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

Three-dimensional transoesophageal echocardiography: how to use and when to use-a clinical consensus statement from the European Association of Cardiovascular Imaging of the European Society of Cardiology

Three-dimensional transoesophageal echocardiography (3D TOE) has been rapidly developed in the last 15 years. Currently, 3D TOE is particularly useful as an additional imaging modality for the cardiac echocardiographers in the echo-lab, for cardiac interventionalists as a tool to guide complex catheter-based procedures cardiac, for surgeons to plan surgical strategies, and for cardiac anaesthesiologists and/or cardiologists, to assess intra-operative results. The authors of this document believe that acquiring 3D data set should become a 'standard part' of the TOE examination. This document provides (i) a basic understanding of the physic of 3D TOE technology which enables the echocardiographer to obtain new skills necessary to acquire, manipulate, and interpret 3D data sets, (ii) a description of valvular pathologies, and (iii) a description of non-valvular pathologies in which 3D TOE has shown to be a diagnostic tool particularly valuable. This document has a new format: instead of figures randomly positioned through the text, it has been organized in tables which include figures. We believe that this arrangement makes easier the lecture by clinical cardiologists and practising echocardiographers.

Atrial giant cell myocarditis with preserved left ventricular function: a case report and literature review

Giant cell myocarditis (GCM) is a rare and fatal inflammatory disorder induced by T-lymphocytes, typically affecting young adults. Generally, this disease presents with a rapidly progressive course and a very poor prognosis. In recent years, atrial GCM (aGCM) has been recognized as a clinicopathological entity distinct from classical GCM. As described by retrievable case reports, although its histopathological manifestations are highly similar to those of classical GCM, this entity is characterized by preserved left ventricular function and atrial arrhythmias, without ventricular arrhythmias. aGCM tends to show benign disease progression with a better clinical prognosis compared with the rapid course and poor prognosis of vGCM. We report a patient with aGCM with a history of renal abscess whose persistent myocardial injury considered to be associated with a history of renal abscess. Infection could be a potential trigger for the development of aGCM in this patient. An extensive literature review was also performed and the following three aspects were summarized: (1) Epidemiology and histopathological characteristics of aGCM; (2) The role of imaging in the evaluation of aGCM; (3) Diagnostic points and therapeutic decisions in aGCM.

Additional value of left atrium remodeling assessed by three-dimensional echocardiography for the prediction of atrial fibrillation recurrence after cryoballoon ablation

Cryoballoon ablation (CBA) is a safe and efficient therapeutic option for atrial fibrillation (AF). However, AF recurrence occurs in 25% of the patients, leading to repeated ablations and complications. Previous reports have shown that left atrium (LA) assessed by M-Mode and two-dimensional echocardiography (2DE) predicts AF recurrence. Nevertheless, these methods imply geometrical assumptions of the LA remodeling, which is a three-dimensional process. We hypothesized that LA remodeling by three-dimensional echocardiography (3DE) has an additional value for AF recurrence prediction post-CBA. 172 consecutive patients (62.2 ± 12.2 years, 61% male) were prospectively recruited. Echocardiography was performed before CBA. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period. 50 (29%) patients had AF recurrence. 3DE LA maximum volume index (LAVI) had the highest incremental predictive value for AF recurrence (HR 5.50, 95% CI 1.34 -22.45, p < 0.001). In patients with non-dilated LA diameter index and LAVI by 2DE, LAVI by 3DE was able to discriminate AF recurrence with a sensitivity of 90% and a specificity of 66%, for an optimal cut-off value of 30.4 ml/m2. LA remodeling by 3DE predicted AF recurrence, even in patients with non-dilated LA by M-Mode and 2DE, suggesting that 3DE might reflect better and earlier the asymmetric and variable nature of LA remodeling and it should be considered for systematic use to evaluate AF recurrence risk post-CBA.

