Use Of 3D Transesophageal Echocardiography Research Articles

Real-time 3D Transesophageal Echocardiography for the Placement of Ventriculoatrial Shunt: A Case Series and Technical Note.

Ventriculoatrial (VA) shunts are used to manage hydrocephalus and idiopathic intracranial hypertension when peritoneal drainage of cerebrospinal fluid is not feasible. The technique of distal catheter placement during VA shunt insertion is controversial, especially between fluoroscopy-guided and transesophageal echocardiography (TEE)-guided techniques. We retrospectively reviewed our utilization of 2-dimensional (2D) ultrasound-guided internal jugular vein catheterization combined with 3-dimensional (3D) TEE-guided distal VA shunt placement and compared it to the conventional fluoroscopy-guided technique. Ten patients underwent 18 VA shunt insertion procedures between November 2012 and October 2022. The patients had a mean (SD) age of 50 (19) years, body mass index of 35 (14)m/kg², and minimal comorbidities. All had previously undergone failed ventriculoperitoneal shunt procedures. The use of 2D ultrasound to guide internal jugular vein catheterization and 3D TEE to guide distal catheter placement resulted in 22-minute shorter surgical times compared with the fluoroscopy-guided technique (91 minutes vs. 113 minutes, respectively). No complications were noted with either technique. The combined use of 2D ultrasound and 3D TEE allowed for faster procedure times and more precise distal catheter confirmation, contributing to a more streamlined surgical procedure. This small case series underscores the feasibility, efficiency, and safety of anesthesiologist-delivered combined 2D ultrasound and 3D TEE during VA shunt insertion. The use of 3D TEE allows repeated confirmation of distal catheter position and has potential to improve patient safety during rare but complex VA shunt insertion procedures.

Rheumatic mitral aggression. Usefulness of 3d transesophageal echocardiography

Rheumatic heart disease is the leading cause of cardiovascular disease in children under 25 years of age worldwide, with the highest prevalence in low-income countries. The usual and distinctive finding of rheumatic aggression is mitral stenosis, which leads to serious cardiovascular consequences. International guidelines establish transthoracic echocardiography (TTE) as the diagnostic test for rheumatic heart disease; however, it has limitations in the measurement of planimetry and those inherent to Doppler. Transesophageal 3D echocardiography (TTE-3D) is a new modality that shows realistic images of the mitral valve and has the added value of accurately locating the plane of maximum stenosis and better determining commissural involvement.

1635 Catch me if you can: a rare case of two-staged MitraClip detachment

Abstract Case report A 74-year-old man presented with acute heart failure and chronic obstructive pulmonary disease exacerbation. His medical history revealed: anterior myocardial infarction in 2005, treated with primary PCI of left anterior descending coronary artery followed by triple coronary artery bypass, atrial fibrillation, hypertension, diabetes mellitus and obesity. Transthoracic and transesophageal echocardiography (TEE) showed severe functional ischemic mitral regurgitation (MR) with multiple jets, the main one involving the A2-P2 scallops due to asymmetric tethering of the posterior leaflet. The vena contracta diameter (VC) was 8 mm, the effective regurgitant orifice area (EROA) 0.53 cm². Global left ventricular (LV) function was preserved with inferior-posterior wall akinesis. After "Heart Team" discussion, due to high surgical risk, the patient was referred for percutaneous mitral valve repair (PMVR) using MitraClip (MC) system (Abbott Vascular, Illinois). One clip (MC-XTR) was placed at the A3-P3 segments; subsequently, prior to releasing a second clip (MC-XTR), the first one partially detached from the posterior leaflet (Fig A). A third clip (MC-NTR) was implanted medially. The grasp was challenging but at the end of the procedure, the first clip appeared stable and marked reduction of MR was achieved (Fig B). 7 days later, the patient became symptomatic for resting dyspnea and worsened his clinical status. A control 2D-3D TEE revealed a complete detachment of the first implanted clip, visible distally into the LV, trapped in the mitral valve subchordal apparatus (Fig C). This resulted in massive MR (VC: 12 mm, EROA: 0.91 cm²) with an eccentric posteriorly directed regurgitant jet (Fig D). The patient underwent emergency surgical retrieval of the migrated clip, and removal of the torn mitral valve anterior leaflet. The other two clips were also removed (Fig E), and a bioprosthetic mitral valve was implanted. The procedure was completed uneventfully and the patient is in stable conditions at 2-months follow-up. Discussion The constant stretching and whip effect of the mitral leaflets captured between the clips arms, used in PMVR, can lead to complications. Partial clip detachment is a rare adverse event described in ∼0.7-4.9% of patients within 30 days after MC intervention*. We experienced a two-staged MC detachment that is an even rarer complication and requires emergency surgery. In addition, we highlights the usefulness of 3D TEE for early diagnosis and better imaging characterization in patients who develop complications after MC procedure. No conflict of interest. *Puls M, Lubos E, Boekstegers P, von Bardeleben RS, Ouarrak T, Butter C, Zuern CS, Bekeredjian R, Sievert H, Nickenig G, Eggebrecht H, Senges J, Schillinger W. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: results from German transcatheter mitral valve interventions registry. Eur Heart J 2016;37:703-12. Abstract 1635 Figure.

