Real time three-dimensional transesophageal echocardiography: a novel approach for the assessment of prosthetic heart valves.

OBJECTIVES: To explore our initial experience with real time three-dimensional transesophageal echocardiography (RT3DTEE) for the assessment of prosthetic valves (PV). METHODS: The study included 40 patients (mean age 35 ± 8.5 years, 68% male) who underwent PV implant. Fifty PV (34 bioprosthetic and 16 mechanical) were evaluated using two-dimensional (2D)TEE and RT3DTEE to rule out PV dysfunction. RESULTS: In all patients, RT3DTEE allowed good and simultaneous visualization of PV leaflets. Ten patients had normal functioning PV (5 in mitral, 3 in aortic, and 2 in tricuspid positions). Infective endocarditis was evident in 13 patients (20 PV) by repeated 2DTEE. RT3DTEE confirmed the 2DTEE diagnosis of endocarditis in same patients. Clear delineation of vegetations (size, site, and number) was obtained from RT3DTEE full volume while the vegetation attachment, consistency, mobility and its relation to valve structure were obtained using zoom 3D. Paraaortic abscesses size, site, extension, wall thickness of the abscess could be identified by RT3DTEE in 7 PV. Through cropping of the full-volume 3D images, the orifice of communication between the abscess cavity and aorta could be visualized well in en face view. Color full-volume allowed the detection of paravalvular regurgitation (size, location, direction, and extent) in 8 patients. In the 18 PV who underwent redo surgery, the intra-operative findings confirmed the RT3DTEE description of PV lesions. CONCLUSION: Real time 3DTEE improved the anatomical and functional assessment of PV with better understanding of the underlying causes of PV dysfunction; hence, it could improve the management planning for such patients.

Real-time three-dimensional transthoracic echocardiography in daily practice: initial experience.

AIM OF THE WORK: To evaluate the feasibility and possible additional value of transthoracic real-time three-dimensional echocardiography (RT3D-TTE) for the assessment of cardiac structures as compared to 2D-TTE. METHODS: 320 patients (mean age 45 ± 8.4 years, 75% males) underwent 2D-TTE and RT3D-TTE using 3DQ-Q lab software for offline analysis. Volume quantification and functional assessment was performed in 90 patients for left ventricle and in 20 patients for right ventricle. Assessment of native (112 patients) and prosthetic (30 patients) valves morphology and functions was performed. RT3D-TTE was performed for evaluation of septal defects in 30 patients and intracardiac masses in 52 patients. RESULTS: RT3D-TTE assessment of left ventricle was feasible and reproducible in 86% of patients while for right ventricle, it was (55%). RT3D-TTE could define the surface anatomy of mitral valve optimally (100%), while for aortic and tricuspid was (88% and 81% respectively). Valve area could be planimetered in 100% for the mitral and in 80% for the aortic. RT3D-TTE provided a comprehensive anatomical and functional evaluation of prosthetic valves. RT3D-TTE enface visualization of septal defects allowed optimal assessment of shape, size, area and number of defects and evaluated the outcome post device closure. RT3D-TTE allowed looking inside the intracardiac masses through multiple sectioning, valuable anatomical delineation and volume calculation. CONCLUSION: Our initial experience showed that the use of RT3D-TTE in the assessment of cardiac patients is feasible and allowed detailed anatomical and functional assessment of many cardiac disorders.

Incremental utility of real time three-dimensional tranthoracic echocardiography in the assessment of congenitally malformed aortic valve.

