Real-time Three-dimensional Transesophageal Echocardiography Research Articles

Mitral Valve Early Systolic Billowing Induces Following Annular Expansion and Leaflet Augmentation in Barlow's Disease: Sequential Analysis using Three-dimensional Echocardiography.

Although systolic expansion of the annulus has been recognized in Barlow's disease, the mechanisms of the unique pathological movement of the annulus and its relation to the leaflet augmentation has not yet been clarified. We aimed to investigate the detailed mechanisms of the characteristic mitral apparatus dynamics in Barlow's disease by frame-by-frame sequential geometric analysis using real-time three-dimensional transesophageal echocardiography. Fifty-three patients with Barlow's disease and severe mitral regurgitation without torn chordae, as well as 10 controls, were included. We evaluated geometric changes in the mitral complex using three-dimensional transesophageal echocardiography at five points during systole. To identify early systolic billowing of leaflets, the annulo-leaflet angle was measured. We also performed a more detailed analysis in four consecutive frames just before and after leaflet free-edge prolapse above the annulus plane. The median annulo-leaflet angle of both leaflets in early systole was greater than 0° (above annulus plane) in patients with Barlow's disease, and billowing of the leaflet body were observed from early systole. The prolapse volume of both leaflets increased markedly from early to mid-systole (1.60 [0.85-2.80] to 4.00 [2.10-6.45] mL; analysis of variance, p < 0.001; post-hoc, p < 0.05). With frame-by-frame analysis, dynamic augmentation of the annulus and leaflets developed between frames just before and just after leaflet free-edge prolapse (analysis of variance, p < 0.01; post-hoc, p < 0.05). In Barlow's disease, early systolic billowing of the mitral leaflet induces systolic annulus expansion followed by leaflet augmentation and leaflet free-edge prolapse.

Influence of device generations on alternations of mitral annulus after transcatheter edge-to-edge repair: a real-time three-dimensional transesophageal echocardiography study

Abstract Background Alternation of the mitral annulus (MA) after transcatheter edge-to-edge mitral valve repair (TEER) is reported to be associated with a reduction of mitral regurgitation (MR). However, the influence of the new device system with 4 device size options (MitraClip G4) on MA geometry compared to the conventional device (G2) remains unknown. Methods and results A total of 129 patients (mean age 79±10 years, male 66%) including 38 primary MR and 91 secondary MR who underwent TEER guided with three-dimensional (3D) transesophageal echocardiography (TEE) were included. MA area, anterior-posterior (AP) diameter, inter-commissure (CC) diameter, and MA ellipticity before and after MitraClip implantation were measured using 3D TEE images assessed by dedicated software. MitraClip G4 was used in 54 cases (42%). In patients with secondary MR, greater changes in MA area, AP diameter, and MA ellipticity were observed in patients treated with G4 compared to G2 (P=0.001, 0.003, and 0.39, respectively). In contrast, patients with primary MR had no differences in the change of MA parameters between G2 and G4. Patients with significant residual MR had less increase of MA ellipticity after device implantation in secondary MR (P=0.014), but not in primary MR (P=0.062). Conclusion In patients with secondary MR, MitraClip G4 made greater changes in MAA, AP diameter, and MA ellipticity compared to MitraClip G2, but not in CC diameter. The change of ellipticity was associated with a reduction of MR after device implantation in secondary MR. These findings indicated that MitraClip G4 may lead favorable MA alternation than G2, especially in secondary MR.

Application of computed tomographic angiography and echocardiography in predicting left atrial appendage thrombosis in patients with non-valvular atrial fibrillation.

We aimed to explore the application of computed tomographic angiography (CTA) and echocardiography in predicting left atrial appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation. The clinical data of 164 atrial fibrillation patients receiving cardiac CTA and real-time three-dimensional transoesophageal echocardiography (RT-3D-TEE) were retrospectively analysed. The patients were divided into group A (anticoagulant treatment group, n = 112) and group B (selective anticoagulant treatment group, n = 52) according to the CHA2DS2-VASc score, which scored for the presence or absence of congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke/transient ischaemic attack, vascular disease, age 65-74 years and gender (female). The CHA2DS2-VASc score was used to predict risk of thromboembolism from atrial fibrillation. The correlations of CHA2DS2-VASc score with CTA-based LAA classification and RT-3D-TEE measurement parameters were explored using Spearman's analysis. Receiver operating characteristic (ROC) curves were plotted to explore the predictive value of CTA and RT-3D-TEE for LAA thrombus. There were significant differences in age, disease course, hypertension, diabetes mellitus, coronary heart disease, heart failure, stroke/transient ischaemic attack/thromboembolism, vascular disease, B-type natriuretic peptide and serum uric acid levels, CHA2DS2-VASc score, LAA classification, left ventricular ejection fraction (LVEF), left atrial diameter (LAD), maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length (p < 0.05). CHA2DS2- VASc score was positively correlated with cauliflower LAA, LAD, maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length, and negatively correlated with LVEF (p < 0.001). ROC curve analysis indicated that CTA, RT-3D-TEE and CHA2DS2-VASc score had similar predictive values for risk of LAA thrombosis in atrial fibrillation patients, with the areas under the curve being 0.778, 0.814 and 0.792, respectively. Both CTA and RT-3D-TEE had high predictive values for LAA thrombosis in atrial fibrillation patients.

