Valvular Heart Disease - COnnecting REpositories · the role of 3DE in evaluating valvular anatomic...

Journal of the American College of Cardiology Vol. 58, No. 19, 2011© 2011 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00

STATE-OF-THE-ART PAPER

Valvular Heart DiseaseThe Value of 3-Dimensional Echocardiography

Roberto M. Lang, MD, Wendy Tsang, MD, Lynn Weinert, BS, Victor Mor-Avi, PHD,Sonal Chandra, MD

Chicago, Illinois

Significant advances in 3-dimensional echocardiography (3DE) technology have ushered its use into clinical prac-tice. The recent advent of real-time 3DE using matrix array transthoracic and transesophageal transducers hasresulted in improved image spatial resolution, and therefore, enhanced visualization of the pathomorphologicalfeatures of the cardiac valves compared with previously used sparse array transducers. It has enabled an unpar-alleled real-time visualization of valves and subvalvular anatomic features from a single volume acquisition with-out the need for offline reconstruction. On-cart or offline post-processing using commercially available and cus-tom 3-dimensional analysis software allows the quantification of multiple parameters, such as orifice area,prolapse height and volume in mitral valve disease, area of the left ventricular outflow tract, and tricuspid annu-lar geometry. In this review, we discuss the incremental role of 3DE in evaluating valvular anatomic features,volumetric quantification, pre-surgical planning, intraprocedural guidance, and post-procedural assessment ofvalvular heart disease. (J Am Coll Cardiol 2011;58:1933–44) © 2011 by the American College of CardiologyFoundation

Published by Elsevier Inc. doi:10.1016/j.jacc.2011.07.035

Three-dimensional echocardiography (3DE) plays an in-creasingly important role in the management of valvularheart disease because of developments in ultrasound andcomputer technologies, which have resulted in improved on-line 3D displays and sophisticated offline volumetric quantifi-cation of valves (1). 3DE’s superiority over 2-dimensionalechocardiography (2DE) lies in its realistic imaging of nativevalves and their anatomic relationships, improved quantifica-tion of valve geometry, and improved reproducibility in diseaseseverity quantification. It supplements 2DE’s prosthetic valveevaluation, allowing visualization of the valve from any orien-tation, and specifically through the addition of the en face view.

3DE offers narrow-angle, zoom or magnified, and wide-angle acquisition modes, resulting in varying pyramidal scanvolumes and degrees of spatial resolution, which allows forcharacterization of specific components of the valvularapparatus (Table 1). The introduction of single-beat full-volume imaging also has circumvented the issues related tomotion artifacts, thereby further improving the ease ofacquisition and quality of data. When compared with 3Dtransthoracic echocardiography (TTE), 3D transesophagealechocardiography (TEE) has higher spatial resolution, re-sulting in images with unparalleled anatomic detail. How-

From the University of Chicago Medical Center, Chicago, Illinois. Dr. Tsang isfunded through a Canadian Institute of Health Research research fellowship grant.All authors have reported that they have no relationships relevant to the contents ofthis paper to disclose. Drs. Tsang and Chandra contributed equally to this work.

Manuscript received May 20, 2011; revised manuscript received July 14, 2011,accepted July 18, 2011.

ever, recent advances in 3D TTE have resulted in improvedimage quality (Fig. 1), providing incremental clinical use-fulness compared with 2D TTE. Besides accurately assess-ing left ventricle (LV) volumes in valvular heart disease, 3DTTE has improved the assessment of valvular anatomicfeatures and regurgitation as well as left ventricular outflowtract (LVOT) dimensions (2–4). In this review, we discussthe role of 3DE in evaluating valvular anatomic features,volumetric valve quantification, pre-surgical planning, in-traprocedural guidance, and post-procedural assessment ofvalvular heart disease.

Mitral Valve

Anatomy and physiology. The mitral valve (MV) is acomplex apparatus requiring its anatomic components, theannulus, leaflets, tendinous chordae, and papillary muscles,to function in concert throughout the cardiac cycle. Char-acterization of the MV by 3DE has shed important mech-anistic and anatomic insight into the pathophysiologicalaspects of mitral regurgitation (MR). The fibromuscular,hyperbolic-paraboloid, or saddle-shaped annulus anchoringthe leaflets is configured to minimize leaflet stress (5). Theanterior annulus shares a fibrous region of continuity be-tween the aortic root and the anterior mitral leaflet (Fig. 2).This anterior aspect of the annulus, which is less prone todilation, is bordered by the left and the right fibroustrigones, which are separated by a rigid span of fibroustissue, the intertrigonal region. The posterior annulus re-
ceives some muscular fiber from the proximal aspect of the

Ltaar3bacuo(

ttrcftatlvioceblu

iibaaSoha

1934 Lang et al. JACC Vol. 58, No. 19, 20113D Echocardiography and Valve Disease November 1, 2011:1933–44

posterior leaflet, which may con-tributes to annular flexibility, andis separated from the LV by col-lagenous elements. The annulusis a dynamic structure requiring3D deformation in its circumfer-ence, excursion, curvature, shape,and size for proper functioning,which in turn is susceptible toventricular remodeling (6).

The current aim of MV recon-structive surgery is to restore nor-mal annulus shape and kinemat-ics from its dilated form indegenerative or myxomatous dis-ease or from its deranged geom-etry secondary to ischemic or di-lated cardiomyopathy. 3DE hasbeen integral for improving ourunderstanding of the underpin-nings of mitral annular geometryand dynamics. By emphasizingthe role of annular nonplanarity,3DE plays a role in assessingsuitability of customized pros-thesis or other repair strategiesaimed at restoring or maintain-ing the saddle shape of the an-nulus. Theoretically, restorationof mitral annular shape, whichcould be measured before andafter surgery using 3D TEE inthe operating room, should leadto a reduction in leaflet stress andshould improve repair durability.

The MV leaflets are the mostsusceptible to alterations. The

atrial or smooth surface is free of any attachments, incontrast to the ventricular surface, or rough zone, where thechordae tendineae connect the leaflets to the papillarymuscles. The posterior leaflet commonly is indented twice,resulting in 3 independently mobile scallops identified as

Probe Positioning for 3-Dimensional EchocardiogTable 1 Probe Positioning for 3-Dimensiona

TransthoraciEchocardiogra

Mitral valve Parasternal long-axi

Apical 4-chamber vi

Aortic valve and root Parasternal long-axi

Apical 5-chamber vi

Tricuspid valve Parasternal short-ax

Parasternal RV inflo

Apical 4-chamber vi

Pulmonary valve and root Parasternal short-ax

Parasternal RV outfl

Abbreviationsand Acronyms

2D � 2-dimensional

2DE � 2-dimensionalechocardiography

3D � 3-dimensional

3DE � 3-dimensionalechocardiography

AV � aortic valve

AVA � aortic valve area

EROA � effectiveregurgitant orifice

LV � left ventricle

LVOT � left ventricularoutflow tract

MR � mitral regurgitation

MV � mitral valve

PBMV � percutaneousballoon mitral valvuloplasty

PISA � proximal isovelocitysurface area

PM � papillary muscle

PV � pulmonary valve

RV � right ventricle

SAM � systolic anteriormotion

TEE � transesophagealechocardiography

TTE � transthoracicechocardiography

TR � tricuspidregurgitation

TV � tricuspid valve

VC � vena contracta

RV � right ventricular.