Ventricular Sigmoid Septum as a Risk Factor for Anthracycline-Induced Cancer Therapeutics-Related Cardiac Dysfunction in Patients With Malignant Lymphoma

Background: Identifying risk factors for cancer therapeutics-related cardiac dysfunction (CTRCD) is essential for the early detection and prompt initiation of medial therapy for CTRCD. No study has investigated whether the sigmoid septum is a risk factor for anthracycline-induced CTRCD. Methods and Results: We enrolled 167 patients with malignant lymphoma who received a CHOP-like regimen from January 2008 to December 2017 and underwent both baseline and follow-up echocardiography. Patients with left ventricular ejection fraction (LVEF) ≤50% were excluded. CTRCD was defined as a ≥10% decline in LVEF and LVEF <50% after chemotherapy. The angle between the anterior wall of the aorta and the ventricular septal surface (ASA) was measured to quantify the sigmoid septum. CTRCD was observed in 36 patients (22%). Mean LVEF and global longitudinal strain (GLS) were lower, left ventricular mass index was higher, and ASA was smaller in patients with CTRCD. In a multivariable Cox proportional hazard analysis, GLS (hazard ratio [HR] per 1% decrease 1.20; 95% confidence interval [CI] 1.07-1.35) and ASA (HR per 1° increase 0.97; 95% CI 0.95-0.99) were identified as independent determinants of CTRCD. An integrated discrimination improvement evaluation confirmed the significant incremental value of ASA for developing CTRCD. Conclusions: Smaller ASA was an independent risk factor and had significant incremental value for CTRCD in patients with malignant lymphoma who received the CHOP-like regimen.

Reference Values of Right Ventricular Volumes and Ejection Fraction by Three-Dimensional Echocardiography in Adults: A Systematic Review and Meta-Analysis

Objective: This study was conducted in order to determine the reference values for right ventricular (RV) volumes and ejection fraction (EF) using three-dimensional echocardiography (3DE) and to identify sources of variance through a systematic review and meta-analysis.

Methods: This systematic review was preregistered with the International Prospective Register of Systematic Reviews (https://www.crd.york.ac.uk/PROSPERO/) (CRD42020211002). Relevant studies were identified by searches of the PubMed, Embase, and Cochrane Library databases through October 12, 2020. Pooled reference values were calculated using the random-effects model weighted by inverse variance. Meta-regression analysis and Egger's test were used to determine the source of heterogeneity. A subgroup analysis was performed to evaluate the reference values across different conditions.

Results: The search identified 25 studies of 2,165 subjects. The mean reference values were as follows: RV end-diastolic volume, 100.71 ml [95% confidence interval (CI), 90.92–110.51 ml); RV end-systolic volume, 44.19 ml (95% CI, 39.05–49.33 ml); RV end-diastolic volume indexed, 57.01 ml/m² (95% CI, 51.93–62.08 ml/m²); RV end-systolic volume indexed, 25.41 ml/m² (95% CI, 22.58–28.24 ml/m²); and RVEF, 56.20% (95% CI, 54.59–57.82%). The sex- and age-specific reference values were assessed according to the studies reporting the values of different sexes and age distributions, respectively. In addition, the vendor- and software-specific reference values were analyzed. The meta-regression analysis revealed that sex, frame rate, pulmonary artery systolic pressure, and software packages were associated with variations in RV volumes (P < 0.05). Inter-vendor and inter-software discrepancies may explain the variability of RVEF.

Conclusions: The reference values for RV volumes and RVEF using 3DE were assessed. The confounders that impacted the variability in RV volumes or RVEF contained the sex, frame rate, pulmonary artery systolic pressure, inter-vendor discrepancies, and inter-software discrepancies.

A case of Wolff–Parkinson–White syndrome in which two-dimensional speckle-tracking echocardiography was useful for identifying the location of the accessory atrioventricular pathway

Background

In Wolff–Parkinson–White (WPW) syndrome, accessory atrioventricular pathways (AP) result in abnormal pre-excitation around the atrioventricular annuli and produce a dyssynchronous contraction of cardiac chambers. Identification of the AP affects the outcome of catheter ablation.

Case summary

We report a case of WPW syndrome and paroxysmal atrial fibrillation in a 65-year-old man. Wolff–Parkinson–White syndrome Type B was suspected from lead V1, but when two-dimensional speckle-tracking echocardiography (2D-STE) was performed, a decrease in regional strain was observed in the anterior basal wall of the left ventricle. We identified the earliest site of atrioventricular conduction, and improvement in the regional strain at the site of ablation was observed after successful AP ablation.

Discussion

Various echocardiographic techniques have been investigated as non-invasive alternatives for AP localization. Longitudinal 2D-STE accurately identified contractile abnormalities associated with the AP, allowing us to non-invasively estimate the localization of the AP in WPW syndrome.