The assessment of the TV annulus by RT 3D TEE for intraoperative surgical decision making60 has never been investigated. However, changes in the shape and geometric assessment of the TV annulus by 3D TTE is feasible, correlates well with cardiac MRI,61 and helps improve the understanding of TV pathophysiology.62
Assessment of tricuspid stenosis using zoom or full-volume modes consists of a description of TV morphology and direct measurement of the TV orifice area. Planimetry of the TV orifice area requires off-line cropping through the smallest TV orifice using analytical software. No studies have described the use of RT 3D TEE in the assessment of tricuspid stenosis. However, RT 3D TTE provided optimal images of the entire TV structure in the presence of rheumatic tricuspid stenosis and allowed off-line measurement of the TV orifice area in all patients.63
TV leaflet morphology has been described in the presence of tricuspid regurgitation by RT 3D TTE64 but not RT 3D TEE.
The normal AV is difficult to image with RT 3D TEE because of its relative anterior position and thin pliable cusps. Complete visualization of the AV cusps in the zoom mode is possible in only a small number of patients.4 Reliable imaging of the AV cusps is best obtained using the live or full-volume modes from midesophageal AV short-axis and long-axis views, respectively. The same imaging modes for the native AV are used in the assessment of AV prosthesis by RT 3D TEE.
The TEE assessment of aortic stenosis (AS) comprises a description of cusp morphology, AV function, and quantification of AS severity.51 Thickening and calcification of AV cusps facilitates imaging by all 3D modes. The 3D images show restricted cusp mobility, although echo dropout from calcification may still limit image quality.
Off-line planimetry of the anatomic aortic valve area (AVA) requires cropping by an arbitrary plane through the smallest AV orifice using zoom or full-volume 3D datasets exported to analytical software. This technique, with RT 3D TTE AV datasets, was found to correlate well with catheter measurement of AVA by the Gorlin formula and be more accurate and reproducible65 than 2D TEE AVA planimetry.66 The continuity equation67 is an accepted method to indirectly estimate the effective AVA1 and is based on the formula:
The role of 2D TEE in the morphologic and functional assessment of aortic insufficiency (AI) has been described.70 Imaging of normal AV cusps by RT 3D TEE is unreliable and its use is, therefore, limited in this setting.
The pulmonic valve is the most anterior, and its cusps are the thinnest of all cardiac valves. Normal pulmonic valve cusps are barely visualized by 2D TEE, and good 3D TEE images are extremely rare. Intraoperative assessment of the pulmonic and TVs by RT 3D epicardial echocardiography (EE) should be considered in selected cases. The assessment of pulmonic stenosis by RT 3D echocardiography has not been reported.
Quantification of native valve regurgitation severity has been well described for 2D TEE using a number of different variables.71 The use of 3D echocardiography is limited by the lack of spectral Doppler mode and the inability to easily perform on-line linear or area measurements. However, 3D color Doppler does allow alternative ways to assess variables, such as vena contracta cross-sectional area, regurgitant jet volume, and proximal isovelocity surface area (PISA).
The measurement of the regurgitant jet vena contracta width is a simple method frequently used to grade regurgitation severity.71 It relies on the assumption that the minimal width of the regurgitant jet has a circular shape. Off-line use of a 3D color Doppler dataset permits cropping on a plane perpendicular to the regurgitant jet and direct planimetry of the vena contracta cross-sectional area. The shape of the vena contracta cross-sectional area of a tricuspid regurgitant jet72 is ovoid and that of a mitral regurgitant jet varies according to MV pathology and can become rather irregular.73 Cropping of the LVOT on a plane parallel to the aortic annulus allows direct planimetry of an AI jet vena contracta area for comparison with the LVOT area.74 Direct measurement of regurgitant jet vena contracta area by RT 3D echocardiography may be more precise than 2D echocardiography because it does not rely on any geometrical assumption.75 This is yet to be studied and may be limited by the poor temporal resolution of 3D images that could miss the optimal frame for accurate assessment.
