3D Transesophageal Echocardiography Research Articles

Echocardiographic navigation in transapical neochord mitral valve repair with significant mitral regurgitation

INTRODUCTION. Significant mitral regurgitation is currently a widespread acquired valvular heart disease and is associated with a significant decrease in survival and deterioration in quality of life. One of the new, unclearly studied, minimally invasive method for correcting significant mitral regurgitation is transapical neochord mitral valve repair, where echocardiography is the key imaging tool.The OBJECTIVE was to analyze the data of world studies devoted to the problem of echocardiographic navigation in transapical neochord mitral valve repair, to determine the echocardiographic criteria applicable to neochord implantation surgery. METHODS AND MATHERIALS. The analysis of studies about using echocardiography in the transapical neochord mitral valve repair has been carried out. Databases searched in this review included PubMed, ResearchGate, and Hindawi.RESULTS. During the analysis, we figured out that 2D and 3D transesophageal echocardiography is the main method for mitral valve imaging during transapical neochord mitral valve repair. Specific parameters which can be useful in addition for standard echocardiographic protocol of mitral valve evaluation have been identified.CONCLUSION. The results of the analysis showed that it is necessary to summarize the experience of present studies and standardize the approach to echocardiographic evaluation of the mitral valve during transapical neochord mitral valve repair.

The role of transesophageal echocardiography in improving device size selection for percutaneous paravalvular leak closure

Abstract Introduction Paravalvular leak (PVL) is an undesirable complication that can occur following valve implantations. The incidence of major leaks, which can clinically manifest as heart failure, hemolytic anemia, or both, has been reported to be 1-5% (1). The mortality rates for redo surgery are reported at 13%, 15%, and 37% for the first, second, and third operations, respectively (2). In recent years, percutaneous PVL closure (PPVLC) procedures, which are associated with lower mortality rates, have emerged as an attractive option for patients who are at high surgical risk. Purpose Determining the appropriate device size for closing a defect is one of the most challenging aspects of PPVLC. Currently, there is no consensus on the optimal imaging modality for this purpose. We aimed to compare transthoracic and transesophageal echocardiographic measurements to accurately determine the device size. Methods We reviewed our hospital records to identify patients diagnosed with moderate-severe and severe PVL from 2018 to 2024. A total of 81 who underwent percutaneous paravalvular leak closure (PPVLC) patients were evaluated. Eight of these 81 patients were excluded due to unsuccessful PPVLC, leaving 73 patients who were successfully treated with PPVLC were included. Technical success was defined as the deployment of the device without any interference with the prosthetic valve and with mild or less residual regurgitation. The defect size for all patients was evaluated using 2D transthoracic echocardiography (TTE), 2D transesophageal echocardiography (TEE), direct measurement of 3D TEE vena contracta, and 3D multi-planar reconstruction TEE (3D-MPR TEE). Results A total of 73 patients with clinically significant moderate to severe or severe mitral and/or aortic paravalvular leak (PVL) were included in the study. Among these patients, 42 underwent aortic PPVLC and the remaining 31 underwent mitral PPVLC. Patients were categorized based on the implanted device size: 17 patients in the 6-7 mm group, 19 patients in the 8 mm group, 15 patients in the 10 mm group, 8 patients in the 12 mm group, and 14 patients in the 14-16 mm group. According to proportional odds logistic regression analysis, the 3D MPR TEE measurement was the strongest predictor of device size accuracy, both in the overall group and within the aortic/mitral subgroups. In the mitral subgroup, however, the predictive power of direct measurement of 3D TEE vena contracta and 3D MPR measurements was similar. Conclusion PPVLC has gained increasing interest, particularly over the last decade. Determining the appropriate device size is especially challenging in cases of mitral PVL. Our findings suggest that using 3D-MPR TEE measurements significantly improves the accuracy of device size selection in both mitral and aortic PVL. Additionally, direct measurement of 3D TEE vena contracta can serve as a viable alternative for patients with mitral PVL. Figure 1. Direct measurement of 3D TEE Figure 2. 3D TEE MPR measurement

Dynamics of the mitral valve annulus in hypertrophic obstructive cardiomyopathy patients undergoing septal myectomy: insights from 3D transesophageal echocardiography

