modeling of the Mitral Valve by Real-time 3-Dimensional Transesophageal Echocardiography

Objectives: The complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Assessing especially the dynamic movement and interaction of MV components to define MV physiology during the complete cardiac cycle remains a challenge. We herein describe a novel semi-automated 4-dimensional MV model. Methods: The model applies quantitative analysis of the MV during a complete cardiac cycle based on real-time 3-dimensional echocardiography (RT3DE) data. In 18 consecutive surgical patients with isolated coronary artery diseases (CAD) (mean age 68 ± 10 years; 13 male) and left ventricular ejection fraction of mean 54 ± 13%, RT3DE was performed. The MV annulus and leaflets were semi-automatically reconstructed. Mitral annular (anteroposterior and anterolateral-posteriomedial diameter, circumference, area) and leaflet dimensions (orifice area, intercommissural distance) were acquired. Variability and reproducibility (intraclass correlation coefficient, ICC) for interobsever and intraobserver comparison were quantified at 4 time points of the cardiac cycle (mid-systole, end-systole, mid-diastole, end-diastole). Results: Mitral annulus dimensions provided excellent reliable and reproducible measurements throughout the cardiac cycle for interobserver (variability range, 0.5–1.5%; ICC range, 0.895–0.987) and intraobserver (variability range, 0.5–1.6%; ICC range, 0.827–0.980) comparison, respectively. Leaflet dimensions showed higher variability and lower correlation in systolic phase (variability range, 0.6–22.4%; ICC range, 0.446–0.915). Whereas leaflet parameters showed high reliability in diastolic phase (variability range, 0.6–9.1%; ICC range, 0.750–0.986). Conclusions: This 4-dimensional model allows detailed reconstruction including quantification of the complex MV structure and dynamic for the first time. The model has proven feasibility, reliability and repeatability.

RT3D TEE Superior to 2D TEE in the Diagnosis and Treatment of Mitral Periprosthetic Leaks

This study compared 2-dimensional vs real-time 3-dimensional transesophageal echocardiography in the diagnosis and treatment of patients with mitral periprosthetic leaks. Benefits of real-time 3-dimensional transesophageal echocardiography include the accuracy and reliability with which it records measurements of chamber size and function, and its improved ability to delineate valvular and congenital abnormalities.

Mitral valve repair: an echocardiographic review: Part 2.

Echocardiographic imaging of the mitral valve before and immediately after repair is crucial to the immediate and long-term outcome. Prior to mitral valve repair, echocardiographic imaging helps determine the feasibility and method of repair. After the repair, echocardiographic imaging displays the new baseline anatomy, assesses function, and determines whether or not further management is necessary. Three-dimensional imaging has improved the assessment of the mitral valve and facilitates communication with the surgeon by providing the surgeon with an image that he/she might see upon opening up the atrium. Further advancements in imaging will continue to improve the understanding of the function and dysfunction of the mitral valve both before and after repair. This information will improve treatment options, timing of invasive therapies, and advancements of repair techniques to yield better short- and long-term patient outcomes. The purpose of this review was to connect the echocardiographic evaluation with the surgical procedure. Bridging the pre- and post-CPB imaging with the surgical procedure allows a greater understanding of mitral valve repair.

Role of real-time three dimensional echocardiography in the assessment of right ventricular function of repaired tetralogy of Fallot

Objective To evaluate the clinical value of real-time 3 dimensional echocardiography (RT-3DE) for measurement of right ventricular function in the repaired tetralogy of Fallot (TOF) compared to cine magnetic resonance imaging (c-MRI). Methods Thirty-seven randomly selected patients with repaired TOF from Jan.2000 to Jun.2007 in Children's Hospital, Fudan University underwent both RT-3DE and c-MRI for the data of right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), right ventricular ejection fraction (RVEF), which were compared to evaluate the reproducibility and correlation of two ways on right ventricular function. Results All the patients completed both RT-3DE and c-MRI on the same day.The correlation for RVEDV, RVESV, RVEF measured by 2 methods was high (r=0.933, 0.943, 0.911, P=0.000, 0.000, 0.105), and it showed that consistency existed in RVEF, as difference was only (1.2±4.5)%.Comparison with c-MRI, RVEDV and RVESV mea-sured by RT-3DE was underestimated, in which difference was (-17.4±16.9) mL, (-9.3±10.5) mL. Conclusions RVEF with RT-3DE can be assessed with acceptable accuracy, but it is not so good for RVEDV and RVESV.Further study needs to be performed to make sure the value of RT-3DE on the assessment of right ventricular function in repaired TOF. Key words: Real-time three dimensional echocardiography; Tetralogy of Fallot; Cardiac magnetic resonance imaging; Right ventricular function

