2-dimensional Transthoracic Echocardiography Research Articles

405 Feasibility of real time three dimensional transthoracic echocardiography for planning mitral reconstructive surgery

405 Feasibility of real time three dimensional transthoracic echocardiography for planning mitral reconstructive surgery

“Coumadin ridge” in the left atrium demonstrated on three dimensional transthoracic echocardiography

An echogenic band like structure was seen in the left atrium on two dimensional transthoracic echocardiography (2D TTE). Full volume three dimensional (3D) TTE and colour Doppler established the surrounding anatomical landmarks, and demonstrated the absence of obstruction related to this band. 3D TTE confirmed that this band like structure was consistent with the ridge between the left atrial appendage and left superior pulmonary vein ('warfarin/coumadin ridge').

Illustration of the Additional Value of Real-time 3-dimensional Echocardiography to Conventional Transthoracic and Transesophageal 2-dimensional Echocardiography in Imaging Muscular Ventricular Septal Defects: Does This Have Any Impact on Individual Patient Treatment?

We sought to answer the question of whether the additional morphologic details obtained by real-time 3-dimensional (3D) echocardiographic (RT3DE) imaging of muscular ventricular septal defect (VSD) has any significant impact on treatment options of individual patient. Muscular VSD can be safely and effectively closed by interventional catheterization procedure using VSD devices under transesophageal echocardiographic (TEE) guidance. Recent application of RT3DE has shown great promise for imaging VSD with better display of the exact geometry, size, and location of the defect. Nineteen patients with different types of VSDs were imaged with RT3DE matrix-array transducer; there were 6 cases with muscular VSD. Based on standard transthoracic echocardiographic and TEE imaging, one patient was considered a good candidate for perventricular VSD device occlusion, three patients were considered for surgical closure, and in two patients no intervention was deemed necessary. RT3DE successfully displayed the exact morphology of the VSD in all 6 patients, whereas transthoracic echocardiography and TEE showed the defect as a dropout with variable diameter in different views. Such planer images did not accurately predict the exact morphology in the patient in whom device occlusion was considered and the device embolized to the left ventricle in a few heartbeats. Surgical circular patch was used in two patients and primary suture was used in two patients in agreement with the 3D morphology. In two patients the 3D morphology of the VSD was small enough that no intervention was considered. RT3DE imaging of muscular VSD can accurately display the exact geometry of the defect, which can have significant impact on treatment strategies of individual patients. This new imaging modality should be an important adjunct to the standard transthoracic echocardiographic and TEE imaging of these defect before any intervention.

Head-to-Head Comparison of Two- and Three-Dimensional Transthoracic and Transesophageal Echocardiography in the Localization of Mitral Valve Prolapse

The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the feasibility and accuracy of 3-dimensional (3D) transthoracic (TTE) and transesophageal (TEE) echocardiography in the evaluation of MV pathology. A pre-operative assessment of MV anatomy is essential to surgical design in patients undergoing MV repair. Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy, 3D TTE and 3D TEE could increase the understanding of MV apparatus and individual scallop identification. One-hundred-twelve consecutive patients with severe mitral regurgitation due to MV prolapse underwent a complete 2D and 3D TTE the day before surgery and a complete 2D and 3D TEE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. Three-dimensional techniques were feasible in a relatively short time (3D TTE: 7 +/- 4 min; 3D TEE: 8 +/- 3 min), with good (3D TTE 55%; 3D TEE 35%) and optimal (3D TTE 21%; 3D TEE 45%) imaging quality in the majority of cases. Three-dimensional TEE allowed more accurate identification (95.6% accuracy) of all MV lesions in comparison with other techniques. Three-dimensional TTE and 2D TEE had similar accuracies (90% and 87%, respectively), whereas the accuracy of 2D TTE (77%) was significantly lower. Three-dimensional TTE and TEE are feasible and useful methods in identifying the location of MV prolapse. They were superior in the description of pathology in comparison with the corresponding 2D techniques and should be regarded as an important adjunct to standard 2D examinations in decisions regarding MV repair.

