Anatomic three-dimensional echocardiographic correlation of bicuspid aortic valve

Three-dimensional echocardiographic assessment of the aortic valve and the aorta

We describe the role of three-dimensional echocardiography in the assessment of the aortic valve and the aorta. The manuscript is heavily illustrated with figures and movie clips.

Application research of three-dimensional transesophageal echocardiography in predicting prosthetic valve size for transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is an alternative method to treat patients with severe aortic valve disease. Accurate measurement of the aortic valve annulus and selection of the appropriate artificial valve are critical to the success of TAVI. Multilayer spiral computed tomography (MSCT) is recommended as the “gold standard” for assessing the aortic valve annulus before TAVI. However, MSCT scanning may not be possible for patients with iodine allergy, renal failure, or pregnancy. The purpose of this study is to evaluate the aortic valve annulus by three-dimensional transesophageal echocardiography (3D-TEE) and compare the results with MSCT, exploring the feasibility of 3D-TEE to guide the selection of artificial valve implantation in TAVI.

Methods

We retrospectively analyzed 74 patients who successfully underwent TAVI in our hospital. Before the operation, 3D-TEE and MSCT were used to measure the maximum diameter, minimum diameter, area-derived diameter, and perimeter-derived diameter of the aortic valve annulus, and the results were analyzed for consistency. To predict the valve size based on 3D-TEE and the MSCT area-derived diameter, we compared the differences between the predicted valve size and the actual implanted valve size, and analyzed the differences between 3D-TEE and MSCT for guiding the selection of the prosthetic valve size.

Results

There was no significant difference between 3D-TEE and MSCT in the measurement of the maximum diameter, minimum diameter, area, and perimeter of the aortic annulus and their derived diameter (P>0.05). The intraclass correlation coefficients for the maximum diameter, minimum diameter, area-derived diameter, and perimeter-derived diameter of the aortic annulus were 0.89, 0.83, 0.84, and 0.92, respectively. There was no statistical difference in the accuracy of both methods, 3D-TEE and MSCT, in predicting different prosthetic valve sizes for TAVI (P>0.05).

Conclusions

3D-TEE and MSCT have good agreement for measuring the values of various parameters of the aortic annulus. The accuracy of both methods was similar for predicting the aortic prosthetic valve size. 3D-TEE may provide guidance for selecting the prosthetic valve size for TAVI.

Diagnostic accuracy study of routine echocardiography for bicuspid aortic valve: a retrospective study and meta-analysis

BACKGROUND

Transthoracic echocardiography (TTE) is the standard procedure to distinguish tricuspid aortic valve (TAV) from bicuspid aortic valve (BAV). Published studies assessed the accuracy of TTE for BAV under ideal conditions. Conversely, we aimed at assessing accuracy of TTE for BAV under routine conditions.

METHODS

This retrospective, cross-sectional study of 216 adults included 132 men aged 62±14 years. Of these, 108 had BAV and 108 were age-matched individuals with TAV. All diagnoses were confirmed at surgery. We assessed TTE in two patient groups. First, in the (I) group of all 216 individuals, where we assessed accuracy for BAV according to the original diagnoses as documented by the primary investigators during original TTE examination. Second, we assessed accuracy for BAV according to expert re-evaluation in (II) all 158 TTE with availability of original recordings. Third, we performed a meta-analysis of published results on the accuracy of TTE for BAV according to PRISMA standards.

RESULTS

Sensitivity, specificity and accuracy of (I) primary investigators was 46.3%, 97.2, and 71.8% as compared to (II) expert re-evaluation with 59.7%, 93%, and 77.8%, respectively. Sensitivity was significantly higher at re-evaluation (P<0.001). TTE at a non-tertiary care center (P=0.012), presence of aortic aneurysm (P=0.001) and presence of severe aortic valve calcification (P=0.003) predicted an inaccurate diagnosis of BAV. Conversely, meta-analysis of published TTE studies identified a pooled sensitivity of 87.7% and a pooled specificity of 88.3% for BAV.

