3D Echocardiography

Third Edition

Edited by
Takahiro Shiota
Third edition published 2021
by CRC Press
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Library of Congress Cataloging-in-Publication Data

Names: Shiota, Takahiro, editor.

Title: 3D echocardiography / edited by Takahiro Shiota.
Description: Third edition. | Boca Raton : CRC Press, 2020. | Includes bibliographical references and index. |
Summary: “The previous edition, which was highly commended at the British Medical Book Awards, has been updated with recent
publications and improved images. This 3rd edition added important new topics such as 3D Printing, Surgical and Transcatheter
Managements, Artificial Valves, and Infective Endocarditis”-- Provided by publisher.
Identifiers: LCCN 2020006246 (print) | LCCN 2020006247 (ebook) | ISBN 9780367252885 (hbk) | ISBN 9780429287534 (ebk)
Subjects: MESH: Echocardiography, Three-Dimensional--methods | Heart Valve Diseases--diagnosis | Coronary Artery Disease--diagnosis
Classification: LCC RC683.5.U5 (print) | LCC RC683.5.U5 (ebook) | NLM WG 141.5.E2 | DDC 616.1/207543--dc23
LC record available at https://lccn.loc.gov/2020006246
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 CONTENTS

Preface to the first edition v

Preface to the second edition vi
Preface to the third edition vii
Acknowledgments viii
Editor ix
Contributors x
Abbreviations xii

Chapter 1  PRINCIPLES OF 3D ECHOCARDIOGRAPHIC IMAGING 1

Bart Bijnens, Filip Loncaric, and Jan D’hooge

Chapter 2  LEFT VENTRICLE 13

Luigi P. Badano and Denisa Muraru

Chapter 3  STRESS ECHOCARDIOGRAPHY 28

Andreas Franke

Chapter 4  RIGHT VENTRICLE 35

Takahiro Shiota

Chapter 5  LEFT ATRIUM 43

Charles Fauvel, Olivier Raitière, and Fabrice Bauer

Chapter 6  HYPERTROPHIC CARDIOMYOPATHY 51

Marta Sitges, Filip Loncaric, and Takahiro Shiota

Chapter 7A  PRIMARY MITRAL REGURGITATION 68

Eric Brochet and Alain Berrebi

Chapter 7B  SECONDARY MITRAL REGURGITATION 83

Patrizio Lancellotti, Yun Yun Go, and Raluca Dulgheru

Chapter 8  MITRAL STENOSIS 95

Jose Alberto de Agustín and Jose Zamorano

Chapter 9  AORTIC STENOSIS 103

Patrizio Lancellotti, Tadafumi Sugimoto, and Raluca Dulgheru

Chapter 10  AORTIC REGURGITATION 111

Agnès Pasquet and Jean-Louis Vanoverschelde

Chapter 11  TRICUSPID REGURGITATION 120

Denisa Muraru and Luigi P. Badano

Chapter 12  INFECTIVE ENDOCARDITIS 131

Raluca Dulgheru

  iii
Chapter 13  SURGICAL MANAGEMENT 142
Takahiro Shiota

Chapter 14  NONSURGICAL TRANSCATHETER TREATMENT 147

Takahiro Shiota, Hiroki Ikenaga, and Hiroto Utsunomiya

Chapter 15  ARTIFICIAL VALVES 158

Giovanni La Canna, Iside Scarfò, and Philippe Pibarot

Chapter 16  ADULT CONGENITAL HEART DISEASE 176

Pastora Gallego and Silvia Montserrat

Chapter 17  AORTA 208

Masaaki Takeuchi

Chapter 18A  SPECKLE TRACKING 215

Nicolas Duchateau, Filip Loncaric, Marta Sitges, and Bart Bijnens

Chapter 18B  TISSUE TRACKING 223

Tomoko Ishizu, Yasuhiko Abe, and Yoshihiro Seo

Chapter 19  CARDIAC MASSES 235

Sonia Velasco del Castillo and Miguel Angel García-Fernández

Chapter 20  ATRIAL FIBRILLATION 249

Laurien Goedemans, Nina Ajmone Marsan, Jeroen J. Bax, and Victoria Delgado

Chapter 21  3D PRINTING 260

Israel Valverde

Index 269

iv
 PREFACE TO THE FIRST EDITION
Echocardiography is now an indispensable tool in
clinical cardiology. Quite a few textbooks are available
at medical bookstores and on the internet where you can
find new developing aspects of echocardiography. One
of the most impressive and innovative advancements of
echocardiography today is 3D echocardiography. There
have been few comprehensive books to introduce this new
echocardiographic method. Therefore, in this book, I would
like to provide you with the most recent developments in
this emerging field, focusing on the clinical values of 3D
echocardiography.
For a long time now, 3D echocardiography has been
recognized and conceived as an ideal tool for clinical
cardiology. Three-dimensional ultrasound theoretically can
provide what 2D echocardiography cannot; first, complete
information about absolute heart chamber volumes, such
as right ventricular volumes and aneurysmal left ventricular
volumes. Second, 3D ultrasound also allows viewers an
intuitive recognition of cardiac structures from any spatial
point of view, such as en face views of the mitral valve leaflets.
However, the idea had not materialized because of technical
and engineering difficulties.
Quite recently, newer types of transthoracic real-time
3D echo systems have been developed, following the
introduction of a real-time volumetric 3D system made
by a small venture company in the mid-1990s. Nowadays,
multiple powerful echo system vendors are engaged in this
business with massive advertisements, which increasingly
stimulate users’ interests. The difference between the
new models and older ones, including older-type real-
time 3D echo, is clear. First, the newer ones provide an
easier, handier, and more user-friendly means to acquire
and view 3D images. Second, image quality has improved
significantly thanks to the advancement of ultrasound and
computer technology.
Just a decade ago, it took almost a whole day to reconstruct
a single 3D echocardiographic image with complicated
gating and synchronization of many 2D planes. Those old-
time 3D images were almost always miserable. Even after
spending several hours putting the images together, it was
hard to even find the location of the mitral valve. Now it
takes only a few minutes to see 3D images of the mitral valve,
seeing the heart as if you were a surgeon in the operating
room. With the use of newer systems, you can at least tell the
mitral anterior leaflet from the posterior leaflet, and when
lucky, the location of the origin of the mitral regurgitation.
You can visualize it thanks to the improved color Doppler
3D imaging of the most recent systems. Such blood flow
information is quite valuable and is often indispensable in
clinical cardiology.
Another important change in the clinical environment
is the approval of reimbursement for 3D echocardiography
in patients. Such advancement in technological and
socioeconomic factors has prompted clinical application
of this new technology. Magnetic resonance imaging
(MRI) and computerized axial tomography (CAT) can
also provide us with 3D imaging even more impressively in
certain patients, such as those with an aortic aneurysm. Still,
3D echocardiography shares some of the vital advantages
that conventional 2D echocardiography has over the MRI/
CAT scan: portability and handiness as well as Doppler color
flow imaging.
As you will see in most chapters, there are still certain
limitations to currently available 3D ultrasound methods,
even with the help of state-of-the-art, real-time 3D echo
systems. In particular, relatively low image quality and low
frame (volume) rate hinder everyday clinical use of 3D
echocardiography. However, ongoing strenuous efforts for
further development of this method will overcome such
limitations in the very near future. For example, real-time
transesophageal 3D echocardiography which could provide
stunning 3D valve motion images, was recently introduced
in the literature and in clinical settings. Again, the fact
remains that 3D echocardiography is one of the ultimate
goals of cardiac imaging.
In this textbook, as this technology is still on the rise and
not yet completed, we tried to demonstrate the potential
values of 3D echocardiography in the everyday clinical
setting of cardiology practice. In order to show the benefits
of 3D echocardiography, some chapters show examples of
conventional clinical 2D echocardiography with a hope to
reveal the additive value of 3D information. Again, most
chapters of this book are written for practical use while
academically competent. Therefore, I did not intend to
include massive, heavily complicated mathematic nor
engineering aspects of 3D echocardiography for busy
readers who are interested in the clinical applicability of
this new method.
I sincerely hope that this textbook will provide you with
essential knowledge and impressive pictures of modem
3D echocardiography for your practice in the twenty-first
century.
Takahiro Shiota md, phd
Los Angeles, California
  v
 PREFACE TO THE SECOND EDITION
The first edition of 3D Echocardiography, one of the first books
on the topic, was published in 2007. At that time, the book
received a mixed review from Circulation, one of the most
prestigious cardiology journals (Circulation 2008;117:e156).
Their primary critique was the lack of convincing 3D images
and examples of clinical use, suggesting the next version be
improved with better quality 3D images and an emphasis
on clinical value.
Since the publication of the first edition, 3D
echocardiography technology has improved dramatically,
and vastly increasing numbers of published papers have
enhanced our knowledge of this imaging modality. Clinical
use of 3D echocardiography has grown, and acceptance
of this technology for the care of patients has truly come
to pass. We aim that this new edition will answer and
vi 
meet all the helpful criticisms of the original review with
substantial new convincing content. This edition contains
truly impressive cardiac images and evidence of clinical use,
mainly thanks to the development of live or real-time 3D
transesophageal echocardiography (TEE).
Inside 3D Echocardiography you will find a new world of
echocardiography supplemented with thoroughly updated
references. All the authors in this book are true experts
in the field of echocardiography, especially in the areas
about which they have written. I hope you will enjoy the
superior 3D echo images and academic quality writing in
each chapter.
Takahiro Shiota md, phd
Los Angeles, California
 PREFACE TO THE THIRD EDITION
To know is good
To l i k e is b e tt e r
To e njo y is bes t
Confuc ius
When I was asked to compile the third edition of
3D Echocardiography, initially I was not sure about
what I could change or add to aid our readers. As
if reading my mind, my publisher presented me
with feedback from our readers of the second edi-
tion. As is often the case with honest feedback, the
comments left me feeling a bit discouraged. How-
ever, as I dug deeper into the criticism, much of it
was reasonable and insightful - such as the technical
difficulty of viewing the 3D movies and the lack
of important chapters, like 3D printing. My goal
with this new edition is to address these shortcom-
ings as a way of saying thank you to our previous
readers and to share upgraded content for the next
generation of imaging specialists and general car-
diologists.
To me, 3D echocardiography is an integral part
of clinical assessments for patients who may obtain
benefits from this unique imaging method. As a
clinical echocardiography specialist with over 35
years of experience, I am fully aware of the value,
benefits, and popularity of 2D echo, as well as the
weaknesses of 3D echo. In a sense, however, 3D
echo includes all 2D echo information, just like
2D echo includes all M-mode information. Such
opinions may provoke disagreement from those
who believe 2D echo can do everything needed
for practical clinical evaluation.
However, I would argue that 3D
echocardiography, especially real-time 3D
transesophageal echocardiography (TEE), has
become an indispensable tool in our daily practice
of cardiology, particularly for the management of
structural heart disease. It now plays a vital role
not only in the echocardiography laboratory,
but in the operating room and catheterization
laboratory as well. Computer and ultrasound
technologies have advanced dramatically and
made this change possible. I believe that in the
future, this positive trend will continue to improve
current shortcomings.
In 1997, when our paper on real-time 3D echo
was published in Circulation, there were few
individuals among clinical cardiologists, or even
echocardiography specialists, who believed it had a
future in clinical management. When I was using a
huge real-time 3D echo machine in the operating
room in the late 1990s, there was almost no one who
could envision its widespread use in the operating
room. However, when real-time 3D TEE was
introduced in our community circa 2007, things
changed dramatically. Seemingly overnight, there
were many general cardiologists, interventionists,
and even surgeons who appreciated the clinical
value of 3D echocardiography.
Quite a few books on this methodology were
published after the development of real-time 3D
TEE. Most 3D echo books show beautiful 3D
images, but they are not very systematic and they
do not provide an in-depth discussion regarding
its clinical or academic contributions or its future.
I hope this new edition inspires academic efforts
in future clinical applications and encourages
further improvement of this modality.
Please enjoy the most up-to-date clinical and
academic information, images, and videos of 3D
echo in comparison with 2D echo.
Takahiro Shiota md, phd
Los Angeles, California
  vii
 ACKNOWLEDGMENTS
The joys of creating a book are many. Chief among them
is acknowledging the people who share my passion for
finding innovative solutions to unsolved problems, and for
imparting knowledge and amusement to friends living in
distant places.
I feel truly grateful to all the authors who have
contributed their time and expertise. Newly added and
updated chapters with high-quality 3D/2D images make this
edition an exciting one.
My sincere appreciation goes to Drs. Siegel, Rader,
Pollick, Singh, Skaf, and our sonographers, AJ, Kira, and
viii 
Sandra, for implementing the clinical application of 3D
echocardiography at Cedars-Sinai Smidt Heart Institute. In
addition, I wish to express my gratitude to our surgeons,
interventionists, and anesthesiologists, especially to Drs.
Trento, Makkar, Kar, and Makar. Our team efforts became
a reality with their support.
I am thankful to my publisher, CRC Press/Taylor &
Francis, Harry in particular for his dedicated assistance
for my editing. Finally, my personal thanks go to my wife
and my two daughters, Mai and Kana, for their thoughtful
proofreading.

