Two-dimensional Transesophageal Echocardiography Research Articles

The Value of Three-Dimensional Echocardiography Derived Mitral Valve Parametric Maps and the Role of Experience in the Diagnosis of Pathology

Accurate segmental mitral valve (MV) analysis is essential for surgical planning. Although real-time three-dimensional (3D) transesophageal echocardiography has improved the ability to visualize the MV, accurate localization of MV pathology from 3D transesophageal echocardiographic images still remains experience dependent. Three-dimensional parametric maps of the MV obtained from these images further simplify the visualization of MV anatomy. The aims of this study were to examine whether 3D parametric maps of the MV could improve the diagnostic accuracy in localizing pathology and to determine their usefulness for readers with different levels of training. Five novice (American Society of Echocardiography [ASE] level 2), three intermediate-level (ASE level 3; <500 MV cases), and two expert (ASE level 3; >500 MV cases) readers interpreted MV segmental anatomy in 50 patients (30 with degenerative MV disease, 20 with normal MVs). All readers reviewed two-dimensional and 3D transesophageal echocardiographic and 3D parametric maps at sequential weekly sessions. The results were compared with surgical findings. Expert readers were the most accurate irrespective of image type. Novice readers were the least accurate and commonly misinterpreted P2 and P3 scallops. Their accuracy was highest when interpreting 3D parametric maps (from 87% with two-dimensional transesophageal echocardiography to 92%). Intermediate readers' accuracy fell between the other two groups irrespective of image type and showed no change with the use of parametric maps. This is the first study to show that the interpretation of 3D parametric maps improves the accuracy of localization of MV pathology by novice readers. Therefore, parametric maps should be used routinely by less experienced readers during the assessment of degenerative MV disease.

Transcatheter closure of a mechanical perivalvular leak using real‐time three‐dimensional transesophageal echocardiography guidance

A 47-year-old female with symptomatic mitral stenosis from a prior undersized mitral annuloplasty ring underwent mitral valve replacement with a mechanical valve. Later, she developed heart failure from a severe paravalvular leak (PVL). Because of the excessive mortality risks from a possible third open heart procedure, the patient was instead referred for transcatheter PVL closure. Standard fluoroscopy, invasive hemodynamics, and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) imaging were performed during device placement with excellent image quality. The case highlights the unique benefit of 3D TEE imaging for preprocedure sizing, guidance of device deployment intraprocedure, and confirmation of PVL closure.

The added value of real-time three-dimensional echocardiography in the diagnosis of supravalvar mitral ring: case report and review of the literature.

Supravalvular mitral stenosis is a rare condition characterized by an abnormal ridge, with one or two orifices, covering and obstructing the mitral valve. Preoperative identification of the supravalvular ring is the target for obtaining good surgical results. Two-dimensional echocardiogram and transesophageal echocardiography both failed in reaching this objective. In this case, we showed that three-dimensional echocardiogram is a new technique that provides additional and more accurate echocardiographic characterization of congenital supravalvular mitral stenosis.

Transesophageal Echocardiographic Finding of Left Atrial Appendage Lobe Mimicking a Mass Lesion

We describe an elderly patient undergoing ablation for atrial fibrillation in whom, two-dimensional transesophageal echocardiography showed a mass-like lesion in or adjacent to left atrial appendage (LAA). This mass-like effect was produced by en face visualization of the top of a LAA lobe in the presence of a small effusion in the transverse sinus of the pericardium.

Transesophageal Echocardiographic Detection of Thrombus Superimposed on Metastatic Left Atrial Tumor

We present a 32-year-old male with metastatic thymic carcinoma invading the left atrium in whom two-dimensional transesophageal echocardiography was able to differentiate a thrombus superimposed on the tumor.

