Real-time 3-dimensional echocardiography in assessing atrial and ventricular septal defects: an echocardiographic-surgical correlative study

ACR appropriateness criteria on suspected congenital heart disease in adults

The number of adults with congenital heart disease is increasing in North America. This is attributable to a variety of factors, including improvements in surgical techniques and increases in immigration. Cardiac imaging is critical for the initial assessment of adults with newly suspected congenital heart disease as well as for the serial assessment of adults with known congenital heart disease. Chest radiography and echocardiography continue to be the initial tools used to evaluate adult congenital heart disease. However, cardiac computed tomography and magnetic resonance imaging have significantly improved over the years and have become integral to the evaluation of adult congenital heart disease, often precluding the necessity for invasive cardiac catheterization. Noninvasive imaging is particularly useful for the surveillance of patients with surgically corrected congenital heart disease, who often require 2 or more additional operations.

Real‐time three‐dimensional echocardiography provides novel and useful anatomic insights of perimembranous ventricular septal aneurysm

BACKGROUND

Real-time three-dimensional echocardiography (RT3DE) is a new image modality, and it can display a unique image reconstruction in a variety of heart diseases. However, clinical assessment of ventricular septal aneurysm (VSA) by RT3DE has not been reported. This pilot prospective study is to survey what kinds of new insights of VSA can be provided by RT3DE as compared with conventional 2-dimensional echocardiography (2DE).

METHODS

We investigated the diagnostic value of RT3DE and 2DE in 60 consecutive patients with VSA. From different transthoracic windows, structures of interest can be displayed from any orientation through adjusting cropping and slicing the RT3DE datasets. The results were compared with those in 2DE.

RESULTS

RT3DE reconstruction of VSA was feasible in 56 of 60 patients (93%). When compared with 2DE, additional information provided by RT3DE included blood flow through left ventricle to right ventricle, visualization of VSD enface border in 56 patients (93%), morphology of the VSA from apical short axis view in 48 patients (86%), hypertrophied margin of the interventricular septum in 26 patients (43%), dynamic changes of VSA and tricuspid valve in 18 patients (30%), adhesion of chordae tendineae in VSA in 16 patients (26%).

CONCLUSIONS

Structures of interest can be evaluated from unique RT3DE in any orientation during scanning. RT3DE offers additional novel views and has the advantages of not only displaying better visualization of VSA, but also adequately showing the spatial relationship with its adjacent structures. It can provide novel and useful anatomic insights than 2DE while assessing patients with VSA.

Three-Dimensional Echocardiography in Congenital Heart Disease

Matrix array technology has brought three-dimensional echocardiography into the clinical practice of cardiology. Arguably, this advancement is most notable in the field of pediatric cardiology. Full-volume acquisitions now can be undertaken in the youngest of infants with excellent image quality. This article illustrates the clinical application of three-dimensional echocardiography in congenital heart disease.

[Three-dimensional echocardiography in cardiac surgery. Current status and perspectives]

Three-dimensional (3D) echocardiography is a new imaging technique that can provide useful information about cardiovascular morphology, pathology, and function. Recent refinements in instrumentation, data acquisition, post-processing, and computation speed allow 3D echocardiography to play an important role in cardiac imaging. These modalities provide comprehensive information on ventricular and valve morphology and function. Combined with 3D color Doppler sonography, further assessment of valvular function and determination of flow in the left ventricular outflow tract and cross-septal defects are now possible. Three-dimensional color flow imaging also makes echocardiography accurate for assessing the severity of mitral regurgitation. The purpose of this review is to describe technical developments in 3D echocardiography and its clinical application in cardiac surgery. Moreover, based on clinical studies at our centre, we describe the morphology of the mitral valve, its flow pattern, and function of the mitral annulus.

Real-time three-dimensional echocardiography: technological gadget or clinical tool?

