Three-dimensional Echocardiography in Congenital Heart Disease: An Expert Consensus Document from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Standardization in paediatric echocardiographic reporting and critical interpretation of measurements, functional parameters, and prediction scores: a clinical consensus statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology and the Association for European Paediatric and Congenital Cardiology

This document has been developed to provide a guide for basic and advanced reporting in paediatric echocardiography. Furthermore, it aims to help clinicians in the interpretation of echocardiographic measurements and functional data for estimating the severity of disease in different paediatric age groups. The following topics will be reviewed and discussed in the present document: (i) the general principle in constructing a paediatric echocardiographic report, (ii) the basic elements to be included, and (iii) the potential and limitation of currently employed tools used for disease severity quantification during paediatric reporting. A guide for the interpretation of Z-scores will be provided. Use and interpretation of parameters employed for quantification of ventricular systolic function will be discussed. Difficulties in the adoption of adult parameters for the study of diastolic function and valve defects at different ages and pressure and loading conditions will be outlined, with pitfalls for the assessment listed. A guide for careful use of prediction scores for complex congenital heart disease will be provided. Examples of basic and advanced (disease-specific) formats for reporting in paediatric echocardiography will be provided. This document should serve as a comprehensive guide to (i) structure a comprehensive paediatric echocardiographic report; (ii) identify the basic morphological details, measures, and functional parameters to be included during echocardiographic reporting; and (iii) correctly interpret measurements and functional data for estimating disease severity.

Evolving Role of Three-Dimensional Echocardiography for Right Ventricular Volume Analysis in Pediatric Heart Disease: Literature Review and Clinical Applications

Accurate knowledge of right ventricular (RV) volumes and ejection fraction is fundamental to providing optimal care for pediatric patients with congenital and acquired heart disease, as well as pulmonary hypertension. Traditionally, these volumes have been measured using cardiac magnetic resonance because of its accuracy, reproducibility, and freedom from geometric assumptions. More recently, an increasing number of studies have described the measurement of RV volumes using three-dimensional (3D) echocardiography. In addition, volumes by 3D echocardiography have also been used for outcome research studies in congenital heart surgery. Importantly, 3D echocardiographic acquisitions can be obtained over a small number of cardiac cycles, do not require general anesthesia, and are less costly than CMR. The ease and safety of the 3D echocardiographic acquisitions allow serial studies in the same patient. Moreover, the studies can be performed in various locations, including the intensive care unit, catheterization laboratory, and general clinic. Because of these advantages, 3D echocardiography is ideal for serial evaluation of the same patient. Despite these potential advantages, 3D echocardiography has not become a standard practice in children with congenital and acquired heart conditions. In this report, the authors review the literature on the feasibility, reproducibility, and accuracy of 3D echocardiography in pediatric patients. In addition, the authors investigate the advantages and limitations of 3D echocardiography in RV quantification and offer a pathway for its potential to become a standard practice in the assessment, planning, and follow-up of congenital and acquired heart disease.

Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography

Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.

Intracardiac Three-Dimensional Image as Surgical Decision-Making Tool of Congenital Heart Disease

This study aimed to evaluate the anatomical reproducibility of a preoperative intracardiac 3D image (IC image) created using computed tomography, and to investigate its usefulness as a surgical decision-making tool. Between 2012 and 2022, ventricular septal defect (VSD) patients, and double outlet right ventricle (DORV) or transposition of the great arteries (TGA) with pulmonary stenosis (PS) patients who underwent cardiac surgery and had preoperative computed tomography were enrolled. SYNAPSE VINCENT® (Fujifilm) was used to create an IC image which was analyzed retrospectively. In 14 VSD patients, the diagnostic consistency rate in the Soto classification with intraoperative findings was 100% (14/14) for IC image versus 64% (9/14) for transthoracic echocardiography (P = 0.04). The defect size showed a higher correlation coefficient with IC image (0.837, P = 0.001) than with transthoracic echocardiography (0.567, P = 0.034). In 11 DORV/TGA with PS patients, the diagnostic consistency rate in the Lev classification was 100% (9/9) for IC image versus 77% (7/9) for transthoracic echocardiography (P = 0.47). The secondary interventricular foramen (SVF)/left ventricular outflow tract (LVOT) ratio by IC image was significantly smaller in the biventricular-repair group (median 0.71, IQR 0.67-1.06) than in the univentricular-repair group (median 1.79, IQR 1.53-2.42) (P = 0.006). An IC image is useful as a surgical decision-making tool for simple VSDs and complex congenital heart diseases such as DORV or TGA with pulmonary stenosis. The SVF/LVOT ratio determined from the IC image may be a useful indicator for avoiding LVOT obstruction.

