Real-time 3-dimensional Echocardiography Research Articles

Real-Time 3-Dimensional Transesophageal Echocardiography in the Evaluation of Post-Operative Mitral Annuloplasty Ring and Prosthetic Valve Dehiscence

This study sought to assess the use of real-time (RT) 3-dimensional (3D) transthoracic and transesophageal echocardiography (TEE) in the evaluation of post-operative mitral valve dehiscence. Mitral valve replacement or repair may be complicated by post-operative dehiscence of the valve or annuloplasty ring resulting in clinically significant mitral regurgitation or hemolysis. Diagnosis is generally performed using 2-dimensional transthoracic echocardiography and TEE. Recently, an RT 3D TEE probe has been developed to produce high-quality real-time images. We used RT 3D TEE to evaluate mitral regurgitation after mitral valve repair or replacement as a result of mitral ring dehiscence. We studied the additional information and diagnostic utility provided by RT 3D TEE. Eighteen patients were studied (8 patients after repair and 10 after replacement). Real-time 3D TEE allowed accurate evaluation of the pathology, including definition of the type of ring or prosthesis used; description of the site, size, shape, and area of the dehisced segment; and clear definition of the origin of the mitral regurgitation. In mitral valve dehiscence, RT 3D TEE provides additional information about the exact anatomic characteristics of the dehiscence that can be used to help in planning the most appropriate corrective intervention.

Real-time 3-dimensional echocardiography early after acute myocardial infarction: Incremental value of echo-contrast for assessment of left ventricular function

Accurate and reproducible assessment of left ventricular (LV) systolic function is important in patients with acute myocardial infarction (AMI). Real-time 3-dimensional echocardiography (RT3DE) is an accurate technique, but it relies heavily on good image quality. The aim of the present study was to evaluate the incremental value of contrast-enhanced RT3DE. A total of 140 consecutive patients (58 +/- 11 years, 78% men) with ST-elevation AMI clinically underwent nonenhanced and contrast-enhanced RT3DE within 24 hours from AMI to evaluate global and regional LV systolic function. Endocardial border definition was graded for each of the 16 LV segments as follows: 0 = border invisible, 1 = border visualized only partially, and 2 = complete visualization of the border. Three image-quality groups (good, fair, and uninterpretable) were identified. Left ventricular volumes and ejection fraction were measured off-line. Wall motion was graded for each visible segment as follows: 1 = normal, 2 = hypokinetic, 3 = akinetic, and 4 = dyskinetic. During contrast-enhanced RT3DE, as compared with nonenhanced RT3DE, the number of segments with complete visualization of the endocardial border increased from 66% to 84% (P < .001); and the number of patients with a good-quality echocardiogram increased from 59% to 94% (P < .001). Intra- and interobserver agreement for assessment of global and regional LV systolic function improved during contrast-enhanced RT3DE, as compared with nonenhanced RT3DE. Assessment of LV systolic function in AMI patients with RT3DE is frequently hampered by suboptimal echocardiographic quality. Contrast-enhanced RT3DE is of incremental value, improving the endocardial border visualization and the reproducibility of LV function assessment.

Role of real-time 3-dimensional transesophageal echocardiography in transcatheter aortic valve implantation☆

An 86-year-old woman with symptomatic severe aortic stenosis successfully underwent transapical aortic valve replacement. Real-time 3-dimensional transesophageal echocardiographyprovideduniqueviewsduring theprocedure.This case illustrates its advantages over 2-dimensional echocardiography in guiding device placement (Fig. 1, Video 1) and in assessingcoronarypatencyafter implantation (Fig.2,Video2). www.elsevier.com/locate/ejcts European Journal of Cardio-thoracic Surgery 35 (2009) 909

Assessment of left ventricular dyssynchrony and function using real-time 3-dimensional echocardiography in patients with congenital right heart disease