CONCLUSIONS

The current study shows that TTE yields almost ideal diagnostic accuracy when ideal investigators examine ideal patients. However, the study also shows that TTE yields suboptimal diagnostic accuracy under routine conditions. TTE in non-tertiary care settings, concomitant aortic aneurysm, and presence of severe aortic valve calcification predict an inaccurate diagnosis of BAV.

Usefulness of intra-operative epicardial three-dimensional echocardiography to guide aortic valve repair in children

The aim of this study was to determine the additional important information obtained on prebypass epicardial 3-dimensional imaging (E-3D) compared with transesophageal 2-dimensional echocardiography (TEE-2D) in young patients who undergoing aortic valve repair. From January 2004 to May 2007, all patients who underwent reconstructive surgery of the native aortic valve and intraoperative TEE-2D and E-3D were retrospectively reviewed. Thirteen structural anatomic variables of the aortic valve for TEE-2D and E-3D were evaluated, scored, and compared (by a blinded observer) with intraoperative surgical findings. Nineteen patients underwent valve repair. The median age at surgery was 10 years (range 1 day to 24 years). The primary aortic valve disease was regurgitation (n = 19), and 2 patients had additional valvar stenosis. TEE-2D and E-3D were able to detect 82% (n = 204) and 91% (n = 225), respectively, of the intraoperative findings (n = 247) (p = 0.006). Individual evaluation scores were higher for E-3D (median 12, interquartile range 11 to 13) than for TEE-2D (median 11, interquartile range 10 to 12) (p = 0.01) compared with surgical findings (score 13). Differences in detection sensitivity occurred for commissural fusion (n = 7), leaflet perforation or deficiency (n = 5), and leaflet prolapse (n = 2). TEE-2D was more likely to have false-negative findings than E-3D (36 vs 16 findings, p = 0.001). In conclusion, intraoperative E-3D provides additional important information over TEE-2D for aortic valve repair in young patients. Such 3-dimensional echocardiographic imaging has become an important intraoperative modality for valve repair at the investigators' institution.

Real-time 3-dimensional echocardiography in the operating room

Real-time 3-dimensional transesophageal echocardiography (RT-3D-TEE) represents a novel clinical and intuitively educational perioperative cardiovascular imaging modality. The development of RT-3D-TEE allows for live 3D imaging as it circumvents most of the disadvantages of reconstructive 3D methods. RT-3D-TEE will likely revolutionize perioperative assessment of complex 3D structures, such as the mitral valve (MV), as it provides important mechanistic insights into functional and ischemic mitral regurgitation. The MV is particularly suited to live RT-3D-TEE assessment because of the complex interrelationships among the valve, chordae, papillary muscles, and myocardial walls. The 3D en face view of the MV is in accordance with the surgical view and allows to illustrate the unique saddle shape of the MV annulus and to define and localize mitral leaflet lesions in MV prolapse, endocarditis, or congenital MV abnormalities, all potentially important in guiding surgical repair. RT-3D-TEE will soon be integrated into routine perioperative practice. Its unique ability of real-time acquisition, online rendering and cropping capabilities, accurate identification of the precise pathology and location of cardiac disease, together with its ability to promptly quantify 3D data sets using built-in software, will likely help in transitioning this modality into standard of care.

Understanding atrioventricular septal defect: anatomoechocardiographic correlation

OBJECTIVE

Correlate the anatomic features of atrioventricular septal defect with echocardiographic images.

MATERIALS AND METHODS

Sixty specimen hearts were studied by sequential segmental analysis. Echocardiograms were performed on 34 patients. Specimen hearts with findings equivalent to those of echocardiographic images were selected in order to establish an anatomo-echocardiographic correlation.

RESULTS

Thirty-three specimen hearts were in situs solitus, 19 showed dextroisomerism, 6 were in situs inversus and 2 levoisomerism. Fifty-eight had a common atrioventricular valve and 2 had two atrioventricular valves. Rastelli types were determined in 21 hearts. Nine were type A, 2 intermediate between A and B, 1 mixed between A and B, 4 type B and 5 type C. Associated anomalies included pulmonary stenosis, pulmonary atresia atrial septal defect, patent ductus arteriosus and anomalous connection of pulmonary veins. Echocardiograms revealed dextroisomerism in 12 patients, situs solitus in 11, levoisomerism in 7 and situs inversus in 4. Thirty-one patients had common atrioventricular valves and three two atrioventricular valves. Rastelli types were established in all cases with common atrioventricular valves; 17 had type A canal defects, 10 type B, 3 intermediate between A and B, 1 mixed between A and B and 3 type C. Associated anomalies included regurgitation of the atrioventricular valve, pulmonary stenosis, anomalous connection of pulmonary veins, pulmonary hypertension and pulmonary atresia.

