Incremental value of right parasternal transthoracic echocardiographic examination over the left parasternal approach in assessing ascending aorta size: Additional benefit of three-dimensional echocardiography.

BACKGROUND: The ascending aorta (AA) has not been well studied using two-dimensional right parasternal transthoracic echocardiographic examination (2DRPE). AIM: The aim of the present study was to assess the incremental value of 2DRPE over two-dimensional left parasternal transthoracic echocardiographic examination (2DLPE) in evaluating the size of AA in adult patients (pts) and, secondly, to determine whether live/real time three-dimensional (3D) RPE provided any additional benefit over 2DRPE. MATERIALS AND METHODS: The AA was successfully imaged by 2DLPE, 2DRPE, and 3D RPE in 87 of 141 (61.7%) pts which comprised of two groups of consecutive pts separated by an interval of 2 weeks. RESULTS: The maximum length of AA visualized by 2DRPE (4.98 ± 0.89) was larger than 2DLPE in 76/87(87%) pts (P < 0.001). Both the maximum systolic AA inner luminal width and leading edge-to-leading edge width by 2DRPE were greater than 2DLPE (P < 0.001). Similar to other noninvasive imaging modalities where mid-AA width is taken at level of right pulmonary artery, mid-AA width could also be taken at this level by 2DRPE in 79/87(91%) pts since this landmark was visualized during 2DRPE. However, this vessel could be visualized in only 2/87 (2%) pts with 2DLPE. 3DRPE conferred additional benefit over 2DRPE. The maximal AA length by 3DRPE was larger than 2DRPE in 60/87(69%) pts, and the maximal inner lumen and leading edge to leading edge widths were larger in 54/87(62%) and 66/87(76%) pts, respectively. CONCLUSION: Our preliminary study demonstrates significant incremental value of 2DRPE over 2DLPE in the assessment of AA. 3DRPE confers an additional advantage over 2DRPE.

Three-dimensional transthoracic echocardiographic identification of individual cusps of the pulmonary valve: Potential misidentification by the two-dimensional technique.

We demonstrate the incremental value of live/real time three-dimensional transthoracic echocardiography (3DTTE) over the two-dimensional modality in the identification of all three cusps of the pulmonary valve in patients in whom only two leaflets could be detected by the latter technique. This was because of the ability of 3DTTE to view the cusps enface permitting assessment of relationship to one another and the surrounding cardiac structures. In addition, 3DTTE showed not only the potential errors that can occur in pulmonary valve cusp identification when the two-dimensional modality is used alone but also how some of these errors can be avoided by paying attention to the surrounding structures.

Two- and three-dimensional transthoracic echocardiographic assessment of superior vena cava, crista terminalis, and right atrial appendage using the right parasternal approach.

BACKGROUND: The noninvasive assessment of superior vena cava (SVC), crista terminalis (CT), and the right atrial appendage (RAA) has clinical implications in determining the right atrium (RA) pressure in adult patients in whom the inferior vena cava cannot be imaged, in planning electrophysiological procedures and for evaluation of thrombi in RA/RAA. It is difficult to image these structures using standard two-dimensional transthoracic echocardiography (2DTTE), but the right parasternal approach has shown promise in the very few studies published so far. AIM: The aim of this study was to show the feasibility of this approach and its usefulness in qualitative and quantitative assessments of these structures by both 2D and three (3D) TTE in patients with and without known cardiac pathologies. MATERIAL AND METHODS: The study consisted of 38 adult patients, 17 of whom had cardiac pathologies (Group 1) while the remainder (Group 2) had no evidence of heart disease clinically or by echocardiography. RESULTS AND CONCLUSION: Both SVC and RAA could be imaged by 2DTTE and 3DTTE in 53% of 40 patients (two separate groups of 20 consecutive patients) studied demonstrating the technical feasibility of this approach. SVC size and collapsibility, CT and RAA size, and RAA fractional shortening were evaluated in both groups by both 2D and 3DTTE. 3DTTE provided incremental value over 2DTTE by its ability to view en face the SVC in short axis and the base of RAA and RAA volumes resulting in more comprehensive assessment of their size and function.