Patients after repair of congenital right heart disease (CRHD) may exhibit left ventricular (LV) dyssynchrony (LVD). However, the diagnosis of LVD is difficult and its reliability limited because current methods do not assess LVD of the whole LV simultaneously. The aim of the study was to assess LVD according to a novel global systolic dyssynchrony index (SDI) derived from real-time 3-dimensional echocardiography in patients after repaired CRHD. Two-dimensional echocardiography and real-time 3-dimensional echocardiography were performed in 30 patients after CRHD repair and in 30 matched healthy controls. Real-time 3-dimensional echocardiography data sets provided time-volume curves, and 2 global SDIs were derived from the dispersion of time to reach minimal systolic volume according to a 16- or 17-LV segment model. Both SDIs were significantly elevated in the patient as compared with the control group (P < .001). A cutoff value for both SDIs was calculated and LVD defined as one of the SDIs exceeding cutoff. Left ventricular dyssynchrony was present in 5 (100%) of 5 patients with a LV ejection fraction (EF) <50% and 13 (52%) of 25 patients with preserved LVEF, thus being diagnosed in a total of 18 (60%) of 30 patients. Moreover, patients with LVD showed a significantly higher degree of pulmonary regurgitation (P = .01) with elevated right ventricular volumes and altered septal motion. Stepwise multivariate analysis identified LVEF (P = .005) and the degree of pulmonary regurgitation (P = .02) as independent predictors of LVD. Left ventricular dyssynchrony can be detected in about 60% of patients after CRHD repair and is mainly due to significant pulmonary regurgitation resulting in an altered septal motion and systolic LV function.

Three-Dimensional Echocardiographic Assessment of Acquired Left Ventricular to Right Atrial Shunt (Gerbode Defect)

A 60-year-old man was readmitted 1 year after bioprosthetic aortic valve replacement for recurrent endocarditis. Transthoracic 2-dimensional color Doppler revealed a novel finding of a left-to-right shunt from the left ventricular outflow tract to the right atrium immediately superior to the septal leaflet of the tricuspid valve consistent with an acquired Gerbode defect. Real-time 3-dimensional echocardiography was used to accurately delineate the course of the shunt. To avoid overestimating right ventricular systolic pressure by mistaking such a shunt for an eccentric jet of tricuspid regurgitation, it is important to accurately differentiate the two. Real-time 3-dimensional echocardiography now provides rapid, detailed 3-dimensional appreciation of the origin and course of such shunts with easy facility of orienting views to the flows of interest by cropping. Such information can help design optimal surgical or catheter-based therapy.

Multimodality Cardiac Stress Testing: Combining Real-Time 3-Dimensional Echocardiography and Myocardial Perfusion SPECT

Early experience is described in implementing a new multimodality stress test for accurate correlation of complementary functional and perfusion information from real-time 3-dimensional (3D) echocardiography and SPECT, respectively. The proposed new multimodality stress test has the potential for simultaneously improving sensitivity and specificity in the detection of early coronary artery disease (CAD). Pre- and poststress real-time 3D echocardiography and SPECT images were acquired in 20 patients referred for CAD evaluation and processed using previously developed algorithms for automatic fusion and quantitative analysis of myocardial function and perfusion. All cases of CAD were diagnosed by reviewing quantitatively analyzed fused images, using newly developed software. Real-time 3D echocardiography, SPECT, advance processing, and image review were successfully performed in all 20 patients. Compared with the angiographic findings in 12 patients, diagnosis based on fused images correctly identified 13 of 13 diseased arteries, compared with 11 of 13 identified by SPECT and 6 of 13 identified by echocardiography-based analysis. The results suggest the feasibility and potential effectiveness of novel multimodality stress testing.

Three-Dimensional Echocardiography: Is it Ready for Everyday Clinical Use?

SINCE THE EARLY DAYS OF B-MODE ECHOCARDIOGRAPHY, the instrumentation and applications of echocardiography have expanded rapidly. In the early 1990s, von Ramm and colleagues developed the first prototypes of real-time 3-dimensional echocardiography (RT-3DE). In 2009, RT-3DE is available in many

Real-time 3-dimensional transesophageal echocardiography: improved localisation and spatial orientation of mitral valve prolaps

Objectives: Our study aimed to evaluate hypothetical superiority of intraoperative real-time 3-dimensional transesophageal echocardiography (RT3DTEE) to established 2-dimensional imaging (2DTEE) in assessing mitral valve prolapse (MVP) localisation, dimensions and associated pathologies of importance for surgical planning.