Takahiro Shiota, MD, PhD, is Professor of Medicine at
Cedars-Sinai Medical Center, Los Angeles, and Clinical
Professor of Medicine at UCLA School of Medicine,
California. He is a pioneer in 3D echocardiography and
published the first book on this topic in 2007 while he was
Professor of Medicine at the Cleveland Clinic, Ohio.
Dr. Shiota published a unique 3D echo book of case
presentations. He is the editor of 3D Echocardiography, Second
EDITOR
Edition, which was highly commended at the 2014 British
Medical Association Book Awards. Dr. Shiota regularly
contributes articles on how to improve diagnostic accuracy.
He has published many original papers in premier journals
on the clinical value and use of 3D echocardiography for
surgery and transcatheter procedures.
  ix
 CONTRIBUTORS

Yasuhiko Abe Charles Fauvel

Canon Rouen University Hospital
Tokyo, Japan Rouen, France

Jose Alberto de Agustín Andreas Franke

San Carlos University Hospital KRH – Siloah Hospital
Madrid, Spain Hannover, Germany

Nina Ajmone Marsan Pastora Gallego

Leiden University Medical Center Virgen del Rocio University Hospital
Leiden, The Netherlands Institute of Biomedicine
Seville, Spain
Luigi P. Badano
University of Milano-Bicocca Miguel Angel García-Fernández
Milan, Italy Complutense University
Madrid, Spain
Fabrice Bauer
Yun Yun Go
Rouen University Hospital
National Heart Center
Rouen, France
Singapore
Jeroen J. Bax
Laurien Goedemans
Leiden University Medical Center
Leiden University Medical Center
Leiden, The Netherlands
Leiden, The Netherlands
Alain Berrebi Hiroki Ikenaga
HEGP/IMM Hiroshima University
University of Paris Hiroshima, Japan
Paris, France
Tomoko Ishizu
Bart Bijnens University of Tsukuba
Pompeu Fabra University Tsukuba, Japan
Barcelona, Spain
Giovanni La Canna
Eric Brochet Humanitas Clinical and Research Hospital
Bichat University Hospital Milan, Italy
Paris, France
Patrizio Lancellotti
Victoria Delgado University of Liège Hospital
Leiden University Medical Center Liège, Belgium
Leiden, The Netherlands
Filip Loncaric
Jan D’hooge Hospital Clinic
KU Leuven University of Barcelona
Leuven, Belgium Barcelona, Spain

Nicolas Duchateau Silvia Montserrat

CREATIS Hospital Clinic
Lyon 1 University University of Barcelona
Lyon, France Barcelona, Spain

Raluca Dulgheru Denisa Muraru

University of Liège Hospital University of Padua
Liège, Belgium Padua, Italy

x 
Agnès Pasquet Tadafumi Sugimoto
Université Catholique de Louvain Mie University
Brussels, Belgium Tsu, Japan

Philippe Pibarot Masaaki Takeuchi

Québec Heart and Lung Institute University of Occupational & Environmental Health
Laval University Kitakyushu, Japan
Québec, Canada
Hiroto Utsunomiya
Olivier Raitière Hiroshima University
Rouen University Hospital Hiroshima, Japan
Rouen, France
Israel Valverde
Iside Scarfò
Virgen del Rocio University Hospital/Institute of
Humanitas Clinical and Research Hospital
Biomedicine
Milan, Italy
Seville, Spain
Yoshihiro Seo
Nagoya City University Jean-Louis Vanoverschelde
Nagoya, Japan Université Catholique de Louvain
Brussels, Belgium
Takahiro Shiota
Cedars-Sinai/UCLA Sonia Velasco del Castillo
Los Angeles, California Galdakao Hospital
Galdakao, Spain
Marta Sitges
Hospital Clinic Jose Zamorano
University of Barcelona Ramón y Cajal University Hospital
Barcelona, Spain Madrid, Spain

Contributors xi
 ABBREVIATIONS
2D two-dimensional
3D three-dimensional
A FO fossa ovalis
AATS American Association for Thoracic Surgery
AF atrial fibrillation
AI mapping activation imaging mapping
ALC anterolateral commissure
AMI acute myocardial infarction
AR aortic regurgitation
AS aortic stenosis
ASA alcohol septal ablation
ASD atrial septal defect
ASE American Society of Echocardiography
AV aortic valve
AVA anatomical AVA
AVA aortic valve area
AVSD atrioventricular septal defect
B IVA isovolumic myocardial acceleration
BAV bicuspid aortic valve
C K
CCT cardiac computed tomography
ccTGA congenitally corrected TGA
CDS clip delivery system
CE continuity equation
CFM color flow mapping
CHD congenital heart disease
CHF chronic heart failure
CHF congestive heart failure
CIED cardiac implantable electronic device
CMR cardiac magnetic resonance
CRT cardiac resynchronization therapy
CS coronary sinus
CT computed tomography
CTD cor triatriatum dexter
CW continuous-wave
D MRI magnetic resonance imaging
DICOM digital imaging and communications in
medicine
D-TGA complete transposition of the great arteries
E
EACTS European Association for Cardio-Thoracic
Surgery
ECG electrocardiogram
EDV end-diastolic volume
EF ejection fraction
EOA effective orifice area
EROA effective regurgitant orifice area
ESRD external sewing ring diameter
ESV end-systolic volume
xii 
F
FAC fractional area change
FMR functional mitral regurgitation
FTR functional tricuspid regurgitation
H
HCM hypertrophic cardiomyopathy
HFpEF heart failure with preserved ejection fraction
HFrEF heart failure with reduced ejection fraction
I
IAS interatrial septum
iASD iatrogenic atrial septal defect
ICD implantable cardioverter-defibrillator
ICE intracardiac echocardiography
ID internal orifice diameter
IE infective endocarditis
IPR intraprosthetic regurgitation
IVC inferior vena cava
KBR knowledge-based reconstruction
L
LA left atrium
LAA left atrial appendage
LAVV left atrioventricular valve
LCS left coronary sinus
L-TGA levo-transposition of the great arteries
LV left ventricle
LVAD left ventricular assist device
LVOT left ventricular outflow tract
M
MDCT multidetector row computed tomography
MPI myocardial performance index
MPR multiplanar reconstruction
MR mitral regurgitation
MS mitral stenosis
MV mitral valve
MVA mitral valve area
MVA mitral valvular orifice area
MVN mitral valve navigation
N
NCS noncoronary sinus
NRRD n-dimensional Nearly Raw Raster Data
format
O
OR operating room
OTR organic tricuspid regurgitation
P SMR secondary mitral regurgitation
PBMV percutaneous balloon mitral valvuloplasty SSD sum of squared differences
PCV prosthetic cardiac valve STE speckle tracking echocardiography
PET positron emission tomography STS Society of Thoracic Surgeons
PFO patent foramen ovale SVA sinus of Valsalva aneurysm
PFR peak early filling rate SVC superior vena cava
PHT pressure half-time SVD structural valve deterioration
PISA proximal isovelocity surface area SV systolic volume
PMC posteromedial commissure
PM papillary muscle T
PMV percutaneous mitral valvuloplasty 3D FVCD three-dimensional full-volume color Doppler
PMVR percutaneous mitral valve repair 3D WMT three-dimensional wall motion tracking
POA planimetric orifice area TA tricuspid annulus
PV pulmonary valve TAPSE tricuspid annular plane systolic excursion
PVE prosthetic valve endocarditis TAVR transcatheter aortic valve replacement
PVL paravalvular leak TDI tissue Doppler imaging
PVR paravalvular regurgitation TEE transesophageal echocardiography
TMVR transcatheter mitral valve replacement
Q TOF tetralogy of Fallot
QCT quad-chamber tracking TPVR transcatheter pulmonary valve replacement
TR tricuspid regurgitation
R TS puncture transseptal puncture
RA right atrium TTE transthoracic echocardiography
RCS right coronary sinus TTVR transcatheter tricuspid valve replacement
RF radiofrequency TV tricuspid valve
RO regurgitant orifice TVI time-velocity integral
ROI region of interest
U
RV regurgitant volume
UVH univentricular heart
RV right ventricle
RV EDV right ventricular end-diastolic volume V
RV EF right ventricle ejection fraction VC vena contracta
RVOT right ventricular outflow tract VCA vena contracta area
VSD ventricular septal defect
S VSR ventricular septal rupture
SAM systolic anterior motion
SD spectral Doppler W
SDI systolic dyssynchrony index WBC white blood cell