Abstract Background Mitral annulus (MA) dynamics in HOCM patients and the impact of surgical myectomy on them is not fully understood. This study aimed to evaluate the MA dynamics and their changes after septal myectomy in HOCM patients. Methods This prospective, single-center study included 26 HOCM patients undergoing septal myectomy. Intraoperative Three-dimensional Trans-Esophageal Echocardiography (3DTEE) for the mitral valve (MV) was performed pre- and post-surgery followed by offline analysis of the acquired volumes to assess MA dimensions and dynamics before and immediately after myectomy using a dedicated post-processing software (4D MV analysis, QLAB version 15, Philips Healthcare). Results Pre-operatively, throughout four phases of the cardiac cycle (late diastole, early systole, mid-systole, and late systole), there were no significant dynamic changes in MA dimensions, Specifically, the anteroposterior (AP) diameter (3.753 ± 0.48, 3.756 ± 0.48, 3.866 ± 0.49, and 3.997 ± 0.49 cm, respectively; P=0.286), inter-trigonal diameter (2.88 ± 0.59, 2.89 ± 0.58, 2.89 ± 0.58, and 2.93 ± 0.60 cm, respectively; P=0.982), inter-commissural diameter (3.52 ± 0.38, 3.519 ± 0.36, 3.509 ± 0.35, and 3.526 ± 0.37 cm, respectively; P=0.999), 3D saddle-shaped annulus area (11.336 ± 2.26, 11.346 ± 2.27, 11.599 ± 2.3, and 12.031 ± 2.41 cm², respectively; P=0.714), annulus height (1.135 ± 0.24, 1.154 ± 0.25, 1.164 ± 0.24, and 1.148 ± 0.24 cm, respectively; P=0.981), aorto-mitral angle (105.64 ± 11.7, 104.62 ± 11, 103.8 ± 9.4, and 104.9 ± 10.40, respectively; P=0.949), and saddling (0.322 ± 0.06, 0.328 ± 0.06, 0.33 ± 0.06, and 0.326 ± 0.07, respectively; P=0.231). Post-operative comparisons revealed a notable _yet not statistically significant_ increase in the intercommissural and intertrigonal diameters in the mid systolic phase after myectomy that may be related to the relief of the obstruction. However, no statistically significant changes in MA dynamics throughout the four phases of the cardiac cycle regarding the AP diameter (P=0.939, 0.914, 0.965, and 0.505, respectively), inter-trigonal diameter (P=0.709, 0.701, 0.797, and 0.710, respectively), inter-commissural diameter (P=0.597, 0.990, 0.396, and 0.328, respectively), 3D saddle-shaped annulus area (P=0.854, 0.828, 0.880, and 0.619, respectively), annulus height (P=0.344, 0.318, 0.27, and 0.342, respectively), aorto-mitral angle (P=0.756, 0.702, 0.320, and 0.255, respectively), and saddling (P=0.1, 0.2, 0.062, and 0.067, respectively). Conclusion In HOCM patients, MA exhibits reduced dynamic motion, with a notable loss of normal systolic AP contraction and saddling. Immediate postoperative assessments did not demonstrate significant improvements in MA dynamics. Therefore, further longitudinal studies are necessary to assess long-term changes in MA dynamics due to LV remodeling following septal myectomy procedures.

Left atrial appendage: a comparative analysis using 2D and 3D transoesophageal echocardiography