LV Outflow Tract Area in Discrete Subaortic Stenosis and Hypertrophic Obstructive Cardiomyopathy: A Real-Time 3-Dimensional Transesophageal Echocardiography Study

Precise anatomical analysis of stenotic lesions of the left ventricular outflow tract (LVOT) in discrete subaortic membranous stenosis (DSS) and hypertrophic obstructive cardiomyopathy (HOCM) is challenging due to their complex nature [(1,2)][1]. In the present study, we clarified the difference of

Three-Dimensional Echocardiography and Cardiac Magnetic Resonance Imaging in the Screening of Long-Term Survivors of Childhood Cancer After Cardiotoxic Therapy

The left ventricular (LV) volumes, ejection fraction (EF), and dyssynchrony indexes for the 16 and 12 cardiac segments (Tmsv16-SD and Tmsv12-SD, respectively) were analyzed among nonadult, anthracycline-exposed long-term survivors of childhood cancer and compared with those of healthy controls using conventional and real-time 3-dimensional echocardiography (RT-3DE) with cardiac magnetic resonance (CMR) imaging in a prospective, cross-sectional, single tertiary center setting. Seventy-one survivors and gender-, body surface area-, and age-matched healthy controls were studied by conventional echocardiography and RT-3DE. Fifty-eight of the 71 survivors underwent also CMR. The survivors were evaluated in 2 groups. Group I consisted of 63 exposed to anthracyclines and group II consisted of 8 also exposed to cardiac irradiation. By RT-3DE, the group I survivors had a lower LVEF (57% vs 60%, respectively, p = 0.003) and larger body surface area-indexed LV end-systolic volume (31 vs 28 ml/m(2), respectively, p = 0.001) than controls. The Tmsv16-SD was higher in group II than in I (1.93% vs 1.39%, respectively, p = 0.003). None of the survivors had an abnormal fractional shortening (<28%), but 10% had an LVEF <50% by RT-3DE. An LVEF <55% was detected in 45 of 58 (78%) of those imaged with CMR. In conclusion, RT-3DE seems to detect more abnormalities in cardiac function than conventional echocardiography following childhood cancer therapy. The LV dyssynchrony indexes derived from RT-3DE appear potentially useful in assessing the early signs of cardiotoxicity between anthracycline and cardiac irradiation exposed long-term survivors of childhood cancer.

Real-Time 3-Dimensional Transesophageal Echocardiography in the Assessment of Ventriculoatrial Shunt (Gerbode Defect) Complicating Simultaneous Mitral and Tricuspid Valve Repair

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5][![Graphic][6] ][6] A 67-year-old man presented with worsening dyspnea 1 month after double mitral and tricuspid valve repair. Physical examination revealed high-pitched holosystolic murmur across the