Abbreviations xiii
 1 Principles of 3D Echocardiographic Imaging
INTRODUCTION
Volumetric or three-dimensional (3D) imaging in
echocardiography has grown rapidly in the last decades and
has evolved from combining different two-dimensional (2D)
acquisitions toward the true, real-time clinical systems we
now have. While it has not completely replaced high-end 2D
ultrasound scanners, rapid technical developments and its
theoretical potential will make 3D echocardiography the
modality of choice for clinical practice in the future.
This chapter discusses the principles underlying real-time
3D ultrasound imaging that are relevant for understanding
the images and recognizing its potential and limitations.
First, the requirements of an imaging system used for
cardiovascular applications are described, leading to the
rationale behind 3D systems and sketching the properties
needed for these systems to be useful in a clinical
environment. Next, the technical properties of standard
grayscale imaging, providing low-frame-rate 2D images, are
described, after which these are extended to high frame
rate, multiplane, and 3D imaging. Besides the acquisition
of 3D information, there are several ways to visualize this,
from multiplane over reslicing up to 3D rendering. Each of
these has intrinsic advantages and disadvantages.
REQUIREMENTS FOR CARDIAC IMAGING
In clinical practice, cardiac imaging serves several objectives.
Mainly it is used to obtain relevant information and preferably
quantification of cardiac and myocardial morphology,
on cardiac function and on perfusion. When using
echocardiography, the relevant morphological information
extracted from the images translates into anatomical
information on myocardium, pericardium, valves, and so
on. For cardiac function, wall motion and deformation,
valve function, and hemodynamics are studied, using visual
assessment, myocardial strain imaging, and Doppler blood
flow. Using additional contrast, some limited information on
perfusion can be obtained.
In order to be useful, these parameters have to be
efficiently visualized and preferably quantified. For this,
there are some requirements on the images obtained. These
include intrinsic image quality, with a sufficient temporal
and spatial resolution, and appropriate tools for processing
the data. With regard to spatial resolution, one would prefer
this to be as high as possible in order to detect the smallest
anatomical details. However, in some cases, for example,
when evaluating cardiac function, or to guide interventions,
it might be sufficient to have a resolution that is just enough
for detecting clinically relevant information. In terms
of myocardial function, a resolution cell about the order
of magnitude of 1 cm3 seems appropriate, since smaller
disease is not likely to be clinically relevant. However, keep
in mind that it is important that this resolution is obtained
everywhere within the myocardium. This figure is clearly
not good enough when trying to evaluate the morphology
of the valve and valvular apparatus and chordae. In this
case, a submillimeter resolution would be more appropriate.
This implies that there is no one unique definition for
the required spatial resolution; it depends on the specific
purpose of the information. Similar considerations can be
made with regard to the temporal resolution. In the cardiac
cycle, there are some very fast events, especially during the
isovolumic periods, so a very high temporal resolution is
needed if these are studied. This means that typically a
temporal resolution of over 200 Hz is required. Given some
of the intrinsic limitations in the processing of some derived
parameters (like deformation), a frame rate of 200–300 Hz
is thus desirable for quantification of myocardial motion
and deformation. For visual interpretation of wall motion,
30 Hz would be sufficient since the human visual system
is not able to discriminate faster-moving images. However,
higher frame rates enable the images to be displayed in slow
motion, thus enabling a better evaluation of events.
In order to assess and quantify the resulting images,
the appropriate tools need to be available. Online
quantification embedded in the ultrasound scanners is often
complemented with an offline workstation, enabling more
advanced visualization and quantification of the images
(e.g., advanced 3D visualization and volume calculations,
deformation analysis, etc.). For these, user friendliness is
crucial in order to enable their use in a clinical environment,
and approaches such as these using machine learning or
artificial intelligence can improve the user experience,
standardization of quantification, and speed of analysis.
BASICS OF STANDARD
2D ECHOCARDIOGRAPHIC IMAGING
Ultrasonic waves are longitudinal compression waves with a
frequency above 20 kHz, as 20 kHz is the highest frequency
detectable by the human ear. In cardiac imaging, typical
frequencies used are 2 MHz for transthoracic imaging,
5 MHz for transesophageal imaging, and 30–40 MHz for
intravascular applications. These base frequencies are often
combined with harmonic imaging to improve the signal-to-
noise ratio.
Ultrasonic waves are both generated and detected by a
piezoelectric material. This kind of material deforms under
the influence of an electric field, and vice versa, an electric
potential is induced over the material by deforming it.
When an acoustic wave is generated by means of a
piezoelectric material, it will propagate away from its origin
in the medium with which the material is in contact. During
propagation, the amplitude of the wave will decrease/
attenuate mainly due to spherical spreading of the wave
Principles of 3D Echocardiographic Imaging  1
and conversion of acoustic energy to heat. This depends
on the properties of the medium and the frequency of the
propagating wave, with higher frequencies showing more
attenuation.
When the ultrasound wave encounters an abrupt change
in tissue properties, it will partially propagate further and
partially be reflected. The direction of the reflected wave
(referred to as a specular reflection in ultrasonic imaging) is
defined by the angle of incidence of the incident wave and
the characteristics of the surface separating both media. The
transmitted wave does not propagate in the same direction as
the incident wave and is therefore referred to as the refracted
wave. The amount of energy reflected or transmitted is
defined by the acoustic properties of both media and the
angle of incidence of the incident wave. Boundaries of tissues
with high densities, such as bone, calcifications, or metals used
in, e.g., mechanical valves, will reflect almost all ultrasound
energy and prohibit the propagation of the pulses into deeper
structures, thus shadowing parts of the tissues. Additionally,
all biological tissues are microscopically inhomogeneous and
show spatial fluctuations in acoustic properties. An acoustic
wave propagating in such an inhomogeneous medium will be
scattered at these inhomogeneities (referred to as scatterers).
All scatterers will retransmit energy in all directions.
Depending on the shape of the scatterer and its size relative to
the wavelength, the energy will be retransmitted in different
directions. These scatterer reflections form the basis of the
appearances of the tissues on ultrasound images.
To construct echocardiographic images, an ultrasonic
pulse is transmitted into a medium. After transmission of the
pulse, the same transducer serves as a receiver, and both the
specular and scatter reflections are recorded as a function
of time. Figure 1.1 illustrates this principle. An ultrasound
pulse is transmitted into the object, containing scatterers
(e.g., the myofibers in the myocardium) (top left). As soon as
in the tissue
Ultrasound
RF signal
Received
Depth into the tissue
in the tissue
Ultrasound
RF signal
Received
Depth into the tissue
Figure 1.1  While a transmitted ultrasound pulse propagates through the tissue, encountered scatterers generate reflections back to the
transducer, which are converted into an electrical signal (= the radiofrequency [RF] signal).
2  3D Echocardiography
the pulse encounters scatterers, part of the energy is reflected
back toward the transducer (top right). While the pulse
propagates deeper into the tissues, the first reflections reach
the transducer and generate an electrical signal, referred to as
the RF (radiofrequency) signal (bottom left). When the pulse
reaches the most distal parts of the tissue, it is attenuated
so much that it will no longer generate any reflections, and
all previously generated reflections will be received by the
transducer and converted into an electrical signal that can
be used for image reconstruction (bottom right).
The time period between transmitting the pulse and
receiving an echo is a measure of the distance between
the transducer and the object causing the reflection. If
the velocity of the wave in the medium is known, the exact
distance can be calculated from the “time of flight.”
These received RF signals form the basis for ultrasonic
imaging. The signal corresponds to information from
one line within the object under investigation. In order to
create a 2D tomographic image, the whole object has to
be scanned. In cardiac applications, since the ribs would
reflect all ultrasound, the limited window of the intercostal
spaces has to be used in order to deliver the ultrasonic
pulse to the structure to visualize. This means that the
“scanning” of thoracic organs has to be done based on
sending ultrasound in all required directions using sector
sweeping. To make a visually interpretable image of the RF
signals resulting from scanning the object, some processing,
like signal demodulation, depth gain compensation, and
compression, has to be performed. Figure 1.2 illustrates
how an ultrasound sector scan is generated. The RF signal
resulting from a transmission into a particular direction
within the sector is processed and visualized as gray
values (corresponding to the strength of the reflections)
in the image, showing the proper geometrical relation
to the direction of the scan line (Figure 1.2A). Once all
in the tissue
Ultrasound
RF signal
Received
Depth into the tissue
in the tissue
Ultrasound
RF signal
Received
Depth into the tissue
 A 0
B 0 C 0
10 10 10
20 20 20
30 30 30
Depth (mm)

Depth (min)

Depth (min)
40 40 40
50 50 50
60 60 60
70 70 70
80 80 80
90 90 90
–30 –20 –10 0 10 20 30 –30 –20 –10 0 10 20 30 –30 –20 –10 0 10 20 30
Width (mm) Width (mm) Width (mm)
Object Image Object Image Object Image

Figure 1.2  Reconstruction of ultrasound sector images. The radiofrequency signal from one scan line is converted into gray values and
visualized corresponding to the geometrical arrangement of the sector scan. When lines are constructed in all adjacent directions, a full
frame can be constructed resulting in a tomographic cross section of the object.

reflections from a certain direction are received, the
next pulse can be sent into a slightly different direction,
adjacent to the previous line acquisition (Figure  1.2B).
This way, the whole sector can be scanned, resulting in
one complete tomographic cut (= one frame) through the
object under investigation (Figure 1.2C). This processing
can be repeated over and over again, showing the temporal
changes of the object.
TOWARD HIGH-FRAME-RATE IMAGING
The number of frames that can be generated per second is
referred to as the frame rate, which plays an important role
in the temporal resolution and thus the ability of the system
to investigate fast-changing properties of tissues. When
using the straightforward approach of sector scanning,
as described earlier, a frame rate of about 30 Hz can be
obtained in cardiac applications while using a 90° scanning
angle containing 120 scan lines and an imaging depth of
20 cm.
However, some cardiac applications, like deformation
imaging, require higher frame rates. Also, if 3D imaging
would be attempted, meaning that several 2D slices in the
third dimension would be required (typically 100), the
frame rate would go down unacceptably. This means that
the straightforward sector-scanning approach cannot be
used, and other ways of obtaining the image information
have to be implemented.
In order to explain the high frame rate and 3D
acquisition technique, first one has to understand how
beamforming, using a “phased-array” transducer, works.
Figure 1.3 (left) shows an example of a classical transducer
(where focusing in the elevation direction is obtained from
concave crystals). The active surface, used for transmitting
and receiving the ultrasound pulses, is made up of smaller
individual crystals, arranged adjacent to each other so
that their subdivision is in the direction of the intended
scan plane. Using this setup for the crystals within the
transducer makes it possible to control each individual
crystal. This enables focus of the beam during transmission
of the ultrasound pulse (Figure 1.4, left). The pulse being
sent out by an individual crystal can be delayed with regard
to the others. If the pulses sent out from the outer side
of the transducer are transmitted earlier compared to
the central ones, the resulting ultrasound field converges
toward a certain point in space, and a “focal point” is
created in the image. Additionally, this setup makes it
possible, for example, to delay all crystals from one side
of the transducer compared to the contralateral side,
resulting in a sound field that is directed toward the side
with the biggest delay. This way, the direction in which
the beam is sent can be controlled, and a sweep can be

Figure 1.3  The active surface of a phased-array transducer consists of an assembly of smaller piezoelectrical crystals that can be controlled
individually. The classical transducers consist of one row of crystals, where the subdivision is made in the plane used as a scan plane (Left).
For transducers with improved spatial resolution and for 3D acquisition, so called 2D arrays are used, where the whole active surface of the
transducer is made up of individual crystals (Right). (Courtesy of GE Medical Systems.)

Principles of 3D Echocardiographic Imaging  3
 Transmit beam former Receive beam former

∆t ∆t

∆t Reflected ∆t
Transmitted
wave front
wave front
∆t diverging ∆t Σ
converging
toward
into focal point
∆t transducer ∆t RF signal
∆t ∆t
Individually Received
Transducer Transducer
delayed pulses echoes
crystals crystals

Figure 1.4  When the transducer is made up of individual crystals, the pulses sent out by each crystal can be delayed compared to their
neighbors. By sending out pulses from the outer sides of the transducer first, the ultrasound beam can be focused (or steered) (left). The
reflected signals from the object will be received at a different time point by each of the individual crystals in the array. Compensating for
this, before combining them, will result in the most optimal radiofrequency signal. (Δt, time delay introducer; ∑, signal summation.)

performed in order to compose one tomographic sector

scan of an object, or the whole image can be tilted in a Transducer
certain direction to scan an adjacent plane. crystals
Similarly, having individual crystals in the receiving
transducer (mostly the same probe) makes it possible to
optimize the RF signal composed within the system. Each Σ
of the individual crystals will receive a slightly different
reflection from the object since their distance to the object RF signal

is not identical. This means that when a reflection comes Received

from the center of the image, the outer crystals will receive echoes
the signal slightly later then the central ones (Figure 1.4,
right). Compensating for this difference before combining
them to compose the final RF signal will yield the optimal
signal strength. In order to perform this compensation,
one has to make assumptions on the direction from
which the ultrasound reflections are originating. This is Transducer
crystals
straightforward, since the system knows in which direction
the original pulse was transmitted.
However, this principle can be extended to try to
obtain more information than a single scan line in the Σ
image from each single transmitted pulse. If a wider RF signal
pulse was sent out, illuminating a relatively large volume
with ultrasound, when receiving the reflections, one Received
echoes
would specifically look in individual directions to detect
structures in each direction, and one could obtain
information about a larger region than would be possible
with one scan line. This is exactly what is done in parallel
beamforming.1 Figure 1.5 illustrates what happens at
the receiving side of the system. When the delays used Transducer
to construct the RF signal are set up to “look forward” crystals
(top), the reflections from an object in the central line of
the scan plane are optimally combined, while reflections
from other directions are suppressed. When “looking Σ
under an angle” (middle and top), one can specifically
RF signal
isolate reflections from objects in that direction. When
an ultrasound scanner is equipped to “look into different Received
directions” in parallel, it is possible to construct several echoes
lines (under slightly different angles) within the images
with each individual transmit pulse. Typically, current
high-end clinical 2D systems are equipped with four Figure 1.5  In systems equipped with parallel beamforming, the
parallel beamformers, enabling an increase in the frame reflections from the individual crystals are processed in parallel
rate by a factor of four. (In 3D systems, this is often 4 × 4 circuits. In each of these, the combining of the signals is optimized in
[up to 8 × 8], thus receiving a pyramid of 16 [up to 64] order to look into a slightly different direction. (∑, signal summation.)