P1, P2, and P3, with analogous virtual subdivisions on thenonindented anterior leaflet (A1, A2, and A3) (Fig. 2).

eaflet segmentation based on this Carpentier nomencla-ure is used widely when localizing specific MV lesions. Thenatomic features of the leaflets, including the quadrangularnd semicircular shapes of the posterior and anterior leaflets,espectively, is appreciable easily on a standard magnifiedDE image. The surgeon’s view is also how the valve shoulde displayed when viewed from the left atrium with theortic valve (AV) in the 12-o’clock position. Sharing aommon view, the echocardiographer and the surgeon cannderstand and communicate the anatomic locations with-ut the mental integration associated with 2-dimensional2D) imaging.

During systole, there is billowing of the MV leaflets intohe atrium, resulting in leaflet curvature. 3DE demonstratedhat, although curvature across most of the MV surface isemarkably constant, there is a single focus of regionalurvature heterogeneity within the P1 region and 2 largeoci in P2 (7). This may account for the increased suscep-ibility of these 2 segments to prolapse or flail in degener-tive MV disease. The zone of coaptation, approximately 5o 10 mm in height, resulting from anterior and posterioreaflet apposition, is demonstrated optimally in surgicaliews by 3DE. Quantification of the coaptation index by 3Dmaging has diagnostic relevance in assessing normalizationf valve geometry and function after annuloplasty (8). Theavoconvex line of closure between the leaflets does notxtend to the annulus, but rather ends at the junctions ofoth mitral leaflets, forming the posteromedial and antero-ateral commissures. These structures are well characterizedsing narrow-sector acquisitions.The tendinous chordae, critical in their role in withstand-

ng tensile stress exerted by the papillary muscles (PMs),nsert with some variation into the leaflets and are viewedest from the ventricular perspective with wide-angledcquisitions. Primary chords are responsible for leafletpposition, but when pathologic, result in regurgitation.econdary or “strut” chords contribute toward maintenancef normal ventricular geometry, and abnormalities do notave adverse effects on leaflet coaptation (9). There is 1nterolateral PM compared with the multiheaded postero-

y En Face Image Acquisitionocardiography En Face Image Acquisition

Transesophageal Echocardiography

0° to 120° midesophageal views

60° midesophageal, short-axis view

120° midesophageal, long-axis view

0° to 30° midesophageal, 4-chamber view

40° transgastric view

90° high-esophageal view

w 120° midesophageal, 3-chamber view

raphl Ech

cphy

s view

ew

s view

ew

is view

w view

ew

is view

ow vie

1935JACC Vol. 58, No. 19, 2011 Lang et al.November 1, 2011:1933–44 3D Echocardiography and Valve Disease

medial PM, but there exists considerable variation in thesize and number of these muscles. During 3D TEE, PMpathological features, including fibrosis, necrosis, or rupture,can be visualized optimally via the transgastric views usingthe narrow-angled acquisition mode.Degenerative MV disease. A systematic segmental analy-sis of 3DE images not only localizes the lesions, but also thecause in the case of degenerative (Barlow’s disease) ormyxomatous (fibroelastic deficiency) MV disease. The enface views of the MV permit visualization of leaflet prolapseand flail segments without rotational artifacts (Fig. 3). Thediagnosis of MV prolapse by conventional 2DE has beenless accurate because of the discrepancy between the non-planar leaflet–annular relationship in intersecting 2D views.In 3D volume-rendered images, a prolapsing scallop orsegment is identified as a bulge into the left atrium, whichcan be color-coded to differentiate from normal adjoiningsegments or scallops (Fig. 4). 3DE is highly accurate andreproducible in localizing prolapsing segments, especiallycommissural or A1 involvement, when compared with thegold standard of surgical inspection (10). Accurate diagnosisof these prolapsing segments and their specific location andcomplexity is important, because they require careful match-ing between the complexity of reparability with surgicalexpertise. It is feasible with 3D TTE to identify accuratelysimple versus complex MV lesions and to perform morpho-logical assessment of the repaired MV after surgery (3).

Figure 1 Valvular Anatomic Features Displayed by 3D TTE

Three-dimensional (3D) transthoracic echocardiography (TTE) images of (A) astenotic rheumatic mitral valve from the left atrial perspective, (B) a mitralvalve with P2 segmental prolapse from the left atrial perspective, (C) a normaltricuspid valve from the right ventricular perspective, and (D) a normal aorticvalve as viewed from the aorta.

Concomitant use of 3D color Doppler analysis of the

regurgitant jet further improves the accuracy of 3DEmethods.

In the degenerative MVs, 3D TEE allows reproduciblevolumetric measurements of annular area, circumference,and planarity index, facilitating assessment of disease com-plexity, repair strategies, and post-surgical success (10,11).By quantifying the extent of excess leaflet length, surfacearea, and billowing volume, 3DE analysis helps to identifypatients at risk of having systolic anterior motion (SAM)after MV repair. Although sizing of MV annuloplasty ringsremains controversial, accurate sizing permissible by 3DEimaging potentially can prevent SAM, and therefore, post-operative regurgitation. The propensity for SAM develop-ing after MV repair in part is dependent on the degree ofmitroaortic angle, presence of excess tissue, and displace-ment of mitral coaptation line, all of which can be charac-terized by 3DE (12). The contribution of subvalvular-ventricular geometry, annular nonplanarity, LV outflowcross-sectional area, and intrinsic leaflet abnormalities, suchas increased leaflet area to SAM, were made evident by arecent study (12). 3DE may play a significant role inidentifying interventional targets in patients with persistentMR resulting from SAM despite MV surgery.Ischemic or functional MR. Alteration of MV apparatusgeometry from enhanced tethering of leaflets or PM dis-placement in ischemic or dilated cardiomyopathy leads todecreased leaflet apposition with resultant MR. However, itseems that the MV dysfunction in ischemic or functionalMR is multifactorial. 3DE studies in animals demonstrateresolution of MR after plication of the infarct region,lending credibility to the idea that valvular derangement attimes is linked inextricably to the remodeled myocardium(Fig. 4) (13). Quantifying differences in mitral geometry andMR jet characteristics between ischemic and dilated MRcan provide mechanistic insights into these 2 distinct types

Figure 2 Aortic and Mitral Valve Anatomic FeaturesDisplayed on 3D TEE

(A) Schematic and (B) 3-dimensional (3D) transesophageal echocardiography(TEE) en face image of the mitral valve from left atrial perspective depictingnormal anatomy. Figure illustration by Craig Skaggs.


of MR and accordingly can alter surgical interventions.Currently, both MR types are subject to the same surgicalstrategy of annular reduction. Quantification of geometric

Figure 3 Differential Diagnoses of Mitral Leaflet Prolapse

2D TEE long-axis view demonstrating anterior leaflet prolapse (A, top) with a 3D transesonosed when the free edge of the leaflet overrides the plane of the mitral annulus during sdue to chordae elongation (B, top) with 3D transesophageal example as seen from the lelet body into the left atrium due to excess leaflet tissue, with the leaflet free edge remainichordae rupture (C, top) with a 3D transesophageal example of P2 flail as viewed from th