Novel Techniques in Imaging Congenital Heart Disease: JACC Scientific Statement

Recent years have witnessed exponential growth in cardiac imaging technologies, allowing better visualization of complex cardiac anatomy and improved assessment of physiology. These advances have become increasingly important as more complex surgical and catheter-based procedures are evolving to address the needs of a growing congenital heart disease population. This state-of-the-art review presents advances in echocardiography, cardiac magnetic resonance, cardiac computed tomography, invasive angiography, 3-dimensional modeling, and digital twin technology. The paper also highlights the integration of artificial intelligence with imaging technology. While some techniques are in their infancy and need further refinement, others have found their way into clinical workflow at well-resourced centers. Studies to evaluate the clinical value and cost-effectiveness of these techniques are needed. For techniques that enhance the value of care for congenital heart disease patients, resources will need to be allocated for education and training to promote widespread implementation.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Imaging and guiding intervention for tricuspid valve disorders using 3-dimensional transesophageal echocardiography in pediatric and congenital heart disease

In the pediatric and congenital heart disease (CHD) population, tricuspid valve (TV) disorders are complex due to the variable TV morphology, its sophisticated interaction with the right ventricle as well as associated congenital and acquired lesions. While surgery is the standard of care for TV dysfunction in this patient population, transcatheter treatment for bioprosthetic TV dysfunction has been performed successfully. Detailed and accurate anatomic assessment of the abnormal TV is essential in the preoperative/preprocedural planning. Three-dimensional transthoracic and 3D transesophageal echocardiography (3DTEE) provides added value to 2-dimensional imaging in the characterization of the TV to guide therapy and 3DTEE serves as an excellent tool for intraoperative assessment and procedural guidance of transcatheter treatment. Notwithstanding advances in imaging and therapy, the timing and indication for intervention for TV disorders in this population are not well defined. In this manuscript, we aim to review the available literature, provide our institutional experience with 3DTEE, and briefly discuss the perceived challenges and future directions in the assessment, surgical planning, and procedural guidance of (1) congenital TV malformations, (2) acquired TV dysfunction from transvenous pacing leads, or following cardiac surgeries, and (3) bioprosthetic TV dysfunction.

Imaging of a case of atrioventricular septal defect: The added value of using the third dimension in echocardiography

The role of 3D echocardiography has been increasing in the management of patients with congenital heart disease (CHD), particularly in pre-surgical planning, catheter-guided interventions, and functional assessment of the heart.

Multimodality Imaging of Right Heart Function: JACC Scientific Statement

Right ventricular (RV) size and function assessed by multimodality imaging are associated with outcomes in a variety of cardiovascular diseases. Understanding RV anatomy and physiology is essential in appreciating the strengths and weaknesses of current imaging methods and gives these measurements greater context. The adaptation of the right ventricle to different types and severity of stress, particularly over time, is specific to the cardiovascular disease process. Multimodality imaging parameters, which determine outcomes, reflect the ability to image the initial and longitudinal RV response to stress. This paper will review the standard and novel imaging methods for assessing RV function and the impact of these parameters on outcomes in specific disease states.