OBJECTIVES: To study the feasibility and additional value of real time three-dimensional transthoracic echocardiography (RT3D-TTE) for anatomical and functional assessment of malformed aortic valve (AV) compared to conventional two-dimensional TTE (2D-TTE). METHODS: Malformed AV was evaluated in 35 patients (mean age 18 ± 9.5 years, 70% male) by both 2D-TTE and RT3D-TTE. The anatomical definition of aortic cusps (number, direction, and commissures) was evaluated by a 3-point visualization score (1: nonvisualized, 2: inadequate, 3: adequate). 2D-TTE and RT3D-TTE measurements included AV area and maximum diameters of both AV annulus and left ventricular outflow tract (LVOT). RESULTS: Adequate visualization of AV cusps was achieved in 86% of patients by RT3D-TTE compared to 63% by 2D-TTE. The mean and median visualization score obtained by RT3D-TTE were higher than that by 2D-TTE. The opening of commissures was detected in (80%) of patients by RT3D-TTE compared to (34%) by 2D-TTE. AV area planimetry could be obtained in 77% of patients by RT3D-TTE compared to 43% by 2D-TTE. RT3D-TTE visualization score of AV cusps and commissures showed better interobserver agreement (Kappa: 0.62 and 0.72, respectively) than 2D-TTE (0.58 and 0.69, respectively). RT3D-TTE and 2D-TTE measurements of AV annulus and LVOT were well correlated (r = 0.85; P < 0.001) but the RT3D-TTE measurements were significantly larger than that obtained by 2D-TTE (2.05 ± 0.7 cm and 2.5 ± 0.86 cm vs 1.94 ± 0.67 cm and 1.98 ± 0.74 cm; P < 0.01). CONCLUSION: RT3D-TTE is a feasible technique that allows comprehensive quantitative and qualitative assessment of malformed AV.

Organized intrapericardial haematoma: a rare cause of heart failure after 2 years of trauma.

Intrapericardial organized haematoma secondary to blunt chest trauma is an extremely rare cause of constrictive pericarditis. We report a 30-year-old male who presented with heart failure for 12 months and was found to have an organized intrapericardial haematoma secondary to blunt chest trauma in a road traffic accident 2 years prior. The use of multiple imaging modalities including two-dimensional (transthoracic and transoesophageal) echocardiogram and cardiac magnetic resonance imaging established the diagnosis. Surgical excision of the haematoma and removal of the constricting pericardium relieved his symptoms.

An incidental finding of mitral valve network.

A 63-year-old male presented with a 6-month history of worsening exertional dyspnea and was found to have three-vessel coronary artery disease. Transesophageal echocardiography revealed a filamentous structure attached to the anterior mitral valve leaflet, which was confirmed during surgery as filamentous network. To our knowledge, this is the first report to describe such a network attached to the mitral valve.

Right atrial metastasis mimicking myxoma in advanced hepatocellular carcinoma.

Hepatocellular carcinoma is the most common primary tumor of the liver accounting for 4.6% of all new human cancers. Cardiac metastasis in hepatocellular carcinoma is an uncommon secondary cardiac malignancy. We described two cases of advanced hepatocellular carcinoma with large masses in the right atrium mimicking atrial myxoma. The RA masses were incidentally detected during two-dimensional echocardiographic examination.

Value of Three-Dimensional Echocardiography in Assessing Double-Orifice Mitral Valve in an Asymptomatic Patient.

Double-orifice mitral valve (DOMV) is a rare congenital anomaly consisting of an accessory bridge of fibrous tissue, which divides the mitral valve (MV) into two orifices. The mitral leaflets are essentially normal in most cases, but they can be regurgitant or stenotic. It is most commonly associated with a variety of other cardiac anomalies. Isolated DOMV with normal MV function is very rare. We present here a rare case of congenital DOMV in a 25-year-old female diagnosed by real-time three-dimensional echocardiography (RT3DE). RT3DE enabled complete anatomical and functional assessment of MV apparatus. It added much valuable information over conventional 2DE that helped in establishment of the diagnosis, identification of the anatomical type, and selection of the proper management.

Real-time three-dimensional echocardiographic assessment of inferior vena caval thrombosis.

Inferior vena cava thrombosis (IVCT) represents a subset of deep venous thrombosis. Because of the variety of its clinical presentations, the exact incidence is elusive. We present two cases of IVCT that was incidentally discovered during a routine two-dimensional echocardiography. Real-time three-dimensional echocardiography (RT3DE) assessment of IVCT added more valuable information that may help in its management. To the best of our knowledge, this is the first case report using RT3DE in the assessment of IVCT.

Right atrial myxoma associated with an atrial septal defect by real-time three-dimensional echocardiography.