Contribution of Three-Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Defects (ASD)

The article examines the contribution of real-time three-dimensional transesophageal echocardiography (3D TEE) in the assessment of ostium secundum atrial septal defects (ASD) in adults. 3D TEE provides a precise and comprehensive view of cardiac anatomy, enabling the evaluation of size, shape, and border quality of the ASD. In a series of 27 cases, 3D TEE demonstrated a strong correlation between 3D-measured ASD parameters and the size of the closure device required. This technique is crucial for accurate pre-interventional evaluation, enhancing the success and safety of percutaneous or surgical interventions for ostium secundum ASD. Three-dimensional transesophageal echocardiography represents a significant advancement in cardiovascular imaging for complex structural heart abnormalities.

Transvalvular Regurgitation across a Tilting Disk Prosthetic Mitral Valve: Role of Intraoperative Real-time Three-dimensional Transesophageal Echocardiography

Transvalvular Regurgitation across a Tilting Disk Prosthetic Mitral Valve: Role of Intraoperative Real-time Three-dimensional Transesophageal Echocardiography

Assessment of Right Ventricular Mechanics by 3D Transesophageal Echocardiography in the Early Phase of Acute Respiratory Distress Syndrome.

AimTo compare global and axial right ventricular ejection fraction in ventilated patients for moderate-to-severe acute respiratory distress syndrome (ARDS) secondary to early SARS-CoV-2 pneumonia or to other causes, and in ventilated patients without ARDS used as reference.MethodsRetrospective single-center cross-sectional study including 64 ventilated patients: 21 with ARDS related to SARS-CoV-2 (group 1), 22 with ARDS unrelated to SARS-CoV-2 (group 2), and 21 without ARDS (control group). Real-time three-dimensional transesophageal echocardiography was performed for hemodynamic assessment within 24 h after admission. Contraction pattern of the right ventricle was decomposed along the three anatomically relevant axes. Relative contribution of each spatial axis was evaluated by calculating ejection fraction along each axis divided by the global right ventricular ejection fraction.ResultsGlobal right ventricular ejection fraction was significantly lower in group 2 than in both group 1 and controls [median: 43% (25–75th percentiles: 40–57) vs. 58% (55–62) and 65% (56–68), respectively: p < 0.001]. Longitudinal shortening had a similar relative contribution to global right ventricular ejection fraction in all groups [group 1: 32% (28–39), group 2: 29% (24–40), control group: 31% (28–38), p = 0.6]. Radial shortening was lower in group 2 when compared to both group 1 and controls [45% (40–53) vs. 57% (51–62) and 56% (50–60), respectively: p = 0.005]. The relative contribution of right ventricular shortening along the anteroposterior axis was not statistically different between groups [group 1: 51% (41–55), group 2: 56% (46–63), control group; 56% (50–64), p = 0.076].ConclusionDuring early hemodynamic assessment, the right ventricular systolic function appears more impaired in ARDS unrelated to SARS-CoV-2 when compared to early stage SARS-CoV-2 ARDS. Radial shortening appears more involved than longitudinal and anteroposterior shortening in patients with ARDS unrelated to SARS-CoV-2 and decreased right ventricular ejection fraction.