Real-Time Three-Dimensional Transesophageal Echocardiography in the Intraoperative Assessment of Mitral Valve Disease

The aims of this study were to evaluate the feasibility of real-time 3-dimensional (3D) transesophageal echocardiography in the intraoperative assessment of mitral valve (MV) pathology and to compare this novel technique with 2-dimensional (2D) transesophageal echocardiography. Forty-two consecutive patients undergoing MV repair for mitral regurgitation (MR) were studied prospectively. Intraoperative 2D and 3D transesophageal echocardiographic (TEE) examinations were performed using a recently introduced TEE probe that provides real-time 3D imaging. Expert echocardiographers blinded to 2D TEE findings assessed the etiology of MR on 3D transesophageal echocardiography. Similarly, experts blinded to 3D TEE findings assessed 2D TEE findings. Both were compared with the anatomic findings reported by the surgeon. At the time of surgical inspection, ischemic MR was identified in 12% of patients, complex bileaflet myxomatous disease in 31%, and specific scallop disease in 55%. Three-dimensional TEE image acquisition was performed in a short period of time (60 +/- 18 seconds) and was feasible in all patients, with optimal (36%) or good (33%) imaging quality in the majority of cases. Three-dimensional TEE imaging was superior to 2D TEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease (P < .05). Real-time 3D transesophageal echocardiography is a feasible method for identifying specific MV pathology in the setting of complex disease and can be expeditiously used in the intraoperative evaluation of patients undergoing MV repair.

Reference values for left ventricular volumes with real-time 3-dimensional echocardiography

Reference values for left ventricular volumes with real-time 3-dimensional echocardiography

Quantification of Left Ventricular Systolic Dyssynchrony by Real-Time Three-Dimensional Echocardiography

To assess real-time 3-dimensional echocardiography (RT3DE)-derived left ventricular (LV) systolic dyssynchrony parameters: (1) normal values, (2) characteristics in patients with heart failure (HF) and a wide or narrow QRS complex, (3) interobserver and intraobserver variability with current state of the art RT3DE hardware and software technology, and (4) incremental value in patients with HF who receive cardiac resynchronization therapy (CRT). The study involved 84 patients with HF (mean age 54 +/- 15 years, 50 men) and 60 healthy volunteers (mean age 41 +/- 15 years, 36 men). Semiautomated LV endocardial border tracking was used to calculate regional time-to-minimum systolic volume and to generate parametric maps and the systolic dyssynchrony index (SDI), defined as the standard deviation of time-to-minimum systolic volume of the 16 LV segments expressed in percentage of R-R duration. The volume rate of the RT3DE datasets in patients with HF was 31 +/- 9 Hz (range 15-42 Hz). The normal value of the SDI was 4.1% +/- 2.2% (range <1.0%-8.9%). Patients with HF had a larger SDI (13.4% +/- 8.1%, P < .001). There was only a weak correlation (r2 = 0.07, P < .05) between the QRS duration and the SDI. Interobserver interclass correlation and variability of the SDI depended on image quality (good: 0.993 and 9%, moderate: 0.907 and 16%, respectively). Interobserver agreement for the identification of the most delayed LV segment depended on image quality (good: 90%, moderate: 76%). Thirty-nine patients underwent CRT. At the 12-month follow-up, LV volumetric responders had a significant reduction in the SDI (16.3% +/- 3.3% to 7.7% +/- 2.4%, P < .001). With state of the art technology, RT3DE allows reproducible assessment of LV systolic dyssynchrony, which may be useful to identify potential responders to CRT.

Real-Time 3-Dimensional Echocardiography in the Operating Room

Real-time 3-dimensional transesophageal echocardiography (RT-3D-TEE) represents a novel clinical and intuitively educational perioperative cardiovascular imaging modality. The development of RT-3D-TEE allows for live 3D imaging as it circumvents most of the disadvantages of reconstructive 3D methods. RT-3D-TEE will likely revolutionize perioperative assessment of complex 3D structures, such as the mitral valve (MV), as it provides important mechanistic insights into functional and ischemic mitral regurgitation. The MV is particularly suited to live RT-3D-TEE assessment because of the complex interrelationships among the valve, chordae, papillary muscles, and myocardial walls. The 3D en face view of the MV is in accordance with the surgical view and allows to illustrate the unique saddle shape of the MV annulus and to define and localize mitral leaflet lesions in MV prolapse, endocarditis, or congenital MV abnormalities, all potentially important in guiding surgical repair. RT-3D-TEE will soon be integrated into routine perioperative practice. Its unique ability of real-time acquisition, online rendering and cropping capabilities, accurate identification of the precise pathology and location of cardiac disease, together with its ability to promptly quantify 3D data sets using built-in software, will likely help in transitioning this modality into standard of care.