A 40-year-old woman presented with a 1 month history of shortness of breath and easy fatigability. Two-dimensional echocardiography and real-time three-dimensional echocardiography (RT3DE) showed a large right atrial mass protruding into the right ventricle and an atrial septal defect (ASD). Successful excision of the mass, which proved to be a myxoma, and closure of the ASD completely relieved her symptoms. To our knowledge, this is the first report of RT3DE in a patient with right atrial myxoma associated with an ASD.

Imaging of ventricular septal tumor in an asymptomatic adolescent using multiple modalities.

Primary cardiac tumors are rare at all ages, and especially so in childhood, where the most prevalent type of benign cardiac masses are rhabdomyomas followed by fibromas, both of which have a predilection for ventricular septum. We report an unusual case of a tumor involving the ventricular septum in an asymptomatic 17-year-old adolescent who has been known to have this tumor for 10 years. The use of multiple imaging included myocardial contrast two-dimensional echocardiography, real time three-dimensional echocardiography (with and without myocardial contrast), and magnetic resonance imaging supported the diagnosis of cardiac rhabdomyoma.

Bicaval obstruction complicating right atrial tuberculoma: the diagnostic value of cardiovascular MR.

Cardiac tuberculosis is rare and usually involves the pericardium. Myocardial tuberculoma is a very rare occurrence and only a few cases were reported. We describe the use of cardiovascular magnetic resonance in the diagnosis of a rare case of cardiac tuberculoma involving the right atrium which was complicated by a bicaval obstruction. The patient made a remarkable improvement with the anti-tuberculous treatment. To our knowledge, this complication has never been reported in relation to cardiac tuberculoma.

Role of real time three-dimensional echocardiography in heart failure.

The incidence and prevalence of heart failure (HF) are increasing with high morbidity and mortality rates. Echocardiography is a very useful diagnostic tool for the evaluation of HF patients. Real time three-dimensional echocardiography (RT3DE) was introduced in the last decade and has proved to provide an accurate assessment of ventricular volume, mass, and function. In addition, it provides a comprehensive evaluation of the valves. However, its application remained limited to research work in selected cases because of a suboptimal image quality. The recent advances in the transducer and computer software technology enhanced the use of RT3DE in clinical practice. The application of RT3DE adds much information that helps in the assessment of HF patients. RT3DE became the standard in the assessment of left ventricular (LV) volumes, function, and mass. RT3DE is a promising tool for testing LV dyssynchrony due to its accuracy and reproducibility comparable to magnetic resonance imaging. The application of RT3DE for stress and myocardial perfusion studies is encouraging due to its short image acquisition time, but still requires wide-scale studies. Through cropping of the RT3DE full-volume, the direct visualization of the heart valves (especially mitral valve) in a surgical view could be easily obtained. In the near future, one would expect RT3DE to become an integral part of the assessment of HF patients.

Aspergillus cyst of aortic valve bioprosthesis.

Aspergillus endocarditis (AE) is an ominous complication of cardiac surgery with a dismal prognosis. We present a 35-year-old female who developed AE 4 months after her aortic and mitral valve replacement. Transesophageal echocardiography revealed an aortic root abscess and a cystic mass attached to the aortic bioprosthesis. Intraoperatively, the cyst was filled with fungal material. The aortic bioprosthesis was replaced and the patient was treated with amphotericin B. Six weeks later her condition suddenly deteriorated and she died on the same day. Early performance of transesophageal echocardiography and extended blood culture is mandatory in suspected cases of AE.

Central role of real-time three-dimensional echocardiography in the assessment of intracardiac thrombi.