The complex anatomy of cardiac structures requires three-dimensional spatial orientation of images for a better understanding of structure and function, thereby improving image interpretation. Real-time three-dimensional echocardiography is a recently developed technique based on the design of an ultrasound transducer with a matrix array that rapidly acquires image data in a pyramidal volume. The simultaneous display of multiple tomographic images allows three-dimensional perspective and the anatomically correct examination of any structure within the volumetric image. As a consequence, it is less operator-dependent and hence more reproducible. Dedicated software systems and technologies are based on high-performance computers designed for graphic handling of three-dimensional images by providing possibilities beyond those obtainable with echocardiography. This methodology allows simultaneous display of multiple superimposed planes in an interactive manner as well as a quantitative assessment of cardiac volumes and ventricular mass in a three-dimensional format without a pre-established assumption of cardiac chamber geometry. In addition, myocardial contraction and/or perfusion abnormalities are clearly identified. Finally, real-time three-dimensional colour Doppler flow mapping enables complete visualisation of the regurgitant jet and new ways of assessing regurgitant lesion severity. Thus, this technique expands the abilities of non-invasive cardiology and may open new doors for the evaluation of cardiac diseases. In this article, current and future clinical applications of real-time three-dimensional echocardiography are reviewed.

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?

OBJECTIVE

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.

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Three-Dimensional Echocardiography

Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenal of clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiologists' decisions are based on images created from ultrasound wave reflections. From the time ultrasound imaging technology provided the first insight into the human heart, our diagnostic capabilities have increased exponentially as a result of our growing knowledge and developing technology. One of the most significant developments of the last decades was the introduction of 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-line reconstruction to real-time volumetric imaging. While continuing its meteoric rise instigated by constant technological refinements and continuing increase in computing power, this tool is guaranteed to be integrated in routine clinical practice. The major proven advantage of this technique is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. Another benefit of 3D imaging is the realistic and unique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3D imaging is extremely useful in the intraoperative and postoperative settings because it allows immediate feedback on the effectiveness of surgical interventions. In this article, we review the published reports that have provided the scientific basis for the clinical use of 3D ultrasound imaging of the heart and discuss its potential future applications.

Live 3D Echocardiography: A Replacement for Traditional 2D Echocardiography?

OBJECTIVE

We describe the development of real-time 3D imaging and review the previously used versions of 3D echocardiography so that the reader will appreciate why current developments truly do represent a quantum leap in the technology.

CONCLUSION

Three-dimensional echocardiography has now been shown to have several advantages over 2D echocardiography, particularly for volume measurements, visualization of septal defects, and whole-valve evaluation. Given these data, it is clear that 3D echocardiography is here to stay and soon will become part of routine echocardiographic examinations.

Real Time Three-Dimensional Echocardiography in Assessing Ventricular Septal Defects: An Echocardiographic-Surgical Correlative Study

BACKGROUND

Two-dimensional echocardiography (2DE) enhanced by combining with color Doppler technology has significant limitations in providing precise quantitative information, geometric assumptions to calculate chamber volume, mass, and ejection fraction. Reconstructed three-dimensional echocardiographic (3DE) systems (from multiple cross-sectional echocardiographic scans) are still cumbersome and time-consuming. Real time 3DE (RT-3DE) with shorter imaging time than with 3D reconstruction techniques can obtain qualitative and quantitative information on heart disorders. Our purpose was to investigate the feasibility and potential value of RT-3DE as a means of accurately and quantitatively estimating the size of VSD to correlate with the surgical findings.

MATERIALS AND METHODS

38 patients with VSD were examined with RT-3DE. 3D image database was postprocessed using TomTec echo 3D workstation. The results were compared with the results measured by 2 DE and surgical findings. RT-3DE produced novel views of VSD and improved quantification of the size of the defect. The sizes obtained from 3DE have equivalent correlation with surgical findings as diameter measured by 2DE (r = 0.89 vs r = 0.90). Good agreement between blinded observers was achieved by little interobserver variability.