Validation of a Novel Software Tool for Automatic Aortic Annular Sizing in Three-Dimensional Transesophageal Echocardiographic Images

Accurate aortic annulus (AoA) sizing is crucial for transcatheter aortic valve implantation planning. Three-dimensional (3D) transesophageal echocardiography (TEE) is a viable alternative to the standard multidetector row computed tomography (MDCT) for such assessment, with few automatic software solutions available. The aim of this study was to present and evaluate a novel software tool for automatic AoA sizing by 3D TEE. One hundred one patients who underwent both preoperative MDCT and 3D TEE were retrospectively analyzed using the software. The automatic software measurements' accuracy was compared against values obtained using standard manual MDCT, as well as against those obtained using manual 3D TEE, and intraobserver, interobserver, and test-retest reproducibility was assessed. Because the software can be used as a fully automatic or as an interactive tool, both options were addressed and contrasted. The impact of these measures on the recommended prosthesis size was then evaluated to assess if the software's automated sizes were concordant with those obtained using an MDCT- or a TEE-based manual sizing strategy. The software showed very good agreement with manual values obtained using MDCT and 3D TEE, with the interactive approach having slightly narrower limits of agreement. The latter also had excellent intra- and interobserver variability. Both fully automatic and interactive analyses showed excellent test-retest reproducibility, with the first having a faster analysis time. Finally, either approach led to good sizing agreement against the true implanted sizes (>77%) and against MDCT-based sizes (>88%). Given the automated, reproducible, and fast nature of its analyses, the novel software tool presented here may potentially facilitate and thus increase the use of 3D TEE for preoperative transcatheter aortic valve implantation sizing.

Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect.

Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect.

Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect.

Use of 3D Transesophageal Echocardiography and the Clock-Face Model to Localize and Facilitate Closure of a Mitral Paravalvular Defect.

Utility of real-time three-dimensional echocardiography in improved assessment of a mitral valve papillary fibroelastoma.

Key Clinical MessagePrimary cardiac tumors are exceedingly rare. They are usually first identified by transthoracic echocardiography. However, transesophageal echocardiography (TEE), with the aid of real‐time three‐dimensional (3D) imaging, can provide additional important mass characteristics. We present a case that demonstrates the usefulness of 3D TEE in characterizing a papillary fibroelastoma.

Mitral valve rheumatic multiple fenestrations

We describe a case that demonstrates and confirms the usefulness of 3D transesophageal echocardiography in the morphological analysis of the mitral valve in a rare occurrence of postrheumatic mitral leaflet perforation.

Preoperative morphological analysis by transesophageal echocardiography and predictive value of plasma landiolol concentration during systolic anterior motion mitral valve repair : a report of three cases

We report three cases with systolic anterior motion (SAM) after mitral valve plasty. Preoperative mitral valve morphology is a risk factor for SAM. The morphological characteristics of SAM have been revealed in several studies. We found a small distance between coaptation and the interventricular septum in all cases, and cases 2, and 3 had a low AL/PL ratio, whereas case 3 had a large PML, which was revealed by transesophageal echocardiography. With the use of 3D transesophageal echocardiography, when mitral valve prolapse was investigated, in all three cases, it was easy to specify lesions. The issue for the future is 3D analysis when SAM is occurring.

Challenges to the Clinical Integration of Transthoracic Three-Dimensional Echocardiography