Figure 4 3D Volumetric Quantification of the Mitral Valve

(A) Zoomed, en face 3D TEE image of a patient with P2 flail mitral leaflet with visinimetry image from 3D TEE of a stenotic rheumatic mitral valve. (D) Volumetric reonstrating a funnel-shaped deformity with displacement of the papillary muscles. (demonstrating increased annular planarity and dimensions. (F) Volumetric reconsttry of the anatomic regurgitant orifice (arrow). A � anterior; AL � anterolateral; Ao

parameters such as tenting length and volume with local-ization of the variable peak-tenting site not only is feasible,but also is superior by 3DE (14). 3DE can guide the site and

l example as seen from the left atrium (A, bottom). Leaflet prolapse should be diag-2D TEE long-axis view demonstrating bileaflet billowing of the mitral valve with prolapsem (B, bottom). Leaflet billowing is diagnosed when there is systolic excursion of the leaf-w the plane of the mitral annulus. 2D TEE long-axis view demonstrating flail valve due totrium (C, bottom). Abbreviations as in Figure 2.

tured chords and (B) the corresponding 3D parametric image. (C) En face pla-uction of the mitral valve in a nonischemic dilated cardiomyopathy patient dem-umetric reconstruction of a mitral valve with prolapsing P1 and P2 leaflets

of a mitral valve with a prolapsing posterior leaflet demonstrating the asymme-rtic valve; P � posterior; other abbreviations as in Figure 2.

phageaystole.ft atriung beloe left a

ble rupconstrE) Volruction� ao


choice of intervention in ischemic MR by visualizing theactual tethering sites contributing to abnormal leaflet dy-namics. 3DE has demonstrated that normal annular mitraldynamics, designed to prevent regurgitation, althoughdampened in ischemic MV, are less affected in degenerativevalves where conformational changes in geometry causemalcoaptation with resultant MR. These findings mayinfluence surgical repair techniques. 3D TTE may be suitedideally to gauging after surgery the relationship between thechoice of surgical repair, its effects on MV geometry anddynamics, and consequent durability.

3DE studies in ischemic MR suggest that leaflet adapta-tions to tethering and annular dilation may be essentialtoward maintenance of total leaflet area, annular area ratio,and residual coaptation area. When there is insufficientcompensation with leaflet-to-closure area ratio �1.7, itresults in moderate to severe MR, which suggests a mech-anism to target potentially by modifying leaflet area as atherapeutic approach to functional MR (15).Quantification of MR. 3DE allows not only color Dopp-ler evaluation, but also evaluation of the anatomic regurgi-tant orifice area, which is devoid of the flow convergencelimitations and the geometric distortions underlying func-tional and degenerative MR (Fig. 4). The alterations in MVgeometry stemming from tethered or flail leaflets yieldcomplex, 3D elliptical or slit-like, rather than circular andpossibly multiple, separate regurgitant orifices along theclosure line (16). The presence of complex noncircular ormultiple orifices, or both, has important implications for 2Dassessment of the vena contracta (VC) and proximal isove-locity surface area (PISA), especially when 3D color Dopp-ler imaging challenges the assumptions of spherical PISAand circumferential VC (17).

Visualization of regurgitant jets, especially eccentric ones,is feasible and quantifiable in most patients with 3D TEE(18). 3DE has demonstrated improved accuracy in measur-ing 3D PISA-derived effective regurgitant orifice area(EROA) and regurgitant volumes (18). Compared with2DE, 3DE is less hindered by eccentricity of the jets,allowing proper visualization of proximal flow convergence,and thus enabling judicious use of PISA, especially whenthe hemisphericity principle is less applicable in instances ofprolate or oblate hemispheroidal shapes.

2D VC diameter may overestimate the EROA because ofthe complexity of the underlying orifice shape (19). VC areameasurement by multibeam high-pulse repetition frequency3D color Doppler has significant potential for accurateassessment of MR severity unhampered by gain, Nyquistlimit, and phasic restrictions (20). Regurgitant volumederived from EROA measured by 3D planimetry correlateshighly with measurements from velocity-encoded cardiacmagnetic resonance imaging (21).Mitral stenosis. 3DE is preferred for assessing mitralstenosis severity, because the 2DE PISA method is weak-ened by dependency on the opening angle and radius of
convergence, and the 2DE planimetry method results in
area overestimation in patients with poor acoustic windowsor if the narrowest cross section in the MV funnel orifice isnot identified (22). Multiplanar analysis of 3DE dataaccurately and reproducibly identifies the smallest orificearea (Fig. 4), which has been shown to correlate stronglywith area measurements derived invasively using the Gorlinformula (23).

Aortic Valve

Anatomy and physiology. To describe the complete ana-tomic features of the AV, one must also include the aorticroot. The aortic root complex is composed of the sinuses ofValsalva, the fibrous interleaflet triangles, and the AVleaflets. The basal attachments of the AV leaflets delineatethe origin of the aortic root from the LV, whereas thesinotubular junction separates the aortic root from theascending aorta. Along its anterior margin lies the subpul-monary infundibulum, and posteriorly lies the orifice of theMV and the muscular interventricular septum. Overall,approximately two-thirds of the circumference of the lowerpart of the aortic root is connected to the septum, and theremaining one-third is connected via the fibrous continuityto the MV (Fig. 5).

There are 3 AV leaflets attached in a semilunar fashionthroughout the entire length of the root, with the highestpoint of attachment at the level of the sinotubular junctionand the lowest at the junction in the ventricular myocar-dium. The origin of the AV leaflet from the ventricularmyocardium is located below the anatomic ventriculoarterialjunction. Because of these anatomic features, the definitionof aortic annulus has varied with the surgical definitionreferring to a semilunar crown-like structure demarcated bythe hinges of the AV leaflets, whereas the imaging defini-tion refers to the virtual projected ring that connects the 3most basal insertion points of the leaflets. The entire aorticannulus can be assessed from a single 3DE dataset (Fig. 5).Changes in the projected aortic annular area throughout thecardiac cycle have been quantified, demonstrating that it islargest in the first third of systole and smallest duringisovolumic relaxation (24).

The AV leaflets are identified by their relationship to thecoronary arteries. Marked variation exists for all aspects ofthe leaflets, including height, width, surface area, andvolume of the sinuses of Valsalva, all of which can beevaluated easily with 3DE. Furthermore, the distance fromthe projected aortic annulus to the coronary artery ostia canbe measured on 3DE images (25). Identification of shortdistances is important in the assessment of the AV beforetranscatheter AV implantation, because obstruction of thecoronary ostium is a potential complication of the proce-dure. 3DE also has helped to increase our knowledge ofnormal motion of the aortic leaflets (26). It is now recog-nized that this pattern of opening does not parallel com-pletely the pattern of blood flow (27). In addition, it is noted
that the AV orifice shape during systole may be stellate,

2rs

tnmwmHoci

wfrcialefflvg

I3lrmmp8roAsaawsArsttisbste


circular, triangular, or an intermediate form of these variants(26). Normal adult aortic annular area measured by planim-etry on 3DE images is 4.0 � 0.8 cm2 (25). Compared withDE, 3DE measurements have been shown to be highlyeproducible with the small variability originating fromuboptimal cut plane selection (28).

The increase in popularity of transcatheter AV implan-ation for the treatment of aortic stenosis has driven theeed for accurate aortic root measurements. Aortic rooteasurements obtained from 3DE showed good correlationith measurements obtained by multislice computed to-ography and cardiac magnetic resonance imaging (29,30).owever, 3DE measurements usually are larger than those

btained by 2DE, but smaller than those obtained withomputed tomography and cardiac magnetic resonancemaging.