Determination of Regurgitant Orifice Area with the Use of a New Three-Dimensional Flow Convergence Geometric Assumption in Functional Mitral Regurgitation

Geometry of the proximal isovelocity surface area (PISA) in functional mitral regurgitation (MR) is elongated, leading to underestimation of the effective regurgitant orifice (ERO) area. This underestimation could be corrected by a new hemiellipsoidal method. Thirty patients with functional MR were examined by real-time 3-dimensional (D) echocardiography. Two ERO areas were calculated from 3D measurements: ERO area by the hemispheric method and that by the new hemiellipsoidal method with our customized program. Each ERO area was compared with that by the 2D quantitative Doppler method. Color 3D images showed an elongated PISA geometry including 2 geometric types ("mountain" or "valley") in all patients with functional MR. Our hemiellipsoidal method could be adapted for all geometric types of PISA and underestimated ERO area by only 26%, whereas the underestimation by the hemispheric PISA method was 49%. The underestimation by the hemispheric PISA method can be significantly corrected by our hemiellipsoidal method.

Abstract 5794: Geometric Changes of Mitral Annulus Assessed by Real-Time 3-Dimensional Transesophageal Echocardiography

Background: The mitral annular (MA) geometric changes have been reported in patients with various cardiac diseases such as atrial fibrillation (Af), mitral regurgitation (MR) and dilated cardiomyopathy (DCM). The advances of real-time 3D transesophageal echocardiography (TEE) enable us to analyze the MA geometry more accurately and reliably than 3D transthoracic echocardiography (TTE). We sought to determine the independent predictors for MA geometric changes in patients with Af, significant MR, and DCM by 3D TEE. Methods: We examined 32 subjects by 3D TEE and 2D TTE; 6 with lone Af, 9 with mitral valve prolapse (MVP), 3 with organic MR, 6 with DCM, and 8 normal subjects. Left ventricular (LV) end-diastolic and end-systolic volume indices (EDVI and ESVI), ejection fraction (EF), left atrial volume index (LAVI), and MR severity were assessed by 2D TTE. We measured MA area index, commissural length, and MA height (Figure 1 ). For the index of the saddle-shaped MA geometry, MA shape index was calculated as the (MA height)/(commissural length). Results: Patients with MVP and those with DCM had larger MA area index and lower MA shape index than normal subjects (all, P &lt;0.05). MA area index was associated with LAVI, MR severity, and LV EDVI (all, P &lt;0.05) (Figure 2 ). MA shape index was associated with LV EF, ESVI, and the presence of Af (all, P &lt;0.05) (Figure 3 ). In multivariate analysis, LAVI, MR severity, and LV EDVI independently predicted for MA area index, and LV EF was independent predictor for MA shape index (all, P &lt;0.05). Conclusion: MA dilatation was independently associated with larger LA and LV volumes and severer MR, not LV EF, while the saddle-shaped MA geometry was associated with LV EF. Figure 1 Figure 2 Figure 3

Left Atrial Volume and Function in Patients With Obstructive Sleep Apnea Assessed by Real-Time Three-Dimensional Echocardiography