4  3D Echocardiography
scan lines from each transmitted pulse.) This would
enable wide-angle 2D grayscale imaging at a frequency
of 120 Hz instead of the 30 Hz that can be achieved with
classical systems.
Other solutions to additionally increase the frame rate
could be to abandon the traditional “sequential scanning,”
where pulses are sequentially sent out in adjacent directions
to build up a sector. In this classical approach, one has to
wait for all reflections to propagate back to the transducer
before sending out the next pulse. However, if consecutive
transmitted pulses are in directions that are widely apart
and the receiving system is intelligent enough to isolate
from which direction the reflections originate, it would
be possible to send pulses at a faster rate, since they would
influence each other only marginally. If consecutive pulses
can be sent out at a higher rate, this again increases the
resulting frame rate. Other approaches to speed up the
pulsing would be to “encode” each pulse with a unique
signature so that the receiver can identify from which
transmitted pulse a specific reflection originates.
However, note that parallel processing also has a few
disadvantages. First, a “wide pulse” has to be sent out,
meaning that ultrasound energy is spread out over a larger
volume so that transmittal energies have to increase in
order to obtain similar signal-to-noise values. Next, besides
limitations due to ultrasound physics, the beamformer is
one of the most expensive parts of the ultrasound scanner,
so putting several of them in parallel will increase the
price of the scanner. This problem could be solved using
powerful computing in the systems instead of “hardware”
beamformers, and this is starting to be incorporated in the
latest generation of clinical scanners.
In addition to production of potentially cheaper systems,
this approach enables the construction of true 3D systems
as described later.
FROM HIGH-FRAME-RATE TO 3D IMAGING
The approach used for parallel processing can be extended
to 3D imaging. However, in order to look at “out-of-plane”
information, one has to isolate reflections coming from a
conical volume instead of from a sector. This can be done
when a “2D array” is used within the transducer (Figure 1.3,
right).2 If each of the individual crystals in this array can
be controlled and the signals can be combined in order to
“look in all directions,” one can both transmit and receive
signals from 3D objects (and additional active focusing in
the elevation plane becomes possible).3–5
Although the principles for 3D imaging are well known
and not different from the ones used for high-frame-rate
imaging, there are several practical problems to be solved.
First, the construction of the transducer is more complex.
Classical phased-array transducers used in cardiology would
typically contain 64–96 individual crystals. Extending to a
“2D” array would mean that it should contain 962 = 9216
crystals. Besides creating these, it is virtually impossible to
wire each individual crystal up to the main system, since
as many cables should be used. To make this work, most
manufacturers miniaturize this into integrated circuits that
are embedded in the head of the transducer. Additionally,
to obtain a similar spatial resolution as classical 2D
systems, the 3D systems have to speed up image scanning
by approximately a factor of 100 (if we would like to have
100 image lines in all directions). As previously explained,
parallel processing can easily speed up 2D imaging with a
factor of four; a similar approach in 3D would speed it up by a
factor of 16, still well below what is needed for comparable
spatial resolution. As explained, this can only be done when
software beamformers are used, placing high requirements
on the computing power embedded in the scanner.
The 3D real-time echocardiographic scanners used
in clinical practice approach these problems using
miniaturization of the receiving side of the scanner so
that most of the processing is performed in the probe
(explaining also why 3D transducers are commonly more
bulky compared to 2D ones). In order to come as close as
possible to the desired spatial resolution for 3D systems, all
approaches described earlier to increase frame rate (and
additionally often reducing the sector/volume width), are
used in these systems, this time not to increase the temporal
resolution but to optimize spatial resolution.
The end result is that as long as full-resolution software
beamformers are not available, the commercially available
systems have to use a trade-off between spatial, temporal
resolution, and field of view. This results in the use of
several approaches in order to still obtain clinically relevant
information. One approach is to lower the constraints on
3D spatial resolution using multiplane imaging, where two
or three scan planes are used, instead of the full volumetric
cone, to examine the 3D object. Another approach is to
reduce the volume being scanned and compound a larger 3D
volume over several cardiac cycles using electrocardiograph
(ECG) triggering. This way, slightly different adjacent
volumes, acquired over three to four consecutive heartbeats,
are combined into one larger volume with a high spatial
resolution. However, this approach might introduce
stitching artifacts.6 Of course, reducing the temporal
resolution enables a higher spatial resolution to be used.
This approach can be taken when, for example, volumes
are calculated to obtain ejection fractions. For this purpose,
lower temporal resolution will not significantly increase the
errors in the measurements.
3D CARDIAC IMAGING
Using the previously described technology, it is possible to
acquire real-time echocardiographic images containing 3D
information.
A first approach is to use multiplane imaging.7 Here,
several planes (typically two to three) with a similar central
line but under different angles (Figure 1.6, bottom right)
are scanned simultaneously. This way it becomes possible
to obtain, for example, a simultaneous apical four-, three-,
and two-chamber view of the same heart cycle. Besides faster
acquisition and better correspondence of the images, when
all views are seen simultaneously and in real time, it is much
easier to make sure that the scan planes contain the true apex
and make no angle with the long axis of the ventricle, thus
Principles of 3D Echocardiographic Imaging  5
Figure 1.6  Using 3D systems, one can acquire multiplane images. This way, one can image different echocardiographic views from the same
heart cycle simultaneously with acceptable temporal and spatial resolution for assessment of cardiac function. This also helps considerably
to avoid foreshortening and to image the true apex ( ).
foreshortening the view. This approach results in acceptable
temporal and spatial resolution using the current systems. It
is also possible to implement blood pool and tissue Doppler
acquisition.8 One potential application is quantitative stress
echo, where multiplane images can be acquired together with
velocities for deformation analysis.9 This can significantly
reduce scanning time and improve comparison of different
walls of the myocardium. Figure 1.6 ( ) shows an example
of this approach.
Ultimately, one would like to be able to perform true
3D acquisition where real-time imaging of the whole
heart is possible at high temporal and spatial resolution.
As described earlier, one often has to make a compromise
between spatial and temporal resolution.
When acquiring a true 3D echocardiographic dataset,
information from structures within a 3D cone, originating
from the transducer, is obtained. Once this information is
available and stored in the scanner, it is possible to visualize
and analyze it in several ways.
A first approach is reslicing the dataset. This way, it is
possible to obtain a “traditional” scan plane from the same
heart cycle. Figure 1.7 ( ) shows an example where nine
equidistant short-axis views are obtained from an apical
3D acquisition. Since the planes used for reslicing can be
controlled and adapted, the resulting slices correspond to
true short-axis planes, avoiding oblique slicing as is often
the case in 2D systems. Note, however, that the spatial
resolution of these images is limited compared to high-end
2D systems and that it reduces for more distal slices due to
6  3D Echocardiography
divergence of the ultrasound scan lines. This is inherent to
ultrasound where lateral resolution of the (cardiac) systems
is always much worse than the axial resolution, even in
high-end 2D systems. These full 3D datasets are ideally
suited for quantification of exact volumes of any chamber
as illustrated in Figure 1.8 ( ). Several approaches are
available for the automated quantification of these images,
many using machine learning algorithms.10
Besides reslicing the 3D datasets, resulting in images
that are familiar from working with 2D systems, 3D imaging
offers new ways of visualizing the data. The approach
used for this is called “3D rendering” of the data. There
are two major categories of rendering algorithms: volume
or surface rendering. In volume rendering, an attempt is
made to visualize 3D information on a 2D image in such a
way that more distal data are perceived as more distal, and
“transparency” is used to give an idea of the texture of the
object. The tools used for this offer the possibility to view
the dataset from different angles and cut away parts of the
structures in order to visualize the parts of interest. Once
the user is familiar with the way to handle the dataset, it is
relatively easy to navigate through all the information. This
type of visualization can be easily combined with reslicing.
Figure 1.9A ( ) shows an example of this approach. In the
top middle of the image, a navigation icon is shown that
indicates the planes used for reslicing the dataset. The left
part shows these resliced scan planes. The right image is the
3D visualization of the dataset, which is controlled by the
user, with an indication of the viewpoint in the icon in the
Figure 1.7  An example of reslicing a full 3D dataset. Once the data from the 3D cone is acquired, several traditional “scan planes” can be
visualized. This image shows nine short-axis views obtained from an apical 3D acquisition .
top middle. Figure 1.9B ( ) shows how the 3D visualization
can help, as compared to the 2D (multiplane) views, to
visualize the extent of the basal septal hypertrophy in a
hypertensive patient.
Besides visualizing the full 3D dataset, one can
concentrate on the surface of some objects within the
dataset. Figure 1.10A ( ), Video shows a normal mitral valve
where the open as well as closed geometric complexity can
be more easily appreciated in the 3D images as compared
to a set of 2D images. Figure 1.10B shows the tricuspid valve
in the same individual. In order to obtain these images,
interfering structures are first cut away, and the structure
of interest is isolated (segmented) by manipulating
the grayscale values of the datasets, for example, using
thresholding. This approach enables easy visualization of
prominent structures within the dataset. However, keep in
mind that it intrinsically ignores a lot of the data and should
thus be seen as an addition to reslicing the datasets to show
all details of the structures.
All of these approaches can also be used for the
visualization and quantification of blood pool Doppler
information.11,12 Figure 1.11 ( ) shows how 3D visualization
of the Doppler flow can help in assessing valves. Figure 1.11A
and B show the closing and opening frames of a normal
mitral valve to illustrate how the complex flow in relation to
the anatomy can be observed as compared to the traditional
2D approach. Figure 1.12 ( ) shows a transesophageal
echocardiography (TEE) image of a patient with mild
mitral regurgitation where the complementarity of 3D
anatomy and jet shape and directions is illustrated. Figure
1.13 ( ) illustrates how this helps to assess the function of a
MitraClip where forward flow is evenly distributed between
both orifices, but the regurgitant jet only originates from
one of them. The extent and direction of the jet are directly
assessible from the 3D flow TEE images.
Combining all information from 3D images with
fluoroscopy and even physical printing into a tangible object
allows for planning even the most complex interventions.13,14
Table 1.1 summarizes the inherent differences between
the 2D and 3D approaches toward evaluating cardiac
structure and function.
LIMITATIONS AND FUTURE DEVELOPMENTS
As previously mentioned, and is clear from the images,
3D echocardiography offers clear advantages to acquire,
visualize, and quantify the heart, therefore providing new
possibility for improving clinical cardiac imaging.15–17
Applications (such as real-time intervention guidance and
volume quantification) have been shown to benefit from
3D imaging and are routinely used in many centers.18–20
However, the current state-of-the-art 3D ultrasound
scanners are not yet able to fully replace the high-end 2D
scanners due to a lack of sufficient spatial and temporal
resolution.
Theoretically, there are ways to create 3D systems with
a similar, or even superior, spatial and temporal resolution
compared to current 2D systems. These approaches all rely
Principles of 3D Echocardiographic Imaging  7
 A

Figure 1.8  The 3D datasets are optimal for volume quantifications given that they capture the true complex shape of the left ventricle (A) ( )
or left atrium (B), thus ensuring the most accurate measurements.

Figure 1.9  An example of volume rendering of a full 3D dataset obtained from an apical view. The left part of (A) shows two perpendicular
slices obtained from reslicing the dataset, while the right image shows the 3D visualization. The navigation image in the top middle visualizes
the planes used for reslicing and the viewpoints used for the 3D image . (B) An example of a hypertensive patient where the extent of basal
septal hypertrophy can be more easily assessed .

8  3D Echocardiography
 A

Figure 1.10  An example of surface rendering of a full 3D dataset obtained from an apical view. In this image (right), the mitral valve is
isolated in the dataset, and its surface is visualized in closed and opened positions (A) . Tricuspid valve surface is visualized (B).

on improved or alternative beamforming, both during
transmission of the ultrasound beam and during receiving
of the reflections from the object under investigation.21–23
For example, it was recently shown that volumetric frame
rates benefit from transmitting multiple lines simultaneously
in spatially “remote” regions within the conical volume.24
When combining this multiline transmission scheme with
parallel receive beamforming (i.e., 4 × 4 parallel receive
lines), these authors demonstrated an increase in volume
rate with a factor of 64 without significant impact on image
quality. Alternatively, the parallel beamforming scheme
described earlier can be pushed to the extreme by widening
the transmitting beam to cover the entire field of view (i.e.,
using a diverging wave on transmit) and reconstructing

A B

Figure 1.11  (A and B) A 3D blood pool Doppler image of the opening and closing of the mitral valve, illustrating the complementarity of
complex valve anatomy with flow information .

Principles of 3D Echocardiographic Imaging  9
 A B

Figure 1.12  (A and B) A TEE investigation of a patient with mild mitral regurgitation clearly showing the relation between anatomy and
flow with regurgitation resulting from malcoaptation of the leaflets .

all image lines in the volume by receive beamforming
only. Although this approach limits spatial resolution and
contrast-to-noise ratio, techniques to preserve them have
been proposed, and it was demonstrated that it enables
reconstructing clinically relevant images at very high
time resolution (i.e., >1000 Hz).25 As both the multiline
and diverging wave transmit approaches have their own
strengths and weaknesses, more recently, a hybrid approach
was proposed that takes advantage of the strengths of both
technique referred to as multiplane transmit imaging.26
However, these novel approaches rely on using a large
amount of crystals in the transducer and the ability to
independently control transmission and receiving by them.
When this can be done in real time by the processors in the
systems, the appropriate datasets can be created, but this
implies huge data streams and fast complex calculations,

A B C

Figure 1.13  A TEE investigation of a patient with an implanted MitraClip where the 3D anatomical image shows the open (A) and closed
(B) orifices created by the clip, and the 3D flow shows the shape and direction of the regurgitant jet coming only from one orifice. In C, the
corresponding 2D cross-section through the middle of the valve is shown .