Because of the aortic-mitral curtain, normal AV functionould require that the aortic and MVs are coupled to

unction in a reciprocal, interdependent fashion. Withecent advancements in 3DE technology and the use ofustom software, this valvular coupling has been examinedn normal human hearts (24). It was found that mitralnnular contraction facilitates aortic annular expansion,eading to improved blood flow through the AV during LVjection, and conversely, that aortic annular contractionacilitates mitral annular expansion, which improves bloodow through the MV during LV filling. Clinically, thisalvular coupling is observed through decreased MV regur-

Figure 5 3D TEE Assessment of the Aortic Root

Zoomed 3D TEE image of the aortic valve as viewed from the aorta in (A) diastolejected aortic annulus (green ring), surgical aortic annulus (crown ring), and sinotwhich allows (F) accurate planimetry of the aortic annulus. Ao � aorta; LA � left ain Figure 2.

itation severity after AV replacement. a

maging of the AV. When compared with 2DE, the use ofDE increases accurate identification of abnormal aorticeaflet morphological features, especially bicuspid and quad-icuspid AVs. Also, 3DE is useful for the assessment of AVasses, Lambl’s excrescences, and AV papillary fibroelasto-as (31). Initial studies using early generation 3D TEE

robes found that adequate AV assessment was possible in1% of patients (32). 3DE also improves accuracy of aorticoot measurements. In particular, wide-angled acquisitionsf the aortic root (Fig. 5) allow accurate planimetry of theV, the LV outflow tract, the sinuses of Valsalva, and the

inotubular junction, because the cropping plane can beligned parallel to the structure in question. The ability tossess supravalvular and subvalvular anatomic featuresithin the 3D volume also allows adequate assessment of

erial aortic outflow tract stenoses.ortic stenosis. The use of 3DE has improved the accu-

acy and reproducibility of the quantification of aortic andubaortic stenosis. The most commonly used methods forhe noninvasive determination of aortic valve area (AVA) ishe continuity equation, which assumes that the LVOT areas circular. However, analysis of 3DE images has demon-trated that the LVOT cross-section is not always circular,ut often is elliptical. By uniformly assuming a circularhape, AVA may be underestimated (4). It has been shownhat accuracy of the AVA calculated by the continuityquation is improved by substituting planimetered LVOT

B) systole. (C) Quantification of the aortic root, with (D) identification of the pro-junction (yellow ring). (E) Wide-angled 3D TEE acquisition of the aortic root,; LV � left ventricle; LVOT � left ventricular outflow tract; other abbreviations as

and (ubulartrium

rea measured from 3DE (4).


Another approach that improves AVA assessment isthrough the use of direct volumetric measurements of strokevolume from 3DE, thereby obviating the inaccuracies in-troduced by LVOT measurements (33). With this method,AVA is calculated by dividing 3DE-derived stroke volumeby AV Doppler time-velocity integral. 3DE stroke volume-derived AVAs were shown to have superior accuracy com-pared with the continuity equation and 2D volumetricmethods. Although 3DE areas were slightly smaller thanthose obtained with invasive measurements, the differenceswere clinically negligible (33).

Rather than using the continuity equation, other authorshave suggested that direct planimetry of the AVA from3DE should be performed routinely (34). Overall, thesestudies have demonstrated that planimetered AVA is clin-ically feasible and relatively accurate when compared withinvasive measures and equivalent, if not superior to, 2Dplanimetry (34).

With 3DE, it has been shown that valve shape is animportant determinant of pressure loss in patients with aorticstenosis (35). This is because the 3D geometry of the aorticleaflets affects the pattern of flow convergence toward andbeyond the orifice. Thus, flatter AVs result in smaller effectiveareas and high-pressure gradients, which can result in clinicallyimportant differences between planimetered and effective valveareas calculated by the continuity or Gorlin equation.Aortic regurgitation. 3DE can be used to improve theassessment of aortic regurgitation. The cross-sectional areaof the VC is a surrogate for EROA, and hence, a goodpredictor of regurgitation severity. However, quantificationof the VC using 2D color Doppler images can result inincorrect estimates resulting from geometric assumptionsthat the regurgitant orifice shape is always planar and round,when in reality its geometry can be variable. 3D methods,which reconstruct the VC region allowing true measure-ments of the cross-sectional area, have been shown to bemore accurate (36).

Other 3DE methods for improving the assessment ofaortic regurgitation are still experimental and have yet to bestudied in humans. One such method involves direct measure-

Figure 6 3D TTE Assessment of the Tricuspid Valve

(A) Schematic of the tricuspid valve annulus as it becomes more dilated and circuthe (B) right atrial and (C) right ventricular perspectives. Ant � anterior; Post � p

ment of PISA by computing the difference between 3DE-determined left and right ventricular stroke volumes (37).

Tricuspid Valve

Anatomy and function. The tricuspid valve (TV) is com-posed of leaflet tissue, papillary muscles, chordae tendineae,the supporting annulus, and the annular attachments to theright atrium and right ventricle (RV) myocardium. Thereare 3 TV leaflets of varying sizes that are attached to thefibrous tricuspid annulus. The anterior leaflet is the largestand is attached to the annulus from the RV infundibularregion anteriorly and extends to the inferolateral wallposteriorly. The posterior leaflet is the second largest leafletand is attached to the posterior portion of the annulus fromthe septum to the inferolateral wall. The septal leaflet is thesmallest and it extends along the interventricular septumfrom the infundibulum to the posterior ventricular border.Characteristically, the tricuspid septal leaflet is insertedapically in the interventricular septum relative to the septalinsertion of the anterior MV leaflet (Fig. 6). The TV has 2papillary muscles: anterior and posterior. The anteriorpapillary muscle is attached via the chordae tendineae to theanterior and posterior leaflets, whereas the posterior papil-lary muscle is attached to all 3 leaflets. Although there is noseptal papillary muscle, there are chordae attaching theanterior and septal leaflets to the interventricular septum.

Using 3DE, the tricuspid annulus has been shown to havean elliptical saddle shape and an average area of 9.8 � 2.2cm2 (38). Compared with the MV, the TV annulus shape isless nonplanar, with a wider angle of 170° (39). Thetricuspid annulus has 2 high points oriented superiorlytoward the right atrium and 2 low points oriented posteri-orly toward the RV apex (38). The saddle shape of the TVstems from its bicuspid embryologic origin (38).

3DE has been used to assess tricuspid annular dynamics.During isovolumic contraction, the tricuspid annular areafirst increases slightly as a result of atrial relaxation, followedby a decrease during systole secondary to RV contraction,becoming smallest during mid systole. Subsequently, during

h tricuspid regurgitation. 3D TTE zoomed view of a normal tricuspid valve fromr; Sept � septum; other abbreviations as in Figure 1.

lar witosterio

caetrmcqf

iad

Watea


late systole, the tricuspid annulus increases in size withfurther expansion during isovolumic relaxation caused byright atrial enlargement from passive atrial filling. As soonas the TV opens, there is an abrupt reduction in annular areafollowed by an increase, reaching its maximum size in latediastole, after which atrial contraction reduces annular size.