Multiplying the vena contracta cross-sectional area measured as described above by the regurgitant velocity-time integral obtained by 2D spectral Doppler estimates the regurgitant volume. This technique using RT 3D TTE is feasible and reliable for MR,75,76 tricuspid regurgitation,72 AI,74 and pulmonic insufficiency.77
Calculation of the effective orifice area (EROA) by the PISA method assumes a perfect hemisphere. Studies using 3D color Doppler have demonstrated that PISA is not always hemispheric and this geometric assumption may underestimate the EROA.78,79 In vitro estimation of EROA by RT 3D TEE using the PISA method in a laboratory model of MR is feasible, precise, and highly reproducible78 but awaits in vivo testing.
Transcatheter AV implantation is a new treatment option for patients with symptomatic AS deemed too high risk for conventional AV surgery.80 The technique consists of positioning and deployment of a stented bioprosthetic valve over a balloon catheter in the native AV position approached through the femoral artery (retrograde)81,82 or a minithoracotomy (antegrade).83 The prosthetic valve is deployed after a balloon valvuloplasty under fluoroscopic guidance.
The ascending aorta, aortic arch, and descending aorta can be examined using all 3D imaging modes. The wider sector of the zoom mode more completely images aortic pathology than the live mode from standard 2D TEE views. The distal ascending aorta and proximal aortic arch remain difficult to image by RT 3D TEE in the blind spot created by air in the trachea and right bronchus. Given the size and thin walls of a root aneurysm, the full-volume mode achieves better image quality.
RT 3D TEE can provide detailed images of complex pathology of the aortic root and aorta including aortic aneurysm, aortic dissection, pseudoaneurysm88 of the intervalvular fibrosa, and sinus of Valsalva aneurysm (Fig. 18) (Video 15, see Supplemental Digital Content 15, http://links.lww.com/AA/A96; see Video 15 legend at Appendix 1, http://links.lww.com/AA/A104). The diagnosis of aortic dissection by RT 3D TTE was found to integrate and potentially increase the accuracy of 2D TTE for this specific application.89
The TTE matrix array probe has been successfully used to perform RT 3D epicardial echocardiography (EE) intraoperative scanning. RT 3D EE can overcome the limitations of RT 3D TEE for imaging the most anterior structures of the heart, such as the AV and the aortic root.90 Compared with 2D TEE and epiaortic scanning, RT 3D epiaortic imaging provided better topographic definition of atheromatous disease91 of the ascending aorta before surgical cannulation.92 The use of RT 3D TEE in detecting aortic plaque has not been reported.
The left atrium cannot be entirely visualized by TEE and 3D TEE does not overcome this limitation, thus left atrial volume cannot be accurately measured by RT 3D TEE. Off-line measurement of left atrial cross-sectional area by RT 3D TEE requires importing a 3D zoom or full-volume dataset of the MV into analytical software and cropping the left atrium on a plane parallel to the mitral annulus. Although this measure seems more precise than the anteroposterior diameter measured by 2D TEE,93 its value in clinical practice has not been investigated. This contrasts with the accurate estimation of left atrial volume by RT 3D TTE,94 which was successfully used to predict survival in patients with previous stroke and congestive heart failure.95
The LAA has a pyramidal shape and its geometry can be imaged by RT 3D TEE using the zoom mode (Fig. 19A) (Video 16, see Supplemental Digital Content 16, http://links.lww.com/AA/A97; see Video 16 legend at Appendix 1, http://links.lww.com/AA/A104) as accurately as by cardiac CT.96 Although 2D TEE is considered the “gold standard” for the assessment of LAA thrombus, RT 3D TEE (Fig. 19B) (Video 16, see Supplemental Digital Content 16, http://links.lww.com/AA/A97; see Video 16 legend at Appendix 1, http://links.lww.com/AA/A104) provides a higher specificity in defining LAA pathology than 2D TEE.97,98 The use of RT 3D TTE99 provides similar accuracy but lower specificity than TEE in excluding LAA thrombus.
Adequate assessment of the LV should include an estimate of LV volume, global and regional wall motion, mass, and synchronicity. In the operating room setting, the LV is still often assessed by qualitative “eyeballing” from 2D TEE images. Quantitative 2D TEE assessment of LV function93 is time consuming and may be limited by geometric assumptions and foreshortened views.