10  3D Echocardiography
Table 1.1  3D vs. 2D Cardiac Imaging
Feature 2D 3D

Intrinsic Standardized image acquisition
Potential Acquisition time
Amount of structural information
available
Visualizing complex structures
Volume quantification
Quantitative cardiac mechanics
Blood flow assessment
Multimodality imaging
Advanced use
Current State Spatial resolution
of the Art
Temporal resolution
Steep learning curve
Standard protocol with multiple views to
acquire
Only in a single slice, so multiple views
needed
Need for combing different views in the
head of the sonographer
Models have to be used to calculate
volumes, making assumptions of shape
Multiple views needed and out-of-plane
motion is a problem
Limited to the plane visualized, missing
complex flow patterns; caveat: Doppler
angle dependency
Difficult to register with other imaging
modalities
Limited use to extract shape information
for printing or computational modeling
Excellent
Excellent
Intuitive, since a large portion of the heart is shown
A limited number of full datasets cover all required
information
All information contained in the volume and can be
extracted offline
Straightforward visualization of complex
geometrical structure such as valves
Exact volumes can be determined, whatever
cardiac remodeling present
Complex 3D deformation can be extracted
Capturing complex flow patterns; caveat: Doppler
angle dependency
Ideal for combining modalities such as with
computed tomography, magnetic resonance
imaging, or real-time fluoroscopy
Possibility to extract shape information for printing
or computational modeling
Good for interventional imaging, limited for
detailed morphology; will improve in future
generations
Good for interventional imaging, limited for
functional assessment; will improve in future
generations

which are challenging to implement in the current
generation of clinical systems. Several research groups
have equipment to perform this approach, but it uses long
acquisition times and offline processing, requiring hours or
days to reconstruct data from one heartbeat. Nevertheless,
when restricting the computational load by going to
multiplane imaging, it was recently demonstrated that both
multiline and diverging wave transmit schemes can be used
for real-time, high-frame-rate cardiac imaging.27 Therefore,
it can be expected that future computers will be able to
handle this data and thus allow real-time implementation
of full-volume, high-frame-rate 3D imaging.
Besides acquisition, continuous improvements are made
in the processing and visualization tools used for these
datasets. Since many clinical applications of true 3D images
are still being explored, the ideal visualization of cardiac
structures is not yet determined, and novel approaches are
being explored.28,29 Additionally, true 3D quantification
tools to perform, e.g., real-time automatic quantification
of volumes and motion/deformation of the myocardium,
are only starting to become available, but machine learning
seems very promising for this.30–32
CONCLUSION
Real-time 3D imaging is the logical evolution within
cardiac ultrasound given that it addresses optimizing the
inherent clinical needs and can be based on optimizing
beamforming and image reconstruction. While spatial and
temporal resolution is inferior to high-end 2D imaging, it
is sufficient and superior for many clinical applications like
interventional guidance or volume quantifications.
REFERENCES
1. Shattuck DP, Weinshenker MD, Smith SW et al. Explososcan: A parallel
processing technique for high speed ultrasound imaging with linear phased
arrays. J Acoust Soc Am. 1984;75(4):1273–82.
2. Yen JT, Steinberg JP, Smith SW. Sparse 2-D array design for real time
rectilinear volumetric imaging. IEEE Trans Ultrason Ferroelectr Freq Control.
2000;47(1):93–110.
3. Smith SW, Pavy HR, Ramm OT. High-speed ultrasound volumetric
imaging system. IEEE Trans Ultrason Ferroelectr Freq Control. 1991;38(2):100–8.
4. Von Ramm OT, Smith SW, Pavy HR. High-speed ultrasound volumetric
imaging system. IEEE Trans Ultrason Ferroelectr Freq Control. 1991;38(2):109–15.
5. Sheikh K, Smith SW, von Ramm O, Kisslo J. Real-time, three-
dimensional echocardiography: Feasibility and initial use. Echocardiography.
1991;8:119–25.
6. Brekke S, Rabben SI, Stoylen A et  al. Volume stitching in three-
dimensional echocardiography: Distortion analysis and extension to real
time. Ultrasound Med Biol. 2007;33(5):782–96.
7. Yao J, Cao QL, Pandian NG et  al. Multiplane transthoracic
echocardiography: Image orientation, anatomic correlation, and clinical
experience with a prototype phased array multiplane surface probe.
Echocardiography. 1997;14:559–78.
8. Helmcke F, Nanda NC, Hsiung MC et al. Color Doppler assessment of
mitral regurgitation with orthogonal planes. Circulation. 1987;75:175–83.
9. Ahmad M, Xie T, McCulloch M, Abreo G, Runge M. Real-time three-
dimensional dobutamine stress echocardiography in assessment stress
echocardiography in assessment of ischemia: Comparison with two
dimensional dobutamine stress echocardiography. J Am Coll Cardiol.
2001;37:1303–9.
10. Gandhi S, Mosleh W, Shen J, Chow CM. Automation, machine learning,
and artificial intelligence in echocardiography: A brave new world.
Echocardiography. 2018;35(9):1402–18.

Principles of 3D Echocardiographic Imaging  11
11. Tan TC, Zeng X, Jiao Y et  al. Three-dimensional field optimization
method: Clinical validation of a novel color doppler method for quantifying
mitral regurgitation. J Am Soc Echocardiogr. 2016;29(10):926–34.
12. Heo R, Son JW, Ó Hartaigh B et  al. Clinical implications of three-
dimensional real-time color Doppler transthoracic echocardiography in
quantifying mitral regurgitation: A comparison with conventional two-
dimensional methods. J Am Soc Echocardiogr. 2017;30(4):393–403.e7.
13. Zorinas A, Janusauskas V, Davidavicius G et al. Fusion of real-time 3D
transesophageal echocardiography and cardiac fluoroscopy imaging in
transapical catheter-based mitral paravalvular leak closure. Postepy Kardiol
Interwencyjnej. 2017;13(3):263–8.
14. So KC, Fan Y, Sze L, Kwok KW, Chan AK, Cheung GS, Lee AP. Using
multimaterial 3-dimensional printing for personalized planning of
complex structural heart disease intervention. JACC Cardiovasc Interv.
2017;10(11):e97–8.
15. Roelandt JR. Three-dimensional echocardiography: New views from old
windows. Br Heart J. 1995;74:4–6.
16. De Castro S, Yao J, Pandian NG. Three-dimensional echocardiography:
Clinical relevance and application. Am J Cardiol. 1998;81:96G–102G.
17. Kisslo J, Firek B, Ota T et al. Real-time volumetric echocardiography:
The technology and the possibilities. Echocardiography. 2000;17:773–9.
18. Scohy TV, Cate FJT, Lecomte PV et  al. Usefulness of intraoperative
realtime 3D transesophageal echocardiography in cardiac surgery. J Card
Surg. 2008;23(6):784–6.
19. Gopal AS, Keller AM, Rigling R, King DL Jr, King DL. Left
ventricular volume and endocardial surface area by three-dimensional
echocardiography: Comparison with two-dimensional echocardiography
and nuclear magnetic resonance imaging in normal subjects. J Am Coll
Cardiol. 1993;22:258–70.
20. Rusk RA, Mori Y, Davies CH et al. Comparison of ventricular volume
and mass measurements from B- and C-scan images with the use of real-
time 3-dimensional echocardiography: Studies in an in vitro model. J Am
Soc Echocardiogr. 2000;13(10):910–7.
21. Lu JY. Designing limited diffraction beams. IEEE Trans Ultrason Ferroelectr
Freq Control. 1997;44(1):181–93.
12  3D Echocardiography
22. He Z, Ma Y. Optimization of transmitting beam patterns of a conformal
transducer array. J Acoust Soc Am. 2008;123(5):2563–9.
23. Bjastad TG. High frame rate ultrasound imaging using parallel beam
forming. PhD thesis, Norwegian Institute of Science and Technology, 2009.
24. Ortega A, Provost J, Tong L, Santos P, Heyde B, Pernot M, D’hooge J. A
comparison of the performance of different multiline transmit setups for
fast volumetric cardiac ultrasound. IEEE Trans Ultrason Ferroelectr Freq Control.
2016;63(12):2082–91.
25. Provost J, Papadacci C, Arango JE, Imbault M, Fink M, Gennisson JL,
Tanter M, Pernot M. 3D ultrafast ultrasound imaging in vivo. Phys Med Biol.
2014;59(19):L1–13.
26. Chen Y, Tong L, Ortega A, Luo J, D’hooge J. Feasibility of multi-
plane transmit beam forming for real-time volumetric cardiac
imaging: A simulation study. IEEE Trans Ultrason Ferroelectr Freq Control.
2017;64(4):648–59.
27. Ramalli A, Harput S, Boni E, Eckersley RJ, Tortoli P, D’hooge J.
High-frame-rate tri-plane echocardiography with spiral arrays: From
simulation to real-time implementation. IEEE  Trans Ultrason Ferroelectr
Freq Control. 2020;​67(1):57–69.
28. Littlefield RJ, Heiland RW, Macedonia CR. Virtual reality volumetric
display techniques for three-dimensional medical ultrasound. Stud Health
Technol Inform. 1996;29:498–510.
29. Bol GR, Koning AH, Scohy TV et al. Virtual reality 3D echocardiography
in the assessment of tricuspid valve function after surgical closure of
ventricular septal defect. Cardiovasc Ultrasound. 2007;5:8.
30. Angelini ED, Homma S, Pearson G et  al. Segmentation of real-
time three-dimensional ultrasound for quantification of ventricular
function: A clinical study on right and left ventricles. Ultrasound Med Biol.
2005;31(9):1143–58.
31. Hansegard J, Urheim S, Lunde K et al. Semi-automated quantification
of left ventricular volumes and ejection fraction by real-time three-
dimensional echocardiography. Cardiovasc Ultrasound. 2009;7:18.
32. Nesser HJ, Mor-Avi V, Gorissen W et al. Quantification of left ventricular
volumes using three-dimensional echocardiographic speckle tracking:
Comparison with MRI. Eur Heart J. 2009;30(13):1565–73.
 2 Left Ventricle
INTRODUCTION
Quantification of left ventricular (LV) size and
function represents the most frequent indication for an
echocardiographic study. The LV ejection fraction is a
strong predictor of clinical outcome in a wide variety of
cardiac conditions including ischemic heart disease,1
valvular heart diseases, 2 cardiomyopathies, 3,4 congenital
heart diseases, and heart failure. 5 Cardiac surgery or
transcatheter procedure indications in valvular heart
diseases, 2,6 optimal medical treatment, and suitability for
device implantation in heart failure with reduced ejection
fraction5 or cardiotoxic medication withdrawal7 are among
the most critical decisions that rely on a precise assessment
of LV function.
2D echocardiography is the most frequently used
imaging modality to assess LV size and function, and
current guidelines recommend the 2D echocardiography LV
ejection fraction to assess LV systolic function.8 However, 3D
echocardiography has proven to be more accurate, avoiding
geometric assumptions about LV shape,9–11 and to have
incremental value for outcome prediction in comparison
to conventional 2D echocardiography.12–14 Myocardial
deformation analysis using 3D echocardiography has raised
interest lately in an attempt to obtain an early detection of
myocardial dysfunction, before any detectable decrease in
LV ejection fraction.15
3D ECHOCARDIOGRAPHY ACQUISITION
AND DISPLAY OF THE LEFT VENTRICLE
DATASET ACQUISITION
For measurement purposes, the LV is generally acquired
as a full-volume dataset over four to six heartbeats (a
“multibeat” acquisition) during a single breath-hold
by “stitching” together dynamic subvolumes scanned
during consecutive cardiac cycles.16 While this breath-
hold–based approach enables the acquisition of datasets
with relatively high volume rates (temporal resolution)
and spatial resolution, the disadvantage is that “stitching
artifacts” can occur as a result of changes in the position
of the heart relative to the transducer during the
acquisition process (either patient or transducer motion
during acquisition, and/or translation of the heart within
the chest during respiration) or changes in cardiac
cycle duration (arrhythmias).16,17 Both technological
progresses in transducer engineering and increased
computational power of computers have made available
single-beat acquisitions of full-volume datasets with
sufficient temporal and spatial resolution. This technology
avoids stitching artifacts secondary to arrhythmias and
respiratory motion, and allows acquisition of full-volume
datasets of the LV, also in uncooperative patients and in
patients with irregular arrhythmias (e.g., atrial fibrillation),
even if the single-beat datasets have lower temporal and
poorer spatial resolution than those acquired using the
multibeat modality. With the previous generation of 3D
echocardiography probes, these limitations affected the
identification of the true end-systolic frame, which had
a variable impact on the measurement of LV end-systolic
volumes and, consequently, on the calculation of ejection
fraction. Recently, a new generation of piezoelectric
elements and probes has been developed that can acquire
single-beat 3D echocardiography datasets of the LV with
enough temporal (>20 vps) and spatial resolution to allow
accurate measurement of LV volumes.18
3D echocardiography acquisition of the LV is generally
obtained from the apical approach using transthoracic
echocardiography or from the transesophageal approach
using the midesophageal four-, two-, or three-chamber
views (Figure 2.1, ). Depending on the shape of the LV
and its position within the chest, more off-axis transducer
positions, compared to the ones used with conventional
2D echocardiography, may be appropriate for acquisition.
The goal is simply to encompass the whole LV within the
pyramidal 3D echocardiography dataset with the best
possible visualization of the LV endocardial border. Pivotal,
to obtain a good quality 3D echocardiography dataset, is
the optimization of the 2D echocardiography image. To
obtain the best 2D echocardiography image quality, both
positioning the probe in a higher intercostal space (from
which the conventional 2D echocardiography views will be
foreshortened) and respiratory maneuvers can be used.
Pending that the entire LV is encompassed within the 3D
echocardiography dataset, any foreshortening of LV cut
planes will be corrected during the postprocessing of the
dataset. Moreover, to improve both the temporal and spatial
resolution of the 3D echocardiography dataset, both the
image depth will be decreased (to eliminate the left atrium
and the right ventricle from the acquisition volume) and
the size of the pyramidal dataset will be reduced to the
minimum to include the LV only. Finally, to guarantee
optimal image quality, transducer frequency and overall
gain should be adjusted appropriately. In order to avoid
dropout artifacts and allow homogeneous distribution of
gain, time gain compensation slides are aligned in a straight
line a little higher than 50%, and the overall gain is higher
than with conventional 2D echocardiography imaging.
Multiplane visualization of the LV showing the azimuthal,
the elevation, and the transversal planes during acquisition
may help to ensure that the entire LV is encompassed within
the 3D echocardiography pyramidal dataset (Figure 2.1).
DATASET DISPLAY
Once the dataset has been acquired, there are several ways
to display it depending on the clinical question the clinician
Left Ventricle  13
 A B

Figure 2.1  Acquisition of 3D datasets of the left ventricle using the transthoracic (Panel A, ) and the transesophageal (Panel B, ) approach.
During the acquisition, a multislice (12-slice) display is used with three longitudinal cut planes on the left (the upper one, the four-chamber
view, is the reference one; the other two are oriented at 60° and 120° by default), and six transversal cut planes on the right. This visualization
display is used to ensure that the whole left ventricle is encompassed within the 3D datasets and to assess regional wall motion, distribution
of hypertrophy, or masses.

