J Cardiovasc Ultrasound.  2012 Mar;20(1):1-22. 10.4250/jcu.2012.20.1.1.

Current Clinical Applications of Transthoracic Three-Dimensional Echocardiography

• Badano LP
• Boccalini
• Muraru D
• Bianco LD
• Peluso D
• Bellu R
• Zoppellaro G
• Iliceto S

• KMID: 2177335
• DOI: http://doi.org/10.4250/jcu.2012.20.1.1

Abstract

The advent of three-dimensional echocardiography (3DE) has significantly improved the impact of non-invasive imaging on our understanding and management of cardiac diseases in clinical practice. Transthoracic 3DE enables an easier, more accurate and reproducible interpretation of the complex cardiac anatomy, overcoming the intrinsic limitations of conventional echocardiography. The availability of unprecedented views of cardiac structures from any perspective in the beating heart provides valuable clinical information and new levels of confidence in diagnosing heart disease. One major advantage of the third dimension is the improvement in the accuracy and reproducibility of chamber volume measurement by eliminating geometric assumptions and errors caused by foreshortened views. Another benefit of 3DE is the realistic en face views of heart valves, enabling a better appreciation of the severity and mechanisms of valve diseases in a unique, noninvasive manner. The purpose of this review is to provide readers with an update on the current clinical applications of transthoracic 3DE, emphasizing the incremental benefits of 3DE over conventional two-dimensional echocardiography.

Keyword

Three-dimensional echocardiography; Left ventricle; Right ventricle; Mitral valve; Aortic valve; Tricuspid valve; Left atrium

MeSH Terms

Aortic Valve
Echocardiography
Echocardiography, Three-Dimensional
Heart
Heart Atria
Heart Diseases
Heart Valves
Heart Ventricles
Imidazoles
Mitral Valve
Nitro Compounds
Tricuspid Valve
Imidazoles
Nitro Compounds

Figure

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  Fig. 1 Different acquisition modalities available with three-dimensional echocardiography: A: Zoom mode; it can acquired either single-beat (to encompass a specific region or structures like en-face valve display without the need of cropping) or multi-beat to improve spatial and temporal resolution while maintaining the small volume size (e.g. to assess rapidly moving structures like vegetations). B: Real-time acquisition with a limited depth (usually around 30° in elevation) generally used to monitor interventional procedures. C: Multi-beat full-volume (reaching up to 100° in elevation) to encompass a large part of the heart in order to assess spatial relationships between cardiac structures or quantitate size and function of cardiac chambers. D: Three-dimensional color mode to assess shape and extension of regurgitant jets and determine the location and size of cardiac defects.

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  Fig. 2 Schematic representation of two-dimensional (i.e. tomographic; A) and single-beat three-dimensional (i.e. volumetric; B) of the left ventricular short-axis at mitral valve level. Volumetric rendering displays many more details and allow better appreciation of spatial relationship among cardiac structures. C shows the multi-beat acquisition modality: two to six consecutive single-beat sub-volumes are stitched together to obtain a full-volume with higher spatial and temporal resolution.

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  Fig. 3 From the same pyramidal three-dimensional data set, the left ventricle can be analyzed using different display modalities: volume rendering, to visualize morphology and spatial relationships among adjacent structures; surface-rendering, for quantitative purposes; and multi-slice (multiple two-dimensional tomographic views extracted automatically from a single 3D data set) for morphological and functional analysis at different regional levels.

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  Fig. 4 Normal mitral valve visualized en-face by transthoracic three-dimensional echocardiography: A: Left ventricular perspective. B: Left atrial perspective or "surgical view". RV: right ventricle, AML: acute myleogenous leukemia, PML: promyelocytic leukemia, LAA: left atrial appendage, Ao: aorta, RA: right atrium.

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  Fig. 5 Degenerative mitral valve disease: A: Apical long-axis view showing a flail of posterior mitral leaflet. B: Volume rendering of the showing the location and extent of the prolapsing segment. C and D: Surface rendering of the valve leaflets, annulus and aortic annulus to provide an automated quantitative analysis of valve morphology and geometry useful to plan the surgical approach.