In the normal heart, the LV is the largest cardiac structure. A 3D full-volume acquisition is the only imaging modality that can capture the entire LV volume at sufficient frame rate (25 Hz) that allows dynamic assessment. This begins from an optimized 2D midesophageal 4-chamber view. Unfortunately, RT 3D TEE does not overcome the limitation of ultrasound, thus poor endocardial definition on the baseline 2D TEE image will result in a poor-quality full-volume dataset. Little information is present from the initial full-volume 3D image of the LV epicardium until cropping reveals the endocardial cavity. More useful analysis is obtained by exporting the dataset into analytical software that enables semiautomated volumetric and dynamic quantification of global and regional LV function.
LV volumes can be measured with RT 3D TEE using 2 off-line methods: 3D-guided biplanes or direct volumetric analysis. The 3D-guided biplane method more easily positions 2 perpendicular 2D planes to accurately cut the LV along its long axis at the true apex (Fig. 20A). Ideal midesophageal 4-chamber and 2-chamber 2D views are simultaneously displayed, and the LV volume, ejection fraction, and mass are calculated by applying the modified Simpson biplane method of disks to the end-systolic and end-diastolic frames.93 Although this method minimizes foreshortening of the LV when using TEE, it still relies on geometric assumptions.
Direct volumetric analysis consists of rendering a cast of the LV cavity to measure its volume throughout a cardiac cycle. This process requires the initial identification of 4 LV walls and the apex from 2D LV views derived from the full-volume 3D dataset. Semiautomated endocardial border detection creates a dynamic cast of the LV endocardial cavity (Fig. 20B) (Video 17, see Supplemental Digital Content 17, http://links.lww.com/AA/A98; see Video 17 legend at Appendix 1, http://links.lww.com/AA/A104). The end-diastolic volume and end-systolic volume are measured, and the stroke volume and ejection fraction are calculated. This method more accurately quantifies LV volumes particularly in patients with an abnormal ventricular shape or regional wall motion abnormalities. This in part relates to better alignment through the cardiac apex, inclusion of more endocardial surface during analysis, and the lack of geometric shape assumption.
No studies have been published on the use of RT 3D TEE for the assessment of global LV function. When compared with 2D TTE, LV volume quantification by RT 3D TTE is more reproducible, has a high test-retest correlation,100 and correlates well with cardiac MRI in the measurement of both normal101 and abnormal LV volume.100,102–105 Nevertheless, RT 3D TTE tends to consistently slightly underestimate LV volume compared with MRI. This is possibly explained by the different quantification software used to process MRI and 3D TTE datasets and the variable experience of the echocardiographer performing the LV quantification.106 Commercially available analytical software for RT 3D TTE and TEE datasets were found to offer the same level of accuracy and reliability in the measurement of LV volume.107
LV mass is a frequently used measure for the diagnosis and follow-up of LV pathology in the perioperative setting. LV mass is calculated by multiplying the volume of the LV myocardium by its weight.93 Myocardial volume is determined by the difference between epicardial and endocardial volumes at end-diastole.
Myocardial volume can be measured off-line from an LV full-volume 3D dataset by 2 methods: 3D-derived biplanes and 3D direct volumetric analysis. A biplane estimate of myocardial volume is obtained from tracing the LV epicardial and endocardial end-diastolic volumes in optimized midesophageal 4-chamber and 2-chamber views. The 3D direct volumetric analysis calculates the difference in end-diastolic volumes from rendered endocardial and epicardial LV casts to estimate the volume of LV myocardium.
The measurement of LV mass by RT 3D TTE using both these 3D methods correlates well with cardiac MRI.102,108 Furthermore, RT 3D TTE showed a lower interobserver variability than 2D TTE.109 The use of RT 3D TEE in the assessment of LV mass has not been studied.
For the assessment of regional LV wall motion, the 3D LV cast is automatically divided into 16 wedges plus an apical cap, resembling the 17 segments of the American Heart Association/American Society of Echocardiography model (Fig. 20C). The RT 3D TEE assessment of regional LV wall motion is based on a change in LV chamber volume over time from altered segmental myocardial contractility. Unlike standard 2D TEE, there is no direct measurement of myocardial thickening or displacement of individual segments. Graphic display of a single cardiac cycle for each of the 17 subvolumes allows rapid detection of abnormalities in systolic endocardial motion with simultaneous assessment of all 17 segments (Fig. 20D) (Video 17, see Supplemental Digital Content 17, http://links.lww.com/AA/A98; see Video 17 legend at Appendix 1, http://links.lww.com/AA/A104).