Utility of Three-Dimensional and Four-Dimensional Transesophageal Echocardiography in Decision-Making in a Patient with Iatrogenic Left Ventricle-to-Right Atrium Shunt (Gerbode Defect)

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Two-dimensional echocardiography is the workhorse of cardiovascular imaging.

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Three-dimensional echocardiography can improve diagnostic capability.

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In structural and congenital heart disease, 3D echo can be extremely useful.

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Three-dimensional echo should be used more often in cardiac interventional procedures.

Novel TrueVue series of 3D echocardiography: Revealing the pathological morphology of congenital heart disease

Aims: This study explored the advantages and limitations of novel series of three-dimensional (3D) echocardiographic techniques and summarized their application methods for congenital heart diseases (CHDs).

Method and result: Two-dimensional (2D), traditional 3D echocardiography, and TrueVue plus light and/or Glass novel 3D technologies were performed on 62 patients with CHD, and a clinical survey was designed to judge whether the novel 3D images were more helpful for understanding the cardiac condition and guide treatment than traditional 3D images. TrueVue increased the visual resolution and simulated the true texture of cardiac tissue, significantly improving the display ability of abnormal anatomical structures in CHDs. TrueVue Glass displayed the blood channel and the internal structure of cardiac cavity more intuitively, indicating a new observation aspect not shown by conventional echocardiography. The clinical survey results showed that the new 3D imaging methods effectively increased the diagnostic confidence of echocardiographers, enabled surgeons to better understand the details of lesions, promoted efficient communication, and improved the confidence of both doctors and patients in treatment.

Conclusion: The combined application of TrueVue, TrueVue Light, and TrueVue Glass more closely simulated real anatomical features, showed more comprehensive and subtle blood flow in the lumen, not only increased the visual effect but also provided more useful diagnostic information, improved the accuracy of evaluation and treatment of CHD when compared to traditional imaging techniques, indicating that this combined application has significant clinical value.

Considerations for Biventricular Conversion of Fontan Circulation

Despite significant improvements in the management of Fontan circulation in patients with single ventricle physiology, long-term outcomes continue to be suboptimal. Conversion to biventricular circulation is increasingly gaining popularity, particularly in the subset of patients who are not ideal Fontan candidates. Meticulous image-guided planning, extensive preoperative discussions, and a team-based approach are required for successful execution of complex biventricular conversion. A segmental approach to the anatomy of the heart defect allows methodical planning of the technique of biventricular conversion. Ventricular size and function continue to be the Achilles heel of successful biventricular repair. Long-term studies comparing outcomes in patients converted to biventricular circulation to those in patients with Fontan physiology are required to appropriately tailor management approaches to an individual patient.

Characterization of blood-mimicking fluids for echocardiography imaging of ventricular septal defects

PURPOSE

Ventricular septal defects (VSD) are congenital heart malformations and, in severe cases, they require complex interventions under echocardiography guidance. Heart phantoms can be helpful to train and to understand the complex hemodynamics of VSD. The goal of this study was to characterize the best blood mimicking fluids in such heart phantoms for modelling the hemodynamics of VSD patients using echocardiography.

METHODS

Four fluid compositions were considered. Distilled water was used as a baseline, while the other three fluids were developed based on physical properties of human blood, such as the viscosity and the refractive index. Three bi-ventricular heart phantoms of three different pediatric patients with complex VSD were designed from preoperative CT imaging. Custom molds were printed in 3-D and the anatomical structure was casted in polyvinyl alcohol cryogel. The VSD in each heart phantom were observed using echocardiography and color Doppler imaging was used for the hemodynamic study.

RESULTS

Heart phantoms with blood mimicking fluids of 30% glycerol and 27% glycerol, 10% sodium iodide were found to be anatomically realistic under echocardiography imaging. Hemodynamic parameters such as the pressure gradient and the volume of the shunt were characterized using color Doppler imaging.

CONCLUSION

Proper composition of blood mimicking fluids are important for improving the realism in echocardiographic heart phantoms and they contribute to better understand the complex hemodynamic of VSD under echocardiography.