CONCLUSION

RT-3DE offers intraoperative visualization of VSD to generate a "virtual sense of depth" without extending examining time. From an LV en face projection, the positions, sizes, and shapes of VSDs can be accurately determined to permit quantitative recording of VSD dynamics. It is a potentially valuable clinical tool to provide precise imaging for surgical and catheter-based closure of difficult perimembranous and singular or multiple muscular VSD.

Characterization of Atrial Septal Defect Assessed by Real-time 3-Dimensional Echocardiography

OBJECTIVE

The aim of this study was to describe a quantitative evaluation by real-time 3-dimensional (3D) echocardiography (RT-3DE) of atrial septal defect (ASD) and atrial septum that is important for patient selection for transcatheter closure, and to assess the reliability of RT-3DE findings compared with operation.

METHODS

Forty-five patients, who were scheduled for surgical or transcatheter closure of an ASD, were included in the study.

RESULTS

In 43 patients (96%), 3D reconstructions allowed optimal imaging of the ASD. The correlations between the ASD maximal diameter by RT-3DE and operation or balloon sizing were excellent (r > 0.95). All surrounding rims of the atrial septum could be assessed on 3D reconstruction; except for the aortic rim, a cross-sectional reconstruction was created mimicking the transesophageal echocardiographic cross section (r > 0.92).

CONCLUSION

RT-3DE allows accurate determination of ASD location, ASD size, and surrounding tissue of the atrial septum, and might replace transesophageal echocardiography for patient selection for surgical or transcatheter closure.

Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography in the Characterization of Ventricular Septal Defects in Adults

In this report, we present 12 patients (range 14-76 years, mean 40 +/- 22.7 years) who underwent surgical repair of a ventricular septal defect (VSD). Location, size, and surrounding anatomy of the VSD were assessed prior to intervention in all patients with live/real time three-dimensional transthoracic echocardiography (3DTTE). In 9 patients, measurements of maximum dimension, circumference, and area by 3DTTE correlated well with the same measurements from intraoperative three-dimensional transesophageal echocardiographic (3DTEE) reconstruction. 3DTTE measurement of maximum dimension of VSDs also agreed well with maximum dimension by surgery in 10 patients. Live/real time 3DTTE accurately defined VSD location, size, and surrounding anatomy in all patients studied by us. VSD characterization by live 3DTTE agreed well with surgery descriptions and 3DTEE measurements.

[Progress in pediatric cardiology and congenital heart defects]

We present a review of progress reported in the fields of pediatric cardiology and congenital heart disease between July 2004 and July 2005. The review covers diagnosis, medical treatment, interventional cardiology, and surgery. Among advances in diagnosis, we highlight new diagnostic imaging methods such as three-dimensional echocardiography, magnetic resonance imaging, CT angiography, and tissue Doppler imaging. In the area of fetal cardiology, we focus on advances in fetal interventions, such as percutaneous aortic valvuloplasty, percutaneous pulmonary valvuloplasty, and intact or restrictive atrial balloon septostomy. In interventional cardiology, we highlight advances in the application of percutaneous techniques to adult congenital heart disease to help solve problems resulting from previous surgery, and we review new devices for enabling the percutaneous closure of muscular and membranous ventricular septal defects. In cardiac surgery, a number of developments in valved conduits and in aortic translocation in patients with complex transposition of the great arteries are of particular interest.

Real-Time 3-Dimensional Echocardiography: A Review of the Development of the Technology and Its Clinical Application

Real-time 3-dimensional echocardiography (RT3DE) is a new imaging technique that can provide accurate, important, and additional information concerning cardiovascular morphology, pathology, and function. This article will review the development of the technology of RT3DE and its clinical application. As the technique continues to evolve, RT3DE is bound to play an increasingly important role in the diagnosis, prognosis, and treatment of patients with various forms of cardiovascular disease.