Incremental value of live/real time three-dimensional transesophageal echocardiography in the assessment of ventricular septal rupture following acute myocardial infarction.

Ventricular septal rupture is a serious complication following acute myocardial infarctions and is associated with a significant mortality rate. Classically, two-dimensional transthoracic echocardiography has been used to diagnose this complication and visualize its location. Two-dimensional transesophageal echocardiography has supplemented the transthoracic approach by providing more accurate assessment of the defect size and in guiding closure both percutaneously and intraoperatively. This modality, however, is limited to two-dimensional views only, and a greater breadth of information is instead available through the use of three-dimensional transesophageal echocardiography. We present a series of 11 patients in which live/real time three-dimensional transesophageal echocardiography offered incremental benefits over two-dimensional imaging alone.

Does three-dimensional transesophageal echocardiography provide incremental value in percutaneous closure of ascending aortic pseudoaneurysm?

Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two- and three-dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre- and postclosure settings.

Incremental benefit of three-dimensional transesophageal echocardiography in the assessment of a primary pericardial hemangioma.

Hemangiomas are rarely found in the heart and pericardial involvement is even more rare. We report a case of primary pericardial hemangioma, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Our case also highlights the importance of systematic cropping of the 3D datasets in making a diagnosis of pericardial hemangioma with a greater degree of certainty. In addition, we also provide a literature review of the features of cardiac/pericardial hemangiomas in a tabular form.

Incremental benefit of three-dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion.

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto-ostial left main coronary artery PCI, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.

Transesophageal echocardiography for incremental value of Amplatezer cribriform septal occluder for percutaneous transcatheter closure of complex septal defects: Case series.

BACKGROUND: The anatomy of septal defects can be complex and morphologically unpredictable. Balloon sizing of such defects may not be feasible, and an appropriately sized commercial occluder may not be available. Therefore, percutaneous transcatheter closure of such defects can be challenging because of an increased risk of complications. In this study, we have described the efficacy and safety of transcatheter closure of complex septal defects using Amplatzer cribriform occluder devices, assessed by real time three-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE). METHODS AND RESULTS: Four complex septal defects were involved in this investigation: (1) reimplanted multiple atrial septal defects (ASD) with one device embolization; (2) postinfarction ventricular septal defect; (3) long tunnel patent foramen ovale; and (4) postoperative residual ASD. All patients underwent percutaneous transcatheter interventions due to the high risk of surgical complications, and one of the three available cribriform ASD device sizes (18 mm, 25 mm, or 35 mm) was implanted. Perioperative RT 3D TEE combined with fluoroscopy was used for monitoring during the procedure. All defects were successfully occluded by cribriform septal occluder devices using the transcatheter technique. CONCLUSION: Our patients with complex septal defects were successfully treated by transcatheter closure using an Amplazter cribriform septal occluder device with careful planning based on patient presentation and close interdisciplinary collaboration. RT 3D color Doppler TEE provided precise information for the selection of the appropriate occluder device and facilitated the procedure by guiding the catheter through the often challenging patient anatomy.

Incremental value of live/real time three-dimensional transthoracic echocardiography over the two-dimensional technique in assessing carcinoid heart disease involving the aortic valve.

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in assessing involvement of the aortic valve.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of aortic atherosclerotic thrombi and ulcers.

We present two cases in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided incremental value in the assessment of atherosclerotic disease in the aorta. In one patient, it identified additional atherosclerotic ulcers as well as thrombi within them which were missed by two-dimensional (2D) TEE. In both cases, the size of the large mobile atherosclerotic plaque was underestimated by 2DTEE as compared with 3DTEE. Furthermore, 3DTEE provided volume quantification of the thrombi and ulcers which is not possible by 2DTEE. The echocardiographic findings of atherosclerotic plaques were confirmed by computed tomography in one patient and by surgery in the other.

Transcatheter Closure of Atrial Septal Defect with Attenuated Anterior Rim after Transcatheter Aortic Valve Implantation: Can It Be Carried out as a Single Procedure?