Studies have suggested that obstructive sleep apnea (OSA) contributes to the deterioration of left ventricular diastolic function. This may lead to atrial myocardial overstretching and enlargement, which could be associated with increased cardiovascular risk. The aim of this study was to evaluate left atrial (LA) volume and function in patients with OSA compared with controls without OSA and their associations with any left ventricular diastolic abnormalities using real-time 3-dimensional echocardiography (RT3DE). Fifty-six patients with mild to severe OSA and 50 controls of similar age and with similar body mass indexes, blood pressure, and frequency of hypertension were analyzed. All subjects underwent polysomnography and RT3DE. A larger 3-dimensional maximum LA volume indexed for body surface area, larger volume before atrial contraction, and higher active atrial ejection fraction were found in patients with OSA (P < .01 for all). Mitral annular early diastolic velocity (E') was reduced in patients with OSA (P = .03), whereas late diastolic velocity (A') and the ratio of mitral valve early diastolic velocity to mitral annular early diastolic velocity (E/E') were increased in the same group (P < .05 for both). In addition, a lower E'/A' ratio was also found in the OSA group (P = .02). An increase in 3-dimensional maximum LA volume indexed for body surface area was observed, depending on OSA severity. The apnea-hypopnea index and E/E' ratio were independent predictors of an increase in 3-dimensional maximum LA volume in a multiple regression model. Using RT3DE, this study demonstrates that OSA induces a functional burden on the left atrium, resulting in remodeling. These functional and structural changes are related to the impairment of diastolic function in this population.

Echocardiographic Parameters of Mechanical Synchrony in Healthy Individuals

Definition and validation of the ranges of normal values and agreement among echocardiographic measures of mechanical synchrony in healthy subjects are mostly lacking. The aims of this study were (1) to assess the ranges of normal values for 5 tissue Doppler imaging parameters, real-time 3-dimensional echocardiographic measures, and speckle-tracking measures of mechanical synchrony; (2) to evaluate interinstitutional variability; (3) to compare the ranges of normal values with those reported in previous research; and (4) to analyze the agreement among all parameters in the same healthy subject. Time to peak systolic velocity (Ts), the delay between Ts at the basal septal and lateral segments, peak velocity difference, strain derived by tissue Doppler imaging, Ts derived by tissue synchronization imaging, systolic synchrony index (SSI) derived by real-time 3-dimensional echocardiography, and longitudinal and radial strain derived by speckle tracking were prospectively collected and analyzed at 2 different institutions in 160 consecutive healthy subjects. The ranges of normal values, expressed as means +/- 2 SDs, were 30.32 +/- 29.36 ms for the SD of Ts, 15.51 +/- 99.88 ms for septal-lateral delay, 60.75 +/- 81.62 ms for peak velocity difference, 33.07 +/- 29.96 ms for tissue synchronization imaging, 34.16 +/- 23.26 ms for the SD of strain, 2.74 +/- 2.16% for SSI, 28.91 +/- 23.02 ms for the SD of longitudinal strain, and 10.4 +/- 6.31 ms for radial strain. There was large interinstitutional variability for all parameters. Three-dimensional SSI and radial strain were within the published upper range limit for healthy subjects. Ninety percent of healthy subjects were consistently classified to be synchronous by 1 parameter. With a composite index, more subjects than expected showed dyssynchrony (10% vs 2.5%). In conclusion, 3-dimensional SSI and radial strain were the most reproducible parameters and consistently discriminated normal healthy subjects from the cardiac resynchronization therapy volume responders.

Standard Values for Real-Time Transthoracic Three-Dimensional Echocardiographic Dyssynchrony Indexes in a Normal Population