Analysis of mitral valve morphology in dogs undergoing mitral valve repair with three-dimensional transesophageal echocardiography

IntroductionInformation about real-time three-dimensional (3D) transesophageal echocardiography (TEE) for the evaluation of canine mitral valve morphology is lacking in veterinary medicine. ObjectivesTo evaluate the feasibility of 3D TEE for the evaluation of canine mitral valves and whether there was a difference in mitral valve morphology between American College of Veterinary Internal Medicine (ACVIM) stages. AnimalsThirty-one dogs were evaluated, including nine dogs classified as ACVIM stage B2, 15 as stage C, and seven as stage D. Materials and methodsThree-dimensional TEE was performed after anesthetic induction for mitral valve surgery, and the 3D geometry of the mitral valve apparatus was measured. ResultsThe intraclass correlation coefficient was good in both inter- and intraobserver analyses of the 3D measurements of mitral valve annulus geometry and excellent in both inter- and intraobserver analyses in the 3D measurements of mitral valve annular and leaflet sizes. Annulus height to commissural width ratio of stage D dogs showed significantly lower values than B2 dogs (B2: 14.2% [9.1–20.5%]; C: 10.6% [6.5–24.1%]; D: 9.5% [4.7–13.8%]). The aortic–mitral angle of stages C and D were significantly flatter than stage B2 (B2: 122.32 ± 9.39; C: 133.66 ± 8.43; D: 140.70 ± 10.70). ConclusionsReal-time 3D echocardiography using TEE is a feasible method to evaluate the morphology of the mitral valve in dogs. The saddle shape of the mitral annulus and aortic–mitral angle were flatter in stage D. Further studies are required to understand the pathology of mitral valve disease in dogs.

Comparison of Four Different Techniques for Estimation of Left Ventricular Volumes Using Intraoperative Real Time Three Dimensional Transesophageal Echocardiography--A Prospective Observational Study

The primary objective of the present study was to compare cardiac output derived with four methods of QLab (Philips, Amsterdam, Netherlands) software using real-time three-dimensional (3D) transesophageal echocardiography, with cardiac output obtained with the 3D left ventricular outflow tract (LVOT) cardiac output method. The secondary objective was to assess left ventricular (LV) volumes, LV ejection fraction, and cardiac output derived with four different methods of real time 3D transesophageal echocardiography processed in QLab software and to determine whether these parameters differed among these four methods. A prospective observational study. A tertiary referral center and a university level teaching hospital. The study comprised 50 patients scheduled for elective coronary artery bypass surgery without any concomitant valvular lesions. Three-dimensional full-volume datasets were obtained in optimum conditions. The 3D datasets were analyzed using four different methods in QLab, version 9. In method A, LV volumes were derived without endocardial border adjustment. In method B, LV volumes were obtained after endocardial border adjustment in the long-axis view alone. In method C, the iSlice tool (Philips) was used to adjust the endocardial borders in 16 short-axis slices. In method D, endocardial borders were adjusted after dataset processing to obtain LV volumes. The cardiac output derived with the 3D echocardiography LVOT method was 3.93 ± 1.44 L/min, with method A was 3.26 ± 1.42 L/min, with method B was 3.51 ± 1.2 L/min, with method C was 4.01 ± 1.40 L/min, and with method D was 4.18 ± 1.58 L/min. There was a significant positive correlation between the cardiac output derived using the 3D LVOT method and method C (r = 0.71). Readjusting the endocardial border contours resulted in higher LV volumes than the volumes estimated using semiautomated border algorithms. The iSlice method produced the highest and the most accurate LV volumes, although it required the longest time to analyze and derive results. The ejection fraction obtained with all four methods of QLab demonstrated no statistical differences and had a strong correlation with the two-dimensional echocardiography-derived left ventricular ejection fraction.

Evaluating the novel parameters for assessing the LAA function and thrombus formation with nonvalvular atrial fibrillation.

The dysfunction of left atrial appendage (LAA) is prone to form thrombus when atrial fibrillation (AF) sustained more than 48 h. Traditional 2D-TEE (transesophageal echocardiography) can not accurate evaluate the function of LAA. The purpose of this study is to analyze the relationship of LAA function parameters and thrombus formation in patients with non-valvular atrial fibrillation (NVAF) by real-time three-dimensional transesophageal echocardiography (RT-3D-TEE). High risk patients can be identified according to the characteristics of ultrasonic index in patients with left atrial appendage thrombosis, which has important clinical value and significance in the risk assessment, guiding treatment and judging prognosis. We examined the relationship between the echocardiographic parameters of LAA function and the incidence of thrombus in 102 NVAF patients. They underwent RT-3D-TEE and left atrial appendage thrombus (LAAT)/severe spontaneous echocardiographic contrast (SSEC) was found in 67 patients (thrombus group) but absent in the remaining 35 patients (non-thrombus group). After measured by QLAB software, the LAA functional parameters were significantly associated with LAAT/SEC formation. Univariate analysis indicated that AF time, LAD, LVEF, LAA-OAmax, LAAVmax, LAAVI and LAAEF demonstrated a positive association (P < 0.05). However, logistic regression analysis identified that AF time (OR:1.73, P < 0.05)、LAAEF (OR:4.09, P < 0.01)and LAAVI (OR:3.28, P < 0.01) were independent predictors of LAAT/SSEC. In patients with nonvalvular atrial fibrillation, echocardiographic parameters of LAA function are significantly associated with LAAT/SSEC.