Transcatheter aortic valve replacement (TAVR) has emerged as a highly effective minimally invasive treatment for symptomatically critical aortic stenosis (AS) in patients at high or prohibitive surgical risk. We report a case of staged transcatheter management of critical AS combined with an atrial septal defect (ASD) with attenuated anterior superior rim. The clinical result of this case suggests that both procedures can be safely performed simultaneously. Therefore, combined transcatheter treatment may appear as a possible strategy in patients with concomitant cardiac conditions.

Incremental Value of Live/Real Time Three-Dimensional over Two-Dimensional Transesophageal Echocardiography in the Assessment of Atrial Septal Pouch.

An atrial septal pouch (ASP) results from partial fusion of the septum primum and the septum secundum, and depending on the site of fusion, the pouch can be left-sided (LASP) or right-sided (RASP). LASPs have been described in association with thrombi found in patients admitted with acute strokes, raising awareness of its potential cardioembolic role, especially in those with no other clearly identifiable embolic source. We retrospectively studied 39 patients in whom the presence of an ASP had been identified by three-dimensional transesophageal echocardiography (3DTEE) and who had a two-dimensional transesophageal echocardiogram (2DTEE) performed during the same clinical encounter. The incremental value provided by 3DTEE over 2DTEE included the detection of six ASPs not found by 2DTEE; the detection of two ASPs in the same subject (in four patients) not identified by 2DTEE; larger ASP measurements of length and height in over 80% of the cases; and measurement of the ASP width (elevational axis) for the calculation of the area of the ASP opening, because of its unique capability to view the pouch en face. In addition, the volume of ASP and of the echogenic masses contained in the ASP (four of 39 patients) could be calculated by 3DTEE, which is a superior parameter of size characterization when compared to individual dimensions. One of these patients who presented with ischemic stroke diagnosed by magnetic resonance imaging had a large (>2 cm) mass in a LASP, with echolucencies similar to those seen in thrombi and associated with clot lysis and resolution. This mass completely disappeared on anticoagulant therapy lending credence that it was most likely a thrombus. There was no history of stroke or any other type of embolic event in the other three patients with masses in ASP. In conclusion, this retrospective study highlights the incremental value of 3DTEE over 2DTEE in the comprehensive assessment and characterization of ASPs, which can aid in the clarification of their role in cryptogenic stroke patients.

Abnormal mitral-aortic intervalvular coupling in mitral valve diseases: a study using real-time three-dimensional transesophageal echocardiography.

BACKGROUND: Mitral and aortic valves are coupled via fibrous tissue. This coupling is considered to be important for cardiac function before and after mitral valve surgery. The relationship between mitral-aortic coupling and different types of mitral regurgitation (MR) is not completely understood. METHODS AND RESULTS: Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) was performed in 133 subjects: 30 normal subjects, 15 patients with Carpentier type I MR (annular dilatation and congenital cleft), 40 type II (mitral valve prolapse), 20 type IIIa (rheumatic) and 28 type IIIb (ischemic mitral regurgitation). Custom software was used to track mitral (MA) and aortic annuli (AoA) in 3D space throughout cardiac cycle, allowing measurement of changes in mitral and aortic valve morphology. Normal mitral-aortic coupling is characterized by reciprocal changes in the annular areas throughout cardiac cycle, with systolic reduction of the angle between the two annular planes. In Carpentier type II patients, not only MA but also AoA areas were increased (P < 0.05 vs normal), but the reciprocal pattern of mitral-aortic coupling was preserved. In both type I IMR and IIIb patients, MA and AoA areas were both increased (P < 0.05 vs normal) and the reciprocal behavior of mitral-aortic coupling was lost. Only MA area was increased in type IIIa patients. The extent of mitral-aortic angle reduction during systole was diminished in all 4 Carpentier groups (P < 0.05 vs normal). CONCLUSIONS: Mitral valve diseases may affect normal mitral-aortic coupling and aortic valve function. Different patterns of abnormal mitral-aortic coupling are associated with different Carpentier types of MR.

Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional modality in the assessment of cardiac lymphoma.

We describe a case of cardiac lymphoma where live/real time three-dimensional transesophageal echocardiography provided additional information compared to two-dimensional transesophageal echocardiography regarding the extent of tumor infiltration. In addition, it gave a quantitative assessment of the tumor burden by providing its volume.