The elliptical shape of the tricuspid annulus is requiredthroughout the cardiac cycle to maintain TV competency.With the aid of 3DE, it has been demonstrated thatpreservation of tricuspid annular shape also requires normalMV shape. Anatomically, the mitral and TV form a figureeight across the ventricular septum, with the AV located atthe intersection. During ventricular systole, the high LVpressure bends the interventricular septum and mitral an-nulus toward the RV, resulting in a decrease in TV annulardimensions in the lateral direction, which helps to maintaintricuspid annular shape. Without these geometric changes,the tricuspid annulus would become more circular duringsystole, resulting in poor TV leaflets coaptation.Imaging of the TV. 3D TTE of the TV is possible in 90%to 95% of patients and provides insight into the pathophys-iological features of abnormal TVs (40). 2DE is limitedbecause only 2 of the 3 leaflets can be visualized routinely ona single view. Moreover, linear 2DE TV annulus measure-ments fail to account for its saddle shape. With 3DE, enface images of the TV from either the right atrium or RVcan be obtained, allowing dynamic visualization of all 3tricuspid leaflets and their annular attachments.Tricuspid stenosis. Studies have examined the role of3DE in tricuspid stenosis secondary to rheumatic disease(41). These studies again have shown that the main advan-tage of 3DE results from its ability to image the valve enface. Each leaflet can be assessed with regard to thickness,mobility, calcification, and its relationship to other TVleaflets. 3DE-derived en face views also allow accurateplanimetry of the TV area, which correlates well withtranstricuspidal pressure gradients (41).Tricuspid regurgitation. For tricuspid regurgitation (TR)aused by inherent TV abnormalities, such as Ebstein’snomaly or atrioventricular canal defects, 3DE has greatlynhanced the understanding of leaflet morphological fea-ures and pathophysiological mechanisms underlying theegurgitation. 3DE allows visualization of tricuspid leafletorphological features, level of leaflet attachment and

oaptation, subchordal anatomic features, and accurateuantification of regurgitant jets, all of which are valuableor surgical planning.

In functional TR, the use of 3DE has provided newnsights into the geometrical changes of the tricuspidnnulus. As TR progresses, the annulus becomes moreilated, planar, and circular (Fig. 6) (38). The resultant

circular tricuspid annular shape stems from greater enlarge-ment of the anteroposterior over the mediolateral dimen-sions resulting from preferential tricuspid annular dilation
along the RV free wall. In addition, the annulus flattens, d
pulling its low points away from the papillary muscles,thereby increasing tethering.

3DE also has improved the assessment of TR in thepresence of pacemaker leads (42). The success rate inidentifying the position of the lead as it traverses the TV wasonly 17% on 2D TTE versus 94% with 3D TTE (42). 3DEalso often confirms that severe TR caused by the pacemakerlead is the result of obstruction of posterior or septal leafletclosure.

Finally, 3DE plays an important role in the surgicalplanning of traumatic TR (43). Because of its positionbehind the sternum, the TV is the valve most commonlyinjured in blunt chest trauma. Severe regurgitation occurssecondary to rupture of the anterior leaflet chord or, lessfrequently, secondary to rupture of the anterior PM. Inthese cases, early surgical valve repair is recommended, and3DE has played an important role in determining the extentof valve damage in the planning of surgical repair (43).

Quantification of TR by 3DE color Doppler is feasible,and 3D measurements of the VC have demonstrated goodcorrelation with 2D methods (18). With 3DE, planesparallel to the tricuspid orifice can be obtained, and theentirety of the VC can be appreciated. Similar to VC studiesin MR, this has led to the recognition that the VC in TR isnot circular, but rather elliptical (44).

Pulmonary Valve

Normal anatomy and function. The pulmonary valve(PV) is located anterior to the AV above the RV outflowtract and below the main pulmonary artery. The PV lieswithin the pulmonary root, which is the part of the RVoutflow tract that supports the PV leaflets. The pulmonaryroot complex is composed of the valvular leaflets, the sinusesof Valsalva, the interleaflet triangles, and the free-standingdistal RV muscular infundibulum. The inferior edge of thepulmonary root is defined by the distal RV muscularinfundibulum and the superior edge by the sinotubularjunction. There are 3 leaflets, which attach to the pulmonaryroot in a semilunar fashion. The most basal leaflet attach-ment points are in the infundibular musculature and not theRV myocardium, and the most superior are at the sinotu-bular junction. The basal attachment site marks the pro-jected PV area, which is lower than the anatomic ventricu-loarterial junction.Imaging of the PV. Assessment of the PV by 2DE isdifficult because the valve cusps are difficult to visualize evenon the short axis view, and typically only 2 cusps can bevisualized simultaneously. The en face view of the PV on3DE allows all 3 cusps to be visualized simultaneously (Fig. 7).

ith 3D TTE, PV morphological features can be discernedccurately in 60% of patients, and this percentage increaseso 77% when patients with poor image quality on 2DE arexcluded (45). Visualization rates are only 22%, with wide-ngled volume acquisitions predominantly the result of
ropout.


PV stenosis. Most 3DE studies in PV stenosis havefocused on patients with congenital RV outflow tractobstruction. Imaging of the PV and RV outflow tract from

Figure 7 3D TEE Assessment of the Pulmonary Valve

(A) Two-dimensional and (B) 3D TEE images of the pulmonary root on trans-esophageal echocardiography. Zoomed 3D echocardiographic view of the pul-monary valve as visualized from the right ventricular outflow tract in (C) systoleand (D) diastole. Abbreviations as in Figure 2.

Figure 8 Appearances of Prosthetic Mitral Valves and Annulop

Zoomed 3D TEE images of prosthetic valves. (A) Bileaflet, mechanical mitral valveventricle. Mitral annuloplasty (C) ring and (D) band from the left atrial perspectiveannulus. (F) Single tilting disk valve in the mitral position as viewed from the left

a parasternal window was possible in only 70% and 40% ofpatients, respectively (46). However, when feasible, thesestudies provided highly accurate information on the RVoutflow tract supravalvular, subvalvular, and valvular mea-surements when compared with surgical findings. Also,when using a 3D en face view, the number of cusps,thickness, mobility could be measured, and closure lineswere visualized in 70% of patients (46).PV regurgitation. 3DE studies in pulmonary regurgitationhave focused on the mechanism of regurgitation in congen-ital heart disease and in carcinoid valvulopathy. In carcinoidvalvulopathy, plaque-like deposits of fibrous tissue developon the endocardial surface of right heart valves, resulting inthickened, immobile, and retracted leaflets causing bothstenosis and regurgitation. The en face view of the PV andRV outflow tract allows these complex anatomic features tobe appreciated and assessed.

3DE also shows promise in improving the accuracy ofPV regurgitation quantification. Historically, quantita-tive pulsed Doppler on 2DE is used for measuringpulmonary regurgitant volumes and regurgitant fractions;however, the results are highly variable because of inac-curate calculations of the RV outflow tract area andassumptions of a flat velocity curve (47). 3D colorDoppler allows the cropping plane to be positionedexactly parallel to the VC, which then can be planim-etered accurately and can be used to calculate the severityof pulmonic regurgitation. This 3D method correlateshighly with 2D methods and should be more accurate,given the precise identification of the measurement plane.