Image Quality Influences the Assessment of Left Ventricular Function

Transesophageal echocardiography has become a standard tool for evaluating left ventricular function during cardiac surgery. However, the image quality varies widely between patients and examinations. The aim of this study was to investigate the influence of the image quality on 5 commonly used 2-dimensional methods. Transesophageal real-time 3-dimensional echocardiography (3DE) served as a reference. Left ventricular function was evaluated in 63 patients with sufficient real-time 3DE image quality. The image quality was rated using the ratio of the visualized border divided by the total endocardial border. These ratings were used to generate groups of poor (0%-40%), fair (41%-70%), and good (71%-100%) image quality. The ejection fraction (EF), end-diastolic volume, and end-systolic volume were analyzed by the Simpson method of disks (biplane and monoplane), eyeball method, Teichholz method, and speckle-tracking method. Furthermore, the fractional area change was determined. Each correlation with real-time 3DE was evaluated. Correlations of the EF and volumes, respectively, as determined by long-axis view methods increased with improving image quality: the Simpson biplane method was found to be the most accurate method, with good image quality for the EF (r = 0.946) and volumes (end-diastolic volume, r = 0.962; end-systolic volume, r = 0.989). Correlations of the EF and fractional area change by short-axis view methods decreased with improving image quality, with the Teichholz EF found to be most accurate with poor (r = 0.928) in contrast to good (r = 0.699) image quality. With good image quality, the Simpson biplane method is the most accurate 2-dimensional method for assessing the left ventricular EF. Short-axis view methods, especially the Teichholz method yield better correlations with poor image quality. The eyeball method was unaffected by image quality.

Calibration of the normal cutoff values of systolic dyssynchrony of the left ventricular synchronicity in normal subjects using real-time 3-dimensional echocardiography and the effects of age and heart rate.

The normal data of left ventricular (LV) synchronicity by real-time 3-dimensional echocardiography (RT3DE) are lacking. We assessed the normal range/cutoff values of LV dyssynchrony parameters by RT3DE. For this purpose, RT3DE was performed in 130 healthy subjects, aged 53 ± 12 years. Time to the point of minimal regional systolic volume (Tmsv) was measured from time-volume curves in each segment. Standard deviation (SD) and maximal difference (Dif) of Tmsv were calculated from 16 (6 basal/6 mid/4 apical), 12 (6 basal/6 mid), and 6 (basal) LV segments together with the corresponding parameters adjusted by R-R interval. The data show non-significant difference between Tmsv-16-SD (9.24 ± 3.54 ms) and Tmsv-12-SD (8.80 ± 3.82 ms); with a correlation between two by both unadjusted (ms; r = 0.87) and adjusted (%R-R; r = 0.84) methods (P < 0.001). Heart rate correlated negatively with Tmsv (r = -0.13 to -0.34, P < 0.05-0.001) but had no effect on parameters adjusted for %R-R. Age and gender did not affect any of these parameters. Inter-observer variability was 3.3-4.6 % for 16, 4.8-9.1 % for 12, and 14.4-19.7 % for 6 segments. Thus, RT3DE is a reliable technique for detecting LV systolic dyssynchrony whereas the heart rate, but not age and gender, affects Tmsv parameters. Dyssynchrony parameters by 16 or 12 segments are superior to 6 segments in yielding comprehensive information and lower variability.

Evaluation of Vegetation Size and Its Relationship With Embolism in Infective Endocarditis

Two-dimensional (2D) echocardiography studies have shown that the maximum length of vegetation (MLV)≥10 mm is a predictor of embolic events (EEs) in patients with infective endocarditis. However, 2D measurements probably underestimate the vegetation dimensions. In this study, we evaluated the feasibility of real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in determining MLV and its accuracy in identifying the risk for EEs compared with 2D transesophageal echocardiography (2DTEE). We analyzed 60 patients with vegetations. RT3DTEE measurement of MLV was obtained with Advanced QLAB Quantification Software by cropping the 3D volume with the appropriate 2D plane to obtain the largest value. The standard 2DTEE images were also evaluated to determine the MLV. Major EEs were registered from medical records, and a logistic regression analysis was performed to determine the association between MLV and EEs. The RT3DTEE MLV was larger than the 2DTEE value with a mean difference of 3.2 mm (95% confidence interval, 2.1-4.2 mm). The best cut-off value for prediction of EEs was MLV≥20 mm with RT3DTEE and MLV≥16 mm with 2DTEE. The positive predictive value increased from 59.1% to 65.2% when RT3DTEE was used. The accuracy of classification of patients with EEs increased from 65% to 70% with this new technique. RT3DTEE is a feasible technique for the analysis of vegetation morphology and size that may overcome the shortcoming of 2DTEE, leading to a better prediction of the embolism risk in patients with infective endocarditis.