Abstract Background Percutaneous left atrial appendage (LAA) closure is an alternative intervention to anticoagulation to prevent stroke in patients with atrial fibrillation with a higher risk of bleeding. The imaging of LAA is crucial to determine the optimal ostium dimensions for safe closure and procedural outcomes. Sizing using three-dimensional transoesophageal echocardiography (3D-TOE) is likely to offer a more accurate assessment, as seen in other structural interventions such as annular measurements in transcatheter aortic valve implantation (TAVI). Aim This study aimed to evaluate the accuracy of LAA sizing using two-dimensional transesophageal echocardiography (2D-TOE) and 3D-TOE. Furthermore, we assessed the accuracy of the measurements by correlating both imaging modalities with final device size and post-device leakage. Methods Our study prospectively analysed the LAA dimensions of 63 consecutive patients undergoing transoesophageal echocardiography (TOE) with measurements using both 2D and 3D-TOE (Figure 1 & 2). The assessing clinician remained blinded to measurements that were performed retrospectively by data analysts. Additionally, we retrospectively evaluated outcomes with 25 consecutive LAA closures (Figure 3 & 4), where 2D-TOE was utilised alongside fluoroscopy for sizing in 18 (72%), and 3D-TOE was employed in 8 (32%) of patients. Results The mean age of patients was 76 ± 7 years. The LAA annulus was eccentric in 47 (75%) and circular in 16 (25%) of patients. There was a good intraclass correlation (ICC) between 2D and 3D-TOE (ICC=0.81, p <0.001) and Pearson’s correlation (r=0.84, p <0.001). Bland-Altmann analysis (Figure 5) revealed a bias of 0.19, indicating 3D-TOE LAA measurements were larger overall, with limits of agreement between -0.33cm to 0.71cm. The retrospective analysis showed that 2D-TOE underestimated the final device size by 1.86 ± 1.1 mm, while 3D-TOE underestimated by 0.6 ± 1.2 mm. Clinically, using only 2D-TOE measurements, 9 patients (36%) required upsizing, whereas 3D-TOE accurately predicted the final device size in all but one case. Additionally, in 18 cases guided solely by 2D-TOE, 9 (50%) were complicated by post-device leakage at the six-week follow-up, albeit they were all leaks were less than the guideline cut-off value of 6 mm. In contrast, for 8 patients where 3D-TOE was also used, there was only one case of post-device leak. Conclusion Our study demonstrates that while 2D and 3D-TOE values are mostly consistent, 3D-TOE measurements are larger and more accurately depict the irregular, eccentric nature of LAA orifices. 3D-TOE guidance had better correlation with true device size, resulting in lower post-device leakage and less intra-procedural upsizing. These findings align with TAVI literature, which notes that 2D echocardiography underestimates the true size of the aortic valve annulus compared to CT and 3D echocardiography techniques.

Description of the anatomical characteristics of mitral valve apparatus among patients with moderate or severe primary mitral regurgitation using 3D transesophageal echocardiography

Abstract Background/Introduction There are two types of mitral regurgitation (MR); primary, which is characterized by abnormalities of the mitral valve apparatus and secondary or functional, caused by left atrioventricular remodeling. The implementation of 3D transesophageal echocardiography (3D-TEE) has resulted in the precise depiction of the anatomical characteristics of mitral valve apparatus that prompts appropriate treatment. Purpose The aim of this study is to describe the anatomical characteristics of the mitral valve among patients with moderate or severe primary MR by using 3D-TEE. Methods From 2017 to 2023, 333 3D-TEE examinations have been performed in our center to evaluate MR cases. Specifically, 181 cases were classified as primary MR (52 moderate and 129 severe), in which visualization of the mitral apparatus had been performed via 3D-TEE. The recorded 3D data were retrospectively analyzed with specialized software and the pathophysiology of MR was described in each case. Results The median patient age was 63.9 years (SD±13.5), while 58% of patients were men. The left atrium was moderately or severely enlarged in 79% of the cases and the left ventricular ejection fraction was >60% in 61.5% of the patients. Mitral valve prolapse (MVP) with or without flail was found in 109 (61.9%) patients. Furthermore, it was noticed that MVP had been occurred at the anterior leaflet in 45.5% of the cases, at the posterior leaflet in 25% and at both leaflets in 29.5% of the cases. Moreover, in 65.5% of the cases, one or two mitral valve scallops had been affected. In the MR cases where the predominant pathophysiology was flail valve, the posterior mitral leaflet had been involved in 94.8% of the cases with one or two scallops been affected (83.9%). Among patients with both flail valve and MVP, the former was found at the posterior leaflet, while the latter at the anterior leaflet (in 63.9% of the cases). Mitral valve cleft in the absence of another mitral valve pathology was found in 7 patients (4%), while in 8 patients (4.4%) MVP was present and in 4 cases (2.2%) a combination of MVP and flail was found. The mitral cleft was depicted on P1P2 (38.1%) and P2P3 (23.8%) scallops respectively. Bileaflet cleft was found only in 4.8% of the cases. Moreover, calcified mitral lesions as primary cause of MR were found in 37 patients (21%), while rheumatic mitral valve pathology was found in 13 patients (7.4%). Among the rest causes of MR, infective endocarditis was found in 7 patients (4%) and systolic anterior motion of mitral valve in the context of hypertrophic cardiomyopathy in 3 patients (1.7%). Conclusions The description of mitral valve anatomy with the use of 3D-TEE provides useful information regarding morphological features that are used as favorable criteria for mitral valve repair procedures. It is suggested that cardiologists should get familiarized with 3D-TEE aiming at optimal clinical decisions to achieve maximum benefit for the patient.