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  Fig. 6 Multi-slice display of the left ventricle in a patient with antero-septal myocardial infarction. The three panels on the left show three apical views obtained by rotational slicing of the pyramidal data set. The nine panels on the right show nine short-axis views (from mitral valve level, indicated by the dashed white line on left panels - lower panel on the right, to the apical level, indicated by the dashed yellow line on left panels, upper panel on the left) obtained by parallel slicing of the pyramidal data set. All these views can be changed in both the angle of rotation (longitudinal views) and in the position within the ventricle (short axis views) according to the clinical need during postprocessing.

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  Fig. 7 Left ventricular volume and ejection fraction measurement using three-dimensional full-volume data set. The three longitudinal views (4-, 2-chamber, and long-axis vie and the adjustable short axis view are used to visualize the accuracy of the semiautomated endocardial tracking. On the right a time-volume curve showing the change in left ventricular volume during the cardiac cycle.

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  Fig. 8 The endocardial surface can be subdivided in 16 or 17 color-coded areas corresponding to the left ventricular segmentation. Each segment can be assimilated to a pyramid with the base on the endocardium and the apex at the gravity center of the ventricle. The time to minimal volume of each segment can be measured on the corresponding time-volume curves and the standard deviation of the time to minimal volume of the 16/17 segments has been reported as an index of intraventricular dyssynchrony. A shows synchronous left ventricular contraction (all segments reach the minimal volume approximately at the same time). B shows a dyssynchronous left ventricular contraction showed by the large temporal dispersion of the time to minimal segmental volume.

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  Fig. 9 Left ventricular mass measurement using three-dimensional echocardiography. Using automated or semi-automated endocardial and epicardial boundary detection endocardial and epicardial volumes are measured (A). By subtracting the left ventricular cavity volume from the epicardial volume, the volume of myocardium is obtained (B). Left ventricular mass is calculated by multiplying myocardial volume by its specific gravity (1.05 g/cm3).

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  Fig. 10 Three-dimensional speckle-tracking analysis of left ventricular longitudinal myocardial deformation using two different platforms. Results can be displayed as bull's eye plots (A) and/or time-strain curves (B).

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  Fig. 11 Schematic representation of the position of 3 apical views of left ventricle obtainable with conventional 2D echocardiography. As shown, the 3 longitudinal slices cover only a very limited part of left ventricular circumference and cannot be changed anymore once acquired, if proven unsatisfactory or foreshortened.

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  Fig. 12 A: Surface rendering of the right ventricle obtained by transthoracic three-dimensional echocardiography. B: Time-volume curve showing right volume changes during cardiac cycle. C: Results of the quantitative analysis are shown.

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  Fig. 13 En-face view of a large atrial septal defect from the right atrial perspective obtained by cropping the free wall of the right atrium from a full-volume three-dimensional data-set encompassing the base of the heart. The morphology and size of the defect can be appreciated and quantitated, as well as the extent of peripheral rims and relationships with surrounding cardiac structures. ASD: atrial septal defect, CS: coronary sinus, RA: right atrium, RV: right ventricle.

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  Fig. 14 Bicuspid aortic valve displayed with closed (A) and open (B) leaflets.

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  Fig. 15 Rheumatic mitral stenosis. Volume rendering display from the left ventricular (A) and atrial (B) perspectives. The cut plane shown in A has been optimized to be perpendicular to the direction of the orifice to obtain an accurate orifice area planimetry. The thickened leaflets and fused commissures are well visualized (white arrows). LVOT: left ventricular outflow tract.

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  Fig. 16 A: Three-dimensional color flow acquisition using transesophageal approach showing the origin and the three-dimensional shape of the jet. B: A cut-plane at the level of the jet vena contracta (yellow dashed line) allows to display the actual area and shape of the vena contracta for quantification.

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  Fig. 17 Normal aortic valve in diastole, full-volume acquisition from transthoracic parasternal approach. Volume rendering display from the aortic (A) and left ventricular outflow tract (B) perspectives.

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  Fig. 18 Normal tricuspid valve. Volume rendering display from the right ventricular (A) and atrial (B) perspectives. ATL: anterior tricuspid leaflet, PTL: posterior tricuspid leaflet, STL: septal tricuspid leaflet.

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  Fig. 19 Semi-automated quantification of left atrial volumes (maximal, VMAX; pre A-wave, VpreA; and minimal, VMIN), shape (sphericity indexes at maximal and minimal volumes, VMAX SI and VMIN SI, respectively) and phasic functions (total and active emptying fraction or stroke volumes, Total EF or SV and TrueEF or ASV, respectively) based on three-dimensional echocardiography.

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