Real-time 3D Transesophageal Echocardiography Research Articles

Real-Time Three-Dimensional Transesophageal Echocardiography in Patients with Secundum Atrial Septal Defects: Outcomes following Transcatheter Closure

Successful transcatheter closure of atrial septal defects (ASDs) requires the accurate assessment of defect size and morphology. Assessment of ASD anatomy may be difficult by two-dimensional (2D) echocardiography. The aim of this study was to test the hypothesis that real-time three-dimensional (3D) transesophageal echocardiography (TEE) may provide more accurate morphologic assessment of ASDs than multiplane 2D TEE. Twenty-four patients with ASDs were imaged using 2D and real-time 3D TEE. ASD shape and size were assessed using 3D TEE retrospectively. Maximal ASD dimensions obtained by 3D TEE were compared with unstretched and balloon-stretched dimensions on 2D TEE. Planimetered defect area by 3D TEE was compared with area calculated using the ellipse formula from 2D imaging. Twenty of the 24 patients underwent transcatheter ASD closure. Closure device size was based on findings on 2D TEE. Follow-up was conducted by 2D transthoracic echocardiography. Of the 24 ASDs, 6 (25%) were circular, 10 (42%) were oval, and 8 (33%) were complex in shape. The mean maximal dimension was larger by 3D TEE compared with 2D TEE (1.8 ± 0.8 vs 1.5 ± 0.6 cm; P < .05). There was no difference in the mean area measured by either modality, but for complex-shaped defects, area measured by 3D TEE was larger than that by 2D TEE (2.8 ± 1.3 vs 1.7 ± 1.4 cm(2); P < .05). Follow-up transthoracic echocardiography was available for 19 of the 20 patients undergoing transcatheter closure. Nine patients had residual right-to-left shunting 1 to 6 months after ASD closure, and the majority of these were complex in shape. In patients with residual shunting, ASD area by 3D TEE was 27% larger than by 2D TEE, whereas in patients without residual shunting, there was significantly less discrepancy between 3D and 2D areas (19%; P= .0027). Three-dimensional TEE can identify ASD shape. Maximal dimensions on 3D TEE were well correlated with balloon-stretched 2D dimensions. Two-dimensional TEE can underestimate the area of complex-shaped ASDs, which may result in residual right-to-left shunting.

Real-time three-dimensional echocardiographic assessment of mitral valve: Is it really superior to 2D transesophageal echocardiography?

Aim of our study was to investigate the feasibility of use and possible additional value of real-time 3D transesophageal echocardiography (RT-3D-TEE) compared to conventional 2D-TEE in patients undergoing elective mitral valve repair. After ethical committee approval, patients were included in this prospective study. After induction of anesthesia, a comprehensive 2D-TEE examination was performed, followed with RT-3D-TEE. The intraoperative surgical finding was used as the gold standard for segmental analysis. Only such segments which were surgically corrected either by resection or insertion of artificial chords were judged pathologic. A total of 50 patients were included in this study; usable data were available from 42 of these patients . Based on the Carpentier classification, the pathology found was type I in 2 (5%) patients, type II in 39 (93%) patients and type IIIb in 1 (2%) patient. We found that 3D imaging of complex mitral disease involving multiple segments, when compared to 2D-TEE did not show any statistically significant difference.RT-3D-TEE did not show any major advantage when compared to conventional 2D-TEE for assessing mitral valve pathology, although further study in a larger population is required to establish the validity of this study.

Live Three-Dimensional Transesophageal Echocardiography in an Unusual Case of Aorto-Left Ventricular Tunnel with a Large Interventricular Septal Aneurysm

Aorto-left ventricular tunnel (ALVT) is a rare congenital malformation. We report an unusual case of ALVT with a large interventricular septal aneurysm causing severe aortic regurgitation and left ventricular outflow obstruction diagnosed with real time three-dimensional transesophageal echocardiography (3D TEE). Real time 3D TEE allows for assessment and novel views of complex cardiac abnormalities and can aid in perioperative monitoring.