Utility of Combined Two-Dimensional and Three-Dimensional Transesophageal Imaging for Catheter-Based Mitral Valve Clip Repair of Mitral Regurgitation

Catheter-based mitral valve clip repair (CBMCR) is feasible for selected patients with mitral regurgitation (MR). Two-dimensional (2D) transesophageal echocardiography (TEE) is the standard modality for evaluating MR and procedural guidance. Recently, real-time three-dimensional TEE became available. The aim of this study was to evaluate the value of combined 2D and three-dimensional TEE for CBMCR. In evaluating MR for CBMCR, the confidence of interpretation of 2D TEE was compared with that of combined imaging for the localization of major valve pathology. In patients who underwent CBMCR, the outcomes and the duration of CBMCR were compared. In this retrospective study, MR evaluation was performed by 2D TEE alone and by combined imaging in 80 and 57 patients, respectively. CBMCR was guided by 2D TEE alone in 20 patients and by combined imaging in 39 patients. Examination by combined imaging allowed en face visualization of mitral valve anatomy and MR jet origin. The confidence of interpretation by combined imaging was higher than for 2D TEE (1.1 ± 0.3 vs 1.8 ± 0.7, P < .001).The guidance of CBMCR by combined imaging facilitated alignment of the catheter trajectory, clip positioning, and orientation of clip arms. The procedural success and final MR grade were not different between the two study groups. However, the procedural time of CBMCR using combined imaging compared with that using 2D TEE guidance alone was shorter (241 ± 58 vs 201 ± 68 min, P= .035). The use of combined imaging compared with 2D TEE alone appears to enhance the confidence of interpretation concerning mitral pathology and catheter-clip system location and may also reduce CBMCR time.

Successful Transcatheter Closure of a Residual Patent Ductus Arteriosus with Complex Anatomy after Surgical Ligation Using an Amplatzer Ductal Occluder Guided by Live Three-Dimensional Transesophageal Echocardiography

Residual patent ductus arteriosus (PDA) after surgical ligation is not common, but the anatomy of the residual duct may be distorted by the surgical ligation resulting in a difficult transcatheter closure. Such distorted anatomy of the duct may not be demonstrated by the two-dimensional transesophageal echocardiography (2D TEE). Fortunately, live 3D TEE provided the precise anatomy of the elongated distorted residual duct, and as in the case presented herein, guided the Amplatzer ductal occluder (ADO). We concluded that live 3D TEE provided novel images of complex residual ducts and successful guidance of a ductal occluder.

Evaluation of Tricuspid Valve Morphology and Function by Transthoracic Three-Dimensional Echocardiography

Tricuspid valve (TV) disease commonly occurs in combination with left-sided heart disease. Despite the growing enthusiasm for developing novel minimally invasive therapies for the mitral or aortic valve, the TV disease formerly received less attention and was frequently left untreated. Strong evidence has increased the awareness of the impact of severe TV regurgitation on patient survival, functional capacity, and surgical risk. Preoperative TV accurate description is challenging because, unlike left-sided valves, a complete visualization of tricuspid annulus and all three leaflets in one view is routinely impossible by two-dimensional transthoracic or transesophageal echocardiography. Three-dimensional echocardiography (3DE) with its unrestricted imaging capabilities has sparked significant research interest for a better understanding and improved treatment of valvular heart disease. This review summarizes the current status of 3DE for the assessment of TV morphology and function, with its clinical applications and current limitations, as well as its potential implications for designing TV repair techniques.

Left Atrial Myxomas: Correlation of Two-Dimensional and Live Three-Dimensional Transesophageal Echocardiography with the Clinical and Pathologic Findings

Although transthoracic echocardiography and two-dimensional transesophageal echocardiography (TEE) identify cardiac myxomas with high sensitivity, anatomic and morphologic information is often incomplete. Real-time three-dimensional (3D) TEE is increasingly being used in general clinical practice. However, the use of real-time 3D TEE for the assessment of atrial myxomas has not been described. This case series of 10 patients with left atrial myxomas undergoing two-dimensional and real-time 3D TEE. Correlative pathologic findings demonstrate that 3D imaging accurately identifies these tumors and provides detailed morphologic description of the tumors, which may have clinical importance. Because the 3D TEE is real time and can be performed preoperatively in the operating room, the surgeon may gain a better understanding of the nature and location of the tumor.