Sensitivity and specificity of RT 3D TTE in the detection and follow-up of LV regional wall motion abnormalities have been reported to be very high.110
A full-volume 3D dataset of the LV can be cut in multiple 2D planes and displayed simultaneously. Using this feature, the LV can be displayed as a series of parallel short-axis planes similar to a typical MRI view, allowing assessment of all LV segments in 1 display. The use of this modality in the assessment of LV function has not been studied.
TDI is considered the standard for the assessment of LV dyssynchrony using 2D TTE.115 The technique has a high temporal resolution but is angle dependent and cannot be used with TEE for this specific reason.
Regional synchronicity assessed by RT 3D TEE measures blood ejection (subvolumes) and not tissue motion. Graphic representation of each of the 17 subvolumes from the reconstructed 3D LV model allows prompt assessment of LV synchronicity in a single screenshot (Fig. 20D) (Video 17, see Supplemental Digital Content 17, http://links.lww.com/AA/A98; see Video 17 legend at Appendix 1, http://links.lww.com/AA/A104).
The standard deviation (SD) of the time to minimal systolic volume of all 17 LV segments is a measure of LV dyssynchrony. The time to minimal systolic volume is the time from the ECG R wave to the minimal systolic volume. The SD is calculated as a percentage of a cardiac cycle. RT 3D TEE for the assessment of LV dyssynchrony has not yet been investigated.
In the normal population, RT 3D TTE has defined normal ranges for dyssynchrony indices in 91.6% of subjects with a low interobserver variability.116 RT 3D TTE correlated well with single positron emission CT in the assessment of LV dyssynchrony117 and has been used to guide resynchronization therapy.118,119 Correlation between RT 3D TTE and 2D TDI has been reported to be good120,121 in some studies and fair in others.122 A possible explanation for this poor correlation is that they measure longitudinal and radial LV timing, respectively,122 and thus cannot be compared.
RT 3D TEE overcomes some of these limitations and allows acquisition of full-volume 3D datasets of the RV with off-line measurement of RV volume and function (Fig. 21B) (Video 18, see Supplemental Digital Content 18, http://links.lww.com/AA/A99; see Video 18 legend at Appendix 1, http://links.lww.com/AA/A104) using special analytical software (4D RV-Function© application; TomTec Imaging Systems GmbH, Munich, Germany).
Although the use of RT 3D TEE in the assessment of RV function has not been investigated, data from the RT 3D TTE literature reported feasibility of this technique.126–128 Recent studies have shown good correlation between 3D TTE and cardiac MRI126,127 with better reproducibility than by 2D TTE127 for the assessment of RV volume and function in adults and children.129
Three-dimensional representation of cardiac anatomy may provide a better understanding of complex congenital heart disease.130 RT 3D TTE131 and TEE132 imaging of the cardiac valves and assessment of ventricular function in this patient population have been reported. The lack of a pediatric 3D TEE probe has limited study to patients >15 kg in weight.132
The IAS is imaged using the zoom or full-volume modes with orientation to show the IAS from the left atrium or right atrium. This can facilitate demonstration of common pathology (Fig. 22) (Video 19, see Supplemental Digital Content 19, http://links.lww.com/AA/A100; see Video 19 legend at Appendix 1, http://links.lww.com/AA/A104), such as a patent foramen ovale or atrial septal defect (ASD). Septal defects in the adult congenital population have been extensively studied using 3D echocardiography.133–138
An en face surgical view of different types of ASDs by 3D TTE was reported more than a decade ago.138 Off-line 3D TEE correlates well with an invasive balloon technique, in the measurement of the ASD diameter, and provides a more precise localization of multiple ASDs.137
Assessment of an ASD using RT 3D TTE is more accurate than 2D TTE and better correlates with intraoperative surgical measurement.135,136 RT 3D TTE showed similar accuracy to 2D TEE in determining ASD suitability for device closure and in guiding device size selection.122 RT 3D TEE better defines the shape139 and the spatial relations of the ASD and the surrounding structures such as the AV and the great vessels. The use of RT 3D TEE to guide placement of percutaneous device closure of ASDs has been well described.134,140
Similar to an ASD, ventricular septal defects (VSDs) are imaged by RT 3D TEE using zoom and full-volume modes. The 3D images can be rotated to display a view of the VSD from either the RV or LV. No studies have been reported on the use of RT 3D TEE in the diagnosis or management of a VSD. Assessment of a VSD by RT 3D TTE is feasible, provides high-quality images, and has high correlation with intraoperative surgical findings.133,136,138
RT 3D TEE can accurately assess location, attachment, and size of intracardiac masses to facilitate surgical planning (Fig. 23) (Video 20, see Supplemental Digital Content 20, http://links.lww.com/AA/A101; see Video 20 legend at Appendix 1, http://links.lww.com/AA/A104). Depending on their size, masses are imaged using the live or zoom (smaller masses) and full-volume (larger masses) modes.