One of the most important transformations in echocardiography over the past decade has been the widespread adoption of three-dimensional (3D) transesophageal echocardiography (TEE) for evaluation of the mitral valve. This acceptance occurred after the introduction of the matrix array transducer, which streamlined data acquisition, allowing practical clinical acquisition times and visualization of acquired 3DE images in real-time [1]. The quality of these images is high in the majority of patients, facilitating training, interpretation and the clinical use of these images. These advantages led to the performance of multiple studies, which demonstrated improved clinical diagnosis with their use and so became part of societal guideline recommendations [2]. With increasing user-friendliness with this technology, many centers have expanded the use of 3D TEE to include the peri-procedural monitoring, assessment and guidance of a variety of transcatheter procedures [3]. In contrast to the widespread implementation of 3D TEE, 3D transthoracic echocardiography (TTE) has not experienced a similar increase in clinical use. This is despite many studies demonstrating its value in improving the assessment of left ventricular size and function, which is one of the core requests of most echocardiography laboratories [4–6]. For many years, one of the major limitations to the integration of 3D TTE into routine clinical practice was the requirement to change probes mid-study to acquire 3D images. With the development of transthoracic transducers that allow acquisition of both two-dimensional (2D) and 3DE images using a single probe, a more practical and rapid clinical workflow has become possible. More importantly, the 2D echocardiographic (2DE) image quality obtained from these combined 2D/3D probes are of equal quality to that of previously dedicated 2D probes. However, for 3D TTE to gain similar clinical acceptance to 3D TEE, additional technical improvements in 3D echocardiographic transducers and systems/software need to be developed. These areas include: 1) improvements in spatial and temporal resolution without increasing acquisition or post-processing time; 2) development of automated software that provides quantification of 3D echocardiographic datasets and is integrated into reporting systems; and 3) improvement of storage of 3D echocardiography datasets and analytical results into current reporting systems.

Three-dimensional Echocardiography Is Essential for Intraoperative Assessment of Mitral Regurgitation

Since its introduction, 3-dimensional (3D) transesophageal echocardiography (TEE) has become widely adopted in operating rooms and cardiac catheterization laboratories worldwide. This is because the matrix-array 3D TEE probe allows acquisition of high-quality 3D images in real time with relatively little training. The rapid adoption of this technology has proven that this innovative imaging modality provides additional clinical information beyond that obtained from 2-dimensional (2D) TEE images. These developments have enabled medical centers to create integrated valve programs in which surgeons, interventionalists, and echocardiographers discuss cases and surgical approaches. Response by McCarthy on p 652 In particular, 3D TEE has been proven to be superior to 2D TEE in the assessment of both mitral valve anatomy and mitral regurgitation, promoting its use in the operating room (Table 1).1–3 One reason for this superiority is that 3D TEE allows the mitral valve to be displayed en face in an orientation identical to the surgeon’s view of the mitral valve intraoperatively. This surgeon’s view greatly facilitates communication with cardiac surgeons because they can easily interpret these images. View this table: Table 1. Advantages of 3D Echocardiography in the Evaluation of Mitral Regurgitation in the Operating Room Here, we argue that the widespread acceptance and use of 3D TEE are attributable to the pivotal role this modality plays in the intraoperative assessment of mitral regurgitation. We believe that 3D TEE of the mitral valve is invaluable not only because of the realistic images it provides but also because it improves: 1) lesion localization, 2) identification of the mechanisms causing mitral regurgitation, 3) quantification of the severity of mitral regurgitation, 4) selection of surgical intervention, 5) the choice of the surgeon whose expertise is best suited to perform the operation, 6) guidance of percutaneous mitral valve procedures, and 7) postoperative assessment. Accurate preoperative assessment of the …

Utilidad del ecocardiograma transesofágico 3D en una paciente con membrana subaórtica

Utilidad del ecocardiograma transesofágico 3D en una paciente con membrana subaórtica

Usefulness of 3D Transesophageal Echocardiography in a Patient with Subaortic Membrane

Hospital Italiano de Buenos Aires. Instituto de Medicina Cardiovascular MTSAC Miembro Titular de la Sociedad Argentina de Cardiologia e-mail: mariano.falconi@hospitalitaliano.org.ar Rev ARgent CARdiol 2013;81:359. http://dx.doi.org/10.7775/rac.es.v81.i4.2878 Las imagenes corresponden a una paciente de 37 anos derivada a nuestra institucion por disnea y angina de esfuerzo. En el examen fisico presentaba un soplo sistolico en foco aortico. El ecocardiograma Doppler transtoracico mostro una valvula aortica trivalva con apertura normal y reflujo diastolico leve a moderado, y la presencia de una membrana subaortica con un gradiente pico y medio de 50 y 30 mm Hg, respectivamente. Se realizo un ecocardiograma transesofagico con un equipo Philips IE33 y sonda transesofagica 3D X7-2t. En las imagenes transesofagicas 2D se pudo visualizar una membrana fibrosa en el tracto de salida del ventriculo izquierdo, parcialmente adherida al septum interventricular y la valva anterior mitral (Figura 1, Video 1). Las imagenes 3D desde el lado aortico en sistole y diastole (Video 2) y eje largo (Figura 2, Video 3) fueron de gran utilidad para evaluar la extension y la implantacion de la membrana. Una planimetria 3D mostro un area del tracto de salida del ventriculo izquierdo de 3,4 cm2 y un area efectiva de 1,63 cm2 en relacion con el orificio de la membrana. Se realizaron la reseccion quirurgica de la membrana y una plastica valvular aortica. Los hallazgos intraoperatorios fueron muy similares a las imagenes ecograficas prequirurgicas. En patologias cardiacas complejas, la ecocardiografia 3D es muy util para evaluar la anatomia de la estructura afectada, asi como de los tejidos adyacentes. En el caso particular de la membrana subaortica resulta muy dificil el examen completo con ecografia 2D convencional. En este caso, la ecocardiografia 3D permitio una evaluacion completa de la posicion de la membrana, la implantacion y la extension, de utilidad para el abordaje quirurgico.