Tricuspid leaflet identification on 2D multiplane transesophageal echocardiography: derivation and validation of a simple two-step approach

Abstract Background Tricuspid valve (TV) leaflet identification by two-dimensional (2D) transesophageal echocardiography (TOE) is complex due to the considerable variability in the visualized leaflets. While three-dimensional (3D) imaging can easily overcome this problem by acquiring the whole valve anatomy, the overall image quality is often suboptimal and the technique somewhat unsuitable for real-time monitoring during interventional procedures like TriClip implantation. Using information derived from both 2D and multiplanar reconstruction of 3D datasets, we elaborated a step-wise approach to identify TV leaflets during multiplane 2D TOE and tested it on a validation cohort. Methods TOE data from 83 patients was retrospectively collected. The 3D data of each patient was appropriately sliced to simulate and accurately match what would be seen by "sweeping" the cursor across the TV during real-time multiplane imaging (Fig. 1). Following data analysis, a "two-step" reference table was created and subsequently evaluated for accuracy on a validation cohort of 41 patients from a distinct hospital and country. To evaluate the usability of the approach, 11 echocardiographers were presented with a random selection of 5 multiplane images. They were then instructed to identify the visualized leaflets initially without using the reference table, and subsequently with its assistance. Results After removal of redundant information, 231 unique multiplane sets were obtained. Combining anatomical features (number of leaflets visualized and presence of the interventricular septum) from the 2D views allowed easy and consistent identification of TV leaflets (Fig. 2), as confirmed by correlation with the 3D dataset. The same "two-step" approach was subsequently tested on an independent validation cohort of 41 patients (96 unique multiplane sets). Accurate leaflet identification was possible in 35 patients (85%), while in 6 cases (15%) the image sector was too narrow to confidently assess the presence of the interventricular septum. The accuracy in exact leaflet recognition without the aid of the reference table was rather modest (mean score of 1 out of 5) among echocardiographers with different experience in TV TOE, but significantly increased (mean score of 3.2 out of 5) with the adoption of the proposed approach, accounting for a 44% improvement in accuracy (p< 0.001). Conclusion Simple anatomical features allow precise TV leaflet identification during multiplane 2D TOE. A streamlined "two-step" approach, validated on an independent cohort of patients, significantly improves accuracy in leaflet recognition among both beginner and advanced echocardiographers.

Additive diagnostic value of 3D transesophageal echocardiography (3DTOE) in diagnosis of Infective endocarditis (IE)

