Evaluation of mitral valve prolapse using newly developed real-time three-dimensional echocardiographic system with real-time volume rendering

Identification of prolapsing mitral valve scallops by a three-dimensional multiplanar reconstruction method

BACKGROUND

The objectives of this study were twofold: to assess the diagnostic utility of three-dimensional (3D) multiplanar reconstruction (MPR) in identifying prolapsing mitral valve (MV) scallops, and (2) to compare two-dimensional (2D) transthoracic echocardiography (TTE) and 3DMPR to (2D) transesophageal echocardiography (TEE) approaches among patients with mitral valve prolapse (MVP).

METHODS

Fifty-five patients with MVP who underwent MV repair or replacement were retrospectively analyzed using 3 types of echocardiographic studies (2DTEE, 2DTTE, 3DMPR). The operative (OR) findings were considered the gold standard.

RESULTS

When 3DMPR was combined with 2DTTE, the agreement with the OR findings was moderately strong for the A2 scallop (P < 0.001) and strong for the A3 scallop (P = 0.001), entire anterior leaflet (P < 0.001), P2 scallop (P < 0.001) and the entire posterior leaflet (P < 0.001). In comparison to the OR findings, 2DTEE demonstrated moderately strong agreement for the A2 scallop (P = 0.010) and the entire anterior leaflet (P < 0.001), and strong agreement for the P2 scallop (P < 0.001) and entire posterior leaflet (P < 0.001).

CONCLUSIONS

Three-dimensional MPR should be added to the armamentarium of complementary echo techniques in the evaluation of MVP. There is increased benefit in combining 3DMPR with 2DTTE findings as part of the preoperative evaluation of patients with MVP.

Multiplanar reconstruction of three-dimensional transthoracic echocardiography improves the presurgical assessment of mitral prolapse

BACKGROUND

The aim of this study was to evaluate the value and accuracy of multiplanar reconstruction (MPR) of three-dimensional (3D) transthoracic echocardiographic data sets in assessing mitral valve pathology in patients with surgical mitral valve prolapse (MVP).

METHODS

Sixty-four patients with surgical MVP and preoperative two-dimensional (2D) and 3D transthoracic echocardiography were analyzed. The descriptions obtained by 3D MPR and 2D were compared in the context of the surgical findings.

RESULTS

Two-dimensional echocardiography correctly identified the prolapsing leaflets in 32 of 64 patients and 3D MPR in 46 of 64 patients (P=.016). Among the 27 patients with complex pathology (ie, more than isolated middle scallop of the posterior leaflet prolapse), 3D MPR identified 20 correctly, as opposed to 6 with 2D imaging (P<.001).

CONCLUSION

Interpretation of 3D transthoracic echocardiographic images with MPR improved the accuracy of the description of the MVP compared with 2D interpretation. This added value of 3D MPR was most important in extensive and/or commissural prolapse.

Impact of three-dimensional echocardiography in complex congenital heart defect cases: the surgical view

Other authors have demonstrated the ability of three-dimensional (3D) echocardiography to produce "en face" views of anomalies such as atrioventricular valve disease and atrial and ventricular septal defects. Few data exist about the usefulness of 3D images for more complex congenital heart defects and the surgical impact of this relatively new technology. This study, covering a period of 8 months and including 43 young patients affected by complex congenital heart defects, demonstrated that the routine use of 3D echocardiography is feasible and valuable for some types of cardiac defects. In fact, 3D images have provided more detailed anatomic definition of interrelations between structures in about one-third (15/43) of our cases, yielding new insight into the anatomy analogous to what can be derived from examining a heart specimen. Our surgeons found the 3D images particularly helpful for providing a realistic and almost specimen-like preview of the surgical anatomy that facilitates planning of the surgical program.