Real-time three-dimensional transesophageal echocardiographic guidance versus fluoroscopic guidance for transvenous temporary cardiac pacemaker implantation during transcatheter aortic valve implantation surgeries.

BackgroundFluoroscopic guidance is the traditional method for the implantation of transvenous temporary cardiac pacemakers (TVTPs). This study aimed to compare the time, effectiveness, and safety of real-time three-dimensional transesophageal echocardiography (3D TEE) with those of fluoroscopy in guiding TVTP implantation.MethodsThe records of patients who underwent transcatheter aortic valve implantation (TAVI) guided by real-time 3D TEE or fluoroscopy between July 1, 2016, and June 30, 2020, were retrospectively analyzed. TVTPs were implanted by anesthesiologists via the right internal jugular vein (IJV) in the real-time 3D TEE-guided group (3D TEE group), and by interventional cardiologists via the femoral vein in the fluoroscopy-guided group (fluoro group).ResultsA total of 143 patients (3D TEE-group n=79, and fluoro group n=64) were included. No statistical differences were observed in the baseline characteristics of the two groups. TVTPs were successfully implanted in all of the patients. The needle-to-pace time was significantly shorter in 3D TEE group than in fluoro group (5.2±2.9 vs. 8.5±4.6 min, P<0.001). Further, the incidence of access complications was significantly lower in 3D TEE group than in fluoro group (3.8% vs. 12.5%, P<0.05). One patient in fluoro group who suffered cardiac perforation underwent drainage via pericardiocentesis. No patients in either group died because of TVTP placement. The total complication rates were significantly lower in 3D TEE group than in fluoro group (19.0% vs. 39.1%, P<0.05). No statistically significant differences existed between groups in terms of pacing threshold, the incidence of permanent pacemaker insertion after surgery, the length of postoperative intensive care unit (ICU) stay, or the duration of postoperative hospitalization.ConclusionsReal-time 3D TEE-guided can be used to effectively, quickly, and safely guide TVTP implantation. The procedure can be performed by properly trained anesthesiologists. Therefore, real-time 3D TEE is a suitable option for guiding perioperative TVTP implantation in patients undergoing cardiac surgery.

Geometry of Tricuspid Valve Apparatus in Patients with Mitral Regurgitation due to Fibroelastic Deficiency versus Barlow Disease: A Real-Time Three-dimensional Transesophageal Echocardiography Study

Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography. Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n=42) and FED (n=64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1month. TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8±2.9 vs 9.2±2.4cm2, 4.6±1.6 vs 2.3±1.1mm, and 1.3±0.8 vs 0.3±0.3mL; all P<.01). In contrast, TV tenting height and tenting volume were smaller in BD than in FED (2.6±1.5 vs 4.4±2.4mm and 0.3±0.4 vs 0.9±1.0mL; both P<.01). These morphologic differences in TV were similar to those in MV. There was a strong correlation between MV billowing volume and TV billowing volumes (R=0.83, P<.01). The prevalence of significant residual TR after TAP was greater in BD than in FED (35% vs 0%, P<.01). Moderate correlations between TV billowing height and volume and residual TR after TAP were observed (R=0.47 and 0.49, respectively, both P<.01). Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

Dynamic changes of mitral annulus in patients with degenerative mitral regurgitation and chronic atrial fibrillation undergoing mitral valve reconstruction.