Combined 2D and 3D Transthoracic and Transesophageal Echocardiography in the Evaluation of Nonobstructive and Obstructive Cor Triatriatum Sinister

Cor triatriatum sinister is a rare congenital condition in which the left atrium is partitioned into two chambers by a fibromuscular membrane. Two-dimensional transthoracic echocardiography and 2D transesophageal echocardiography are the standard tests of choice for the assessment of function and physiology, although with complex pathology, evaluation of specific structures may be limited. We are reporting the additional use of 3D transesophageal echocardiography to delineate the anatomical features of the membrane in a comprehensive way not possible by conventional 2D imaging.

Advanced cardiac imaging in percutaneous transvenous mitral annuloplasty

Functional mitral regurgitation is a consequence of ventricular enlargement and annular dilatation. Current treatment options include medical and surgical therapy. Reduction of functional mitral regurgitation has a significant impact on patient prognosis [1]. Percutaneous transvenous mitral annuloplasty (PTMA) systems have been suggested for interventional treatment of functional mitral regurgitation in heart failure patients [2, 3]. These devices are inserted into the coronary sinus. They use the close proximity of the coronary sinus, great and anterior interventricular vein to the mitral annulus to enable remodeling of the mitral annulus. Reduction of mitral regurgitation is based on a reduction of the anterior–posterior mitral annulus dimension resulting in improved leaflet coaptation. Advanced imaging modalities allowing a 3-dimensional display of the complex mitral valve apparatus may allow improved understanding of treatment effects [4]. This report describes the use of 3D transesophageal echocardiography and CT–angiographic fusion imaging to visualize the treatment effect of a PTMA system. The Viacor PTMA system (Viacor, Inc. Wilmington, MA, USA) consisting of a multi-lumen PTFE catheter and Nitinol (nickel–titanium alloy) treatment rods as described recently, was implanted in a 66-year-old male patient. The patient had severe mitral insufficiency due to ischemic cardiomyopathy with dilated mitral annulus. Mitral valve surgery was denied to the patient due to severe comorbidities including pulmonary hypertension and silicosis. Figure 1, panel a demonstrates a hybrid image combining a CT scan of the coronary sinus with the fluoroscopic image before PTMA. Figure 1, panel b is a hybrid image showing the coronary sinus configuration (blue vessel) from the CT scan before PTMA combined with a fluoroscopic image showing the PTMA in place. The PTMA device indicates the new coronary sinus position after force induction by the PTMA device. The green area is obtained from the coronary sinus position before PTMA and with the PTMA device in place (white arrows). It indicates the effect of the device on the area encompassed by the coronary sinus and indirectly reflects also the change in mitral annulus area induced by the device. Figure 1, panels c and d are 3D stop frame images before and with PTMA obtained by 3D real-time TEE demonstrating the deformation of the mitral annulus induced by the device (black arrows). To demonstrate the effect of the annuloplasty procedure on the mitral valve, rendered 3D images were obtained by a dedicated software (Qlab 7.0 , Philips Healthcare, Andover, MA, USA). With this technique the mitral valve including the annulus and leaflets can be characterized with regard to the width of the annulus, the anterior-to-posterior and the anterolateral-to-posteromedial diameter as well as the mitral regurgitant orifice area. A significant reduction of the mitral anterior-to-posterior diameter from 40 to 33 mm and of the mitral regurgitant orifice area from 0.56 cm before the procedure to 0.12 cm after the procedure could be visualized (Figs. 2, panels a, b). Color Doppler echocardiography demonstrates reduction of mitral regurgitation from before PTMA (Fig. 2, panel c) to with PTMA (Fig. 2, panel d). By proximal convergence method a reduction of regurgitant flow was confirmed. This report demonstrates that a combination of different imaging modalities allows improved understanding of R. Hoffmann (&) P. Schauerte M. Kelm J. Balzer Medical Clinic I, University Clinic Aachen, University Aachen, Pauwelsstrasse, 52074 Aachen, Germany e-mail: wilma.hoffmann@t-online.de