Abstract Introduction The clinical manifestations of infective endocarditis (IE) are highly polymorphic, complicating the diagnostic process and leading to delays in treatment, particularly in elderly or immunocompromised patients. Recent studies advocate for early surgery to improve prognosis in IE patients. Advanced surgical planning for the complex pathomorphological spectrum of IE lesions requires detailed anatomical visualization, which is enhanced by three-dimensional transesophageal echocardiography (3DTOE). Purpose This study analyzed the echocardiographic characteristics of complex IE patients referred for additional evaluation in a tertiary center and assessed the role of 3DTOE in their evaluation. Methods This prospective study included all consecutive patients hospitalized in a tertiary clinical center, referred for IE in Serbia from November 2017 to October 2023. Blood cultures, serological assessment, transthoracic echocardiography (TTE), 2D/3DTOE, abdominal sonography, and cerebral CT or MRI scans were systematically performed within 72 hours of admission. Fifty-nine patients with a definitive diagnosis of IE, according to Duke University criteria, who underwent 2D and 3DTOE at the initial diagnostic examination were analyzed. Echocardiographic findings were defined according to current guidelines, with destructive lesions including abscess, pseudoaneurysm, valve dehiscence, perforation, or chordal rupture. Results Echocardiographic findings (Table 1) revealed statistically significant differences between different echocardiography modalities. The most significant difference was observed between TTE and 3DTOE. However, results between 2D and 3DTOE did not reach statistical significance. TOE provided a more detailed description with a higher number of detected lesions, and 3DTOE was even more precise in identifying destructive lesions, particularly perforations (p<0.001). Concerning, Native Valve IE (NVE), Prosthetic Valve IE (PVE), and Cardiac Device IE (CD IE) groups (Table 2), vegetations were most frequently detected in the NVE and CD IE groups, while destructive lesions were predominant in the PVE group. 3DTOE detected longer vegetations and a higher number of destructive lesions, particularly in the PVE group. Conclusion 3DTOE provides a more detailed and precise morphological description of complex destructive lesions of IE compared to TTE and 2DTOE, which is particularly important for patients with PVE. Table 2

The role of 3D transesophageal echocardiography in native mitral valve endocarditis – a case report and review of the literature

The role of 3D transesophageal echocardiography in native mitral valve endocarditis – a case report and review of the literature

Hyperacute Effects of Mitral Transcatheter Edge-to-Edge Repair on Left Ventricular Volumes and Functions.

Transcatheter edge-to-edge repair (TEER) is an effective intervention for high-risk patients with severe symptomatic mitral regurgitation (MR), but its acute impact on left ventricular (LV) function has not been well studied using advanced echocardiographic techniques. This study investigated the immediate effects of TEER on LV volumes and functions, as well as their influence on mid-term outcomes, using high-resolution 3D transesophageal echocardiography. In 80 patients undergoing TEER for severe MR (mean age 79±8 years, 49% with primary MR), LV end-diastolic volume (LVEDV) and stroke volume significantly decreased (161±61 to 147±54 ml and 69±18 to 50±15 ml, respectively), while end-systolic volume increased (92±60 to 97±45 ml; p<0.0001 for all). Left ventricular ejection fraction (LVEF; 48±16% to 38±14%), global longitudinal strain (GLS; 16.2±6.8% to 12.8±5.4%), and global circumferential strain (GCS; 25±10.5% to 18.7±8.5%) deteriorated significantly (p<0.0001 for all). Absolute reductions in LVEF and GCS were associated with baseline values and afterload reduction, indicated by 3D vena contracta area decline (r=0.47 and r=0.65; p<0.0001), while GLS reduction was linked to baseline values and inversely proportional to LVEDV (r=0.63; p<0.0001). Relative LVEF reduction emerged as the strongest predictor of mortality, with a hazard ratio of 1.76 (1.12-2.76) per 10% decrease. In conclusion, the acute decline in LV function following TEER correlates with the degree of MR reduction, with greater impacts observed in circumferential function and patients with higher baseline LVEF. Relative LVEF reduction is a critical echocardiographic predictor of mortality.

Exploratory Study of the Measurement of Geometric Height in 3D Transesophageal Echocardiography as a Predictor of Valve-Sparing Root Replacement for Aortic Regurgitation.

Background: Valve-sparing root replacement surgery is an alternative strategy for patients with aortic regurgitation with or without aortic root enlargement. A detailed understanding of the mechanisms of regurgitation and the morphology of the aortic root would be beneficial for predicting the feasibility and success of valve-sparing surgery. This is an exploratory study of the measurement of geometric height in 3D transesophageal echocardiography as a predictor of valve-sparing root replacement for aortic regurgitation. Methods: Transesophageal echocardiographic findings and long-term outcomes were compared in 124 patients undergoing either valve-sparing root replacement (VSRR group) or composite valve graft replacement (Bentall group) from September 2014 to March 2019. Results: The VSRR group was younger and had better left ventricular function than the Bentall group. Three-dimensional transesophageal echocardiography showed that geometric height was significantly larger in the VSRR group. In receiver-operating curve analysis, the cutoff values of geometric height for the feasibility of valve-sparing surgery were 15.9 mm and 19.8 mm in the tricuspid and bicuspid aortic valve, respectively. The overall survival was 98.6% and the freedom from reoperation rate was 89.7% at 5 years in the VSRR group. Conclusions: Appropriate patient selection and adequate GH may contribute to the success of VSSR and improve long-term outcomes.