Effect of Performing Real Time Three-Dimensional Transesophageal Echocardiography in Addition to Two-Dimensional Transesophageal Echocardiography on Operator Diagnostic Confidence

This study evaluates the effects of performing real time three-dimensional transesophageal echocardiography in addition to conventional two-dimensional transesophageal echocardiography on diagnostic confidence. Operator diagnostic confidence in addressing clinical questions posed by the referral was scored using a five-point scale for two-dimensional transesophageal echocardiography alone and the combination of two-dimensional and real time three-dimensional transesophageal echocardiography in 136 consecutive patients undergoing examination in an academic hospital. Mean diagnostic confidence score was higher for the combined studies compared to two-dimensional transesophageal echocardiography alone (4.5 vs. 4.1, P < 0.001)). The addition of real time three-dimensional transesophageal echocardiography increased diagnostic confidence score in 45 (33.1%) patients, and the percentage of studies with total diagnostic confidence rose from 40.4% with two-dimensional transesophageal echocardiography alone to 65.4% after performing real time three-dimensional transesophageal echocardiography. Type of clinical indication was associated with improved score by the combined exams (P < 0.004). The addition of real time three-dimensional transesophageal echocardiography was most likely to improve diagnostic confidence score in studies performed to assess valve disease (56.1%) and least likely in examinations performed for intracardiac infection (14.9%). The location (anterior or posterior) of the primary cardiac pathology was not associated with improved score by the combined studies (P = 0.498). The addition of real time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography increases diagnostic confidence in examinations routinely performed in an academic practice. Further studies of the impact of real time three-dimensional transesophageal echocardiography on patient management, outcomes and displacement of or need for downstream testing are warranted.

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 transoesophageal echocardiography during percutaneous transcatheter occlusion of mitral periprosthetic paravalvular leak

We present the case of an 86-year-old female patient with a history of mitral valve replacement due to relevant stenosis. After surgery, an increasing periprosthetic valvular leak (PVL) became obvious causing regurgitation and an increasing haemolysis. Conventional two-dimensional transoesophageal echocardiography (2D TEE) showed a defect of 15 mm length located from the lateral to the posterior circumference subdivided by two surgical sutures into three parts. The patient refused additional surgical therapy. Hence, we suggested a percutaneous transcatheter occlusion of the leakage with a 12 × 5 mm Amplatzer(®) Vascular Plug III device (AVP) (AGA Medical Corporation, Plymouth, MA, USA). The placement of the device was supported indispensably by real-time three-dimensional TEE. The device occluded the leakage nearly completely and downgraded the regurgitation from moderate to neglectable. Also haemolytic parameters improved significantly. V-wave decreased promptly from 70 to 35 mmHg after placing AVP. Percutaneous closure of PVL by AVP, a self-expandable nitinol device approved for peripheral vessel occlusion, is described in limited cases with more or less successful results. It is graded as a technically demanding procedure reserved to poor surgical candidates. The main challenge is finding and intubating the leakage and the correct placement of the device. Three-dimensional TEE seems to be superior to conventional 2D TEE as it allows an easier guidance of the device into the defect. Hence, it is strongly recommended for this intracardiac intervention.

Absence of Posterior Mitral Leaflet With Secundum Atrial Septal Defect

A rare case of a 54-year-old woman with absence of congenital posterior mitral leaflet, moderate mitral insufficiency, and large secundum-type atrial septal defect is reported. Two-dimensional color Doppler and transesophageal echocardiography revealed complete absence of the posterior mitral leaflet, a thick muscular formation replacing the posterior leaflet, a 3.3-cm secundum type atrial septal defect, and severe pulmonary hypertension. This report describes the rare case of congenital absence of posterior mitral leaflet associated with secundum type large atrial septal defect in a middle-age woman.

The first three-dimensional visualization of a thrombus in transit trapped between the leads of a permanent dual-chamber pacemaker: a case report

IntroductionTwo-dimensional echocardiography is a useful tool in diagnosing cardiac masses. However, the three-dimensional offline reconstruction technique of transesophageal echocardiography might be superior to two-dimensional transesophageal echocardiography in providing additional information of structural details.Case presentationWe report the case of a 76-year-old Caucasian man with a permanent dual-chamber pacemaker and a worm-like right-heart thrombus in transit. Two-dimensional transthoracic echocardiography and two-dimensional transesophageal echocardiography showed that it was debatable as to whether "the worm" was originating from the leads. Offline three-dimensional transesophageal echocardiography reconstruction technique proved superior in identifying the cardiac mass as a thrombus trapped between the leads of the pacemaker. The thrombus was successfully dissolved by systemic heparin therapy.ConclusionsThe three-dimensional transesophageal echocardiography is useful and effective in patients with implanted pacemakers or defibrillators when other closely competing imaging modalities are contraindicated, such as magnetic resonance imaging. In patients with pacemakers and trapped thrombus in transit for whom surgical therapy might be a high risk, medical therapy seems to offer a safer and convincing alternative. Whether the management of right-heart thrombi has to be modified due to the presence of pacemaker leads is controversial.