117 Real-time 3D transoesophageal echocardiography evaluation of the mitral valve area in patients with mitral stenosis

Planimetry measured by two-dimensional transthoracic echocardiography (TTE, MVA2D) is the reference method for the evaluation of the severity of mitral stenosis (MS) but is significantly less reliable when performed by non-experienced operators and when transthoracic echogenicity is poor. Real-time three-dimensional transoesophageal echocardiography (RT3DTEE, MVA3D) may overcome those limitations but its accuracy has never been evaluated. We prospectively enrolled 43 patients (59 ± 15 years, 86% female) referred for MS evaluation who underwent the same day a TTE and a RT3DTEE. MVA2D was assessed by experienced operators, MVA3D was measured by one experienced (Level III) and one non-experienced operator (Level I) blinded of any clinical and TTE information. RT3DTEE images were digitally stored and analysed offline on a workstation using dedicated software (QLab, Philips) in a random order. MVA3D was measured at the best cross section of the mitral valve defined as the most perpendicular and smallest orifice. MVA3D measured by the experienced operator (1.07 ± 0.31 cm2 [range 0.45–1.85]) did not differ from and correlated well with MVA2D (1.08 ± 0.32 cm2 [range 0.54–2.00], p = 0.84, r = 0.71, p < 0.001), and mean difference was small (−0.01 ± 0.24 cm2). Similarly, the MVA3D measured by the non-experienced operator (1.03 ± 0.31 cm2 [range 0.45–1.69]) did not differ from and correlated well with MVA2D (p = 0.27, r = 0.66, p < 0.001; mean difference −0.05 ± 0.26 cm2). RT3DTEE intra and interobserver (between experienced and non-experienced operators) variability were respectively 0.13 ± 0.10 cm2 and 0.19 ± 0.14 cm2. RT3DTEE provides accurate and reproducible MVA measurements similar to 2D planimetry performed by experienced operators. Thus, RT3DTEE should be considered as an alternative tool for the evaluation of MS severity, especially in patients with poor echocardiographic windows or for team less accustomed to evaluate patients with MS.

Assessment of Mitral Valve Prolapse by 3D TEE: Angled Views Are Key

ASSESSMENT OF MITRAL VALVE ANATOMY by real-time 3-dimensional (3D) transesophageal echocardiography (TEE) has proven to be superior compared to 2-dimensional TEE ([1,2][1]). The standard modalities of real-time 3D TEE have recently been described ([3][2]). Demonstration of the mitral valve as seen

Transapical repair of mitral valve paravalvular leakage using 3‐D transesophageal guidance

We report a case where transapical access with real time 3D transesophageal echocardiographic guidance is used for repair of a mitral valve paravalvular leakage. The transapical approach is a new, elegant, and relative safe alternative for repair of a paravalvular defect in high-risk patients. The use of real time 3DTEE for guiding the procedure provides the operator fast and complete information about the leakage, and allowing online monitoring of the procedure.

Real-Time 3D TEE Allows Optimized Guidance of Percutaneous Edge-to-Edge Repair of the Mitral Valve

percutaneous mitral valve repair using the edge-to-edge technique has been shown to be safe and effective for treatment of mitral regurgitation considering specific indications ([1][1]). Two-dimensional (2D) transesophageal echocardiography (TEE) has been described for guidance of the procedure ([2,

Three‐Dimensional Echocardiography‐Guided Repair of Residual Shunt after Percutaneous Atrial Septal Defect Closure

A 28-year-old woman was referred to closure of a residual shunt produced through a percutaneous device previously implanted in the atrial septum. The imaging protocol to guide the procedure included 2D TEE and real time 3D (RT3D) transesophageal echocardiography (TEE) imaging. RT3D TEE facilitated the evaluation of the defect morphology, and the relationship with the previous device, allowing a proper understanding of the mechanism responsible for the residual shunt. It was also a useful tool for guiding device deployment, providing clear intraprocedural information about catheter position and the spatial relationship with the previous device. In conclusion, RT3D TEE and 2D TEE are complementary techniques for the evaluation and guidance of transcatheter closure of complex atrial septal defects.