A Virtual Reality System for Improved Image-Based Planning of Complex Cardiac Procedures

The intricate nature of congenital heart disease requires understanding of the complex, patient-specific three-dimensional dynamic anatomy of the heart, from imaging data such as three-dimensional echocardiography for successful outcomes from surgical and interventional procedures. Conventional clinical systems use flat screens, and therefore, display remains two-dimensional, which undermines the full understanding of the three-dimensional dynamic data. Additionally, the control of three-dimensional visualisation with two-dimensional tools is often difficult, so used only by imaging specialists. In this paper, we describe a virtual reality system for immersive surgery planning using dynamic three-dimensional echocardiography, which enables fast prototyping for visualisation such as volume rendering, multiplanar reformatting, flow visualisation and advanced interaction such as three-dimensional cropping, windowing, measurement, haptic feedback, automatic image orientation and multiuser interactions. The available features were evaluated by imaging and nonimaging clinicians, showing that the virtual reality system can help improve the understanding and communication of three-dimensional echocardiography imaging and potentially benefit congenital heart disease treatment.

The role of three-dimensional printed cardiac models in the management of complex congenital heart diseases

BACKGROUND

Three-dimensional printing is a process enabling computer-assisted conversion of imaging data from patients into physical "printed" replicas. This has been extrapolated to reconstructing patient-specific cardiac models in congenital heart diseases. The aim of this study was to analyze the impact of three-dimensional printing in surgical decision making in selected cases of complex congenital heart disease by creating patient-specific printed models.

METHODS

Patients with complex congenital heart diseases with unresolved management decisions after evaluation by echocardiography, cardiac catheterization, and cardiac computed tomography were included with intent to aid in surgical decision making. Three-dimensional models were created from computed tomographic images by an outsourced firm using computer applications. All cases were reviewed by the same team before and after the cardiac models were prepared. The management decisions were grouped as either "corrective surgery" or "no surgery or palliation" The impact of the surgical decision pre and post three-dimensional cardiac model was analyzed by applying Cohen's kappa test of agreement.

RESULTS

Ten patients were included, of which five were of increased pulmonary blood flow, and five were of decreased pulmonary flow. The commonest indication for three-dimensional printed models was to establish the routability of the aorta and pulmonary artery to their respective ventricles (in five patients). The nonagreement between the decision taken before and after the cardiac model was 80%, with kappa -0.37 and P value 0.98.

CONCLUSIONS

Three-dimensional printed cardiac models contribute to better decision making in complex congenital heart diseases enabling safer execution of any complex congenital heart surgery.

Non-invasive Imaging in the Evaluation of Cardiac Shunts for Interventional Closure

Multimodality imaging provides important information to guide patient selection and pre-procedural decision making for shunt lesions in CHD. While echocardiography, CT, and CMR are well-established, 3D printing and now virtual reality imaging are beginning to show promise.

Virtual reality three-dimensional echocardiographic imaging for planning surgical atrioventricular valve repair

OBJECTIVES

To investigate how virtual reality (VR) imaging impacts decision-making in atrioventricular valve surgery.

METHODS

This was a single-center retrospective study involving 15 children and adolescents, median age 6 years (range, 0.33-16) requiring surgical repair of the atrioventricular valves between the years 2016 and 2019. The patients' preoperative 3-dimesnional (3D) echocardiographic data were used to create 3D visualization in a VR application. Five pediatric cardiothoracic surgeons completed a questionnaire formulated to compare their surgical decisions regarding the cases after reviewing conventionally presented 2-dimesnional and 3D echocardiographic images and again after visualization of 3D echocardiograms using the VR platform. Finally, intraoperative findings were shared with surgeons to confirm assessment of the pathology.

RESULTS

In 67% of cases presented with VR, surgeons reported having "more" or "much more" confidence in their understanding of each patient's pathology and their surgical approach. In all but one case, surgeons were at least as confident after reviewing the VR compared with standard imaging. The case where surgeons reported to be least confident on VR had the worst technical quality of data used. After viewing patient cases on VR, surgeons reported that they would have made minor modifications to surgical approach in 53% and major modifications in 7% of cases.

