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Three-Dimensional Echocardiography

The Benefits of the Additional Dimension

Roberto M. Lang, MD^_*,_*,1, Victor Mor-Avi, PhD^_*,2, Lissa Sugeng, MD^_*,3, Petra S. Nieman, MD and David J. Sahn, MD^,4

^_* Cardiac Imaging Center, Departments of Medicine and Radiology, University of Chicago, Chicago, Illinois
Cardiac Fluid Dynamics and Imaging Laboratory, Oregon Health and Science University, Portland, Oregon

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 1 The transition from 2-dimensional (2D) to 3-dimensional (3D) imaging. Although 2D imaging is based on scanning a single cross-sectional plane of the heart at a time (left), 3D imaging scans a pyramidal volume (right). RT3D = real-time 3D echocardiography.

View larger version (75K): [in this window] [in a new window] [Download PPT slide]   Figure 2 Different modes of data acquisition using the matrix-array transducer. These include narrow-angled scan (left), zoom mode (middle), and wide-angled scan (right). Reproduced, with permission, from Sugeng et al. (32).

View larger version (38K): [in this window] [in a new window] [Download PPT slide]   Figure 3 Dynamic analysis of real-time 3-dimensional data. Biplanar display (left) can be used to detect left ventricular (LV) endocardial surface at each time point (middle), which allows the calculation of LV volume over time throughout the cardiac cycle (right).

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 4 Effects of volumetric imaging on the accuracy of left ventricular (LV) mass measurements. End-diastolic apical 4- (A4C) and 2-chamber (A2C) views of the LV obtained in a patient using conventional 2-dimensional (2D) imaging (top) and anatomically correct apical 4- and 2-chamber cut planes selected from a real-time 3-dimensional (3D) data set obtained in the same subject (middle). Manually traced endocardial and epicardial boundaries used to calculate LV mass are shown on the images. The LV long-axis dimension was measured on such images in 19 patients (bottom). Note the increase in the length of the LV in both apical views, as assessed by the 3D technique in most patients (large circles and error bars represent mean ± SD, *p < 0.05). Reproduced, with permission, from Mor-Avi et al. (114).

View larger version (56K): [in this window] [in a new window] [Download PPT slide]   Figure 5 Volumetric analysis of regional left ventricular (LV) function. Example of LV endocardial surface detected from a 3-dimensional (3D) data set at 3 different phases of the cardiac cycle, superimposed on a cross-sectional long-axis plane (top left). Schematic representation of the 3D segmentation model: A2C, A3C, and A4C = apical 2-, 3-, and 4-chamber planes, respectively; Ao = central point of the aortic annulus; MV = central point of the mitral valve (top right). Shaded area is an example of an LV endocardial surface segment representing the midseptal (m-sp) wall. Below are examples of regional volume and wall motion time curves and regional shortening fraction (RSF) in 6 apical segments, obtained in a normal subject (left) and a patient with coronary artery disease (CAD) (right) and hypokinesis in the lateral wall (arrow). Ant = anterior; asp = anteroseptal; inf = inferior; lat = lateral; %RR = percent of electrocardiogram RR-interval; pst = posterior; sp = septal.

View larger version (55K): [in this window] [in a new window] [Download PPT slide]   Figure 6 Off-line viewing of real-time 3-dimensional data obtained during dobutamine stress test. These data sets can be used to extract multiple short-axis views at different levels of the left ventricle (left). Example of such views extracted from data sets obtained at rest and during peak dobutamine stress (right).

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 7 Assessment of the improvement in synchrony of left ventricular (LV) contraction with pacing. Regional volume time curves (left) obtained in a patient with LV dyssynchrony without (top) and with (bottom) biventricular pacing. Endocardial surfaces reconstructed from each data set are shown with segmentation and color coding according to regional time to end ejection (middle) along with the bull’s-eye representation of the same data (right). Note the changes in colors with pacing reflecting the effects of resynchronization therapy in this parametric display. Ant = anterior; Ant-Sept = anteroseptal; EF = ejection fraction; Inf = inferior; Lat = lateral; Post = posterior; Sept = septal.

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 8 Simultaneous multiplanar strain rate imaging. Matrix-array technology allows quantitative assessment of strain rate in multiple myocardial segments by analysis of tissue Doppler data obtained from the apical approach.

View larger version (72K): [in this window] [in a new window] [Download PPT slide]   Figure 9 Real-time 3-dimensional (3D) visualization of myocardial perfusion. Contrast-enhanced 3D data set obtained in a patient with severe discrete left anterior descending artery stenosis (left). A region in the interventricular septum shows lack of contrast enhancement, indicating a perfusion defect that was supported by abnormal wall motion. This defect was visible in multiple cross-sections (right), allowing easy estimation of its extent.

View larger version (69K): [in this window] [in a new window] [Download PPT slide]   Figure 10 Volume rendering of the mitral valve obtained from real-time 3-dimensional data. The data set on the left was obtained in a patient with a perforated anterior mitral leaflet, which was confirmed by an intraoperative image (right). Reproduced, with permission, from Schwalm et al. J Am Soc Echocardiogr 2004;17:919–22.

View larger version (72K): [in this window] [in a new window] [Download PPT slide]   Figure 11 Real-time volumetric imaging and analysis of the mitral valve. (Top) Baseline image before mitral balloon valvuloplasty (A) shows a restricted mitral valve opening with bicommissural fusion. After valvuloplasty, splitting of the medial commissure and posterior leaflet tear can be seen (B). (Bottom) Example of 3-dimensional reconstruction of the mitral annulus (C) and leaflets (D) obtained in a patient with dilated cardiomyopathy, showing the saddle shape of the annulus and increased leaflet tenting volume. IVS = interventricular septum; LA = left atrium; LV = left ventricle; M = medial; P = posterior; RV = right ventricle.

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 12 Color flow volume rendering. These data were obtained in a patient with mitral stenosis depicting a 3-dimensional (3D) mitral regurgitant (MR) jet in systole (A). Both regurgitant jet and left atrium (LA) could be manually traced to estimate the MR and LA volume, displayed as a surface-rendered images superimposed on the 3D image (B and C). The vena contracta (arrows) of the regurgitant jet is shown in two orthogonal views (D and E). The level of the vena contracta is visualized along with the gray-scale information (F).

View larger version (82K): [in this window] [in a new window] [Download PPT slide]   Figure 13 Real-time 3-dimensional color Doppler stroke volume computation. Dynamic analysis of Doppler velocities in the left ventricular outflow tract (LVOT) throughout the cardiac cycle allows accurate quantification of left ventricular stroke volume. AV = aortic valve.

View larger version (75K): [in this window] [in a new window] [Download PPT slide]   Figure 14 Real-time 3-dimensional (3D) fetal echocardiography. (A) A 3D image obtained in a 23-week fetus with tetralogy of Fallot and absent pulmonary valve showing a small pulmonary annulus with no valve tissue and a dilated main pulmonary artery. (B) Spatio-temporal image correlation slow-sweep image of ventricular filling in a normal 21-week fetus.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 15 Real-time 3-dimensional imaging of the right ventricle. Subcostal data set shows both inlet and outflow components of the right ventricle required for accurate right ventricular volume determination. MB = moderator band; OS INF = os infundibulum or opening of the right ventricular outflow tract; LV = left ventricle;. PV = pulmonary valve; TV = tricuspid valve.