Illustration of the echocardiographic diagnosis of subaortic membrane stenosis in adults: surgical and live three-dimensional transoesophageal findings

We report here two cases of patients admitted in our institution for heart failure. The first had been previously diagnosed with severe aortic valve stenosis and was referred for aortic valve replacement. The myocardial and valvular anatomy combined with the Doppler profiles allowed, however, to suggest the diagnosis of a discrete subaortic membrane that was confirmed by surgical findings. In the second case, the use of real-time three-dimensional transoesophageal echocardiography (3D TEE) provided superb 3D visualization quality of the subaortic membrane and allowed assessing the stenosis area using the multiplanar review mode. Hence, the use of live real-time 3D TEE is likely to be key in the spatial assessment of this complex lesion.

Current concepts in mitral valve prolapse—Diagnosis and management

Although mitral valve prolapse as a disease entity has been recognized for over 50 years, its precise definition has been elusive. Initial reports based the diagnosis on auscultatory findings (late systolic click - murmur), with left ventricular angiography as a confirmative test. Echocardiography, first the M-mode, and subsequently the two-dimensional, became the dominant diagnostic modality. However, the early reports did not distinguish between billowing valve and flail valve. The advent of surgical repair techniques provided a different perspective; the surgical definition of mitral valve prolapse is often different from that of cardiologists. Intraoperative echocardiography gained wide acceptance necessitating a common language to describe precise terminology of the leaflet anatomy and definition of valve prolapse. The present report proposes a terminology and definitions of valve prolapse with relevance to surgical mitral valve repair. The addition of real-time 3D transesophageal echocardiography now provides highly accurate localization of lesions and the multi segment assessment of valve pathology. The etiologic considerations and surgical repair techniques with the role of echo - surgery team in improved patient outcome are described.

Surgery for Ruptured Sinus of Valsalva Aneurysm into Right Ventricular Outflow Tract: Role of Intraoperative 2D and Real Time 3D Transesophageal Echocardiography

A major limitation of the 2D echocardiography during surgery for a complex cardiac lesion is its inability to provide an accurate spatial orientation of the structure. The real time 3D transesophageal echocardiography (RT-3D-TEE) technology available in Philips IE 33 ultrasound machine is relatively new to an operation suite. We evaluated its intraoperative utility in a patient, who was operated for repair of a ruptured sinus of Valsalva aneurysm (RSOVA) and closure of a supracristal ventricular septal defect. The VSD and RSOVA were visualized through different virtual windows in a more promising way on intraoperative RT-3D-TEE than on the 2D echocardiography. The acquired images could be virtually cropped and displayed in anatomical views to the operating surgeon for a clear orientation to the anatomy of the lesion. RT-3D-TEE is a potential intraoperative monitoring tool in surgeries for complex cardiac lesions.

Use of Real-Time 3D Transesophageal Echocardiography in Percutaneous Intervention of a Flush-Occluded Pulmonary Vein

A 52-year-old man presented with progressive dyspnea on exertion and hemoptysis following unsuccessful cardioversion and radiofrequency ablation for paroxysmal atrial fibrillation 5 months earlier. He underwent magnetic resonance angiography and CT angiography to assess pulmonary venous anatomy and to rule out pulmonary embolism. Imaging demonstrated an occluded left-lower pulmonary vein (Figure A). Figure. A, An MRI image showing both arterial and venous phases of filling. A paucity of pulmonary vasculature is seen in the area normally supplied by the left-lower pulmonary vein (white arrow), suggesting occlusion. B, Real-time 3D TEE of the left pulmonary venous system (rotated image) revealing the origin of the occluded left-lower pulmonary vein (top orifice) in relation to the patent left-upper pulmonary vein (bottom orifice). C, Angiographic image revealing wire passage through an …

En Face View of Atrial Septal Defect by Two-Dimensional Transthoracic Echocardiography: Comparison to Real-Time Three-Dimensional Transesophageal Echocardiography