Emergent bedside real-time three-dimensional transesophageal echocardiography in a patient with cardiac arrest following a caesarean section

Post-caesarean pulmonary embolism (PE) is associated with significant peri-operative morbidity and mortality. This report describes a case of sudden cardiac arrest 2 days post-caesarean due to massive PE diagnosed via bedside transesophageal echocardiography (TEE). Recognition of the PE at the bifurcation of the right and left pulmonary arteries was achieved by real-time three-dimensional TEE, but not two-dimensional TEE. Extracorporeal membrane oxygenation was immediately established and emergent pulmonary thromboembolectomy was performed. The patient was discharged without residual deficits on Day 22 of hospitalization.

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,

Quantitative Assessment of Mitral Regurgitation

Background— Quantification of mitral regurgitation severity with 2-dimensional (2D) imaging techniques remains challenging. The present study compared the accuracy of 2D transesophageal echocardiography (TEE) and 3-dimensional (3D) TEE for quantification of mitral regurgitation, using MRI as the reference method. Methods and Results— Two-dimensional and 3D TEE and cardiac MRI were performed in 30 patients with mitral regurgitation. Mitral effective regurgitant orifice area (EROA) and regurgitant volume (Rvol) were estimated with 2D and 3D TEE. With 3D TEE, EROA was calculated using planimetry of the color Doppler flow from en face views and Rvol was derived by multiplying the EROA by the velocity time integral of the regurgitant jet. Finally, using MRI, mitral Rvol was quantified by subtracting the aortic flow volume from left ventricular stroke volume. Compared with 3D TEE, 2D TEE underestimated the EROA by a mean of 0.13 cm 2 . In addition, 2D TEE underestimated the Rvol by 21.6% when compared with 3D TEE and by 21.3% when compared with MRI. In contrast, 3D TEE underestimated the Rvol by only 1.2% when compared with MRI. Finally, one third of the patients in grade 1 and ≥50% of the patients in grade 2 and 3, as assessed with 2D TEE, would have been upgraded to a more severe grade, based on the 3D TEE and MRI measurements. Conclusions— Quantification of mitral EROA and Rvol with 3D TEE is feasible and accurate as compared with MRI and results in less underestimation of the Rvol as compared with 2D TEE.

Live/Real Time Three‐Dimensional Transesophageal Echocardiographic Findings in Caseous Mitral Annular Calcification

We describe a 77-year-old female with hypertrophic cardiomyopathy in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value over two-dimensional transthoracic and transesophageal echocardiography (2DTTE, 2DTEE) and three-dimensional transthoracic echocardiography (3DTTE) in making a more comprehensive assessment and a more confident diagnosis of caseous mitral annular calcification. 3DTEE revealed a portion of the mass to consist of small, multiple, highly echogenic discrete band-like and punctate areas within a relatively much less echogenic stroma and surrounded by a well defined highly echogenic border. This appearance correlated with the pathological findings of calcific granules/strands located in a liquefied or semiliquefied interior providing a typical toothpaste like appearance. The highly echogenic outer border represented the residual outer portion or rim of the calcific mass which did not undergo liquefaction. These findings on 3DTEE which correlated with the toothpaste like appearance seen at surgery were not visualized on 2DTTE, 2DTEE, and 3DTTE.

A case of quadricuspid aortic valve diagnosed by three-dimensional transesophageal echocardiography and multidetector computed tomography.

As is bicuspid aortic valve, quadricuspid aortic valve (QAV) is a congenital anomaly that can cause aortic regurgitation. This condition has often been diagnosed in the past on the basis of intraoperative findings, but the number of cases diagnosed preoperatively has been increasing in recent years. We report here a case of asymptomatic QAV diagnosed noninvasively using twodimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) and confirmed by multidetector-row computed tomography (MDCT).

Incremental Value of Three-Dimensional over Two-Dimensional Transesophageal Echocardiography in the Assessment of Acute Dysfunction of Mechanical Mitral Valve Prosthesis

We describe acute dysfunction of a bileaflet mechanical mitral valve prosthesis for the first time in a 57-year-old male. Unlike two-dimensional transesophageal echocardiography, three-dimensional imaging convincingly showed a large rounded echo density consistent with a papillary muscle in contact with one of the leaflets showing only partial opening during systole.