Rings/Bands on 3D TEE

wed from the left atrium. (B) Bioprosthetic mitral valve as viewed from the leftn face view from the left atrium of a ball-and-cage valve implanted in the mitral. Abbreviations as in Figure 2.

lasty

as vie. (E) Eatrium


Prosthetic Valves

3D TEE has improved visualization and assessment ofprosthetic valves (Fig. 8) as well as their associated compli-cations, such as endocarditis and paravalvular regurgitation.For mitral mechanical and bioprosthetic valves, the ring,leaflets, and struts can be visualized clearly in most patientswith 3D TEE, regardless of perspective. It must be ac-knowledged that although visualization of a mechanical MVfrom the LV side is improved with 3D TEE, prosthesisshadowing still may hamper visualization. To resolve thisissue, acquisition of the dataset may need to be repeatedfrom a different window. For patients who have undergoneMV repair, the annuloplasty ring and anterior leaflet can bevisualized optimally in 100% and 60% of cases, respectively.

Aortic mechanical and bioprosthetic valve leaflets arevisualized poorly, regardless of perspective. However, theAV prosthetic ring can be well visualized from the LVoutflow and aortic perspective. Similarly, with tricuspidprosthetic valves, the prosthetic ring can be visualizedconsistently, whereas the leaflets are visualized poorly. Thecommon difficulties in adequately visualizing both the aorticand tricuspid prosthetic valve leaflets are because thesevalves lie far from the transducer and because their positionis oblique with respect to the angle of incidence of theultrasound beam. Technological improvements are stillrequired before 3D TEE imaging is optimal for the assess-ment of prosthetic valves in these locations.Prosthetic valve endocarditis. 3D TEE provides addi-tional valuable information for the evaluation of prostheticvalve endocarditis (48). With wide-angled, full-volumedatasets and the ability to manipulate and crop images, deepanatomic structures can be displayed. As well, 3D TEEimages are not limited to conventional 2D planar views,enabling valvular visualization at angles not previouslypossible. Particularly, the en face view has been useful in theassessment of prosthetic valve endocarditis. It allows iden-tification not only of vegetations, but also of discretevalvular dehiscences and their associated regurgitation jets.

In prosthetic valve endocarditis, 3DE has been shown tocorrelate well with surgical and 2D TEE findings and toidentify additional vegetations not seen on 2D TEE (48).3DE also can assist in differentiating vegetations from loosesuture material, and the rocking motion of a partiallydehisced valve is better appreciated on 3DE. However, itmust be noted that because of frame rate limitations on3DE, our experience has shown that 2DE remains superiorfor the identification of small mobile vegetations. Thestrength of 3DE lies in its ability to characterize the massover noting just its presence or absence. Also, intermittentprosthesis problems such as small pannus ingrowths may bemissed on single 3D volumetric datasets.

Similar to prosthetic valve endocarditis, 3DE is valuablein native valve endocarditis. Specifically, the en face viewfrom 3DE improves identification of valvular perforations as
well as complications of valve endocarditis (49,50).
Interventional Valve Procedures

Percutaneous AV implantation. Percutaneous AV replacementis quickly gaining popularity as a less invasive option for AVreplacement. 3D TEE allows accurate assessment of theLVOT and aortic annulus dimensions, which are importantin valve size selection. An undersized device may result inparavalvular insufficiency or detachment and embolizationof the prosthesis. In contrast, oversized devices may result indamage or rupture of the aortic annulus. During theprocedure, 3D TEE helps to guide the catheter with theprosthetic valve into an optimal position. The exact spatialorientation of the device is crucial, because the valve and thecatheter should be aligned coaxially in the LVOT. Advanc-ing the device too far into the aorta may result in occlusionof the coronary ostia, whereas retraction toward the LVOTmay interfere with the motion of the anterior mitral leaflet,resulting in MR (51). After the procedure, 3D TEE isuseful in evaluating results and identifying potential com-plications, including paravalvular and transvalvular regurgi-tation, new wall motion abnormalities, MR, damage to theaortic ring, aortic dissection, pericardial effusion, and cardiactamponade.Paravalvular regurgitation. Ten percent of prosthetic AVsand 15% of prosthetic MVs have some degree of paravalvularregurgitation, which if significant requires surgical or percuta-neous intervention. 3D TEE plays an important role inevaluating the size and location of the paravalvular regurgita-tion and in providing guidance during interventions and duringpost-intervention assessment. 3D TEE en face views of theMV and AV assist in the identification of dehiscence sites andprovide information on location, shape, size, and number (52).Quantification of the dehisced area is performed with multi-planar imaging, and confirmation is obtained with the use of3D color flow. Using 3D TEE, it recently was recognized thatMV dehiscences are located predominantly in the posterior orlateral MV annular region.

Information obtained from 3DE can aid in determining ifa surgical or percutaneous intervention is appropriate. Withsurgery, 3DE can provide accurate information to thesurgeon on the size and location of the leak before cardio-pulmonary bypass, because it may be difficult to obtain thisinformation after the heart has been deflated of blood. 3DTEE also can evaluate the presence of residual regurgitationafter the patient has been weaned off cardiopulmonary, butbypass before the chest is closed.

During percutaneous closure of paravalvular leaks, 3DTEE plays an important role in determining whether anantegrade or retrograde approach should be used and thechoice of closure device. During the procedure, 3D TEEimages guide the operator during the various stages. The majoradvantage of 3DE imaging is the ability to visualize theentire length of intracardiac catheters, as well as the balloonsor devices attached to the catheters and their position in
relation to adjacent structures (53).


Catheter-based MV repair. This procedure is a recentadvancement in the nonsurgical repair of MR. Using apercutaneous catheter-based system, a clip can join the tipsof the mitral leaflets, creating an edge-to-edge Alfieri-typerepair. This results in 2 mitral orifices, with a significantreduction in the total regurgitant orifice and an improve-ment in patient symptoms and functional capacity. 3DE iscrucial to the procedure’s success because it allows a thoroughassessment of valve anatomic features through use of the enface view. 3D TEE also permits imaging of the catheter tipsand the clip during the procedure and assessment of post-procedural residual regurgitation or complications.Mitral valvuloplasty. Percutaneous balloon mitral valvulo-plasty (PBMV) usually is performed in patients with rheumaticmitral stenosis using fluoroscopic guidance alone. However,orientation using radiographic anatomic landmarks often ischallenging, even for experienced interventional cardiologists.3DE is instrumental in guiding PBMV from balloon position-ing to accurate visualization of post-procedural commissuralsplitting and leaflet tears (54). The use of full-volume coloracquisition also allows the rapid diagnosis and quantification ofthe severity of post-procedure MR.

Recently, a 3DE-based score for PBMV was developedto address weaknesses in the Wilkins score (22). Theimprovement is achieved first by evaluating each segment ofeach mitral leaflet separately to account for uneven distri-bution of anatomic abnormalities. Second, it also includesassessment of commissural areas, which is critical in pre-dicting the outcome of PMBV. Finally, the individualcomponents of the scores are weighted according to theirrelative importance in predicting the likelihood of a success-ful PMBV.Shortcomings of 3DE. 3DE imaging is subject to artifactsstemming from gain settings, respiration, electrocardiogra-phy gating disturbances, poor image quality, and arrhyth-mias. Currently, multibeat acquisition from either the trans-thoracic or transesophageal approach at times is limited bystitch artifacts caused by either probe motion or the patient’srespiratory motion. This can be avoided by acquiring trans-thoracic data during held end-expiration and transesopha-geal operating room data by transiently holding the venti-lator. Although the introduction of single-beat acquisitionallows 3DE datasets to be acquired in patients with arrhyth-mias without stitch artifacts, it is limited by low frame rates.Additionally, 3DE is limited by a small field of view inreal-time modes. Undergaining or overgaining also canaffect image quality, with resultant dropouts or blurryimages. Finally, 3D TEE techniques still require a signifi-cant time commitment to learn how to acquire, manipulate,qualitatively interpret, and quantitatively analyze full-volume datasets.