It is generally believed that three-dimensional (3D) echocardiography can provide unique en face views of atrial septal defects (ASDs), whereas conventional two-dimensional (2D) transthoracic echocardiography (TTE) cannot. The purpose of this study was to develop a special 2D TTE-based en face view of ASDs. En face views of ASDs on 2D TTE were obtained in 415 consecutive adult patients and compared with the results of real-time 3D transesophageal echocardiography in 25 of these patients. Acceptable en face views of ASDs on 2D TTE were obtained in 80% of patients, in whom secundum ASDs could be adequately imaged in more standard 2D imaging planes. The ability to visualize en face views of ASDs on 2D TTE was inversely related to their sizes (P<.05). The differences in the major and minor dimensions of ASDs between 2D TTE and real-time 3D transesophageal echocardiography were not statistically significant (P>.05). Conventional 2D transthoracic echocardiographic views significantly underestimated ASD size with superior-inferior directional major axis. Two-dimensional TTE can provide en face views of ASDs and their spatial orientations with respect to neighboring structures. This method may provide incremental information to 3D echocardiography in patients with ASDs.

Utility of Three-Dimensional Transesophageal Echocardiography: Anatomy, Mechanism, and Severity of Regurgitation in a Patient with an Isolated Cleft Posterior Mitral Valve

Echocardiographic assessment of a 72-year-old woman revealed a posterior mitral valve prolapse with an unusual central regurgitation jet. The use of three-dimensional (3D) transesophageal echocardiography elucidated the mismatch between morphologic and color Doppler echocardiographic findings: There was a cleft in the posterior mitral valve in addition to the posterior mitral valve prolapse. This case illustrates that the use of high-quality real-time 3D transesophageal echocardiography (including 3D color Doppler) facilitates the understanding of the anatomy and the mechanism and severity of regurgitation in complex mitral valve pathology and is clearly superior to two-dimensional transesophageal echocardiography alone.

Three-Dimensional Transesophageal Echocardiography Is a Major Advance for Intraoperative Clinical Management of Patients Undergoing Cardiac Surgery

Echocardiography is a key assessment tool for the evaluation of cardiac structure and function. The ability to image cardiac structures using 3-dimensional (3D) echocardiography is evolving. In this article, we present some of the key features of the emerging 3D technology and review its applications with an emphasis on real-time 3D transesophageal echocardiography.

Real-time three-dimensional transoesophageal echocardiography: a new intraoperative feasible and useful technology in cardiac surgery

A new generation of transoesophageal echocardiographic probes with a novel matrix array technique has been recently introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This new tool may potentially provide fast and complete 3D information about cardiac structures improving spatial orientation and overcoming limitations of offline 3D technologies. The aim of this study was to demonstrate the feasibility and usefulness of real-time 3D transoesophageal echocardiography (TOE) for the intraoperative evaluation of cardiac surgery procedures. One-hundred patients underwent transoesophageal echocardiographic examination during cardiac surgery as a part of their routine clinical practice. In the intraoperative pre- and post-cardiopulmonary bypass periods complete 2D and 3D transoesophageal examinations were performed. Feasibility and duration of examinations, and immediate additional anatomical value of 3D versus 2D-TOE were annotated intraoperatively. Image quality, additional clinical value of 3D- compared to standard 2D-TOE and the accuracy in the description of mitral valve pathology by a surgeon and an echocardiographer were evaluated off-line. No complications related to transoesophageal examination occurred and successful intubation was achieved in all 100 patients. Therefore, 200 examinations were performed and analysed considering the pre- and post-cardiopulmonary bypass periods. The mean number of acquisitions per patient was 16 +/- 14, including 3D real-time, zoom, full-volume and colour full volume modalities. The duration of the 3D examination was 16 +/- 10 min and the mean image quality score 2.8 +/- 0.7 (in a scale 1-4). In 36 out of 100 cases (36%) 3D-TOE provided additional anatomical information. The surgeon evaluated 3D images easier and more accurately than 2D images (88% vs. 76% in the evaluation of mitral valve scallop). Real-time 3D TOE may be used routinely for the intraoperative evaluation of cardiac surgery. Imaging with this new probe facilitates intraoperative evaluation of several surgical procedures with an additional clinical value in selected cases.