A B

Figure 2.2  Display modes of the 3D datasets of the left ventricle. Volume rendering, to show anatomy (Panel A, ). Surface rendering to
appreciate global function; the systolic volume is shown as a purple solid surface and the diastolic volume as a gray grid (wireframe) (Panel B).

wants to address: volume rendering display to show anatomy;
multislice display to show wall motion, masses, or distribution
of LV hypertrophy; and surface rendering display to show
function (Figures 2.1 and 2.2, ).
LEFT VENTRICULAR SIZE AND FUNCTION
LEFT VENTRICULAR SIZE AND SYSTOLIC FUNCTION
Despite its important theoretical and technical limitations,
2D echocardiography is still the most frequently used
noninvasive imaging technique to obtain a systematic
evaluation of LV function.8 However, LV volume calculations
by 2D echocardiography are highly operator dependent
(both the apical view acquisition and manual tracing of LV
endocardial border rely on the specific experience of the
operator), use only partial information contained in a few
predefined tomographic planes of the LV to assess global
myocardial function (i.e., the functional contribution of the
segments of the anterior septum and inferolateral wall are
neglected by the biplane algorithms19) (Figure 2.3, ), and
rely on geometrical assumptions about the shape of the LV
that may not be necessarily valid in every patient (Figures 2.2–
2.4). In particular, even when LV apical views are acquired
with great care to try to avoid long-axis foreshortening of
one or both LV views (i.e., the acquired cut plane does
not pass through the true apex resulting in an oblique
view of the LV cavity; Figure 2.4, ), it occurs frequently
in routine clinical practice and is the most frequent cause
of LV volume underestimation using conventional 2D
echocardiography.20 Mor-Avi et  al. obtained the LV long-
axis from both conventional 2D echocardiography apical
four- and two-chamber views, and from anatomically correct
planes obtained by cutting 3D echocardiography datasets,
to show that the latter were significantly longer in both
apical views when evaluated using the 3D echocardiography
technique.20

14  3D Echocardiography
 A B

C D

Figure 2.3  Added clinical value of 3D echocardiography in patients with extensive wall motion abnormalities and distorted left ventricular
(LV) geometry. In a patient with previous anterior myocardial infarction, the calculation of LV volumes and ejection fraction with conventional
biplane discs’ summation algorithm (which takes into account only the function of LV segments included in the apical four- and two-
chamber views) leads to underestimation of LV volumes and overestimation of ejection fraction (end-diastolic volume = 162 mL, end-systolic
volume = 97 mL, and ejection fraction = 39%) (Panels A, , B ), because the contribution of the aneurysmatic anterior septum (Panel C,
white arrows, ) is neglected by the algorithm. Using 3D echocardiography, the functional contribution of all the LV segments is taken into
account. Accordingly, LV volumes are larger, and ejection fraction is significantly lower with important clinical implications (indication to
implantable cardioverter-defibrillator implantation).

The foreshortening of the 2D echocardiography views and
the assumption that what is seen in a few thin tomographic
planes is representative of the wall motion of the whole
myocardial segment of the LV (Figure 2.5, ) wall  are
also the main sources of errors in assessing LV segmental
wall motion. Conversely, the possibility to visualize the
whole endocardial surface and myocardial function in a
theoretically infinite number of anatomically oriented cut
planes (Figure 2.1) obtained from a full-volume 3D dataset
can also improve the accuracy of stress echocardiogram.21
With 2D echocardiography, we do not actually measure
LV volumes. We calculate them using geometrical models to
obtain volumes from areas and linear dimensions. However, the
geometric assumptions about LV shape make the calculations
of LV volumes and ejection fraction more inaccurate in patients
in whom this information would be more clinically relevant (i.e.,
patients in whom there are extensive wall motion abnormalities
or the geometry is distorted, Figures 2.3 and 2.4).22
3D echocardiography has been established as the
most accurate echocardiographic technique for LV
quantitation.23 3D transthoracic echocardiography (TTE)
has been extensively validated against CMR and has been
demonstrated to be more time saving, reproducible, and
accurate than conventional 2D echocardiography for LV
volumes and ejection fraction measurement.24,25 The main
limitations of 2D echocardiography in calculating LV volumes
and EF (i.e., foreshortened views, need of manual tracing
of the endocardium, and geometric assumptions about LV
geometry) have been overcome by 3D echocardiography
that allows actual measurements (by counting the number
of voxels included in the Beutel obtained by mapping the
endocardial surface of the LV, Figure 2.1) of LV volumes
independent on any geometrical assumption about its
shape.16,26 Overall, transthoracic 3D echocardiography has
been shown to slightly underestimate both LV end-diastolic
and end-systolic volumes in comparison with those measured
with CMR, mostly due to the suboptimal spatial resolution
of the 3D echocardiography images. 24,27 LV volumes
obtained by CMR include the trabeculae in the LV cavity,
while with 3D echocardiography, it is often more difficult to
detect the endocardial-trabecular border, and usually the
tracing is identified with the blood-trabecular interface.

Left Ventricle  15
Figure 2.4  “Banana”-shaped left ventricle that prevents the possibility to obtain nonforeshortened views using conventional 2D
echocardiography . 3D echocardiography can build up the beutel of the left ventricle (in red) and measure left ventricular volumes
independent of any geometrical constrain/assumption by simply counting the number of voxels within the beutel.

Figure 2.5  Pitfalls of using 2D echocardiography to assess regional wall motion. The three apical views in Panel A and Panel B are
obtained from the same datasets. The views in Panel B are obtained by rotating the dataset by 20° (simulating a rotation of the probe), and
they show a remarkably different extension of wall motion abnormalities.

As a result, agreement between 3D echocardiography and
CMR measurements has improved when the trabeculae
were included in the LV cavity and also with increasing
investigator experience.28 Finally, reference values for LV
volumes and LV ejection fraction have been reported (Table
2.1),29–34 and now 3D echocardiography is the recommended
echocardiographic technique to measure LV volumes and
ejection fraction.8
Two 3D echocardiography methods are commonly used
to measure LV volumes:
1. Two- or triplane technique (Figure 2.6) is based on the
multiplane technique that uses the 3D echocardiography
matrix probe to acquire simultaneous 2D
echocardiography views in the same heartbeat. After
manual orientation of the reference view (conventionally,
the four-chamber view), the two additional views (two-
chamber and apical long-axis views) are automatically
selected at 60° and 120° from the four-chamber view.
During the acquisition, the echocardiographer can
adjust the acquisition angles in order to optimize view
orientations. The main advantages of this method are
(a) the echocardiographers can immediately realize if
any foreshortening has occurred during acquisition;
(b) wall motion abnormalities occurring in the
inferolateral LV wall and anterior septum (the most
frequently involved LV walls in patients with myocardial
infarction; Figure 2.3) are accounted for in LV ejection
fraction computation; (c) it is more accurate than
conventional 2D echocardiography biplane algorithms
in assessing LV volumes and ejection fraction;35,36 (d)

16  3D Echocardiography
Table 2.1  Reference Values for Left Ventricular Volumes and Ejection Fraction Measured with 3D
Echocardiography
Muraru D et al. Bernard A et al.
Aune E et al. 201030 Fukuda S et al. 201031 Chahal NS et al. 201229 a 201332 201733

Study Population Scandinavian (n = 166) Japanese (n = 410) United Kingdom (n = 494) Italian (n = 226) European (n = 440)
and Asian Indian (n = 484)
Echocardiography iE33 Sonos 7500, iE33, Vivid 7, iE33 Vivid E9 Vivid E9 and iE33
System Vivid E9, SC2000, Artida
Upper Limits of End-Diastolic Volume (mL/m2)
Men 86 74 White = 67 85 97
Indian = 59
Women 74 64 White = 58 78 82
Indian = 55
Upper Limits of End-Systolic Volume (mL/m2)
Men 41 29 White = 29 34 42
Indian = 26
Women 33 25 White = 24 28 35
Indian = 23
Lower Limits of Ejection Fraction (%)
Men 49 53 White = 49 54 50
Indian = 52
Women 49 55 White = 52 57 51
Indian = 52
a This study found unusually small left ventricles.34

A B

Figure 2.6  Multiplane techniques to calculate left ventricular volumes and ejection fraction: 3D guided biplane discs’ summation algorithm
(Panel A); triplane discs’ summation algorithm (Panel B).

it is feasible in patients with irregular atrial fibrillation
or other arrhythmias that would prevent a multibeat
full-volume 3D echocardiography acquisition; and
(e) it is a more user-friendly approach than the 3D
echocardiography volume quantitation software
packages (e.g., the echocardiographer traces the
2
endocardial border as he or she is used to doing with
conventional 2D echocardiography). The limitations
of this technique are due to the fixed relationship
that exists between the three views that does not allow
avoidance of foreshortening of one or more of them
in some patients, the need of manual tracing of the
endocardial border in the three views, and the fact
that this technique also relies on the same geometric
assumptions about LV shape of the biplane discs’
summation rule (even if they are mitigated by the
addition of the third apical view).
. Full-volume 3D echocardiography quantification approach
is based on both semiautomated (Figure 2.7) and fully
automated (Figure 2.8) detection of LV endocardial
surfaces throughout the cardiac cycle followed by
actual measurement of LV volume contained within this
surface. This approach has the important advantage
over the 3D-guided biplane and triplane methods of not

Left Ventricle  17
 A B

Figure 2.7  Semiautomated software packages for the measurement of left ventricular volumes and ejection fraction using 3D datasets.
(Panel A) 4D AutoLVQ (EchoPac, GE Vingmed, Horten, Norway). (Panel B) 3DQ ADV (QLab 9.0, Philips Medical Systems, Andover, MA).