Conclusions

The burgeoning scientific literature on 3DE and valvular
heart disease is evidence of its wide acceptance and incor-
poration into clinical practice. However, transthoracic 3Dimaging is limited by its less-than-optimal frame rates andspatial and temporal resolution. Further improvements insingle-beat acquisition and in 3D color Doppler quantifi-cation are necessary to expedite its integration into routinepractice. Nevertheless, the ease of data acquisition, de-creased emphasis on expertise-driven interpretation, andreproducible quantitative analysis already have laid thefoundation for the use of 3DE in the evaluation, interven-tion, and management of valvular heart disease.

Reprints requests and correspondence: Dr. Roberto M. Lang,University of Chicago Medical Center, 5841 South MarylandAvenue, MC5084, Chicago, Illinois 60637. E-mail: [email protected].

REFERENCES

1. Lang RM, Mor-Avi V, Sugeng L, Nieman PS, Sahn DJ. Three-dimensional echocardiography: the benefits of the additional dimen-sion. J Am Coll Cardiol 2006;48:2053–69.

2. Iwakura K, Ito H, Kawano S, et al. Comparison of orifice area bytransthoracic three-dimensional Doppler echocardiography versusproximal isovelocity surface area (PISA) method for assessment ofmitral regurgitation. Am J Cardiol 2006;97:1630–7.

3. Tamborini G, Muratori M, Maltagliati A, et al. Pre-operative trans-thoracic real-time three-dimensional echocardiography in patientsundergoing mitral valve repair: accuracy in cases with simple vs.complex prolapse lesions. Eur J Echocardiogr 2010;11:778–85.

4. Khaw AV, von Bardeleben RS, Strasser C, et al. Direct measurementof left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valvestenosis. Int J Cardiol 2009;136:64–71.

5. Salgo IS, Gorman JH 3rd, Gorman RC, et al. Effect of annular shapeon leaflet curvature in reducing mitral leaflet stress. Circulation2002;106:711–7.

6. Watanabe N, Ogasawara Y, Yamaura Y, et al. Mitral annulus flattensin ischemic mitral regurgitation: geometric differences between inferiorand anterior myocardial infarction: a real-time 3-dimensional echo-cardiographic study. Circulation 2005;112:1458–62.

7. Ryan LP, Jackson BM, Eperjesi TJ, et al. A methodology for assessinghuman mitral leaflet curvature using real-time 3-dimensional echocar-diography. J Thorac Cardiovasc Surg 2008;136:726–34.

8. Tsukiji M, Watanabe N, Yamaura Y, et al. Three-dimensionalquantitation of mitral valve coaptation by a novel software system withtransthoracic real-time three-dimensional echocardiography. J Am SocEchocardiogr 2008;21:43–6.

9. Messas E, Bel A, Szymanski C, et al. Relief of mitral leaflet tetheringfollowing chronic myocardial infarction by chordal cutting diminishesleft ventricular remodeling. Circ Cardiovasc Imaging 2010;3:679–86.

10. Chandra S, Salgo IS, Sugeng L, et al. Characterization of degenerativemitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complex-ity and planning of mitral valve repair. Circ Cardiovasc Imaging2011;4:24–32.

11. Maffessanti F, Marsan NA, Tamborini G, et al. Quantitative analysisof mitral valve apparatus in mitral valve prolapse before and afterannuloplasty: a three-dimensional intraoperative transesophagealstudy. J Am Soc Echocardiogr 2011;24:405–13.

12. Kim DH, Handschumacher MD, Levine RA, et al. In vivo measure-ment of mitral leaflet surface area and subvalvular geometry in patientswith asymmetrical septal hypertrophy: insights into the mechanism ofoutflow tract obstruction. Circulation 2010;122:1298–307.

13. Liel-Cohen N, Guerrero JL, Otsuji Y, et al. Design of a new surgicalapproach for ventricular remodeling to relieve ischemic mitral regur-gitation: insights from 3-dimensional echocardiography. Circulation2000;101:2756–63.

14. Watanabe N, Ogasawara Y, Yamaura Y, et al. Quantitation of mitral
valve tenting in ischemic mitral regurgitation by transthoracic real-
mailto:[email protected]

mailto:[email protected]

1

1

1

1

1

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

5

5

5

5

5


time three-dimensional echocardiography. J Am Coll Cardiol 2005;45:763–9.

5. Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leafletadaptation to ventricular remodeling: occurrence and adequacy inpatients with functional mitral regurgitation. Circulation 2008;118:845–52.

6. Chandra S, Salgo IS, Sugeng L, et al. A three-dimensional insight intothe complexity of flow convergence in mitral regurgitation: adjunctivebenefit of anatomic regurgitant orifice area. Am J Physiol Heart CircPhysiol 2011;301:H1015–24.

7. Buck T, Plicht B, Kahlert P, Schenk IM, Hunold P, Erbel R. Effectof dynamic flow rate and orifice area on mitral regurgitant strokevolume quantification using the proximal isovelocity surface areamethod. J Am Coll Cardiol 2008;52:767–78.

8. Sugeng L, Weinert L, Lang RM. Real-time 3-dimensional colorDoppler flow of mitral and tricuspid regurgitation: feasibility andinitial quantitative comparison with 2-dimensional methods. J Am SocEchocardiogr 2007;20:1050–7.

9. Little SH, Pirat B, Kumar R, et al. Three-dimensional color Dopplerechocardiography for direct measurement of vena contracta area inmitral regurgitation: in vitro validation and clinical experience. J AmColl Cardiol Img 2008;1:695–704.

0. Skaug TR, Hergum T, Amundsen BH, Skjaerpe T, Torp H, HaugenBO. Quantification of mitral regurgitation using high pulse repetitionfrequency three-dimensional color Doppler. J Am Soc Echocardiogr2010;23:1–8.

1. Song JM, Kim MJ, Kim YJ, et al. Three-dimensional characteristics offunctional mitral regurgitation in patients with severe left ventriculardysfunction: a real-time three-dimensional colour Doppler echocardi-ography study. Heart 2008;94:590–6.

2. Anwar AM, Attia WM, Nosir YF, et al. Validation of a new score forthe assessment of mitral stenosis using real-time three-dimensionalechocardiography. J Am Soc Echocardiogr 2010;23:13–22.

3. Zamorano J, Cordeiro P, Sugeng L, et al. Real-time three-dimensionalechocardiography for rheumatic mitral valve stenosis evaluation: anaccurate and novel approach. J Am Coll Cardiol 2004;43:2091–6.

4. Veronesi F, Corsi C, Sugeng L, et al. A study of functional anatomyof aortic-mitral valve coupling using 3D matrix transesophagealechocardiography. Circ Cardiovasc Imaging 2009;2:24–31.