Multiplanar visualization in 3D transthoracic echocardiography for precise delineation of mitral valve pathology

A novel multiplanar reformatting (MPR) technique in three-dimensional transthoracic echocardiography (3D TTE) was used to precisely localize the prolapsed lateral segment of posterior mitral valve leaflet in a patient symptomatic with mitral valve prolapse (MVP) and moderate mitral regurgitation (MR) before undergoing mitral valve repair surgery. Transesophageal echocardiography was avoided based on the findings of this new technique by 3D TTE. It was noninvasive, quick, reproducible and reliable. Also, it did not need the time-consuming reconstruction of multiple cardiac images. Mitral valve repair surgery was subsequently performed based on the MPR findings and corroborated the findings from the MPR examination.

Accuracy of real-time 3D echocardiography in the evaluation of functional anatomy of mitral regurgitation

OBJECTIVE

To evaluate the feasibility of mitral valve (MV) reconstruction protocol by real-time 3D echocardiography (RT3DE) in the assessment mitral regurgitant (MR) lesions, and to determine the accuracy of RT3DE compared with transthoracic (TTE) and transesophageal (TEE) echocardiographies using surgical findings as gold standard.

PATIENTS AND METHODS

Sixty-three consecutive patients (mean age 61.7+/-12.5 years, 35 men and 28 women) with severe organic MR were enrolled. Data were acquired in zoom and in full-volume modes from apical and/or parasternal windows. A volume rendered en-face view of MV and five serial longitudinal cut planes were reconstructed to visualize all segments of both leaflets.

RESULTS

The feasibility of RT3D reconstruction was 94%. Compared with surgical diagnosis, the accuracy of RT3D was 91% for aetiology, 92% for mechanisms, 94% for prolapse, 88% for flail and 94% for defect location. Diagnostic accuracy was significant higher for RT3D than TTE for all end points except for flail lesion and similar to TEE but inferior to this for flail lesion. The accuracy, sensitivity and specificity were higher in patients with good-excellent than those with poor image quality regarding aetiology, mechanisms and defect location (all p=0.0001).

CONCLUSIONS

RT3D imaging of MV is feasible and accurate in defining aetiology, mechanism and defect location in patients with MR and has incremental diagnostic value if TTE is inconclusive and similar diagnostic value of TEE except for flail lesion. RT3D, at least in patients with good acoustic window, may obviate the need for subsequent TEE and/or can be considered a complementary technique to study MV in patients with MR.

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 Echo for the Assessment of Valvular Heart Disease

Three-dimensional echocardiography (3DE) is a valuable tool to be used in addition to and not instead of two-dimensional echocardiography by providing complementary information and improved quantitative accuracy and reproducibility compared with two-dimensional techniques. 3DE has the potential to become the standard echocardiographic examination procedure for the assessment of valvular disease. This article describes applications of 3DE.

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.

Usefulness of Live/Real Time Three-Dimensional Transthoracic Echocardiography in the Identification of Individual Segment/Scallop Prolapse of the Mitral Valve

In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.

Real-Time Three-Dimensional Echocardiography Is Useful in the Evaluation of Patients with Atrioventricular Septal Defects

OBJECTIVE

We sought to determine whether three-dimensional echocardiography (3DE) is useful in the evaluation of patients with atrioventricular septal defect (AVSD).

BACKGROUND

Recent advances in 3DE have enhanced its practicality. We assessed whether 3DE provided new information compared to 2DE among patients with AVSD.

METHODS

We retrospectively reviewed 52 3DE datasets from 51 patients (median age: 4.6 years, range 0-30 years; median BSA: 0.6 m2, range 0.2-1.9 m2) with any type of AVSD during a 1-year period. 3DE findings were compared to 2DE and surgical reports. For each study, AVSD was classified by 2DE as one of the following: unrepaired balanced defect, repaired balanced defect with residual lesions, repaired balanced defect without residual lesions, or unbalanced defect. 3DE was graded as (1) Additive: 3DE resulted in a new finding or changed diagnosis; (2) Useful: While useful, 3DE did not result in new findings or changed diagnosis; or (3) Not useful.