A Novel 3D Base of the Heart transesophageal Echocardiography View for Identifying Valve Pathology: A Preliminary Comparison with a Gold Standard 2D transesophageal Echocardiography Exam

A Novel 3D Base of the Heart transesophageal Echocardiography View for Identifying Valve Pathology: A Preliminary Comparison with a Gold Standard 2D transesophageal Echocardiography Exam

Incomplete cor triatriatum dexter and percutaneous closure of atrial septal defects, a single-centre experience

Cor Triatriatum Dexter (CTD) is a rare congenital heart malformation, with an estimated incidence of 0.025%, characterised by a membrane dividing the right atrium (RA) into two chambers. A variant, incomplete CTD (CTDi), occurs when the right membrane extends partially into the interatrial septum without fully dividing the RA. CTDi can be associated with interatrial septal defects, found in 5% of patients with atrial septal defects or a patent foramen ovale (PFO). The study reports three adult patients (46–53 years old) with CTDi and a PFO, all presenting cryptogenic stroke and referred for PFO closure. Two cases underwent percutaneous closure with guidance from fluoroscopy and 2D/3D transesophageal echocardiography (TEE), and the last one utilised intracardiac echocardiography (ICE) for device placement. In patients referred for PFO closure, CTDi is common and can complicate visualisation, prolong procedure times, and reduce success rates. Difficulties in device deployment and the risk of residual shunt or embolisation have been reported. The authors highlight that using oversizing techniques, traction manoeuvres during device deployment, and preoperative planning with advanced imaging (such as ICE or 3D TEE) are crucial for successful percutaneous closure in cases with CTDi and PFO.

Advancements in 3D Transoesophageal Echocardiography (TOE) and Computed Tomography (CT) for Stroke Prevention in Left Atrial Appendage Occlusion Interventions.

Left atrial appendage occlusion (LAAO) has emerged as a highly effective alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. Precise pre-procedural planning and meticulous post-procedural follow-up are essential for achieving successful LAAO outcomes. This review explores the latest advancements in three-dimensional (3D) transoesophageal echocardiography (TOE) and computed tomography (CT) imaging modalities, which have considerably improved the planning, intra-procedural guidance, and follow-up processes for LAAO interventions. Innovations in 3D TOE and CT imaging have transformed the approach to LAAO by providing a more detailed and accurate assessment of the left atrial appendage, enabling clinicians to acquire comprehensive anatomical and morphological information, crucial for optimising device selection and positioning, thus reducing the risk of complications and enhancing the overall safety and efficacy of the procedure. Post-procedurally, CT and TOE imaging are invaluable in the monitoring of patients, ensuring that the device is correctly positioned and functioning as intended. Early detection of any complications (e.g., device-related thrombus and peri-device leaks) can help to risk-stratify patient at increased risk of stroke and initiate timely interventions, thereby improving long-term outcomes for patients.

Paediatric 3D transoesophageal echocardiography reveals prolapse of accessory mitral valve tissues into the left atrium in a neonate.

Paediatric 3D transoesophageal echocardiography reveals prolapse of accessory mitral valve tissues into the left atrium in a neonate.

Standardized 3D Transoesophageal Echocardiography Manoeuvre for Enhanced Tenting Height Evaluation During Transcatheter Mitral Valve Edge-to-Edge Repair.