Assessment of the aortic valve by real-time 3-dimensional transesophageal echocardiography

Assessment of the aortic valve by real-time 3-dimensional transesophageal echocardiography

Severe mitral paravalvular leakage: echo-morphologic description of 47 patients from real-time three-dimensional transesophageal echocardiography perspective

Paravalvular leaks (PVLs) commonly occur in mitral prostheses. Real-time 3-dimensional transesophageal echocardiography (RT-3D TEE) may provide invaluable information about complex 3D anatomy of mitral PVLs compared to two-dimensional (2D) TEE findings. We, herein, aimed to evaluate the detailed description of anatomical characteristics of severe mitral PVLs using RT-3D TEE. Patients with diagnosis of severe mitral PVLs were simultaneously examined with 2D transthoracic echocardiography (TTE), 2D TEE, and RT-3D TEE. 3D characteristics of PVLs (localization, number, size, shape, etc.) were recorded and compared to 2D findings. Results were also compared with surgical findings. The study comprised 47 cases (3 bioprosthesis, 44 mechanical) with 61 severe mitral PVLs. The most common PVL localizations were anterolateral commissure, posteromedial commissures and posterolateral region. The mean PVL width measured by 2D TEE was 3.1±1.3 (range; 2-7) mm and the mean width of defect measured by 3D TEE was 3.1±1.1 (range; 2-7) mm (p=0.7). The mean length of defect measured by 3D TEE was 11.1±6.5 mm. The most common defect type was 'oval/round' shaped (n=29; 48%). There were also 19 'crescentic' (31%), 9 'slit like' (15%), and 2 tunnel-like shaped defects. In 22 patients, the site and dimension of the PVLs were all confirmed surgically. RT-3D TEE permits detailed structural evaluation of the prosthesis and description of paravalvular leak morphology compared to 2D TEE. It may provide more accurate information to the clinician in decision making and may contribute to the success of the potential corrective procedures.

Accuracy and Feasibility of Simplified Doppler-Based Left Ventricular Ejection Fraction

Calculation of left ventricular (LV) ejection fraction (EF) by Doppler stroke volume and end-diastolic volume (EDV) derived from LV diastolic diameter (LVIDD) could be reliable and feasible in clinical practice. In subjects with a wide range of LV volumes and EFs, magnetic resonance imaging (MRI) was used to evaluate the accuracy of common formulas (Teichholz and Z method) to estimate EDV from LVIDD (EDVTeich; EDVZ) versus volumetric EDV. The accuracy of simplified Doppler-EF was tested in a separate study sample versus real-time 3-dimensional (RT3D) echocardiography and versus bidimensional Simpson's method. A new equation to calculate EDV from LVIDD was derived using MRI and tested in the RT3D echo samples. Feasibility of Doppler-EF was tested in a third sample of consecutive inpatients and outpatients. In the MRI sample, EDVTeich was greater whereas EDVZ was smaller than volumetric EDV (both p <0.01); however, a quadratic equation estimated EDV from LVIDD with accuracy (R² = 0.97). In the echocardiographic sample, independent of severe segmental wall motion abnormalities, EDVTeich was greater whereas EDV using Simpson's method was smaller than RT3D EDV (all p <0.05); Doppler-EF using EDVTeich was lower compared with EF by Simpson's rule or by RT3D-EF (all p <0.01). However, RT3D-EF showed no differences compared with Doppler-EF when EDV was calculated by the novel MRI-derived equation. Feasibility was 95% for Doppler-EF and 72% using Simpson's method. In conclusion, equations estimating EDV from LVIDD affect the accuracy of simplified Doppler-EF. However, Doppler-based EF may be accurate and feasible even in the presence of LV contractile asynergy.