RESULTS

3DE on unrepaired balanced AVSD and repaired AVSD with residual lesions was more often additive/useful (33/36; 92%) than on repaired AVSD without residual lesions or unbalanced AVSD (9/16 (56%), P=0.009). 3DE was additive or useful in all three patients with unbalanced AVSD being considered for biventricular repair. Useful information obtained by 3DE included: precise characterization of mitral regurgitation and cleft leaflet, substrate for subaortic stenosis, valve anatomy, and presence and location of additional septal defects.

CONCLUSION

3DE provides useful and additive information in unrepaired balanced AVSD, repaired AVSD with residual lesions, and unbalanced AVSD under consideration for biventricular repair.

Initial clinical experience of real-time three-dimensional echocardiography in neonates with isolated congenital ductus arteriosus aneurysm

BACKGROUND

Congenital ductus arteriosus aneurysm (DAA) was considered rare but potentially fatal abnormality, often followed by surgical intervention after careful evaluation. This prospective study used real-time three-dimensional echocardiography (RT3DE) to assist in evaluation of neonatal DAA.

METHODS

A total of 1390 full-term neonates were enrolled in this study between 2002 and 2003. They received two-dimensional echocardiographic (2DE) screening and periodic follow-up. RT3DE was performed selectively for newborns with DAA.

RESULTS

DAA were detected in 116 (8.34%) newborns using 2DE. Maximum diameter of the DAAs ranged from 6.8 to 14.0 mm (8.2+/-1.1 mm). None of the cases were symptomatic or had complications related to DAA. There were no significant differences in sex and gestational age between the newborns with and without DAA. Neonates with DAA had a higher birth body weight and a higher incidence of large-for-gestational-age (P<0.05). RT3DE provided instant, consistent and reliable 3D images of DAA and its related structures and allowed for more rapid examination times and reduction of baby wait times.

CONCLUSIONS

Congenital DAA is as common as has been previously reported. RT3DE is useful in assisting evaluation of DAA. Preferred images of DAA were typically visualized in the high parasternal short-axis view before the third day of life. Routine use of RT3DE is suggested to enhance assessment of neonates with DAA detected by 2DE.

Comparison of real-time 3-dimensional echocardiography with conventional 2-dimensional echocardiography in the assessment of structural heart disease

We evaluated the diagnostic use of a real-time 3-dimensional (3D) echocardiographic system in 106 patients referred for echocardiography during a 4-month period. Real-time 3D echocardiography was performed and recorded in parallel with a routine, comprehensive 2-dimensional (2D) study. The diagnoses were exclusively on the basis of 2D findings. The 3D volumes were sliced offline in the 3 dimensions to selectively display specific cardiac structures and reviewed independent of the 2D findings. The 3D studies were graded as: A, new finding not on 2D studies; B, useful anatomic perspective; C, equivalent to 2D studies; or D, missed 2D findings. Compared with 2D echocardiography, 3D echocardiography was graded A in 7 (7%), B in 19 (18%), C in 65 (61%), and D in 15 (14%) cases. In the 26 grade-A and grade-B studies, mitral valve disease and congenital heart disease accounted for 16 (61%) cases. Suboptimal image quality was present in 7 (47%) of the 15 grade-D studies. Thus, real-time 3D echocardiography yields anatomic information comparable with conventional 2D echocardiography in the majority of patients. It can provide new and useful anatomic insight, particularly in patients with mitral valve disease and congenital heart disease. Suboptimal image quality remains a problem for real-time 3D echocardiography in some patients.

Live Three-Dimensional Echocardiography: Imaging Principles and Clinical Application

Live three-dimensional echocardiography (L3DE) is an important breakthrough in the field of medical ultrasound. It will provide a great potential tool for clinical diagnosis and treatment. In this article, the authors first review the bottlenecks in 3D cardiac imaging and the technical principles of L3DE that have been used to overcome some of these problems. We then discuss the scanning methods, clinical usefulness, and the future of L3DE, drawing on our experiences in examining 124 human patients and in conducting animal verification studies with a live 3D ultrasound system.