Simultaneous Multiplane 2D-Echocardiography

Two-dimensional (2D) transthoracic echocardiography is one of the most frequently used techniques for diagnosis, management and follow-up of patients with any suspected or known cardiovascular disease. It is based on multiple single cardiac planes taken from standard positions on the chest wall. With the development of the matrix transducer, three-dimensional echocardiography (3D) can now be performed in the routine lab reducing the number of cross-sections needed for the information required. However, there are several challenges for the use of 3D echocardiography in daily clinical practice. The 3D transducer has a lower temporal resolution and the acquisition time is time-consuming often requiring offline analysis. Also as 3D echocardiography is a relatively new technique, it requires extra training and has a learning curve. Recently, a new generation 2D/3D matrix transducer has become available, overcoming some of these drawbacks and even introducing a new image modality called “Simultaneous Multiplane Imaging” (SMPI). This new modality permits the use of a full electronic rotation of 360° of the 2D image (iRotate) and a simultaneously adjustable biplane 2D image (xPlane). This thesis investigates the potential contributions of this new imaging modality to cardiovascular imaging and patient care. Firstly it concentrates on how this new imaging modality can be utilized on day-to-day bases in the echo laboratory cutting down the scanning time and making cross-sectional scanning more robust. The following section on congenital and valvular heart disease reveals that this imaging technique makes the diagnose of a secundum atrial septal defect less operator dependent but most importantly a diagnostic transesophageal echocardiography (TEE) will not always be necessary. With 2D xPlane imaging the MV can be assessed in a systematic manner and we could correctly diagnose the site and extent of a mitral valve prolapse. Most patients may thus be operated on without the need for an outpatient pre-operative TEE. In transcatheter aortic valve implantation (TAVI) iRotate echocardiography may it possible to study the whole circumference of the TAVI prosthesis f

Transthoracic three-dimensional echocardiography in adult patients with congenital heart disease

Objectives: This study sought to assess both the feasibility and potential role of transthoracic three-dimensional echocardiography for the evaluation of adult patients with congenital heart disease. Background: The unrestricted views with depth perception provided by three-dimensional echocardiography with dynamic volume-rendered display may enhance visualization of cardiac structures and detection of abnormalities in patients with congenital heart defects. Methods: We studied 33 patients with various heart defects (mitral valve anomalies in 9, aortic valve anomalies in 5, subaortic membrane in 5, ventricular septal defect in 4, transposition of the great arteries in 3, tetralogy of Fallot in 2, other defects in 5). Cross-sectional images of the specific region of interest were acquired from either the parasternal or apical window with the rotational technique (2° interval with electrocardiographic and respiratory gating) and postprocessed for resampling in cubic format. From these three-dimensional data sets a multitude of cut planes were selected, presented in volume-rendered dynamic display and analyzed by two observers for comparison with standard two-dimensional images to assess their additional information. Results: Three-dimensional reconstruction was possible in all patients. Structures of interest were evaluated from unusual viewpoints, providing both cardiologists and surgeons with immediate feedback. When compared with standard two-dimensional images, additional information was provided for 12 patients (36%). The mitral valve, aortoseptal continuity and interatrial septum were the structures for which three-dimensional echocardiography was most useful. Conclusions: Transthoracic three-dimensional echocardiography is feasible and facilitates spatial recognition of the intracardiac anatomy in a significant proportion of patients and enhances diagnostic confidence of complex congenital heart disease

Cardiac catheterization under echocardiographic control in a pregnant woman

A 22 year old woman had signs of rheumatic mitral and aortic valve disease early in pregnancy. Cardiac catheterization was performed during her third month of pregnancy under two-dimensional echocardiographic control without the use of ionizing radiation. Severe mitral stenosis with mild aortic stenosis was found. Five cubic centimeters of 5 percent dextrose in water were injected by hand to obtain left ventriculograms and supravalvular aortograms of sufficient quality to diagnose valvular regurgitation. The use of "echo-catheterization" may have significant advantages in selected clinical situations

Repetitive out of hospital cardiac arrests following pregnancy: A case report of an unfortunate presentation of mitral annular disjunction