CONCLUSION

Anatomo-echocardiographic correlation demonstrated a high degree of diagnostic precision with echocardiography.

[Three-dimensional echography: cardiovascular applications]

Real-time three-dimensional echocardiography is currently used in a standard echocardiographic examination. Volume-rendered images better identify and locate anatomic structures and improve our comprehensive approach to various heart diseases. The assessment of mitral valve disease and congenital cardiopathies and the measurement of left ventricular mass, volume, and ejection fraction are the three main applications of three-dimensional echocardiography. Three-dimensional vascular imaging is an emerging and promising application of three-dimensional echography. The near future of three-dimensional echography requires the integration of all modalities of conventional echography in three dimensional probes, a higher image resolution compared to the current situation, as well as the development of real-time three-dimensional probes dedicated to transesophageal cardiac or vascular examination.

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.

Correlations with operative anatomy of real time three-dimensional echocardiographic imaging of congenital aortic valvar stenosis

OBJECTIVE

To define the anatomic characteristics of the congenitally malformed and severely stenotic aortic valve using trans-thoracic real time three-dimensional echocardiography, and to compare and contrast this with the valvar morphology as seen at surgery.

DESIGN

Prospective cross-sectional observational study.

SETTING

Tertiary centre for paediatric cardiology.

METHODS

All patients requiring aortic valvotomy between December 2003 and July 2004 were evaluated prior to surgery with three-dimensional echocardiography. Full volume loop images were acquired using the Phillips Sonos 7500 system. A single observer analysed the images using "Q lab 4.1" software. The details were then compared with operative findings.

RESULTS

We identified 8 consecutive patients, with a median age of 16 weeks, ranging from 1 day to 11 years, with median weight of 7.22 kilograms, ranging from 2.78 to 22 kilograms. The measured diameter of the valvar orifice, and the number of leaflets identified, corresponded closely with surgical assessment. The sites of fusion of the leaflets were correctly identified by the echocardiographic imaging in all cases. Fusion between the right and non-coronary leaflets was identified in half the patients. Dysplasia was observed in 3 patients, with 1 patient having nodules and 2 shown to have excrescences. At surgery, nodules were excised, and excrescences were trimmed. The dysplastic changes correlated well with operative findings, though statistically not significant.

CONCLUSION

We recommend trans-thoracic real time three-dimensional echocardiography for the assessment of the congenitally malformed aortic valve, particularly to identify sites of fusion between leaflets and to measure the orificial diameter. The definition of nodularity, and the prognosis of nodules based on the mode of intervention, will need a comparative study of patients submitted to balloon dilation as well as those undergoing surgical valvotomy.

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.

Aortic obstruction: anatomy and echocardiography

Echocardiography is a valuable non-invasive technique for identifying the site and type of aortic obstruction. Knowledge of the morphological details of each type of obstruction is the basis for correct interpretation of the diagnostic images and clinical decisions. This study was undertaken to correlate the echocardiographic images with anatomic specimens of equivalent valvular and supravalvular aortic obstruction. Specimens were part of the collection of the Department of Embryology. Fifty six patients were studied, and forty specimens with aortic obstruction were analyzed.

Echocardiographic characteristics: Thirty one (55.3%) patients were women and twenty five (44.7%) men. Valvular aortic obstruction was found in Thirty six patients (64.3 %) and supravalvular aortic obstruction in twenty (35.7%). Anatomic characteristics: Of the forty specimens examined, twenty one (52.5%) had valvular aortic obstruction and nineteen (47.5%) supravalvular aortic obstruction.