Intraoperative three-dimensional transesophageal echocardiography for assessing the defect geometries of mitral prosthetic paravalvular leak during transcatheter closure.

BACKGROUND: Paravalvular leaks (PVLs) are a common complication of prosthetic valve replacement. Use of the transcatheter intervention technique is a suitable alternative in high-risk patients who may not tolerate repeat surgery. Common reasons for failure of this demanding intervention include poor imaging quality and unsuitable anatomy. The purpose of this study was to assess the usefulness and the incremental value of real-time three-dimensional (RT 3D) transesophageal echocardiography (TEE) over two-dimensional (2D) TEE findings in the evaluation of the geometry and track of mitral PVLs during transcatheter closure. METHODS: Five patients with six mitral PVLs at high risk for repeat surgery underwent transcatheter leak closure. Intraoperative RT 3DTEE was used to assess the location, shape, number, and size of the defects. Transapical approaches were used in all cases with fluoroscopic and RT 3D TEE guidance of the wire and catheter, device positioning, and assessment of residual leak after the procedure. RESULTS: In all of the cases, defects with irregular crescent shapes and distorted tracks were clearly delineated by RT 3D TEE. This was compared to those results obtained through 2D TEE, which was unable to characterize the defects. Three cases showed small leaks, which were completely occluded with a patent ductus arteriosus (PDA) device in two cases, and a muscular ventricular septal defect (mVSD) occluder combined with coil devices in one case. One case involved a large leak and early device embolization of the muscular VSD occluder, which was removed surgically, and demonstrated a crescent-shaped defect. One patient had two releaks 2 months subsequent to the procedure due to two new extended leaks at the tails of the crescent-shaped defect. CONCLUSION: RT 3D TEE can clearly delineate the geometries of defects in their entirety, including shape, size, and location of the defect and track canal. It would also appear that RT 3D TEE is superior to 2D TEE in the process of guiding the wire through the difficult canal anatomy, facilitating the overall procedure. The small mitral PVLs can be completely occluded, but subsequent complications occurred with large defect closures because of embolization or releak. Therefore, transcatheter closure of PVLs seems to be an attractive alternative for these patients, but newer occluder designs that better conform to leak geometry will be required to improve outcomes.

Incremental value of three-dimensional transesophageal echocardiography over the two-dimensional technique in percutaneous closure of aortic paraprosthetic regurgitation.

We describe 2 patients with significant aortic paraprosthetic regurgitation who underwent percutaneous closure where live/real time three-dimensional transesophageal echocardiography provided incremental value over two-dimensional transesophageal echocardiography.

The advantages of live/real time three-dimensional transesophageal echocardiography in the assessment of tricuspid valve infective endocarditis.

Currently, tricuspid valve infective endocarditis (TVIE) is encountered in daily clinical practice more frequently due to the increasing prevalence of illicit intravenous drug use and the implantation of intracardiac devices. In this study, we compared findings from intra-operative live/real time three-dimensional transesophageal echocardiograms (3DTEE) and two-dimensional transesophageal echocardiograms (2DTEE) of 10 patients who underwent surgery for native tricuspid valve (TV) endocarditis. Unlike 2DTEE, 3DTEE allowed en face visualization of the 3 TV leaflets from both, atrial and ventricular aspects, in 9 of the 10 cases. In the remaining patient, in whom 3DTEE could not identify all 3 leaflets en face, the TV was found essentially destroyed at surgery. Using 3DTEE, the number of vegetations was accurately reported when compared with the surgical record. Furthermore, the orientation of each vegetation was the same as noted in the surgical findings. 2DTEE missed the identification of vegetations in 5 patients. The attachment site of vegetations to the TV were also not characterized by 2DTEE in 5 patients. In all 10 cases, 3DTEE characterized the vegetations more accurately with larger dimensions, including those in the azimuthal axis, and volumes. In addition, a perivalvular abscess that lead to surgical intervention was identified by 3DTEE, however, missed by 2DTEE. In conclusion, 3DTEE allows en face visualization of the TV apparatus permitting accurate description of the number and dimensions of vegetations identified by our surgical standard, which ultimately informs patients' prognosis and dictates the timing and planning for surgical intervention. Its use should be in conjunction with 2DTEE when evaluating TVIE.