Left Atrial Ejection Fraction Assessed by Real‐Time 3‐Dimensional Echocardiography in Normal Dogs and Dogs with Myxomatous Mitral Valve Disease

Real-time 3-dimensional (RT3D) echocardiography provides a novel technique for assessing left atrial ejection fraction (LAEF) in dogs. Left atrial ejection fraction is associated with severity of myxomatous mitral valve disease (MMVD). Privately owned dogs; 101 with MMVD and 52 healthy control dogs. Prospective observational study using RT3D echocardiographic estimations of LA volumes at atrial end-diastole and atrial end-systole to calculate LAEF in comparison with conventional 2-dimensional echocardiographic variables. Left atrial ejection fraction decreased with increasing LA to aortic ratio (LA/Ao), percentage increase in left ventricular (LV) internal dimension, corrected for body weight (BW), in diastole (LVIDd inc%) and systole (LVIDs inc%), and age for MMVD dogs, and with BW for control dogs. The final models in the multiple regression analyses included LVIDd inc% and age for MMVD dogs, and BW alone for control dogs. LAEF varied widely in both MMVD dogs and control dogs. The wide variation of LAEF and the fact that LAEF does not appear to be an independent marker of disease severity suggest that the clinical importance of determining LAEF in dogs with MMVD might be limited.

Real-Time 3-Dimensional Echocardiographic Assessment of Ventricular Volume, Mass, and Function in Human Fetuses

ObjectivesWe sought to determine the feasibility and reproducibility of real-time 3-dimensional echocardiography (RT3DE) for evaluation of cardiac volume, mass, and function and to characterize maturational changes of these measurements in human fetuses.MethodsEighty pregnant women in the 2nd and 3rd trimesters (59 with normal fetuses and 21 with fetuses with congenital heart disease [CHD]) were enrolled. We acquired RT3DE images using a matrix-array transducer. RT3DE measurements of volume, mass, stroke volume (SV), combined cardiac output (CCO), and ejection fraction (EF) were obtained. Images were scored and analyzed by two blinded independent observers. Inter- and intraobserver variabilities and correlations between fetal cardiac indices and gestational age were determined.ResultsFifty-two of 59 normal data sets (88%) and 9 of 21 CHD data sets (43%) were feasible for analysis. In normal fetuses, the right ventricle (RV) is larger than the left ventricle (LV) (P<0.05), but no difference exists between the LV and RV in mass, SV, CO, and CO/CCO. The EFs for the LV and RV were diminished; the RVSV/LVSV was reduced in CHD fetuses compared with normal fetuses (P<0.05). Fetal ventricular volumes, mass, SV, and CCO fit best into exponential curves with gestational age, but LVEF, RVEF, and RVSV/LVSV remain relatively constant.ConclusionsRT3DE is feasible and reproducible for assessment of LV and RV volume, mass, and function, especially in normal fetuses. Gestational growth of these measures, except for EF, is exponential in normal and CHD fetuses. CHD fetuses exhibit diminished LV and RV EFs.

Diagnosis of cleft mitral valve using real-time 3-dimensional transesophageal echocardiography

Isolated cleft mitral valve is a rare cause of congenital mitral regurgitation (MR). Most commonly, the cleft involves the anterior leaflet of the mitral valve as seen in atrioventricular canal defects, although isolated cleft on the posterior leaflet has been described [1,2]. Real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) allows visualization of the mitral valve in any desired plane orientation. It helps in defining the extent and location of the pathology, and determining the mechanism and severity of valvular dysfunction [3].

LA Volumes and Reservoir Function Are Associated With Subclinical Cerebrovascular Disease: The CABL (Cardiovascular Abnormalities and Brain Lesions) Study