Comparison of Multidetector Computed Tomography and Two-Dimensional Transthoracic Echocardiography for Left Ventricular Assessment in Patients With Heart Failure

Along with coronary evaluation, 64-slice multidetector computed tomography (MDCT) permits comprehensive assessment of left ventricular (LV) anatomy and function; however, how it compares with 2-dimensional transthoracic echocardiography (TTE) in patients with heart failure (HF) is not known. In this study, we compared 25 patients with ejection fractions of <45% who underwent TTE and MDCT. The global ejection fraction by TTE versus MDCT was 36 +/- 8% versus 38 +/- 12% (r = 0.67, p = NS). The mean LV end-diastolic and end-systolic diameters by TTE and MDCT were 56 +/- 8 and 46 +/- 9 mm and 58 +/- 12 and 47 +/- 11 mm, respectively (r = 0.71 and 0.77, respectively, both p >0.20). The mean lateral and septal wall thicknesses by TTE and MDCT were 10 +/- 1.4 and 11 +/- 1.5 mm and 10 +/- 1.3 and 10 +/- 1.4 mm (r = 0.77 and 0.76, respectively, both p >0.20). The mean LV end-diastolic and end-systolic volumes and stroke volume by TTE and MDCT were 123 +/- 45, 78 +/- 31, and 44 +/- 21 ml and 140 +/- 58, 92 +/- 43, and 48 +/- 24 ml, respectively (r = 0.62, 0.67, and 0.60, respectively, all p >0.20). The regional wall motion assessment correlation was good between the 2 modalities (kappa = 0.61). The interobserver correlation between the 2 MDCT readers ranged from good (r = 0.72 for LV end-diastolic volume) to excellent (r = 0.84 for septal wall thickness). In conclusion, MDCT provides comparable results to TTE for LV structure and functional assessment among patients with HF.

Cor Triatriatum Sinister with and without Left Ventricular Inflow Obstruction: Visualization of the Entire Supravalvular Membrane by Real-time Three-dimensional Echocardiography. Impact on Clinical Management of Individual Patient

We present 4 cases of cor triatriatum in whom the diagnosis was correctly made by 2-dimensional transthoracic echocardiography, which showed the supravalvular left atrial membrane that divides the left atrium into 2 chambers. The pulmonary veins were connected normally to the proximal left atrial chamber and the left atrial appendage was connected to the distal left atrial chamber. In 1 patient there was evidence of severe pulmonary venous obstruction to the mitral valve by Doppler examination, while in the other three, there was no venous obstruction. Patients were then examined by real-time 3-dimensional echocardiography (RT3DE, using x4 matrix array transducer connected to Sonos 7500 echocardiographic system Phillips, Andover, Mass, USA). This showed the exact morphology of the membrane and led to cancellation of planed surgical intervention in 1 case in which the membrane was only a broad band crossing the left atrial cavity. In addition to delineating the exact morphology of the intracavitary anomaly, this novel echocardiographic imaging modality should be an additive tool to better understand the natural history of these nonobstructive left atrial membranes via longitudinal follow-up of these patients.

Congenital cardiac diverticulum in the subaortic valve area

We report and review the clinical characteristics and operative techniques of the rare malformation of congenital cardiac diverticulum in the subaortic valve area. Four male patients with congenital ventricular fibrous diverticula in the subaortic valve area are reported. The patients' ages ranged from 4 to 47 years (mean 39 years). The first case was complicated by rupture, pseudoaneurysm formation, and a hemopericardium, and was only diagnosed on the third surgical exploration. The second case was associated with endocarditis involving both aortic and mitral regurgitation. The diverticulum was suspected on 2-dimensional transthoracic echocardiography and confirmed at surgery. In the third case, the subaortic diverticulum was associated with a rupture of the left cusp of the aortic valve with severe regurgitation. In the fourth case, the diverticulum was located between the aortic and mitral valves with a diameter of approximately 30 mm and was associated with multiple perforations of an aortic valve leaflet and severe regurgitation. There were no other congenital thoracoabdominal or cardiac anomalies. At a mean follow-up of 1 year, all patients were well. Congenital cardiac diverticulum in the subaortic valve area is a rare anomaly. Transthoracic echocardiography and transesophageal echocardiography are reliable tools for the diagnosis and follow-up. Isolated congenital cardiac diverticula in the subaortic valve area tend to involve a benign clinical process, but may be complicated by spontaneous rupture or endocarditis. Surgical resection is performed when complications require surgical therapy.

Left Ventricular Diverticulum with Contractile Function in an Unusual Site

The diverticulum of the left ventricular cavity is a rare congenital malformation. Various imaging modalities such as echocardiography, computed tomography, magnetic resonance imaging, and left ventriculography might be used for anatomic and functional properties of this abnormality. This report presents the case of a 48-year-old man with a contractile left ventricular diverticulum in the left ventricular outflow tract area and the evaluation with real-time multiplane and 3-dimensional transthoracic echocardiography.