UNLABELLED: The current study was designed to evaluate the feasibility and clinical utility of real-time 3-dimensional echocardiography (RT3DE) for detection of intracardiac thrombi with comparison to 2-dimensional echocardiography (2DE). The study included 45 consecutive patients with intracardiac thrombi detected by routine 2DE (mean age 45 +/- 8.4 years, 75% males). The relevant features of the thrombus by 2DE and RT3DE (site, shape, and number) were assessed according to a subjective four-point score index for image quality (1 = not visualized, 2 = inadequate, 3 = sufficient and 4 = excellent). Measurements included: maximum diameter and volume. 2DE and RT3DE detected 45 thrombi (34 in the left ventricle, six in the left atrium, four in the left atrial appendage, four in the right atrium, and two in the right ventricle). RT3DE could detect seven additional thrombi in five patients (three in the left atrial appendage and four in the left ventricular apex). Visualization score by 2DE and RT3DE was comparable (Kappa index: 7.2). RT3DE measurements of maximum diameter were well correlated with 2DE (R(2) = 0.88, P < 0.01) and showed better interobserver agreement than 2DE (2.88, -1.92 vs. 5.33, -3.87, respectively). RT3DE was superior to 2DE for assessment of thrombus mobility, differentiation between the thrombus and myocardium, and delineation of the changes in thrombi structure, e.g. calcification, degeneration, or lysis. In addition, volume calculation could be obtained by RT3DE only. IN CONCLUSION: RT3DE is comparable to 2DE for the assessment of the intracardiac thrombi and provided more detailed information beyond the scope of the established 2DE.

Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography.

BACKGROUND: The aim of this study was to validate a new real-time three-dimensional echocardiography (RT3DE) score for evaluating patients with mitral stenosis (MS). METHODS: A two-staged study was conducted. In the first stage, the feasibility of a new RT3DE score was assessed in 17 patients with MS. The second stage was planned to validate the RT3DE score in 74 consecutive patients undergoing percutaneous mitral valvuloplasty. The new RT3DE score was constructed by dividing each mitral valve (MV) leaflet into 3 scallops and was composed of 31 points (indicating increasing abnormality), including 6 points for thickness, 6 for mobility, 10 for calcification, and 9 for subvalvular apparatus involvement. The total RT3DE score was calculated and defined as mild (<8), moderate (8-13), or severe (>or=14). MV morphology was assessed using Wilkins's score and compared with the new RT3DE score. RESULTS: In the first stage, the RT3DE score was feasible and easily applied to all patients, with good interobserver and intraobserver agreement. In the second stage, RT3DE improved MV morphologic assessment, particularly for the detection of calcification and commissural splitting. Both scores were correlated for assessment of thickness and calcification (r = 0.63, P < .0001, and r = 0.44, P < .0001, respectively). Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins's score were leaflet calcification and subvalvular apparatus involvement, and those by RT3DE score were leaflet mobility and subvalvular apparatus involvement. The incidence and severity of mitral regurgitation were associated with high-calcification RT3DE score. CONCLUSION: The new RT3DE score is feasible and highly reproducible for the assessment of MV morphology in patients with MS. It can provide incremental prognostic information in addition to Wilkins's score.

Partial anomalous pulmonary venous connection associated with Lutembacher's syndrome.

Lutembacher's syndrome is a rare combination of congenital atrial septal defect and mitral stenosis (almost always rheumatic). The hemodynamic effect of this combination makes the clinical diagnosis difficult due to a wide variation of clinical presentation. Echocardiography and cardiac catheterization are useful tools for proper diagnosis and planning of the therapeutic strategy. We present a 28-year-old female with Lutembacher's syndrome associated with partial anomalous pulmonary venous connection (PAPVC), which was surgically corrected. To our knowledge, this combination has never been reported in the literature.

Unusual bileaflet tricuspid valve by real time three-dimensional echocardiography.

The right atrioventricular valve is formed by three leaflets as described by the classic anatomic studies. Two-dimensional transthoracic echocardiography (2DE) shows the tricuspid valve (TV) in its long axis. However, short-axis views of the TV leaflets are not generally obtained and therefore distinction between leaflets by 2DE is difficult. Real time three-dimensional echocardiography (RT3DE) overcomes this limitation of 2DE and facilitates obtaining short axis view (enface view) of the TV. In the current case study, en face view of the TV obtained by RT3DE was found to be formed of only two leaflets with two commissures. The surgical findings were consistent with that of RT3DE.

Multivalvular infective endocarditis in a tetralogy of fallot.

Infective endocarditis (IE) is still a problem in patients with adult congenital heart disease. Tetralogy of Fallot (TOF) is one of the most important manifestations of congenital heart disease, which carries a high risk for the development of IE. We present an 18-year-old male with TOF complicated by an aggressive form of IE involving all cardiac valves.