There is a paucity of information describing the real-time 3-dimensional echocardiography (RT3DE) and dyssynchrony indexes (DIs) of a normal population. We evaluate the RT3DE DIs in a population with normal electrocardiograms and 2- and 3-dimensional echocardiographic analyses. This information is relevant for cardiac resynchronization therapy. We evaluated 131 healthy volunteers (73 were male, aged 46 +/- 14 years) who were referred for routine echocardiography; who presented normal cardiac structure on electrocardiography, 2-dimensional echocardiography, and RT3DE; and who had no history of cardiac diseases. We analyzed 3-dimensional left ventricular ejection fraction, left ventricle end-diastolic volume, left ventricle end-systolic volume, and left ventricular systolic DI% (6-, 12-, and 16-segment models). RT3DE data were analyzed by quantifying the statistical distribution (mean, median, standard deviation [SD], relative SD, coefficient of skewness, coefficient of kurtosis, Kolmogorov-Smirnov test, D'Agostino-Pearson test, percentiles, and 95% confidence interval). Left ventricular ejection fraction ranged from 50% to 80% (66.1% +/- 7.1%); left ventricle end-diastolic volume ranged from 39.8 to 145 mL (79.1 +/- 24.9 mL); left ventricle end-systolic volume ranged from 12.9 to 66 mL (27 +/- 12.1 mL); 6-segment DI% ranged from 0.20% to 3.80% (1.21% +/- 0.66%), median: 1.06, relative SD: 0.5482, coefficient of skewness: 1.2620 (P < .0001), coefficient of Kurtosis: 1.9956 (P = .0039); percentile 2.5%: 0.2900, percentile 97.5%: 2.8300; 12-segment DI% ranged from 0.22% to 4.01% (1.29% +/- 0.71%), median: 1.14, relative SD: 0.95, coefficient of skewness: 1.1089 (P < .0001), coefficient of Kurtosis: 1.6372 (P = .0100), percentile 2.5%: 0.2850, percentile 97.5%: 3.0700; and 16-segment DI% ranged from 0.29% to 4.88% (1.59 +/- 0.99), median: 1.39, relative SD: 0.56, coefficient of skewness: 1.0792 (P < .0001), coefficient of Kurtosis: 0.9248 (P = .07), percentile 2.5%: 0.3750, percentile 97.5%: 3.750. This study allows for the quantification of RT3DE DIs in normal subjects, providing a comparison for patients with heart failure who may be candidates for cardiac resynchronization therapy.

Three-Dimensional Transesophageal Echocardiographic Imaging and Volumetry of Giant Left Atrial Myxomas

TWO CASES IN WHICH real-time 3-dimensional transesophageal echocardiography (RT-3D TEE) was able to accurately depict a giant atrial myxoma showing prolapse into the left ventricle with resultant ventricular inflow obstruction are reported. Volumetric calculation of these masses using 3D techniques was more accurate than traditional 2-dimensional approaches when compared with ex vivo volumetric measurements by water displacement. These cases show the efficacy and potential usefulness of RT-3D TEE in cardiac surgery.

Usefulness of Left Ventricular Conic Index Measured by Real-Time Three-Dimensional Echocardiography to Predict Left Ventricular Remodeling After Acute Myocardial Infarction

Early identification of left ventricular (LV) remodeling after acute myocardial infarction (AMI) is of clinical importance. The predictive value of real-time 3-dimensional echocardiography (RT-3DE) for LV remodeling after AMI is unknown. We prospectively studied 62 patients with AMI who underwent RT-3DE at baseline (72 +/- 5 hours) and 1 month and 6 months after AMI. LV remodeling was defined as a >20% increase from baseline in LV end-diastolic volume (LVEDV) at 6 months. At 6 months, 20 patients (32%) with and 42 (68%) without LV remodeling were identified. Patients with remodeling showed increased LVEDV, from 112.6 +/- 17.2 to 138 +/- 31 ml (p <0.001), and decreased LV ejection fraction (LVEF), from 0.50 +/- 0.07 to 0.44 +/- 0.10 (p <0.01). Changes in LVEDV from baseline to 6-month follow-up were positively correlated with peak creatine kinase-MB, LVEDV, LVEF, wall motion score, deceleration time of E wave, LV sphericity index (LVEDV divided by the volume of a sphere whose diameter is the LV end-diastolic long axis), and LV conic index (LVEDV divided by the volume of a cone whose bottom diameter is the internal diameter of the mitral annulus and height is the LV long axis). LV conic index at baseline was found to be the best predictor of LV remodeling, with a sensitivity and specificity of 100% and 90.9%, respectively, and a cut-off value of >3.87. In conclusion, LV conic index measured by RT-3DE in the early phase after AMI can accurately predict LV remodeling over 6-month follow-up.

Live Three-Dimensional Transesophageal Echocardiography-Guided Transcatheter Closure of a Mitral Paraprosthetic Leak by Amplatzer Occluder

Recently introduced real-time 3-dimensional transesophageal echocardiography allows online accurate assessment of cardiac structures. Initial experience indicates that this new technique provides improved anatomic definition and novel views of complex cardiac abnormalities in valve anatomy. We demonstrated the utility of live 3-dimensional transesophageal echocardiography in the assisted transcatheter closure of a mitral prosthesis paravalvular leak by Amplatzer occluder.