Dynamic assessment of the changing geometry of the mitral apparatus in 3D could stratify abnormalities in functional mitral regurgitation and potentially guide therapy.

INTRODUCTION: In functional mitral regurgitation (FMR), effective regurgitant orifice area (EROA) displays a dynamic pattern. The impact of dynamic changes of annulus dysfunction and leaflets tenting on phasic EROA was explored with real-time three-dimensional transesophageal echocardiography (RT3D-TEE). METHODS: RT3D-TEE was performed in 52 FMR patients and 30 controls. Mitral annulus dimensions and leaflets tenting were measured throughout systole (TomTec, Germany). Phasic EROA was measured by proximal isovelocity surface area (PISA) method. RESULTS: Mitral annulus had the minimal area and an oval shape with saddle configuration during early systole in controls, which enlarged and became round and flattened towards mid and late systole (P<0.05). In contrast, annulus in FMR was significantly larger, rounder and flatter (P<0.001), which further dilated and became more flattened at late systole (P<0.05 vs control). Leaflet tenting height in FMR decreased in mid systole and remains unchanged towards late systole. The leaflet tenting volume peaked at early and late systole with a mid-systolic trough in both FMR and controls. But tenting volume of patients with FMR was significantly larger than that of controls (all P<0.001 vs control in whole systole). Further analysis demonstrated that early tenting volume (ß value=0.053, P<0.05) was a predictor of early EROA, whereas late tenting volume (ß value=0.031, P<0.05) and late annular displacement velocity were predictors of late EROA. CONCLUSIONS: The early and late peak EROAs of FMR was primarily contributed by tenting volume at early systole and late systole respectively. These findings would be of value to consider in interventions aimed at reducing the severity of FMR.

Transcatheter intervention for complex ascending aortic pseudoaneurysm after cardiac surgery.

BACKGROUND: Ascending aortic pseudoaneurysm (PsA) is an uncommon but surgically challenging problem with high morbidity and mortality. Herein we describe the efficacy and safety of the different approaches to transcatheter intervention for repair of ascending PsA and assess the selection of occluder devices using real-time 3-dimensional (RT 3D) color Doppler transesophageal echocardiography (TEE).METHODS AND RESULTS: Three patients with complex ascending PsA after cardiac or aortic root surgery were treated with transcatheter intervention due to high risk for redo surgery. Perioperative RT 3D-TEE combined with fluoroscopy was used for monitoring. All ascending PsA were successfully occluded with different devices using the transcatheter technique either with the transapical, transarterial approach, or transvenous combined with hybrid process depending on lesion anatomy. CONCLUSIONS: Treatment of complex ascending PsA with transcatheter or combined hybrid intervention with cautious planning based on patient presentation and well-coordinated teamwork was successful. RT 3D color Doppler TEE provided precise information for the selection of appropriate occluder device, and also facilitated the procedure by guiding the catheter through difficult anatomy.

Incremental value of three-dimensional over two-dimensional transthoracic echocardiography in the assessment of cor triatriatum sinister in a child.

A 2.5-year-old boy presented with frequent hospitalizations due to recurrent respiratory tract infections with dyspnea. A fibromuscular membrane dividing the left atrium with obstruction of left atrial inflow to the left ventricle was documented by two-dimensional transthoracic echocardiography (2DTTE). Live/real time three-dimensional transthoracic echocardiography (3DTTE) provided incremental value over 2DTTE by providing en face views of the 2 obstructing orifices in the membrane enabling accurate assessment of their position, shape and size. 3DTTE also showed clearly the location of the membrane superior and proximal to the left atrial appendage which was not well delineated by 2DTTE. In addition, 3DTTE demonstrated the full extent of the left atrial appendage and careful sequential cropping of the 3D dataset showed it to have 2 distinct lobes and no thrombus. These findings provided comprehensive assessment of the lesion and were helpful in surgical decision making and planning.