5. Otani K, Takeuchi M, Kaku K, et al. Assessment of the aortic rootusing real-time 3D transesophageal echocardiography. Circ J 2010;74:2649–57.

6. Handke M, Heinrichs G, Beyersdorf F, Olschewski M, Bode C,Geibel A. In vivo analysis of aortic valve dynamics by transesophageal3-dimensional echocardiography with high temporal resolution.J Thorac Cardiovasc Surg 2003;125:1412–9.

7. Higashidate M, Tamiya K, Beppu T, Imai Y. Regulation of the aorticvalve opening. In vivo dynamic measurement of aortic valve orificearea. J Thorac Cardiovasc Surg 1995;110:496–503.

8. Kasprzak JD, Nosir YF, Dall’Agata A, et al. Quantification of theaortic valve area in three-dimensional echocardiographic data sets:analysis of orifice overestimation resulting from suboptimal cut-planeselection. Am Heart J 1998;135:995–1003.

9. Messika-Zeitoun D, Serfaty JM, Brochet E, et al. Multimodalassessment of the aortic annulus diameter: implications for transcath-eter aortic valve implantation. J Am Coll Cardiol 2010;55:186–94.

0. Paelinck BP, Van Herck PL, Rodrigus I, et al. Comparison ofmagnetic resonance imaging of aortic valve stenosis and aortic root tomultimodality imaging for selection of transcatheter aortic valveimplantation candidates. Am J Cardiol 2011;108:92–8.

1. Dichtl W, Muller LC, Pachinger O, Schwarzacher SP, Muller S.Images in cardiovascular medicine. Improved preoperative assessmentof papillary fibroelastoma by dynamic three-dimensional echocardiog-raphy. Circulation 2002;106:1300.

2. Kasprzak JD, Salustri A, Roelandt JR, Ten Cate FJ. Three-dimensional echocardiography of the aortic valve: feasibility, clinicalpotential, and limitations. Echocardiography 1998;15:127–38.

3. Gutierrez-Chico JL, Zamorano JL, Prieto-Moriche E, et al. Real-timethree-dimensional echocardiography in aortic stenosis: a novel, simple,and reliable method to improve accuracy in area calculation. EurHeart J 2008;29:1296–306.

4. Goland S, Trento A, Iida K, et al. Assessment of aortic stenosis by
three-dimensional echocardiography: an accurate and novel approach.Heart 2007;93:801–7. d
5. Gilon D, Cape EG, Handschumacher MD, et al. Effect of three-dimensional valve shape on the hemodynamics of aortic stenosis:three-dimensional echocardiographic stereolithography and patientstudies. J Am Coll Cardiol 2002;40:1479–86.

6. Mori Y, Shiota T, Jones M, et al. Three-dimensional reconstruction ofthe color Doppler-imaged vena contracta for quantifying aortic regur-gitation: studies in a chronic animal model. Circulation 1999;99:1611–7.

7. Li X, Jones M, Irvine T, et al. Real-time 3-dimensional echocardiog-raphy for quantification of the difference in left ventricular versus rightventricular stroke volume in a chronic animal model study: improvedresults using C-scans for quantifying aortic regurgitation. J Am SocEchocardiogr 2004;17:870–5.

8. Ton-Nu TT, Levine RA, Handschumacher MD, et al. Geometricdeterminants of functional tricuspid regurgitation: insights from3-dimensional echocardiography. Circulation 2006;114:143–9.

9. Kwan J, Kim GC, Jeon MJ, et al. 3D geometry of a normal tricuspidannulus during systole: a comparison study with the mitral annulususing real-time 3D echocardiography. Eur J Echocardiogr 2007;8:375–83.

0. Anwar AM, Geleijnse ML, Soliman OI, et al. Assessment of normaltricuspid valve anatomy in adults by real-time three-dimensionalechocardiography. Int J Cardiovasc Imaging 2007;23:717–24.

1. Anwar AM, Geleijnse ML, Soliman OI, McGhie JS, Nemes A, TenCate FJ. Evaluation of rheumatic tricuspid valve stenosis by real-timethree-dimensional echocardiography. Heart 2007;93:363–4.

2. Seo Y, Ishizu T, Nakajima H, Sekiguchi Y, Watanabe S, Aonuma K.Clinical utility of 3-dimensional echocardiography in the evaluation oftricuspid regurgitation caused by pacemaker leads. Circ J 2008;72:1465–70.

3. Conaglen PJ, Ellims A, Royse C, Royse A. Acute repair of traumatictricuspid valve regurgitation aided by three-dimensional echocardiog-raphy. Heart Lung Circ 2011;20:237–40.

4. Song JM, Jang MK, Choi YS, et al. The vena contracta in functionaltricuspid regurgitation: a real-time three-dimensional color Dopplerechocardiography study. J Am Soc Echocardiogr 2011;24:663–70.

5. Kelly NF, Platts DG, Burstow DJ. Feasibility of pulmonary valveimaging using three-dimensional transthoracic echocardiography.J Am Soc Echocardiogr 2010;23:1076–80.

6. Anwar AM, Soliman O, van den Bosch AE, et al. Assessment ofpulmonary valve and right ventricular outflow tract with real-timethree-dimensional echocardiography. Int J Cardiovasc Imaging 2007;23:167–75.

7. Stewart WJ, Jiang L, Mich R, Pandian N, Guerrero JL, Weyman AE.Variable effects of changes in flow rate through the aortic, pulmonaryand mitral valves on valve area and flow velocity: impact on quantita-tive Doppler flow calculations. J Am Coll Cardiol 1985;6:653–62.

8. Kort S. Real-time 3-dimensional echocardiography for prosthetic valveendocarditis: initial experience. J Am Soc Echocardiogr 2006;19:130–9.

9. Thompson KA, Shiota T, Tolstrup K, Gurudevan SV, Siegel RJ.Utility of three-dimensional transesophageal echocardiography in thediagnosis of valvular perforations. Am J Cardiol 2011;107:100–2.

0. Walker N, Bhan A, Desai J, Monaghan MJ. Myocardial abscess: a rarecomplication of valvular endocarditis demonstrated by 3D contrastechocardiography. Eur J Echocardiogr 2010;11:E37.

1. Johnson MA, Munt B, Moss RR. Transcutaneous aortic valveimplantation—a first line treatment for aortic valve disease? J Am SocEchocardiogr 2010;23:377–9.

2. Sugeng L, Shernan SK, Weinert L, et al. Real-time three-dimensionaltransesophageal echocardiography in valve disease: comparison withsurgical findings and evaluation of prosthetic valves. J Am SocEchocardiogr 2008;21:1347–54.

3. Tsang W, Lang RM, Kronzon I. Role of real-time three dimensionalechocardiography in cardiovascular interventions. Heart 2011;97:850–7.

4. Langerveld J, Valocik G, Plokker HW, et al. Additional value ofthree-dimensional transesophageal echocardiography for patients withmitral valve stenosis undergoing balloon valvuloplasty. J Am SocEchocardiogr 2003;16:841–9.

Key Words: aortic valve y mitral valve y pulmonic valve y three-imensional echocardiography y tricuspid valve y valvular heart disease.

Valvular Heart Disease - COnnecting REpositories · the role of 3DE in evaluating valvular anatomic...

Documents

Transcript of Valvular Heart Disease - COnnecting REpositories · the role of 3DE in evaluating valvular anatomic...