Background: Transcatheter treatments for structural heart disease, including edge-to-edge mitral valve repair (mTEER), heavily rely on transoesophageal echocardiography (TOE) for pre-procedural assessment and guidance. Trans-septal puncture (TSP) is one of the first key steps of such procedures, with two-dimensional (2D) TOE often providing suboptimal imaging. Three-dimensional (3D) echocardiography could overcome the limitations of 2D TOE and improve the assessment of tenting height. Methods: This single-centre, retrospective study included 64 patients who underwent mTEER between October 2023 and April 2024. Tenting height during TSP was assessed by 2D TOE in mid-oesophageal (ME) four-chamber view and by 3D TOE after the acquisition of a 3D volume, including the interatrial septum, aortic valve, and mitral valve, and subsequent multiplanar reconstruction (MPR). A total of 100 TSP attempts with 2D and 3D TOE were evaluated. Results: Procedural success was obtained in 92.2% of cases. There was a statistically significant difference between 2D and 3D measurements (2D: 4.36 ± 0.61 cm, MPR: 4.59 ± 0.63 mm2, p < 0.001), despite good correlation (r = 0.880, p < 0.001). The difference between 2D and 3D tenting height measurements differed significantly between patients with optimal and suboptimal 2D image windows (p < 0.001). There was no significant difference in septal puncture success between optimal 2D and 3D data (p = 0.942). Conclusions: Adopting 3D TOE with multiplanar reconstruction for assessing tenting height in mTEER procedures offers significant advantages over traditional 2D TOE. Enhanced visualization, accuracy, and potential for standardization improve procedural outcomes and patient safety, making 3D TOE integration into routine practice highly beneficial and recommended.

Determination of Inoue Balloon Size by Analysis of Mitral Valve Geometry Using Three-Dimensional Transesophageal Echocardiography in Patients With Mitral Stenosis

In percutaneous mitral balloon commissurotomy (PMBC) for patients with mitral stenosis (MS), the size of the balloon has traditionally been determined using a crude method based on the patient's height or body surface area. We aimed to evaluate the clinical value of balloon size selection by quantitatively analyzing mitral valve geometry using 3-dimensional (3D) transesophageal echocardiography. In 184 consecutive patients who underwent PMBC, the geometry of the mitral valve annulus was analyzed during mid-diastole, including the measurement of lateral-medial diameters obtained from dedicated 3D software or from analysis using multiplanar reconstruction images. Patients were categorized into 3 groups: those with successful results after PMBC (SU group), those with residual mitral stenosis (MS group), and those with significant MR (MR group). The SU, MS, and MR groups included 110, 50, and 17 patients, respectively. We compared 3 conventional formulas (formulas 1, 2, and 3) based on the patient's height or body surface area, with 2 new formulas derived from data in the SU group: balloon size = 0.0684 × lateral-medial diameters obtained from dedicated 3D software + 24.309 (formula 4) and 0.061 × lateral-medial diameters obtained from analysis using multiplanar reconstruction images + 24.573 (formula 5). Compared with the calculated balloon sizes using formula 4, the inflated balloon sizes were significantly smaller (-0.78 ± 1.02, p <0.001) in the MS group, whereas they were significantly larger (0.56 ± 1.05, p = 0.04) in the MR group. This pattern was also consistent in formula 5. In conclusion, selecting the Inoue balloon inflation size based on the mitral annulus diameter determined by 3D transesophageal echocardiography might be a reasonable approach.

Tricuspid regurgitation in rheumatic heart valve disease. New insights from 3D transthoracic echocardiography