Assessment of tricuspid valve annulus size, shape and function using real-time three-dimensional echocardiography

Tricuspid annulus (TA) evaluation continues to be a major problem in the surgical decision-making process. Obviously, 2-dimensional transthoracic echocardiography (2D TTE) is limited in TA visualization due to its complex 3D shape. The study aimed to determine TA morphology, size and function with real-time three-dimensional echocardiography (RT3DE) in 40 patients divided into two equal groups (I: normal TA and II: dilated). 2D TTE measurements included TA diameter (TAD) at apical 4-chamber (AP4CH) and parasternal short axis (PSAX) views. RT3DE measurements included TA area (TAA), major TAD and minor TAD. TA fractional shortening (TAFS), and TA fractional area change (TAFAC) were calculated from end-systolic and end-diastolic measurements. RT3DE allowed visualization and measurement of the entire oval-shaped TA in all patients irrespective of its size (normal or dilated). 2D TTE measurement of TAD at both AP4CH and at PSAX views was significantly smaller than the major TAD measured by RT3DE (P<0.0001) and nearly matched with the minor TAD in all patients. Calculation of TAFS was comparable with both techniques. TAFAC was significantly higher than TAFS (P<0.0001). So, RT3DE could be relied on more accurately than 2D TTE in the assessment of TA size and function which may aid in decision-making and selection of proper surgical procedure when indicated.

Left Ventricular Systolic Dysfunction and the Risk of Ischemic Stroke in a Multiethnic Population

Left ventricular dysfunction (LVD) is associated with cardiovascular mortality. Its association with ischemic stroke has been mainly documented after myocardial infarction. The stroke risk associated with LVD, especially of mild degree, in the general population is unclear. The purpose of this study was to evaluate the relationship between LVD and ischemic stroke in a multiethnic cohort. LV systolic function was assessed by transthoracic 2-dimensional echocardiography in a subset of subjects from the Northern Manhattan Study (NOMAS), 270 patients with first ischemic stroke and 288 age-, gender- and race-matched community controls. LV ejection fraction was measured by a simplified cylinder-hemiellipsoid formula, and categorized as normal (>50%), mildly (41% to 50%), moderately (31% to 40%) or severely (< or =30%) decreased. The association between impaired ejection fraction and ischemic stroke was evaluated by logistic regression analysis after adjustment for established stroke risk factors. LVD of any degree was more frequent in stroke patients (24.1%) than in controls (4.9%; P<0.0001), as was moderate/severe LVD (13.3% versus 2.4%; P<0.001). A decreased ejection fraction was associated with ischemic stroke even after adjusting for other stroke risk factors. The adjusted odds ratio for any degree of LVD was 3.92 (95% CI, 1.93 to 7.97). The adjusted odds ratio for mild LVD was 3.96 (95% CI, 1.56 to 10.01) and for moderate/severe LVD 3.88 (95% CI, 1.45 to 10.39). The association between LVD of any degree and stroke was present in all age, gender and race-ethnicity subgroups. LVD, even of mild degree, is independently associated with an increased risk of ischemic stroke. The assessment of LV function should be considered in the assessment of the stroke risk.

Use of Real-time 3-dimensional Transthoracic Echocardiography in the Evaluation of Mitral Valve Disease

Three-dimensional (3D) echocardiography (3DE) provides unique orientations of the mitral valve (MV) not obtainable by routine 2-dimensional echocardiography. However, this modality has not been adopted in routine clinical practice because of its cumbersome and time-consuming process. The recent introduction of a full matrix-array transducer has enabled online real-time 3DE (RT3DE) and rendering. This study was designed to: (1) determine the clinical use of RT3DE in patients with MV pathology and in a control group selected for their good acoustic windows (protocol I); and (2) to investigate the feasibility of imaging the MV apparatus in a large group of consecutively imaged patients to determine the acoustic window or perspective from which the MV leaflets, commissures, and orifice are best visualized (protocol II). In protocol I, 65 patients were selected based on MV pathology and good 2-dimensional echocardiography image quality. Protocol II included 150 patients who were consecutively imaged using RT3DE. Images were viewed online (protocol I) and offline on a digital review station (protocol II). RT3DE visualization of the MV apparatus was graded based on the percentage of leaflet dropout and definition. In protocol I, 78% of patients had adequate 3D MV reconstructions with complete visualization of the anterior mitral leaflet (AML) in 84% versus the posterior mitral leaflet (PML) in 77%. The mitral leaflets, commissures, and MV orifice were well seen in 98%; however, the submitral apparatus was only observed in 76% of the patients. RT3DE: (1) correctly identified the prolapsed/flailed scallop in 6 of 8 patients; (2) obtained en face orientation of the MV orifice in 9 of 11 patients with mitral stenosis, allowing accurate measurements of the orifice area and evaluation of the immediate effects of balloon mitral valvuloplasty; and (3) allowed postoperative evaluation of MV repair and the integrity of the struts of a bioprosthetic leaflet. In protocol II, 70% of patients had adequate RT3DE with complete visualization of the AML noted in 55% versus 51% for PML. The mitral leaflets, commissures, and MV orifice were observed in 69%. Irrespective of acquisition window, the AML was best seen from a ventricular perspective. In contrast, the PML was optimally examined from a parasternal window. Both the medial and lateral commissures were equally assessed from either imaging window. In conclusion, RT3DE of the MV is feasible in a large majority of patients. Using different MV acquisitions RT3DE provides important clinical information such as: (1) identification of a prolapsed/flail scallop; (2) measurement of stenotic valve areas; (3) evaluation of MV leaflet integrity postrepair; and (4) identification of a MV perforation. In general the AML is better visualized than the PML. The parasternal window is the optimal approach to visualize both AML and PMLs.