A B

Figure 2.8  Fully automated software packages for the measurement of left ventricular volumes and ejection fraction using 3D datasets.
(Panel A) eSie LVA (Siemens, CA). (Panel B) Heart Model (QLab 12.0, Philips Medical Systems, Andover, MA). (Panel C) 3D wall motion tracking
(Canon Medical Systems, USA).

relying on geometric modeling. The calculated volume
is obtained by directly counting the voxels inside the
endocardial surface. Finally, the LV volumes measured by
the different vendor-specific software packages are fairly
comparable.37
The main clinically relevant differences between 2D
echocardiography and 3D echocardiography methods of
quantification of LV volumes are that (1) transthoracic
3D echocardiography volumes are generally accurate
even in very dilated and aneurysmal ventricles, 38–40
provided that the sonographer takes care to include the
entire LV within the acquisition volume; (2) inter- and
intraobserver reproducibility of 2D echocardiography
LV volumes and ejection fraction are reasonably low for
measurements obtained from groups of patients; however,
their confidence intervals are usually wide, thereby limiting
the ability of 2D echocardiography to detect small changes
in serial measurements performed in a single patient.41
Conversely, the higher test/retest reproducibility of 3D
echocardiography allows for measurement of the extent of
LV remodeling in individual patients and for influencing
their decision-making process.42 The latter will make 3D
echocardiography the ideal imaging technique to be used

18  3D Echocardiography
Table 2.2  Main Differences in the Quantitation of Left Ventricular Volumes and Ejection Fraction by Using 2D
Echocardiography or 3D Echocardiography
2D Echocardiography 3D Echocardiography
Acquisition Two apical views with possible foreshortening of Single dataset that includes the actual apex of the left
either one or both of them ventriclea
Comprehensiveness It takes into account the functional contribution It takes into account the functional contribution of all 17
of 12 left ventricular segments only (the segments left ventricular segments and includes the left ventricular
encompassed by the apical four- and two- outflow tract into the measurement of left ventricular
chamber views) and does not include the left volumes
ventricular outflow tract (15–20 mL)
Volume Assessment Mathematical calculation (using linear and area Measurement of volumes by counting the number of
measurements) based on geometrical voxels within the beutel generated by the mapping of the
assumptions about the left ventricular shapeb endocardial surface (independent of any geometrical
assumption about the shape of the ventricle)
Endocardial Border Tracing Manual in both the four- and two-chamber apical Semiautomated or fully automated mapping of the
views endocardial surface based on speckle tracking or artificial
intelligence (pattern recognition) techniques of the
endocardial border
Comparison with Left Ventricular Underestimation of tens of milliliters Underestimation of units of milliliters
Volumes Calculated by Cardiac
Magnetic Resonance
Reproducibility of Left Ventricular Interobserver variability = 15%–20%. Low test/ Interobserver variability = 5%–10%. High test/retest
Ejection Fraction retest reproducibility reproducibilityc
Feasibility 90%–95% of consecutive patients 80%–90% of consecutive patients
Easy to Use High. The same workflow for every software Mid. Different software packages with completely
package by any vendor different workflow from different vendors. Specific
training is required for each of themd
a Not only does 3D echocardiography avoid the foreshortening of the views, but differently from the 2D echocardiography technique by which a wrong
acquisition of the views can only be corrected by reacquiring them, 3D echocardiography allows a realignment of the cut planes during the postprocess-
ing of the dataset.
b Geometric assumptions about the shape of the ventricle (rotational ellipsoid) lose their validity in patients with deformed ventricles (e.g., “banana”-shaped
ventricle in hypertensive heart disease and hypertrophic cardiomyopathy, dilated and round ventricles) or in ventricles with extensive wall motion
abnormalities.
c Semiautomated and fully automated algorithms used to identify the endocardial border decrease significantly both intra- and interoperator variability
and increase the test/retest reproducibility of left ventricular volume measurements.
d Both these issues will be addressed in the near future with (1) the introduction of the interoperability of the 3D echocardiography datasets among the
different vendors and (2) fully automated software packages based on artificial intelligence techniques.

in clinical trials, because it is an available, low-cost, and safe
technique, and its good accuracy and reproducibility will
allow for a reduction in the number of patients to enroll
compared to conventional 2D echocardiography (Table 2.2).
To further improve the feasibility and reproducibility of
the measurements of LV volumes and ejection fraction by
3D echocardiography, fully automated software packages
that use pattern recognition algorithms based on artificial
intelligence to trace the endocardial border without any
user interaction have been introduced for clinical use
(Figure 2.8). For the same 3D echocardiography datasets,
3D echocardiography fully automated software provides
equivalent LV ejection fraction values among different
observers regardless of their expertise.10,43–45 A recent
meta-analysis,46 including 38 studies (1881 patients), found
that the pooled bias and 95% confidence interval for end-
diastolic and end-systolic volumes, and ejection fraction of
semiautomated software packages were −39 mL (−49 mL
to −30 mL, p < .001), −20 mL (−26 mL to −13 mL,
p < .001), and −1% (−2% to 7%, p = .360), respectively.
Whereas, the corresponding values for fully automated
software were −15 mL (−26 to −3 mL, p = .011), −6 mL
(−11 to −1 mL, p = .016), and −1% (−4% to 1%, p = .356)
compared with CMR. The end-diastolic and end-systolic
volume biases for 3D echocardiography and CMR became
significantly smaller and less heterogeneous when fully
automated software packages were used. A meta-regression
analysis revealed that the end-diastolic volume bias
became larger with an increase in end-diastolic volume
when semiautomated software was used but not when fully
automated software was used. In addition, reproducibility
and test/retest repeatability of measurements was close to
100% using fully automated software packages.
However, it is true that the feasibility of fully automated
measurement of LV volumes in clinical practice is relatively
low (approximately 64% in routine consecutive patients)
due to suboptimal image quality in some patients.18
Moreover, accuracy of the measurements depends critically
on the border sensitivity settings, and it seems that different
settings should be used with different LV anatomies
(i.e., dilated versus nondilated LVs, hypertrophy versus
normal LV mass, etc.). At the moment, the recommended

Left Ventricle  19
sensitivity setting is 60 for end-diastolic volumes and 30
for the end-systolic volumes. However, each lab should
establish its own settings according to their reference
(either manually edited 3D echocardiography volumes or
CMR volumes). Finally, fully automated LV quantifications
by 3D echocardiography use a model-based segmentation
algorithm that employs prior knowledge with regard to the
shape of the LV, heart locations within an image, variations
of the heart shapes, and how the heart is imaged using
ultrasound (pattern knowledge method). Although this
prior information was incorporated into the model through
extensive training using thousands of datasets from a wide
variety of heart shapes and sizes, the software still has
difficulty in accurately delineating the endocardial border
of LVs whose shape and/or pattern of contraction were
not in the training dataset, such as extensive myocardial
infarction with multiple regional motion abnormality.
However, the ease of use and the high reproducibility of
the measurements performed by fully automated software
packages make this strategy promising for spreading
the use of 3D echocardiography to measure LV ejection
fraction in daily practice, also including less-experienced
echocardiography laboratories.
LEFT VENTRICULAR DIASTOLIC FUNCTION
LV diastolic function is an important determinant of
patients’ symptoms and prognosis in various cardiac
conditions.47 The reference method to assess LV diastolic
function is the invasive measurement of LV pressure decay
(i.e., the time constant of the isovolumetric pressure decline
or τ). To try to overcome the practical limitations of an
invasive technique, several methods have been developed
using noninvasive cardiac imaging techniques such as
Doppler echocardiography, radionuclide ventriculography,
gated single-photon emission computed tomography,
and CMR to assess LV diastolic function.48 Every imaging
technique has its own strengths and weaknesses, and several
parameters have been tested.48 In particular, the dynamic
LV volume change during diastole has gained popularity
as a key parameter of diastolic function because it reflects
LV relaxation as well as restoring forces. Semiautomated
or fully automated 3D echocardiography algorithms for
the detection of LV endocardial surface throughout the
cardiac cycle allow the generation of LV volume-time
curves from which the maximum slope change during the
diastolic period can be measured providing a noninvasive
measure of the peak early filling rate (PFR). This approach
was first proposed by Zeidan et  al., who reported no
significant difference in both peak ejection rate and PFR
values between 3D echocardiography and CMR in healthy
subjects and in patients with coronary artery diseases or
hypertension.49 Nakanishi et  al. further validated this
approach with invasive measurement of τ. 50 They found
that a fully automated 3D echocardiography analysis of
LV volumes change during the cardiac cycle was feasible
(feasibility 93%) to obtain LV time-volume curves in clinical
practice. 3D echocardiography-derived PFR index (PFR
values normalized for LV end-systolic volumes) correlated
with τ and decreased according to the grade of the diastolic
20  3D Echocardiography
dysfunction assessed using conventional 2D and Doppler
echocardiography. Finally, they reported that all patients
with normal diastolic function had a PFR index greater
than 2.0.50
LEFT VENTRICULAR DYSSYNCHRONY
To obtain a normal LV pump function, myocardial segments
should not only have a normal contractility, but they should
also contract in a synchronous way.
Mechanical dyssynchrony is defined as differences in
timing of regional contraction among the myocardial
segments.51 Interest in assessing mechanical dyssynchrony
has been closely associated to development of cardiac
resynchronization therapy for patients with heart failure,
reduced LV ejection fraction, and wide QRS on the
electrocardiogram.
The focus of measuring dyssynchrony by echocardiography
has been to determine the timing of regional LV mechanical
contraction, known as intraventricular dyssynchrony, in order
to try to reduce the number of “nonresponder” patients to
cardiac resynchronization therapy (currently around 30%).
The typical intraventricular dyssynchrony pattern found in
patients with left bundle branch block shows very early septal
contraction and free wall stretch from unopposed forces,
followed by late free wall contraction and septal stretch.
Despite the development of several echocardiographic
techniques over the past years to identify dyssynchrony, no
consensus on an ideal approach has been achieved.
To assess the extent of intraventricular dyssynchrony
by 3D echocardiography, the LV is divided into 16 or
17 segments as per the American Heart Association
standard model, 52 and the time from the R wave on the
electrocardiogram to minimum systolic volume is computed
for each LV segment (Figure 2.9). The standard deviation of
the regional times to minimum systolic volume expressed as
a percentage of the cardiac cycle has been proposed as the
systolic dyssynchrony index.53 Several single-center studies
have suggested that an increased systolic dyssynchrony index
prior to implant (i.e., higher than 9.8%) is predictive of
favorable response to cardiac resynchronization therapy54–57
and that the placement of the LV lead in order to stimulate
the most delayed LV segments may be associated with
favorable LV remodeling,57 but these findings have not been
consistent.58,59 Despite the fact that it is likely that a worse
LV function is associated with higher systolic dyssynchrony
indices, 53,60–62 with 3D echocardiography this may be due
to noisy, low-amplitude time-volume curves as much as to
true dyssynchrony.60,63 Moreover, inter- and intraobserver
reproducibility of the 3D echocardiography systolic
dyssynchrony index may be hindered by suboptimal image
quality54 and is less robust than mechanical dyssynchrony
parameters obtained with tissue Doppler imaging.62,64
Finally, the relatively low temporal resolution of 3D
echocardiography as compared to tissue Doppler imaging
was another important issue.65 However, the lower temporal
resolution does not seem to be a major drawback of the
second-generation 3D echocardiography scanners for LV
dyssynchrony assessment. 27 Since 3D echocardiography
measures regional volumes changes and not regional
 A B

Figure 2.9  The full volume of the left ventricle can be divided in 16 or 17 regional pyramidal subvolumes whose base is on the endocardium
(different colors identify different segments), and the apex is in the center of gravity within the cavity of the left ventricle. The volume changes of
individual regional pyramidal subvolumes can be tracked throughout the cardiac cycle (see the time-volume curves in the lower right part of each
figure), and the time to minimum segmental volume (circle) can be measured. The standard deviation of the average of the times to minimum
volume of the 16/17 segments in percent of the R-R interval represents the Systolic Dyssynchrony Index (SDI). (Panel A) Normofunctioning left
ventricle with no dyssynchrony. (Panel B) Severe left ventricular dysfunction with significant mechanical intraventricular dyssynchrony.

velocities (as tissue Doppler imaging, which requires a

high frame rate), it seems likely that echocardiographic LEFT VENTRICULAR MASS
systems able to provide a temporal resolution of 20–30 vps Except in highly trained athletes, LV hypertrophy is a
are adequate to sample the usual frequency of regional maladaptive response to LV overload, and it is associated
volume curves, which is less than 10 Hz.66 To overcome the with adverse outcomes.68 The presence and/or severity of LV
technical limitations of the systolic dyssynchrony index hypertrophy provides useful information regarding future
obtained from the time-volume curves of LV segments prognosis.69 LV mass has been traditionally calculated
during the cardiac systole, it has been proposed to use using M-mode and 2D echocardiography, and their normal
parameters of myocardial deformation obtained from 3D reference values have been well established.8 However, the
speckle tracking echocardiography.67 In comparison to 2D currently recommended algorithm for LV mass calculation,
echocardiography, 3D echocardiography speckle-tracking the cubed formula (most commonly applied to linear
echocardiography provides the simultaneous assessment of dimensions of the LV obtained with 2D echocardiography)
all LV mechanical deformation components (longitudinal, relies on the geometric assumption that the LV is a prolated
radial, and circumferential) using a single volumetric ellipsoid, and has been validated against postmortem
dataset and avoiding the out-of-plane phenomenon inherent pathology findings.70 This assumption is inaccurate in both
to tomographic imaging (see later). Accordingly, 3D remodeled and nonsymmetrically contracting ventricles.
echocardiography speckle tracking provides comprehensive The other two algorithms based on 2D echocardiography
information regarding regional myocardial contraction (the truncated ellipsoid and the area length) also rely on
patterns and has the potential for accurate LV dyssynchrony geometric assumptions about the circular shape of the
assessment and determination for optimal pacemaker lead
position in patients requiring cardiac resynchronization
therapy. Table 2.3  Reference Normal Values of Left
Moreover, 3D echocardiography area strain (a parameter Ventricular Mass (g/m2) by Echocardiography and
that includes both longitudinal and circumferential Cardiac Magnetic Resonance
deformation15) seems to be very promising for the
Male Female
quantification of LV dyssynchrony.67 However, compared
with 2D echocardiography, 3D echocardiography is limited M-mode8 49–115 43–95
by a relatively low temporal resolution, particularly in dilated 2D Echo8 50–102 44–88
hearts when the acquisition of large datasets is needed 3D Echo Japanese31 40–88 34–78
to accommodate the whole LV, and further validation is 3D Echo Italian32 57–97 58–90
necessary to extend the applicability of 3D echocardiography 3D Echo Japanese72 53–85 45–77
speckle tracking echocardiography in everyday clinical 3D Echo American78 52–88 46–74
practice (see Chapter 18). Cardiac Magnetic Resonance 45–83 35–70