This study was designed to assess structural and dynamic changes in the mitral annulus in patients before mitral valve reconstruction for degenerative mitral regurgitation with or without chronic atrial fibrillation. One hundred and fifty one consecutive patients undergoing mitral valve reconstruction for mitral regurgitation due to myxomatous diseasebetween July 2013 and May 2016 were included. Of these, 117 had a sinus rhythm (SR group) and 34 had chronic AF (AF group). Patients who underwent aortic surgery and were found to have no underlying cardiac valve disease nor coronary artery disease were included as the control group (n = 20).Real-time three-dimensional trans-esophageal echocardiography (3D-TEE) was used to assess mitral annulus shape, size, and movements. Annular areas in the control group were the smallest of the three groups and changed considerably through the cardiac cycle. Mean anteroposterior and intercommissural diameter measurements in theSR group were significantly larger but oscillated less than in the control group.Those diameters were the largest in the AF group and oscillated very little. Dilatation of the annulus in the AF and SR groups was accompanied by flattening and marked loss of oscillation in the height-to-intercommissural-width ratio which should peak in early systole. In patients with degenerative mitral regurgitation undergoing mitral valve surgery, preoperative chronic atrial fibrillation is associated with more progressed annular remodeling, characterized by marked enlargement of annular area, circumference, and anteroposterior diameter.

Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation

P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant. One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed. Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P<.001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P=.157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P<.001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients. Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.

Sizing of mitral annuloplasty rings using real-time three-dimensional transesophageal echocardiography and the difference between patients with and without recurrent mitral regurgitation: retrospective cohort study.

Previous studies showed that the mitral inter-commissural (IC) distance differed by a few millimeters between the systolic and diastolic cardiac cycles. However, sizing of the mitral annuloplasty ring with a ring sizer, which should be performed in the systole, is performed in diastole during hyperkalemic cardioplegic arrest. The aim of this study was to investigate whether three-dimensional transesophageal echocardiography (3D-TEE) measurements of the mitral valve in end-systole are effective to determine the size of the annuloplasty ring. This study retrospectively reviewed 92 patients who underwent mitral annuloplasty for degenerative. The IC distance and anterior leaflet height of the A2 segment of the mitral valve were measured by 3D-TEE at the end-systole. The annuloplasty ring size was measured by the surgeons using specific ring sizers. We compared the IC distance measured by 3D-TEE with the implanted annuloplasty size. We also investigated differences in IC distance, A2 height, and ratio of A2 height to IC distance in patients with and without recurrent mild to moderate MR for 36months. There was a significant correlation between the IC distance by 3D-TEE and the implanted ring size (R2 = 0.7023, p < 0.001). Eight cases had mild or greater recurrent MR. There was a significant difference in the ratio of A2 height to IC distance between patients with and without recurrent MR (p = 0.006). A2 height was greater in patients with recurrent MR, but this difference was not significant (p = 0.059). Our results demonstrated a larger ratio of A2 height to IC distance in patients with recurrent MR. 3D-TEE could be useful for the ring sizing.

New horizon of fusion imaging using echocardiography: its progress in the diagnosis and treatment of cardiovascular disease.

Cardiac imaging modalities are essential for the management of cardiac diseases. Multimodality imaging, such as echocardiography, cardiac computed tomography (CT), cardiac magnetic resonance imaging, and fluoroscopy, is required for assessing cardiac condition. In recent years, fusion imaging, which integrates different imaging modalities on the same screen, has been developed. Because the fusion imaging is able to merge the advantages of each modality, it has the potential to be valuable for accurate diagnosis as well as the planning of therapeutic strategies. In the clinical setting, the fusion imaging of real-time transthoracic echocardiography with cardiac CT displayed side by side has reportedly been effective for the diagnosis and the assessment of disease severity in patients with adult congenital heart disease. The overlay of real-time three-dimensional transesophageal echocardiography onto fluoroscopy, which is dynamic fusion imaging, has been used for structural heart disease interventions. The fusion imaging has become increasingly important in the field of cardiac diseases. This review discusses the benefits of echocardiographic fusion imaging.

Echocardiographic Evaluation of Anterior Mitral Valve Aneurysm Without Infective Endocarditis

Mitral valve aneurysm (MVA) is un-common and occurs most commonly as a complication of infective endocarditis. Early diagnosis and surgical treatment are of great importance. In this study, we reported a 30-year-old man with anterior MVA in the A2 scallop without concurrent infective endocarditis, which was recognized by preoperative real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) and confirmed at operation with mitral valve replacement. This study presented a rare condition, and valuated the potential application of RT-3D-TEE in MVA diagnosis.

Identification of mechanical prosthetic heart valves based on distinctive cinefluoroscopic and echocardiographic markers.