Three-Dimensional Transthoracic Echocardiography to Evaluate Cor Triatriatum in the Adult

Cor triatriatum is a rare congenital condition in which the left atrium is partitioned into two chambers by a fibrous or fibromuscular septum. The diagnosis is often made early in childhood, but can rarely be discovered later in adulthood. This delay in diagnosis is likely because of the number and size of the fenestrations in the septum. Echocardiography is the modality most often used to diagnose cor triatriatum. Generally, transesophageal echocardiography (TEE) is superior to transthoracic imaging. Three-dimensional echocardiography, however, is a modality that offers additional information not offered by 2-dimensional echocardiography. Although 3-dimensional TEE has previously been described, we report what we believe to be the first case of 3-dimensional transthoracic echocardiography used to diagnose cor triatriatum. This modality offers an advantage over TEE, as it allows the septum to be viewed easily without the risks or inconvenience of TEE.

Definitive Diagnosis of Descending Thoracic Aortic Dissection by Real Time/Live Three‐Dimensional Transthoracic Echocardiography

We describe a patient with descending thoracic aortic dissection in whom three- dimensional transthoracic echocardiography was able to clearly visualize the dissection flap en face as a sheet of tissue, as well as demonstrate a large communication between the true and false lumen in three dimensions, enabling a definitive diagnosis of dissection.

758 Visualisation of left ventricular and atrial walls from different views at real time 3-dimensional echocardiography, compared to 2-dimensional transthoracic echocardiography

758 Visualisation of left ventricular and atrial walls from different views at real time 3-dimensional echocardiography, compared to 2-dimensional transthoracic echocardiography

The prevalence of bicuspid aortic valve in newborns by echocardiographic screening

This study was carried out to determine the true prevalence of bicuspid aortic valve (BAV) in newborns, which has not yet been determined. One thousand seventy five live born neonates (567 male neonates, 508 female neonates; gestational ages ranging from 27 to 42 weeks, and birth weights ranging from 720 to 4,780 g) were screened by transthoracic 2-dimensional echocardiography to assess the prevalence of BAV. BAV was identified in a prevalence of 4.6 in 1,000 live births. The prevalence of BAV by sex was 7.1 of 1,000 in male neonates, and 1.9 of 1,000 in female neonates. All newborns with BAV were asymptomatic. Mild aortic regurgitation was found in only 1 neonate with BAV. Because BAV may result in aortic valvular stenosis and/or regurgitation, a recommendation of regular follow-ups and antibiotic prophylaxis for infective endocarditis should be necessary.

Mitral Annulus Flattens in Ischemic Mitral Regurgitation: Geometric Differences Between Inferior and Anterior Myocardial Infarction