CONCLUSIONS

The main impact of viewing imaging on VR is the improved clarity of the anatomical structures. Surgeons reported that this would have impacted the surgical approach in the majority of cases. Poor-quality 3D echocardiographic data were associated with a negative impact of VR visualization; thus. quality assessment of imaging is necessary before projecting in a VR format.

Dynamic Systolic Changes in Tricuspid Regurgitation Vena Contracta Size and Proximal Isovelocity Surface Area in Hypoplastic Left Heart Syndrome: A Three-Dimensional Color Doppler Echocardiographic Study

BACKGROUND

The aims of this study were to investigate the dynamic changes in the vena contracta (VC) and proximal isovelocity surface area (PISA) through systole in patients with hypoplastic left heart syndrome and tricuspid regurgitation and to identify the stage of systole (early, mid, or late) in which VC and PISA radius are optimal.

METHODS

Twenty-eight patients with hypoplastic left heart syndrome were prospectively studied using continuous two-dimensional (2D) and three-dimensional (3D) echocardiography. Two-dimensional VC width, 3D VC area, and PISA radii (2D and 3D) were measured frame by frame throughout systole. The maximal 2D VC width, 3D VC area, and PISA radii in the first, middle, and last thirds of systole were compared, and correlations were explored with 3D tricuspid annular areas, right atrial volumes, and right ventricular volumes.

RESULTS

In all, 35 data sets that met inclusion criteria were analyzed. On frame-by-frame analysis, maximal 2D VC width and 3D VC area were found in the first third of systole in 17% and 20% of studies, in the second third in 34% and 31%, and in the final third in 49% and 49%. Similarly, the maximal 2D and 3D PISA radii were found in the first third of systole in 26% and 17% of studies, in the second third in 28% and 34%, and in the final third in 46% and 49%.

CONCLUSIONS

In hypoplastic left heart syndrome, detailed temporal analysis of tricuspid regurgitation-associated VC and PISA by 2D and 3D echocardiography reveals no reliable pattern predicting when in systole these parameters peak. Frame-by-frame measurement is necessary for identification of maximal VC and PISA radius on 2D and 3D color Doppler echocardiography because the severity of tricuspid regurgitation could be underestimated because of temporal variability in VC and PISA.

Tricuspid Regurgitation in Hypoplastic Left Heart Syndrome: Three-Dimensional Echocardiography Provides Additional Information in Describing Jet Location

BACKGROUND

Twenty-five percent of patients with hypoplastic left heart syndrome (HLHS) require tricuspid valve (TV) repair. The location of tricuspid regurgitation (TR) is important in determining the type of repair performed. Studies using three-dimensional echocardiography (3DE) have reported a high incidence of error on two-dimensional echocardiography (2DE) for the identification of TV leaflets. The aim of this study was to compare assessment of TR on 3DE and 2DE in patients with HLHS (jet location, TR grade, and reproducibility).

METHODS

A retrospective, single-center review was performed. Fifty-six patients with HLHS with available two-dimensional and three-dimensional echocardiograms, and mild or greater TR, were included. TR location, grade, vena contracta area, and TV annular diameter were measured on 2DE and 3DE. Reproducibility was assessed by blinded reviewers.

RESULTS

Three-dimensional echocardiography identified the primary jet location as central (57%) followed by anteroseptal (36%). There was poor agreement between findings on 3DE and 2DE for jet location (κ = 0.05; 95 CI, -0.08 to 0.19). Interobserver reproducibility for location on 3DE was excellent (κ = 0.8), whereas reproducibility for 2DE was poor (κ = 0.32). The most common jet location pre-Norwood and pre-Glenn was central (70%), whereas pre-Fontan and post-Fontan, jet location was central (45%) and anteroseptal (48%). Vena contracta area on 2DE correlated moderately with vena contracta area on 3DE (r = 0.60, P < .0001). TV annular diameters on 2DE and 3DE for lateral (r = 0.85, P < .0001) and anteroposterior (r = 0.74, P = .001) dimensions were strongly correlated.