The past 65 years have witnessed remarkable progress in the development of safe, hemodynamically favorable mechanical heart valves. Today, there are a large number and variety of prostheses in use and many prostheses have been used for a while and then discontinued. When patients lack reliable information about their heart valve prostheses, identification of valve model becomes difficult even for specialized physicians in this area. A combination of cinefluoroscopy and echocardiography makes it possible to provide accurate and detailed information regarding identification of prosthetic valve models. Fluoroscopic examination is a useful technique to evaluate patients following mechanical heart valve replacement. However, transthoracic echocardiography and transesophageal echocardiography have almost replaced cinefluoroscopy in the evaluation of prosthetic heart valves. Especially, real-time three-dimensional transesophageal echocardiography provides distinctive images of prosthetic heart valves, particularly for those in the mitral position. A large body of literature has been published to familiarize physicians with the radiological appearance of numerous mechanical prostheses. However, there is a lack of data regarding the identification of prosthetic valve models based on echocardiographic appearance. In this review, we aimed to describe distinctive echocardiographic and cinefluoroscopic markers for identifying the type and brand of several commonly used mechanical prosthetic heart valves.

Intraoperative real-time three-dimensional transesophageal echocardiography as a precise navigator for a successful complicated postoperative left ventricular pseudoaneurysm repair: a case report

BackgroundLeft ventricular pseudoaneurysm (LV-PAN) formation is a rare complication after cardiac surgery and mainly occurs after mitral valve surgery. Echocardiography plays a critical role in the assessment of rupture location, orifice geometry, and anatomical relationship with surrounding structures.Case presentationA 56-year-old man presented with LV-PAN formation 1 year after aortic root replacement combined with aortic replacement despite the lack of direct manipulation of the rupture site in the procedure and postoperative myocardial infarction. Intraoperative real-time three-dimensional transesophageal echocardiography (RT 3-D TEE) during surgical repair of the LV-PAN facilitated understanding of the shape of the LV-PAN orifice and the exact anatomical relationship between the rupture site and the posteromedial papillary muscle. Information sharing with surgeons contributed to avoiding direct papillary muscle injury and thus mitral valve deformation.ConclusionLV-PAN formation after cardiac surgery can present without direct manipulation of the rupture site and major coronary lesion. Intraoperative RT 3-D TEE can facilitate better understanding of the anatomical relationship between the rupture site and the posteromedial papillary muscle and allow for information sharing to avoid complications during surgical repair.

New ultrasonic technologies and application progress

Recently, with the progress of computer technology and related technologies, a variety of new ultrasound technologies have emerged in clinic, which expanded the application fields of ultrasound. This article reviewed the representative new ultrasonic technologies and their application progress, including ultrasonic elastography, contrast-enhanced ultrasound, real-time three-dimensional transesophageal echocardiography, lung ultrasonography, fetal echocardiography and ultrasound-mediated ablation therapy. Key words: Ultrasonography; Elasticity imaging techniques; Echocardiography; Review

Percutaneous closure of the left atrial appendage: The value of real time 3D transesophageal echocardiography and the intraoperative change in the size of the left atrial appendage.

The aim of this study was to investigate the value of real time three-dimensional transesophageal echocardiography (RT3DTEE) in percutaneous closure of the left atrial appendage (LAAC). In addition, this study also explored the change in the size of the left atrial appendage (LAA) from 24hours before the operation to just before implantation during the operation. In a retrospective study, 32 patients underwent two-dimensional transesophageal echocardiography (2DTEE) and RT3DTEE 24hours prior to operation and during operation. The maximal LAA orifice diameter (by 2DTEE, 22.7±2.7 vs 24.6±2.2mm, P<0.01; by RT3DTEE, 24.2±2.9 vs 25.8±2.7mm, P<0.01), the maximal landing zone diameter (by 2DTEE, 19.0±2.8 vs 20.4±2.8mm, P<0.01; by RT3DTEE, 20.4±2.7 vs 22.6±3.0mm, P<0.01), and the maximal depth diameter (by 2DTEE, 25.2±3.2 vs 26.5±3.0mm, P<0.01; by RT3DTEE, 26.4±3.2 vs 27.5±3.7mm, P<0.01) all increased significantly during the operation. The highest correlation (R) between the maximal landing zone diameter and the compressed occluder diameter was determined for RT3DTEE measurements during the operation (R=0.90), whereas the landing zone diameter (R=0.80) measured by 2DTEE was less correlated. In addition, our study showed that RT3DTEE was of great value in discriminating the LAA orifice shape, allowing differentiation of the LAA morphology and identification of the number of LAA lobes. A certain amount of intravenous rehydration just before and during operation increased the LAA size significantly. The measurements by RT3DTEE showed a closer correlation to LAA occluder size than those by 2DTEE. The LAA displayed by RT3DTEE was more visible than that by 2DTEE.