The anatomoechocardiographic correlation clearly showed that the anatomic findings of the specimen hearts and aortas corresponded to echocardiographic images of valvular and supravalvular aortic obstruction and provided solid corroboration of echocardiographic diagnoses.

Feasibility and Accuracy of Real-time 3-Dimensional Echocardiographic Assessment of Ventricular Septal Defects

The aim of this study was to evaluate feasibility, accuracy, and clinical applicability of real-time (RT) transthoracic 3-dimensional (3D) echocardiography (3DE) in the determination of the position, size, and shape of a ventricular septal defect (VSD). In all, 34 patients (age: 2 months-46 years), who were scheduled for surgical closure of a VSD, were enrolled in the study. VSD localization, shape, and dimensions were assessed and compared with measurements performed by the surgeon. Acquisition of RT-3DE datasets was feasible in 30 of 34 (88%) patients. Duration of 3D data acquisition was 6 +/- 2 minutes. Reconstruction time was 23 +/- 16 minutes. Localization and number of VSD were determined correctly by RT-3DE in all patients. There was a good correlation for VSD measurements between RT-3DE and operation (r = 0.95). RT-3DE allows accurate determination of VSD size, shape, and location. The short acquisition time and acceptable reconstruction time make this technique clinically applicable.

Impact of three-dimensional echocardiography in valvular heart disease

PURPOSE OF REVIEW

Recent advances in the field of three-dimensional (3D) echocardiography have allowed improved visualization of cardiac structures. These advances have also provided valuable insights into cardiac function. The purpose of this review is to describe the recent developments in 3D echocardiography in assessing valvular heart disease.

RECENT FINDINGS

Application of 3D echocardiography to valvular heart disease has improved with advances made in both the hardware and software components of 3D ultrasound systems. The most significant advancement has been the development of a matrix transducer that is capable of rapid real-time 3D acquisition and rendering. There have been many studies evaluating 3D echocardiographic assessment of mitral valve disease, aortic valve disease, as well as congenital heart disease using both real-time 3D transthoracic echocardiography (TTE) as well as off-line reconstructed 3D images from transesophageal echocardiography (TEE) using post image processing. More recent studies have combined the structural 3D information with color Doppler 3D imaging, providing qualitative functional information.

SUMMARY

Developments in the field of 3D ultrasound imaging have allowed better qualitative assessment of valvular structures. The addition of color flow Doppler to the 3D imaging has provided improved visualization of regurgitant lesions and holds great promise for improved quantitative assessment of such lesions. The ongoing miniaturization of transducers and improvements in hardware and software components of ultrasound systems will certainly enhance both the ease of image acquisition as well as image quality, which should result in more precise quantitation of valvular dysfunction. However, clinical benefits of 3D echocardiography are yet to be demonstrated in properly conducted clinical trials, which are needed for wider acceptance of this technique.

Percutaneous closure of interatrial communications in adults - prospective embolism prevention study with two- and three-dimensional echocardiography

BACKGROUND

Patients with interatrial communications after paradoxical embolic events are at risk for recurrent thromboembolism. We hypothesized that transcatheter closure of the defects would result in long-term prevention of systemic embolism and performed clinical and echocardiographic follow-up.

METHODS

We included 161 patients (mean age 46.8 +/- 11 years, 83 females) with patent foramen ovale or atrial septal defect and at least one documented paradoxical systemic thrombembolic event and/or a large atrial shunting.

RESULTS

The implantation procedure was successfully performed without major complications in all patients and minor complications in 2.5%. Two and / or three dimensional echocardiography was performed before and after 4 weeks and 12 months using a multiplane transoesophageal probe. After 4 weeks and 6 months two patients had minimal shunting. These residual defects were closed with a second device implantation without shunting after further 4 weeks. During a follow-up of 324.3 patient years (range, 13 to 19 months), recurrent embolic events occurred in only 1 patient (0.6%).

CONCLUSION

After primary paradoxical systemic embolism, results of transcatheter occlusion of the interatrial communications are dependent on the closure device system and can prevent further secondary embolic events for up to 1 year after the percutaneous closure. Three dimensional echocardiography provides dynamic features of the defects and the post closure status and may lead to an improved understanding and diagnosis of the interatrial defect.