The role of 3D TEE has been compared with standard 2D TEE and in 37% of the cases it provided unique information and in 27% of the cases complemented 2D TEE findings.141 Despite the intuitive advantages of RT 3D TEE in the operative management of intracardiac masses, no study has been reported for this specific application. RT 3D TTE has been reported to be more accurate in the measurement of the size of intracardiac masses than 2D TTE and 2D TEE.142
Hypertrophic obstructive cardiomyopathy often presents with an asymmetric interventricular septal hypertrophy and narrowing of the LVOT. Surgical resection of the interventricular septum is a therapeutic option that results in relief of LVOT obstruction, improving symptoms and patient outcome.143
Intraoperative TEE has been successfully used during surgical septal myectomy. Surgical resection is guided by measures taken in a single 2D plane perpendicular to the interventricular septum. The LVOT is, however, a tubular structure that is difficult to accurately describe using 2D images alone.
The perioperative application of 3D TTE in this setting has shown that it may be a useful tool to improve understanding of the LVOT anatomy and guide surgical intervention.144 The intraoperative role of RT 3D TEE has not been investigated (Fig. 24) (Video 21, see Supplemental Digital Content 21, http://links.lww.com/AA/A102; see Video 21 legend at Appendix 1, http://links.lww.com/AA/A104). Systolic anterior motion of the anterior MV leaflet, causing significant MR, is frequently associated with asymmetric septal hypertrophy in the presence of hypertrophic obstructive cardiomyopathy. The RT 3D TEE live mode and en face view145 of the MV can effectively display systolic anterior motion. Of note, RT 3D TTE showed a very high correlation with cardiac MRI in the measurement of LV volume, mass, and wall thickness in this subset of patients.146
The possibility of generating high-quality 3D images with a high frame rate makes RT 3D TEE suitable to guide minimally invasive cardiac procedures.24,147 The ability to rotate the 3D image in any orientation and reproduce the anatomic view provides effective and reliable guidance to the operator.
RT 3D TEE has been successfully used to guide the percutaneous closure of MV paravalvular leaks49,50,148 (Fig. 25) (Video 22, see Supplemental Digital Content 22, http://links.lww.com/AA/A103; see Video 22 legend at Appendix 1, http://links.lww.com/AA/A104), MV clipping,149 ASD device closure,134,140 and LAA device occlusion.150 The development of new minimally invasive cardiac surgical techniques151 combined with the advances in RT 3D TEE technology have permitted the integration of both into experimental robotic surgery workstations.17 This technology uses stereoscopic rendering of RT 3D TEE imaging to guide the beating heart intracardiac procedure.17 This technique has shown promising results in ASD152 and VSD153 closure in an animal model.
The 2 main limitations to current 3D technology are low frame rate with poor temporal resolution of large 3D datasets and artifacts generated by the metallic surgical instruments. Integration of systems to track the position of the surgical instruments in space and RT 3D TEE imaging is under development.
Intraoperative RT 3D TEE has elevated TEE to a new fascinating and challenging dimension. Spectacular pictures, ease of use, and simplification of challenging diagnoses are combined in a tool that has not yet revealed its full potential. The continued evolution of current RT 3D TEE technology should aim to satisfy the needs of the fast and hectic intraoperative environment. Quicker acquisition of 3D full volume and 3D color Doppler combined with on-line automatic 3D LV and RV reconstruction would provide the cardiac anesthesiologist with the most precise tool to assess and monitor LV and RV volumes. Integration of spectral Doppler and TDI should be incorporated into the next generation of 3D TEE probes.154
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