CONCLUSIONS

In children with HLHS, assessment of TR location on 2DE had poor agreement with assessment on 3DE and was poorly reproducible. In contrast, TR jet location on 3DE was highly reproducible. Pre-Glenn, a central TR jet was the most common, while post-Glenn, central and anteroseptal locations were equal, highlighting the importance of preoperative identification of TR jet location in patients with HLHS.

Enhanced Echocardiography Imaging in Reoperation for Complex Congenital Heart Disease in a Child

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Evaluation of the mechanism of MR is essential for appropriate repair.

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2D and 3D TEE are the gold standard for presurgical MV repair in children.

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Enhanced echo imaging improves benefits in complex congenital heart disease.

Stereoscopic Display Is Superior to Conventional Display for Three-Dimensional Echocardiography of Congenital Heart Anatomy

BACKGROUND

Three-dimensional echocardiography (3DE) improves visualization of cardiac lesions. Current viewing of 3DE studies on a conventional display diminishes the encoded stereoscopic (stereo) information for depth perception. This study aims to evaluate clinician subjective and objective experience of stereo display compared with nonstereo display of 3DE in congenital heart disease.

METHODS

In this prospective study, 22 cardiologists, advanced cardiology trainees, and cardiothoracic surgeons used a commercially available stereo display system with proprietary software to view 10 3DE data sets, alternating between simple and complex lesions. In part A, participants viewed each data set, randomized to 1 minute of stereo display followed by 1 minute of nonstereo display, or vice versa. In part B, participants could freely toggle between stereo and nonstereo display for an additional 90 seconds per data set. Participants answered a series of questions and rated their subjective experience using stereo versus nonstereo display mode on a Likert scale. Objective data on time spent in each display mode during part B and duration of interaction and degree of movement of the 3DE data set in parts A and B were also collected.

RESULTS

All clinician groups found stereo display preferable to nonstereo display of 3DE (P < .0001). Viewing complex lesions was rated lower than simple lesions when using nonstereo display (P < .01). Simple and complex lesions were equally well rated when using stereo display (P = .14). When given a choice of display modes in part B, participants spent more time in stereo display (P < .0001) and interacted more with the 3DE data sets in stereo display (P < .0001).

CONCLUSIONS

Interactive stereoscopic display of 3DE was preferred over conventional nonstereo display by all clinician groups for viewing both simple and complex lesions. This preference is especially true for viewing complex lesions.

The Future of Cardiac Ultrasound in the Neonatal Intensive Care Unit

Cardiac ultrasound is increasingly used to guide hemodynamic decision making in the neonatal intensive care unit (NICU). This article focuses on likely future progress in training, accreditation, digital connectivity, miniaturization, and modality development. Many documents have been published internationally to guide cardiac ultrasound training, accreditation, and implementation in the NICU, but challenges remain in providing assessments of hemodynamic status without risking missed structural diagnoses. Advances in simulation training and digital connectivity provide an opportunity to standardize approaches across institutions and continents. Development of machine learning and ultrasound modalities in turn provide huge scope for improving robustness and completeness of assessment.

Three-dimensional right ventricular shape and strain in congenital heart disease patients with right ventricular chronic volume loading

AIMS

Right ventricular (RV) function assessment is crucial in congenital heart disease patients, especially in atrial septal defect (ASD) and repaired Tetralogy of Fallot (TOF) patients with pulmonary regurgitation (PR). In this study, we aimed to analyse both 3D RV shape and deformation to better characterize RV function in ASD and TOF-PR.