Background Mitral annular disjunction (MAD) is an under-recognized cause of arrhythmic sudden cardiac death, especially in young women. The relation between MAD and the occurrence of arrhythmia during pregnancy has not yet been explored. We would like to stress the importance of careful echocardiographic examination and the vulnerable peripartum period. ................................................................................................................................................................................................... Case summary A 29-year-old woman survived an out of hospital cardiac arrest 4 months after delivery of her first child. The diagnosis was not clear and an implantable cardioverter-defibrillator (ICD) as secondary prevention was implanted. Her second pregnancy and delivery were uneventful. The 12-lead electrocardiogram demonstrated sinus rhythm with right bundle branch block, ventricular extra systoles (premature ventricular contractions), and a right superior axis, i.e. origin in the inferolateral basal left ventricle. Transthoracic 2D echocardiography showed myxomatous mitral valve disease with moderate mitral valve insufficiency with normal left and right heart dimensions and function. However, 4 weeks after delivery she experienced a sudden syncope at home. Implantable cardioverter-defibrillator reading revealed primary ventricular fibrillation, induced by a ventricular premature beat (VPB), terminated with a successful ICD shock. A frame-by-frame echocardiographic analysis of the mitral valve using biplane echocardiographic analysis allowed diagnosis of MAD with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole. ................................................................................................................................................................................................... Conclusion Mitral annular disjunction is an under-recognized cause of arrhythmic sudden cardiac death. Biplane echocardiographic analysis of the mitral annulus can identify MAD and as such may help for risk stratification and sudden cardiac death prevention. Careful follow-up is necessary especially during pregnancy and the postpartum period

Echocardiographic chamber quantification in a healthy Dutch population

Aim For accurate interpretation of echocardiographic measurements normative data are required, which are provided by guidelines. For this article, the hypothesis was that these cannot be extrapolated to the Dutch population, since in Dutch clinical practice often higher values are found, which may not be pathological but physiological. Therefore this study aimed to 1) obtain and propose normative values for cardiac chamber quantification in a healthy Dutch population and 2) determine influences of baseline characteristics on these measurements. Methods Prospectively recruited healthy subjects, aged 20–72 years (at least 28 subjects per age decade, equally distributed for gender) underwent physical examination and 2D and 3D echocardiography. Both ventricles and atria were assessed and volumes were calculated. Results 147 subjects were included (age 44 ± 14 years, 50% female). Overall, feasibility was good for both linear and volumetric measurements. Linear and volumetric parameters were consistently higher than current guidelines recommend, while functional parameters were in line with the guidelines. This was more so in the older population. 3D volumes were higher than 2D volumes. Gender dependency was seen in all body surface area (BSA) corrected volumes and with increasing age, ejection fractions decreased. Conclusion This study provides 2D and 3D echocardiographic reference ranges for both ventricles and atria de-rived from a healthy Dutch population. BSA indexed volumes are gender-dependent, age did not influence ventricular volumes and a rise in blood pressure was independently associated with increased right ventricular volumes. The higher volumes found may be indicative for the Dutch population being the tallest in the world

Left atrial deformation analysis in patients with corrected tetralogy of fallot by 3D speckle-tracking echocardiography (from the MAGYAR-path study)

Background: Three-dimensional (3D) echocardiography coupled with speckle-tracking echocardiographic (STE) capability is a novel methodology which has been demontrated to be useful for the assessment of left atrial (LA) volumes and functional properties. There is increased scientific interest on myocardial deformation analysis in adult patients with corrected tetralogy of Fallot (cTOF). Objectives: To compare LA volumes, volume-based functional properties and strain parameters between cTOF patients and age- and gender-matched healthy controls. Methods: The study population consisted of 19 consecutive adult patients with cTOF in sinus rhythm nursing at the University of Szeged, Hungary (mean age: 37.9 ± 11.3 years, 8 men, who had repair at the age of 4.1 ± 2.5 years). They all had undergone standard transthoracic two-dimensional Doppler echocardiographic study extended with 3DSTE. Their results were compared to 23 age- and gender-matched healthy controls (mean age: 39.2 ± 10.6 years, 14 men). Results: Increased LA volumes and reduced LA emptying fractions respecting cardiac cycle could be demonstrated in cTOF patients compared to controls. LA stroke volumes featuring all LA functions showed no differences between the 2 groups examined. LA global and mean segmental uni- and multidirectional peak strains featuring LA reservoir function were found to be diminished in adult patients with cTOF as compared to controls. Similarly to peak strains reduced global and mean segmental LA strains at atrial contraction characterizing atrial booster pump function could be demonstrated in cTOF patients as compared to controls. Conclusions: Significant deterioration of all LA functions could be demonstrated in adult patients with cTOF late after repair

Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography

Aim: Assessment of pulmonary valve (PV) and right ventricular outflow tract (RVOT) using real-time 3-dimensional echocardiography (RT3DE). Methods: Two-dimensional echocardiography (2DE) and RT3DE were performed in 50 patients with congenital heart disease (mean age 32 ± 9.5 years, 60% female). Measurements were obtained at parasternal views: short axis (PSAX) at aortic valve level and long axis (PLAX) with superior tilting. RT3DE visualization was evaluated by 4-point score (1: not visualized, 2: inadequate, 3: sufficient, and 4: excellent). Diameters of PV annulus (PVAD), and RVOT (RVOTD) were measured by both 2DE and RT3DE, while areas (PVAA) and (RVOTA) by RT3DE only. Results: By RT3DE, PV was visualized sufficiently in 68% and RVOTexcellently in 40%. PVAD and PVAA were measured in 88%. RVOTD and PVAD by 2DE at PLAX were significantly higher than PSAX (P < 0.0001) and lower than that by RT3DE (P < 0.001). Conclusion: RT3DE helps inRVOT and PV assessment adding more details supplemental to 2DE

A modified echocardiographic classification of mitral valve regurgitation mechanism: The role of three-dimensional echocardiography

In this report, we provide an overview of a new, updated echocardiographic classification of mitral regurgitation mechanisms to provide a more comprehensive and detailed assessment of mitral valve disorders. This is relevant to modern mitral valve repair techniques, with special attention to the added value of 3D-echocardiography

Influence of age and sex on left ventricular diastolic strain analysis

Speckle tracking analysis (STE) of the left ventricle offers a new method to assess left ventricular (LV) diastolic function. LV diastolic strain measurements offer a non-invasive, global and direct measure of LV diastolic function. However, there is little data on normal values and the influence of anthropomorphic factors which is crucial in clinical practice for new techniques. The aims of this study were to formulate reference values for LV diastolic strain rate, elucidate effects of age and sex on LV diastolic strain analysis and compare STE measurements with conventional LV diastolic measurements. One-hundred-forty-seven healthy subjects aged 20–72 years (≥ 28 subjects per age decade) were prospectively included (Mean age 44 ± 13.7 years, 50% female) and examined with electrocardiography and 2D-echocardiography, including speckle tracking. Left ventricular peak early diastolic strain rate (Sre) was measured in the apical windows, using STE. Men had significantly lower LV Sre values than women (1.02 ± 0.22 vs. 1.18 ± 0.23, p value < 0.001). Left ventricular Sre was inversely associated with age, with values decreasing with ageing. An inverse relation was also found with blood pressure and body surface area. Linear regression analysis showed that LV Sre was independently associated with both age and sex. A multivariable linear regression analysis for LV Sre with conventional LV diastolic variables accounted for 70.9% of the variation of LV Sre, showing good model performance. Reference values for LV Sre are reported and found to be both age- and sex-dependent. Therefore we recommend age- and sex-specific references values to be used in daily clinical practice

Evaluation of pericardial hydatid cysts by different echocardiographic imaging modalities

Cardiac hydatid disease or echinococcosis is a rare complication of Echinococcus granulosus infection. Traditionally, the diagnosis is made with two-dimensional transthoracic echocardiography. This case report shows the complementary function of the different echo modalities (two-dimensional, three-dimensional, and contrast echocardiography) and MRI in the evaluation of pericardial hydatid cyst