The purpose of this study was to assess the relationship of left atrial (LA) phasic volumes and LA reservoir function with subclinical cerebrovascular disease in a stroke-free community-based cohort. An increase in LA size is associated with cardiovascular events including stroke. However, it is not known whether LA phasic volumes and reservoir function are associated with subclinical cerebrovascular disease. The LA minimum (LAVmin) and maximum (LAVmax) volumes, and LA reservoir function, measured as total emptying volume (LAEV) and total emptying fraction (LAEF), were assessed by real-time 3-dimensional echocardiography in 455 stroke-free participants from the community-based CABL (Cardiovascular Abnormalities and Brain Lesions) study. Subclinical cerebrovascular disease was assessed as silent brain infarcts (SBI) and white matter hyperintensity volume (WMHV) by brain magnetic resonance imaging. Prevalence of SBI was 15.4%; mean WMHV was 0.66 ± 0.92%. Participants with SBI showed greater LAVmin (17.1 ± 9.3 ml/m2 vs. 12.5 ± 5.6 ml/m2, p < 0.01) and LAVmax (26.6 ± 8.8 ml/m2 vs. 23.3 ± 7.0 ml/m2, p < 0.01) compared to those without SBI. The LAEV (9.5 ± 3.4 ml/m2 vs. 10.8 ± 3.9 ml/m2, p < 0.01) and LAEF (38.7 ± 14.7% vs. 47.0 ± 11.9%, p < 0.01) were also reduced in participants with SBI. In univariate analyses, greater LA volumes and smaller reservoir function were significantly associated with greater WMHV. In multivariate analyses, LAVmin remained significantly associated with SBI (adjusted odds ratio per SD increase: 1.37, 95% confidence interval: 1.04 to 1.80, p < 0.05) and with WMHV (β = 0.12, p < 0.01), whereas LAVmax was not independently associated with either. Smaller LAEF was independently associated with SBI (adjusted odds ratio: 0.67, 95% confidence interval: 0.50 to 0.90, p < 0.01) and WMHV (β = −0.09, p < 0.05). Greater LA volumes and reduced LA reservoir function are associated with subclinical cerebrovascular disease detected by brain magnetic resonance imaging in subjects without history of stroke. In particular, LAVmin and LAEF are more strongly associated with SBI and WMHV than the more commonly measured LAVmax, and their relationship with subclinical brain lesions is independent of other cardiovascular risk factors.

Localizing Mitral Valve Perforations With 3D Transesophageal Echocardiography

with the advent of real-time 3-dimensional transesophageal echocardiography (3d tee), rapid creation of high-quality, true-to-life images of mitral valve anatomy and pathology has become possible in the vast majority of patients ([1][1]). In addition to common mitral valve lesions, such as

Quantitative Analysis of Mitral Valve Morphology in Mitral Valve Prolapse With Real-Time 3-Dimensional Echocardiography

Background— Few data exist on the relation of the 3-dimensional morphology of mitral valve and degree of mitral regurgitation (MR) in mitral valve prolapse. Methods and Results— Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 112 subjects, including 36 patients with mitral valve prolapse and significant MR (≥3+; MR+ group), 32 patients with mitral valve prolapse but no or mild MR (≤2+; MR− group), 12 patients with significant MR resulting from nonprolapse pathologies (nonprolapse group), and 32 control subjects. The 3-dimensional geometry of mitral valve apparatus was measured with dedicated quantification software. Compared with the normal and MR− groups, the MR+ group had more dilated mitral annulus ( P &lt;0.0001), a reduced annular height to commissural width ratio (AHCWR) ( P &lt;0.0001) indicating flattening of annular saddle shape, redundant leaflet surfaces ( P &lt;0.0001), greater leaflet billow volume ( P &lt;0.0001) and billow height ( P &lt;0.0001), longer lengths from papillary muscles to coaptation ( P &lt;0.0001), and more frequent chordal rupture ( P &lt;0.0001). Prevalence of chordal rupture increased progressively with annulus flattening (7% versus 24% versus 42% for AHCWR &gt;20%, 15%–20%, and &lt;15%, respectively; P =0.004). Leaflet billow volume increased exponentially with decreasing AHCWR in patients without chordal rupture ( r 2 =0.66, P &lt;0.0001). MR severity correlated strongly with leaflet billow volume ( r 2 =0.74, P &lt;0.0001) and inversely with AHCWR ( r 2 =0.44, P &lt;0.0001). In contrast, annulus dilatation but not flattening occurred in nonprolapse MR patients. An AHCWR &lt;15% (odds ratio=7.1; P =0.0004) was strongly associated with significant MR in mitral valve prolapse. Conclusion— Flattening of the annular saddle shape is associated with progressive leaflet billowing and increased frequencies of chordal rupture and may be important in the pathogenesis of MR in mitral valve prolapse.