METHODS AND RESULTS

We prospectively included 110 patients (≥16 years old) into this case-control study: 27 ASD patients, 28 with TOF, and 55 sex- and age-matched healthy controls. Endocardial tracking was performed on 3D transthoracic RV echocardiographic sequences and output RV meshes were post-processed to extract local curvature and deformation. Differences in shape and deformation patterns between subgroups were quantified both globally and locally. Curvature highlights differences in RV shape between controls and patients while ASD and TOF-PR patients are similar. Conversely, strain highlights differences between controls and TOF-PR patients while ASD and controls are similar [global area strain: -31.5 ± 5.8% (controls), -34.1 ± 7.9% (ASD), -24.8 ± 5.7% (TOF-PR), P < 0.001, similar significance for longitudinal and circumferential strains]. The regional and local analysis highlighted differences in particular in the RV free wall and the apical septum.

CONCLUSION

Chronic RV volume loading results in similar RV shape remodelling in both ASD and TOF patients while strain analysis demonstrated that RV strain is only reduced in the TOF group. This suggests a fundamentally different RV remodelling process between both conditions.

Emerging 3D technologies and applications within congenital heart disease: teach, predict, plan and guide

3D visualization technologies have evolved to become a mainstay in the management of congenital heart disease (CHD) with a growing presence within multiple facets. Printed and virtual 3D models allow for a more comprehensive approach to educating trainees and care team members. Computational fluid dynamics can take 3D modeling to the next level, by predicting post-procedural outcomes and helping to determine surgical approach. 3D printing and extended reality are developing resources for pre-procedural planning and intra-procedural guidance with the potential to revolutionize decision-making and procedural success. Challenges still remain within existing technologies and their applications to the CHD field. Addressing these gaps, both by those within and outside of CHD, will transform education and patient care within our field.

Applications of three-dimensional transesophageal echocardiography in congenital heart disease

Three-dimensional echocardiography allows for presurgical planning for congenital heart disease, reduces radiation using fusion imaging in catheter interventions, and provides guidance during catheter interventions and lead placements or extractions. The purpose of this review is to detail applications of three-dimensional transesophageal echocardiography in presurgical planning of congenital heart disease, guidance of catheter interventions such as fusion imaging, and guidance in electrophysiology lead extractions or placements.

Three-Dimensional Echocardiography - Role in Clinical Practice and Future Directions

Echocardiography has become an extension of the physical examination in cardiovascular practice. Frequently, it is used to confirm a clinical diagnostic suspicion. Another important role is to detect the underlying cardiovascular lesion to explain a patient's symptom complex or an abnormality found on chest radiography, electrocardiography, or cardiac enzyme tests. Patients are referred to the echocardiography laboratory because of their symptoms or due to non-specific laboratory abnormalities, and echocardiographers are expected to provide a definite diagnosis or a therapeutic clue. The introduction of the matrix array transducer into clinical practice allowed the acquisition of three-dimensional (3D) datasets. 3D echocardiography (3DE) has many advantages over 2-dimensional echocardiography, such as: (1) improved visualization of the complex shapes and spatial relations between cardiac structures; (2) improved quantification of the cardiac volumes and function; and (3) improved display and assessment of valve dysfunction. 3DE is increasingly utilized during routine clinical practice. This review article is aimed to examine the current clinical utility and future directions of 3DE.

Diagnosis and treatment of adults with congenital heart disease

Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.