3D transesophageal echocardiography: a review of recent literature 2007–2009

The use of two-dimensional (2D) transesophageal echocardiography (TEE) is nearly universal in cardiac surgical operating rooms around the world. Cardiac anesthesiologists or cardiologists perform these examinations, facilitating significant advancements in surgical techniques by the immediacy and accuracy of intra-operative ultrasound imaging. Three-dimensional (3D) TEE capabilities have been available since the 1990s but penetration has been poor. With the advent of real-time 3D TEE, interest in this technology has increased dramatically. This is a comprehensive review of English language publications in the field from 2007 to 2009. This review utilized Pubmed databases, with search strategy based on primary key words: 3D echocardiography, transesophageal echocardiography, cardiac surgery, and/or cardiopulmonary bypass. Three major areas of clinical practice are impacted by the findings of these studies: cardiac valve repair and replacement, assessment of ventricular function, and image guidance for percutaneous procedures. The review resulted in the conclusion that 3D TEE provides unique and dynamic 3D spatial information that cannot be obtained by 2D TEE or fluoroscopy. In addition to technical and process advancements, future studies should address educational value in terms of acceleration of learning curves, and impact on surgical decision making.

Intraoperative evaluation of left atrial myxoma using real-time 3D transesophageal echocardiography

Intraoperative evaluation of left atrial myxoma using real-time 3D transesophageal echocardiography

Assessment of the Aortic Root Using Real-Time 3D Transesophageal Echocardiography

Precise evaluation of the aortic root geometry prior to transcatheter aortic valve implantation is important for procedural success in patients with aortic stenosis (AS). To determine the potential for 3-dimensional transesophageal echocardiography (3DTEE), the aims of the present study were: (1) to assess the accuracy of 3DTEE measurements of the aortic root using multidetector computed tomography (MDCT) as a reference, and (2) to examine whether aortic root geometry differs between patients with and without AS. 3DTEE and contrast-enhanced MDCT were performed in 35 patients. Multiplanar reconstruction was used to measure the left ventricular outflow tract (LVOT) and aortic annulus diameter/area, aortic valve area (AVA), and distances between the annulus and coronary artery ostium. The same 3DTEE measurements were performed in patients with (n=71) and without AS (n=80). Aortic annular and LVOT areas measured by 3DTEE were slightly but significantly smaller compared with values obtained with MDCT. Both methods revealed that the aortic annulus and LVOT have an oval shape. Aortic annular and LVOT area, AVA and the distances between the aortic annulus and the coronary ostia correlated well between the 2 modalities. Only minor differences in aortic root geometry were observed between patients with AS and those without. The geometry of the aortic annulus can be reliably evaluated using 3DTEE as an alternative to MDCT for the assessment of aortic root.

Prevalence and Clinical Implication of Complex Atherosclerotic Plaque in the Descending Thoracic Aorta of Japanese Patients Assessed by Transesophageal Echocardiography

Aging and westernization of lifestyle has accelerated the prevalence and severity of atherosclerotic cardiovascular diseases in the Japanese population. The aim of this study was to examine the prevalence of complex plaque formation in the descending thoracic aorta (DTA) as assessed by real-time 3-dimensional transesophageal echocardiography (3DTEE) and its relation to clinical factors. A prospective analysis of atherosclerotic plaque in the DTA of 350 consecutive patients who were clinically indicated for real-time 3DTEE was performed. Systematic assessment of the DTA plaques was performed using a biplane mode from the aorta at the level of the stomach to the aortic arch. When a large plaque (>4mm) was identified, detailed 3-dimensional (D) observations were performed using a 3D zoom mode. Complex plaque was defined as either mobile or an ulcer-like pouch in the DTA. Complex plaques were detected in 51 patients (15%), who were more advanced in age and had a higher prevalence of chronic kidney disease. A multivariate analysis revealed that the presence of complex plaque was an independent predictor of renal impairment. The prevalence of complex plaque was not low in the this Japanese study population. A close association between complex plaque and renal dysfunction raises the possibility that complex plaque in the DTA is a potential cause of renal dysfunction.