Abstract Background The assessment of tricuspid valve (TV) and functional tricuspid regurgitation (FTR) in left side valvular disease is crucial in assessing the need for surgical intervention. Despite the declining incidence of rheumatic disease, it remains a a common cause of valvulopathy. According to current guidelines, TV surgery is recommended in presence of severe TR or non-severe with annulus dilatation assessed by two-dimensional echo (2DE). Objectives To assess tricuspid annulus (TA) 3D dimensions in relation to the severity of tricuspid regurgitation (TR) and to identify new parameters associated with the presence of severe TR in this scenario. Methods Fifty patients (Age: 69±9, 82% women) with rheumatic heart disease without previous valve replacement and functional tricuspid regurgitation (FTR) were prospectively included. Two-dimensional echocardiography (2DE) and three-dimensional transthoracic full-volume datasets of the tricuspid valve (TV) were acquired. Two orthogonal planes corresponding to the anatomical antero-posterior (APD), septum-lateral (SLD), long intercommisural (LID), and area (A3D) of the TA were analyzed by 3D transesophageal echocardiography (3DTE) (Figure 1), in addition to 2D diameter. TR was graded into two groups: severe (n=14) or non-severe (n=26). The area under the curve (AUC), sensitivity (Se), and specificity (Sp) to identify the presence of severe FTR were calculated. Results All parameters differed significantly (p&amp;lt;0.05) between the two groups (2D: 18.6±1.9 vs. 23.3±2.0 mm/m2; APD 17.0±3.3 vs. 21.5±3.0 mm/m2; SLD: 18.9±2.0 vs. 22.5±2.0 mm/m2; LID: 20.9±2.6 vs. 26.1±3.5 mm/m2; A: 5.6±1.3 vs. 7.6±1.4 cm2/m2). 2D diameter (Cut-off point: 20.6 mm/m2, AUC: 0.850, Se: 86%, Sp: 72%), A3D (Cut-off point: 6.5 cm2/m2, AUC: 0.835, Se: 86%, Sp: 78%), and LID (Cut-off point: 23.3 mm/m2, AUC: 0.833, Se: 78.6%, Sp: 77.8%) were the parameters with the best performance for severe FTR detection. Conclusions New 3D-derived parameters provide relevant information in the assessment of TA and offer good diagnostic performance for identifying severe FTR in this subgroup of patients.2D/3D Echo TA measurements

Comparative Assessment of Aortic Annulus Diameters between 3D Transesophageal Echocardiography and Cardiac MDCT in Patient with Sclerocalcific Aortic Stenosis

Comparative Assessment of Aortic Annulus Diameters between 3D Transesophageal Echocardiography and Cardiac MDCT in Patient with Sclerocalcific Aortic Stenosis

Left atrial appendage orifice morphology in sickness and in health.

The left atrial appendage (LAA) is the primary site of embolism in individuals with atrial fibrillation (AF). We aimed to evaluate the morphological features of the LAA orifice in patients with sinus rhythm, paroxysmal AF, and persistent AF using three-dimensional (3D) transesophageal echocardiography (TOE). We also intended to identify morphometric parameters of the LAA orifice that may be potentially associated with an increased risk of ischemic stroke. We prospectively enrolled 106 patients undergoing TOE. Patients were divided into three groups: group1 (sinus rhythm), group2 (persistent AF), and group3 (paroxysmal AF). All patients underwent acomprehensive evaluation through transthoracic echocardiography (TTE) and TOE. Off-line analyses were performed of the recorded images. The LAA minor orifice area and minimal orifice diameter were greater in patients with persistent AF compared with individuals in sinus rhythm. Patients with persistent AF also had deeper LAAs compared with those in sinus rhythm. None of the LAA orifice morphometric measures were related to ischemic stroke risk. The only independent predictors of ischemic stroke were heart rhythm and the CHA2DS2VASc score. Persistent AF is associated with LAA dilation, increased depth, and larger orifice size. To our knowledge, this is the first study to demonstrate LAA orifice structural remodeling in patients with AF using 3D TOE.

Pediatric Three-dimensional Transesophageal Echocardiography: A Game Changer in Congenital Heart Disease.

Despite its potential, pediatric three-dimensional (3D) transesophageal echocardiography (TEE) faced technical limitations due to the size and rigidity of early probes designed for adults. In this paper, we present our experience in using the new pediatric 3D TEE probe in complex congenital heart disease (CHD). Recent advancements in the field of miniaturization have led to the development of a new pediatric 3D TEE probe, specifically designed for young children (weight ≥4.5 kg). This probe features a smaller, flexible design and high-spatial and temporal resolution, enabling detailed views of intracardiac structures and real-time imaging crucial for complex diagnosis, planning interventional and surgical procedures. We used this new probe in pediatric cases (weight between 4.5 and 6 kg) with complex congenital heart disease. In double-outlet right ventricle or in Taussig Bing anomaly the new 3D TEE probe enabled detailed assessment of ventricular septal defect and its relations with tricuspid valve apparatus, and provided details of mitral valve leaflets not detectable by the transthoracic approach, even in small children. These cases highlight the probe's ability to provide detailed anatomical information, enhancing surgical planning and outcomes. The pediatric 3D TEE probe has the potential to be a game changer in defining intracardiac anatomy in complex CHD.