Systematic Evaluation of Systemic Right Ventricular Function

Background: The right ventricle serves as the subaortic systemic ventricle (sysRV) in patients with congenitally corrected transposition of the great arteries (ccTGA) and in patients with transposition of the great arteries (TGA) surgically repaired by an atrial switch. SysRV can lead to late complications, primarily heart failure, significant regurgitation of the systemic atrioventricular (AV) valve, and ventricular arrhythmias with sudden cardiac death. We sought to investigate the value of 2D- and 3D-echocardiographic parameters of sysRV function. Methods: Consecutive adult patients with sysRV who presented at the adult congenital heart disease outpatient clinic were prospectively enrolled. All patients received comprehensive transthoracic echocardiography, including 3D-echocardiography, cardiac magnetic-resonance-imaging (CMR), cardiopulmonary-exercise-testing, and blood analysis for NT-proBNP. Results. A total of 27 patients were included, 18 with TGA and nine with ccTGA. Median age was 37 years (Q1 = 31, Q3 = 44), 44% were male, median NT-proBNP was 189 pg/mL (Q1 = 155, Q3 = 467); sufficient 3D-echocardiography datasets were acquired in 78% of patients. All echocardiographic 2D and 3D volumetric function parameters correlated with CMR data, whereas a correlation was not seen with any of the longitudinal function parameters. NT-proBNP correlated with tricuspid annular plane systolic excursion (r = −0.43, p = 0.02) and CMR ejection fraction (EF) (r = −0.62, p = 0.003). Conclusion: Systematic evaluation of sysRV is complex and should include not only volumetric parameters but also parameters of longitudinal function in addition to measurement of NT-proBNP. In patients with good image quality, 3D-echocardiography can be used to assess volumes and EF.

Forme Fruste Cor Triatriatum Dexter by Transesophageal Echocardiography and Its Impact on Percutaneous Heart Procedures: A Case Series

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Cor triatriatum dexter (CTD) can complicate percutaneous atrial septal interventions.

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Clinically silent (forme fruste) CTD is detectable by new echocardiography techniques.

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Using these techniques could improve patient selection and guide interventions.

Emerging clinical applications of strain imaging and three-dimensional echocardiography for the assessment of ventricular function in adult congenital heart disease

Management of congenital heart disease (CHD) in adults (ACHD) remains an ongoing challenge due to the presence of residual hemodynamic lesions and development of ventricular dysfunction in a large number of patients. Echocardiographic imaging plays a central role in clinical decision-making and selection of patients who will benefit most from catheter interventions or cardiac surgery.. Recent advances in both strain imaging and three-dimensional (3D)-echocardiography have significantly contributed to a greater understanding of the complex pathophysiological mechanisms involved in CHD. The aim of this paper is to provide an overview of emerging clinical applications of speckle-tracking imaging and 3D-echocardiography in ACHD with focus on functional assessment, ventriculo-ventricular interdependency, mechanisms of electromechanical delay, and twist abnormalities in adults with tetralogy of Fallot (TOF), a systemic RV after atrial switch repair or in double discordance ventricles, and in those with a Fontan circulation.

Incorporating three-dimensional echocardiography into clinical practice

Three-dimensional echocardiography (3DE) has many advantages over two-dimensional echocardiography, such as (1) improved visualization of the complex shapes and spatial relations between cardiac structures, (2) improved quantification of the cardiac volumes and function, and (3) improved display and assessment of valve dysfunction. The aim of this review article is to focus on the current clinical utility of 3DE.

Three-dimensional rotational angiography in congenital heart disease: Present status and evolving future

Three-dimensional rotational angiography (3D-RA) enables volumetric imaging through rotation of the C-arm of an angiographic system and real-time 3D reconstruction during cardiac catheterization procedures. In the field of congenital heart disease (CHD), 3D-RA has gained considerable traction, owing to its capability for enhanced visualization of spatial relationships in complex cardiac morphologies and real time image guidance in an intricate interventional environment. This review provides an overview of the current applications, strengths, and limitations of 3D-RA acquisition in the management of CHD and potential future directions. In addition, issues of dosimetry, radiation exposure, and optimization strategies will be reviewed. Further implementation of 3D-RA will be driven by patient benefits relative to existing 3D imaging capabilities and fusion techniques balanced against radiation exposure.

Anesthetist-delivered intraoperative transesophageal echocardiography in pediatric cardiac surgery

This article reviews the evidence for anesthetist-delivered perioperative transesophageal echocardiography for children undergoing cardiac surgery. It addresses the additional issues of training, developing practice, accreditation, and the requirement for collaboration with pediatric cardiologists, surgeons and other members of the perioperative team. Finally an overview of the potential structure of an anesthetist-delivered perioperative transesophageal echocardiography service is presented.