New surgical strategies to restore the saddle shape of the mitral annulus are expected to increase annuloplasty effectiveness. Preoperative and postoperative configuration of the curved annulus, however, is difficult to quantify with 2-dimensional echocardiography. We sought to investigate the geometric deformity in the mitral annulus in ischemic mitral regurgitation (MR), comparing inferior and anterior myocardial infarction (MI) with the use of a custom quantitation software system with transthoracic 3-dimensional echocardiography. We performed real-time 3-dimensional echocardiography in 23 patients with ischemic MR attributable to inferior MI or anterior MI and in 10 controls. Three-dimensional data were cropped into 18 radial planes, and we manually marked the annulus in mid systole. Three-dimensional annular images were reconstructed, and annular circumferences, areas, and heights were quantified. Annulus was significantly more dilated and flattened in ischemic MR than in controls and was further deformed in anterior MI as compared with inferior MI (control: circumference 9.9+/-0.7 cm, area 9.6+/-0.5 cm2, height 5.0+/-0.7 mm; inferior MI: circumference 11.5+/-1.2 cm [P<0.01 compared with control], area 11.4+/-2.0 cm2 [P<0.05 compared with control], height 3.5+/-1.6 mm [P<0.05 compared with control]; anterior MI: circumference 14.2+/-2.4 cm [P<0.0001 compared with control, P<0.05 compared with inferior MI], area 13.7+/-2.8 cm2 [P<0.01 compared with control, P<0.05 compared with inferior MI], height 1.7+/-1.5 mm [P<0.0001 compared with control, P<0.05 compared with inferior MI]). Mitral annulus flattens in ischemic MR. Deformity of the mitral annulus was greater in anterior MI group than in the inferior MI group.

Aortic dimensions in patients with bicuspid aortic valve without significant valve dysfunction

The dimensions of the entire aorta at different anatomic levels were measured by transthoracic 2-dimensional echocardiography in 162 consecutive patients with isolated bicuspid aortic valves (BAVs) without significant aortic valve dysfunction. Aortic dilation involved the aortic root and the ascending aorta but was not present in the descending and abdominal aorta. A significant increase in the dimensions of the aortic arch was found in patients with BAVs aged >40 years. Ascending aortic diameter and the extension of aortic dilation were significantly correlated with age, but no correlation was found between aortic dimensions and aortic valve morphology.

Additional impact of electrocardiographic over echocardiographic diagnosis of left ventricular hypertrophy for predicting the risk of ischemic stroke

Background Patients with left ventricular hypertrophy (LVH) have an increased risk of ischemic stroke. Although echocardiography is commonly used for the diagnosis of LVH, there is little information about the potential role of electrocardiography in providing additional prognostic information. The purpose of this study is to determine if electrocardiographically derived criteria for LVH provide additional prognostic value over echocardiography for predicting ischemic stroke in a multiethnic population. Methods A population-based, case-control study was conducted in 177 patients who had had a first ischemic stroke and in 246 control patients matched for age, gender, and race or ethnicity. Left ventricular mass was measured by using 2-dimensional transthoracic echocardiography. Logistic regression analysis was performed to assess the risk of stroke associated with the presence of LVH diagnosed by electrocardiography (defined by 4 established criteria) after adjustment for the presence of other stroke risk factors and for echocardiographically determined LVH. Results After adjustment for the presence of other established stroke risk factors, ECG-LVH was associated with ischemic stroke, using Sokolow-Lyon (odds ratio [OR] 2.12, 95% CI 1.05-4.30), Cornell voltage (OR 2.06, 95% CI, 1.26-3.35), and Cornell product criteria (OR 2.12, 95% CI, 1.13-3.97). Cornell voltage criterion (men, >2.8mV; women, >2.0mV) was associated with ischemic stroke even after adjustment for echocardiographically determined LVH (OR 1.73, 95% CI, 1.04-2.88). The combination of echo-LVH and a positive Cornell voltage criterion was associated with a 3.5-fold increase in stroke risk. Conclusions Our study indicates that the presence of ECG-LVH is associated with an increased risk of ischemic stroke after adjustment for other stroke risk factors. For Cornell voltage criteria, this relationship persisted even after adjustment for echocardiographic LVH. Electrocardiographic results can provide independent information for left ventricular myocardial changes and should be considered together with echocardiographic results to fully assess the risk of ischemic stroke.

The Structural and Dynamic Recognition of Discrete Subaortic Stenosis by Real-Time Three-dimensional Transthoracic Echocardiography

Discrete subaortic stenosis is a rare condition to cause left ventricular outflow obstruction. It is sometimes difficult to diagnose it because conventional transthoracic echocardiography may fail to show its 3-dimensional feature. We document the feasibility of on-line 3-dimensional transthoracic echocardiography, by which we can obtain the important 3-dimensional structural and dynamic information of discrete subaortic stenosis.

Echocardiographic abnormalities in primary antibody deficiency

Objective: To document cardiac abnormalities secondary to pulmonary disease in primary antibody deficiency. Patients and methods: A cross sectional audit study of patients from a regional immunology centre. Subjects undergoing...