Three-dimensional echocardiography for the assessment of atrioventricular valves in congenital heart disease: past, present and future

Clinical and 2D/3D-Echo Cardiography Determinants of Mitral Valve Reoperation in Children With Congenital Mitral Valve Disease

Background

Congenital mitral valve disease (CMVD) presents major challenges in its medical and surgical management.

Objectives

The purpose of this study was to investigate the value of 3-dimensional echocardiography (3DE) and identify associations with MV reoperation in this setting.

Methods

All children <18 years of age who underwent MV reconstruction for CMVD in 2002 to 2018 were included. Preoperative and postoperative 2-dimensional echocardiography (2DE) and 3DE data were collected. Competing risks and Cox regression analysis were used to identify independent associations with MV reoperation. Receiver operating characteristic and decision-tree analysis were implemented for comparison of 3DE vs 2DE.

Results

A total of 206 children underwent MV reconstruction for CMVD (mitral stenosis, n = 105, mitral regurgitation [MR], n = 75; mixed disease, n = 26); 64 (31%) required MV reoperation. Variables independently associated with MV reoperation were age <1 year (HR: 2.65; 95% CI: 1.13-6.21), tethered leaflets (HR: 2.00; 95% CI: 1.05-3.82), ≥ moderate 2DE postoperative MR (HR: 4.26; 95% CI: 2.45-7.40), changes in 3D-effective orifice area (3D-EOA) and in 3D-vena contracta regurgitant area (3D-VCRA). Changes in 3D-EOA and 3D-VCRA were more strongly associated with MV reoperation than changes in mean gradients (area under the curve [AUC]: 0.847 vs AUC: 0.676, P = 0.006) and 2D-VCRA (AUC: 0.969 vs AUC: 0.720, P = 0.012), respectively. Decision-tree analysis found that a <30% increase in 3D-EOA had 80% accuracy (HR = 8.50; 95% CI: 2.9-25.1) and a <40% decrease in 3D-VCRA had 93% accuracy (HR: 22.50; 95% CI: 2.9-175) in discriminating MV reoperation for stenotic and regurgitant MV, respectively.

Conclusions

Age <1 year, tethered leaflets, 2DE postoperative MR, changes in 3D-EOA and 3D-VCRA were all independently associated with MV reoperation. 3DE parameters showed a stronger association than 2DE. 3DE-based decision-tree algorithms may help prognostication and serve as a support tool for clinical decision-making.

3D Approaches in Complex CHD: Where Are We? Funny Printing and Beautiful Images, or a Useful Tool?

Echocardiography, CT and MRI have a crucial role in the management of congenital heart disease (CHD) patients. All of these modalities can be presented in a 2D or a 3D rendered format. The aim of this paper is to review the key advantages and potential limitations, as well as the future challenges of a 3D approach in each imaging modality. The focus of this review is on anatomic rather than functional assessment. Conventional 2D echocardiography presents limitations when imaging complex lesions, whereas 3D imaging depicts the anatomy in all dimensions. CT and MRI can visualise extracardiac vasculature and guide complex biventricular repair. Three-dimensional printed models can be used in depicting complex intracardiac relationships and defining the surgical strategy in specific lesions. Extended reality imaging retained dynamic cardiac motion holds great potential for planning surgical and catheter procedures. Overall, the use of 3D imaging has resulted in a better understanding of anatomy, with a direct impact on the surgical and catheter approach, particularly in more complex cases.

Correlation of ventricular septal defect height and outcomes after complete atrioventricular septal defect repair

 

OBJECTIVES

There are limited data available on the height of the ventricular component of the septal deficiency (VSD) in patients undergoing complete atrioventricular septal defect (CAVSD) repair. VSD height may influence optimal choice of repair strategy with potential consequences for long-term outcomes. We aimed to measure VSD height using 2-dimensional echocardiography and review its association with postoperative outcomes.

METHODS

We retrospectively reviewed the preoperative echocardiograms of 45 consecutive patients who underwent CAVSD repair between May 2010 and December 2015 at a single centre. VSD height and left ventricular length on the four-chamber view were measured. Demographic details and early and late outcomes including reoperation and long-term survival were studied.

RESULTS

Twenty patients underwent modified single-patch repair and 25 patients underwent double-patch repair of CAVSD. VSD height in the modified single-patch group ranged from 4.2 to 11.7 mm and in the double-patch group ranged from 5.1 to 14.9 mm. Nine patients had a deep ‘scoop’ with a VSD height of >10 mm, (7 double patch, 2 modified single patch). VSD height did not correlate with a specific Rastelli classification. There was no significant difference in the VSD height (P = 0.51) or the VSD height-to-left ventricular length ratio (P = 0.43) between the 2 repair groups. There was no 30-day mortality. Eight patients required reoperation; however, VSD height was not a significant predictor of reoperation (hazard ratio 0.95, 95% confidence interval 0.69–1.33; P = 0.08).

CONCLUSIONS

There was no correlation between VSD height and risk of reoperation after CAVSD repair. A deep ventricular scoop is uncommon in CAVSD patients.

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.

Innovation in 3D Echocardiographic Imaging

PURPOSE OF REVIEW

The purpose of this review is to detail three-dimensional echocardiographic (3DE) innovations in pre-surgical planning of congenital heart disease, guidance of catheter interventions such as fusion imaging, and functional assessment of patients with congenital heart disease.

RECENT FINDINGS

Innovations in 3DE have helped us delineate the details of atrioventricular valve function and understand the mechanism of atrioventricular valve failure in patients with atrioventricular septal defect and single ventricle post repair. Advancement in holographic display of 3D datasets allows for better manipulation of 3D images in three dimensions and better understanding of anatomic relationships. 3DE with fusion imaging reduces radiation in catheter interventions and provides presentations of 3DE images in the similar fashion as the fluoroscopic images to improve communication between cardiologists. Lastly, 3DE allows for quantitative ventricular volumetric and functional assessment. Recent innovations in 3DE allow for pre-surgical planning for congenital heart disease, reduce radiation using fusion imaging in catheter interventions, and enable accurate assessment of ventricular volume and function without geometric assumptions.

Tricuspid Valve Repair in Infancy Using Neochordae: Three-Dimensional Echocardiographic Imaging

Tricuspid regurgitation (TR) in infancy poses a surgical challenge. Both two- and three-dimensional echocardiography (3DE) can provide detailed information about the mechanism(s) of valve failure and insights into valve adaptation during follow-up. We report two patients who underwent tricuspid valve repair using Gore-Tex neochordae, repairs which were facilitated by and assessed with 3DE. Both infants had less than mild residual TR and no valve tethering at hospital discharge. Furthermore, follow-up 3DEs have helped to confirm valve competence, lack of tethering, and growth of the valve and valve apparatus.