Left Ventricle  21
short-axis view and are affected by the foreshortening of
the apical four-chamber view and by the uncertain position
of the transversal axis in the apical view, though they are
more robust than the cubed formula in distorted LV with
wall motion abnormalities.
Theoretically, 3D echocardiography avoids all the
geometrical assumptions about LV shape and provides an
actual measurement of the LV mass by subtracting the 3D
echocardiography endocardial volume from the epicardial
one and multiplying the result (i.e., the myocardial volume)
by the myocardial specific gravity (1.05 g/mL) to obtain
the actual LV mass. 3D echocardiography measurements
of LV mass have been validated against CMR,71 and
reference values have been published. 31,32,72 Interestingly,
the normal ranges reported for LV masses measured by 3D
echocardiography are narrower than those obtained with
2D echocardiography, and more similar to CMR values
(Table 2.3). Despite the fact that 3D echocardiography
has been recommended to measure LV mass by
echocardiography, particularly in abnormally shaped
ventricle or in individuals with asymmetric or localized
hypertrophy,73 whether the use of 3D echocardiography
cut-off values for LV mass index would provide more
clinically useful prognostic information compared to
conventional M-mode and 2D echocardiography methods
remains to be clarified.
LEFT VENTRICULAR SHAPE
LV volumes, ejection fraction, and mass do not completely
characterize the LV. Another important determinant of LV
performance is its shape. There are many ways to describe
LV shape. Probably, the best-known and the simplest method
is the sphericity index. Using 2D echocardiography, the
sphericity index has been defined as the short- to long-axis
dimension ratio in the end-diastolic apical four-chamber
view.74 Unlike 2D echocardiography, which is limited to flat
tomographic planes, 3D echocardiography can yield volumes
to quantify sphericity. With 3D echocardiography, the LV
shape is defined by how different the shape of the LV is from
a sphere, with a perfect spherical LV having a value of 1.0.
Mannaerts et al.75 were the first to define the use of the 3D
A B
Figure 2.10  Left ventricular sphericity index in a normal left ventricle (Panel A) and in a patient with dilated cardiomyopathy (Panel B).
22  3D Echocardiography
echocardiography-derived sphericity index. This index was
defined as the ratio between the actual LV volume and the
volume of a sphere with a diameter equal to the length of the
LV long axis (Figure 2.10).
LV sphericity, measured using 3D echocardiography,
has been used to describe LV remodeling after myocardial
infarction and after mitral valve surgery.75,76 It has been
demonstrated that both patients who survived an ST elevation
myocardial infarction and those with dilated cardiomyopathy
who have more spherical LVs have worse prognosis.75,77 A
recent study reported age-related changes in LV sphericity
index.78
LEFT VENTRICULAR MYOCARDIAL
MECHANICS
LV volumes, ejection fraction, and shape are parameters
that reflect LV chamber remodeling that, in addition to
myocardial function, is also affected by loading conditions
and heart rate. Recently, echocardiographic techniques
that allow measurement of myocardial deformation have
been made available. 2D echocardiography strain obtained
with speckle tracking analysis has rapidly become the most
useful clinical and research tool to quantify myocardial
mechanics.79 Among the different 2D echocardiography
strain and strain rate parameters, global longitudinal
strain was the most robust and useful for identifying latent
LV dysfunction in patients receiving potentially cardiotoxic
drugs and for predicting prognosis in different clinical
scenarios.80
The 2D echocardiography speckle tracking technique is
based on the presence of distinctive patterns of grayscale
values within the ultrasound images of myocardial tissue due
to constructive and destructive interference of reflections
from the individual myocardial scatterers occurring when
the ultrasound beams hit the myocardium. 81,82 These
natural acoustic markers are commonly referred to as
“speckles.” The speckles included within a spatial unit
(kernel) are arranged in distinct patterns that are unique
for each kernel within the ultrasound image,81 serving as a
unique target that can be tracked frame by frame during
Figure 2.11  3D calculation of left ventricular torsion by summing up the rotations of the Apex and the Base divided by the distance L
between the two.

the cardiac cycle by the 2D echocardiography speckle
tracking algorithm.79,80 However, the 2D echocardiography
speckle tracking technique relies on the assumption that
speckles are moving linearly within the scan plane of the
2D echocardiography image in consecutive frames of the
same cardiac cycle. Due to the different spatial orientations
of myocardial fibers in the various layers of the LV wall, LV
mechanics is more complex, and myocardial deformation
involves a combination of apex-to-base shortening and
thickening with simultaneous clockwise rotation of base
and counterclockwise rotation of the apex (Figure 2.11).83
Accordingly, speckles have a complex motion in the 3D
space and thus are subject to through-plane motion from
the 2D echocardiography scan planes during the cardiac
cycle. Recent developments of ultrasound transducer
and computer technology have allowed the possibility of
3D echocardiography imaging of the LV with relatively
high spatial and temporal resolution, thus allowing
3D echocardiography strain measurements that have
the potential to eliminate some of the aforementioned
limitations of the 2D echocardiography speckle tracking
technique15,84,85 (Table 2.4 and see Chapter 18).
The postprocessing of the 3D echocardiography dataset
to measure the different myocardial strain components starts
with the automatic generation of a region of interest (ROI)
from endocardial and epicardial border traces, followed by
the automated segmentation of the LV into a 17-segment
model. Each ROI contains cubes with specific 3D patterns
of natural acoustic markers that are matched and searched
through the cardiac cycle by the 3D echocardiography
speckle tracking algorithm, a process called “block
matching” (Figure 2.12). The 3D echocardiography speckle
tracking algorithm calculates the quality of each match,
identifies any outliers, and removes them before performing
the weighted spatial averaging of the results. The results are
mapped to an average myocardial mesh, so that the shape of
the mesh model of the LV can be updated for all frames.15
Finally, quantitative results of LV deformation are derived

Table 2.4  Comparison between the Characteristics of 2D Echocardiography and 3D Echocardiography Speckle
Tracking Analysis
Characteristic 2D Echocardiography Strain 3D Echocardiography Strain

Acquisition Three apical and three parasternal short-axis views Single apical full volume of the left ventricle
Rhythm Regular (2D views acquired in sequence) Regular (multibeat full-volume acquisition)
Temporal resolution 50–80 fps 30–40 vps
Feasibility in sinus rhythm >90% 75%–80%
Reliance on image quality Very important Critical
Myocardial deformation components Longitudinal strain Longitudinal strain
Circumferential strain Circumferential strain
Radial strain Radial strain
Ventricular twist Area strain
Mechanical dispersion Ventricular twist
Ventricular torsion
Bull’s-eye map Static (regional peak strain values) Both static and dynamic
Global strain computation Peak strain values Either peak values or instantaneous strain values
Radial strain Measured Calculated by the law of volume conservation
Out-of-plane motion of speckles Yes No
Definition of end systole Timing of aortic valve closure Timing of minimal left ventricular volume
Drift compensation Yes No

Left Ventricle  23
 B
A
Figure 2.12  3D speckle tracking strain measurement. (A) Shows the principle of “block matching,” in which specific 3D patterns of natural
acoustic markers are tracked from end diastole (green cube) to end systole (red cube); (B) longitudinal strain; (C) area strain; and (D)
circumferential strain.
from this mesh model. Since the blocks are tracked in a
3D volume, they can be followed in any direction within
the myocardial segment, thus avoiding the out-of-plane
motion of the 2D echocardiography kernels. Furthermore,
3D echocardiography speckle tracking is a time-saving
technique, as it allows the measurement of all myocardial
deformation components of the LV (i.e., longitudinal,
circumferential, and radial) from a single volumetric
dataset of the LV and avoids the errors caused by heart
rate variability that may occur when multiple acquisitions
from different acoustic windows are needed, as with 2D
echocardiography speckle tracking (Figure 2.11).
Since strain values obtained with 2D echocardiography and
3D echocardiography speckle tracking analysis are different even
when acquired in the same subjects, normal reference values
for 3D echocardiography strain should be established before
using this methodology clinically. Two studies have reported
normal values of 3D echocardiography strain in relatively large
cohorts of healthy subjects over a wide range of ages.86,87 Both
studies reported a significant age dependency, characterized
by a reduction in global longitudinal myocardial deformation
in the older cohorts of subjects. Significant differences in all
global strain values were noted among the different vendor-
specific software packages88 and between vendor-specific and
vendor-independent software packages.87 Interestingly, when
strain values obtained with vendor-independent software were
compared between Kaku and Muraru’s studies, similar values for
global longitudinal and circumferential strain were obtained.
These initial results clearly show that 3D echocardiography
24  3D Echocardiography
global longitudinal and circumferential strain are robust and
reproducible parameters to quantify LV mechanics. However,
the same software should be used in cross-sectional and
longitudinal studies of the same patient, because the values
are not interchangeable among the different vendor-specific
software packages.
CONCLUSION
3D echocardiography is the ideal noninvasive, fast, safe, and
cost-effective technique for the quantification of LV volumes
and ejection fraction. It eliminates the errors associated
with apical view foreshortening and geometric assumptions
about LV shape that negatively affect 2D echocardiography
accuracy. Moreover, in patients with good acoustic window,
measurements performed with 3D echocardiography are
very close to those obtained by the gold standard CMR
measurements. Finally, 3D echocardiography facilitates the
calculation of LV shape, the measurement of LV mass, and
the analysis of regional LV function.
REFERENCES
1. Steg PG, James SK, Atar D et al. ESC Guidelines for the management
of acute myocardial infarction in patients presenting with ST-segment
elevation: The Task Force on the management of ST-segment elevation
acute myocardial infarction of the European Society of Cardiology (ESC).
Eur Heart J. 2012;33:2569–619.
2. Vahanian A, Alfieri O, Andreotti F et al. Guidelines on the management
of valvular heart disease (Version 2012). Eur Heart J. 2012;33:2451–96.
3. Haugaa KH, Basso C, Badano LP et al. Comprehensive multi-modality
imaging approach in arrhythmogenic cardiomyopathy—An expert
consensus document of the European Association of Cardiovascular
Imaging. Eur Heart J Cardiovasc Imaging. 2017;18:237–53.
4. Badano LP, Miglioranza MH, Edvardsen T et al. European Association
of Cardiovascular Imaging/Cardiovascular Imaging Department of the
Brazilian Society of Cardiology recommendations for the use of cardiac
imaging to assess and follow patients after heart transplantation. Eur Heart
J Cardiovasc Imaging. 2015;16:919–48.
5. Ponikowski P, Voors AA, Anker SD et  al. 2016 ESC guidelines for
the diagnosis and treatment of acute and chronic heart failure: The
Task Force for the diagnosis and treatment of acute and chronic heart
failure of the European Society of Cardiology (ESC). Developed with the
special contribution of the Heart Failure Association (HFA) of the ESC.
Eur J Heart Fail. 2016;18:891–975.
6. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS guidelines for the
management of valvular heart disease. Eur Heart J. 2017;38:2739–91.
7. Plana JC, Galderisi M, Barac A et al. Expert consensus for multimodality
imaging evaluation of adult patients during and after cancer therapy: A
report from the American Society of Echocardiography and the European
Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging.
2014;15:1063–93.
8. Lang RM, Badano LP, Mor-Avi V et al. Recommendations for cardiac
chamber quantification by echocardiography in adults: An update from
the American Society of Echocardiography and the European Association
of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233–70.
9. Muraru D, Badano LP, Piccoli G et al. Validation of a novel automated
border-detection algorithm for rapid and accurate quantitation of left
ventricular volumes based on three-dimensional echocardiography. Eur J
Echocardiogr. 2010;11:359–68.
10. Thavendiranathan P, Liu S, Verhaert D et al. Feasibility, accuracy, and
reproducibility of real-time full-volume 3D transthoracic echocardiography
to measure LV volumes and systolic function: A fully automated endocardial
contouring algorithm in sinus rhythm and atrial fibrillation. JACC Cardiovasc
Imaging. 2012;5:239–51.
11. Rodríguez-Zanella H, Muraru D, Secco E et al. Added value of three-
vs. two-dimensional echocardiography left ventricular ejection fraction to
predict arrhythmic risk in patients with left ventricular dysfunction. JACC
Cardiovasc Imaging. 2019;12:1917–26.
12. Stanton T, Jenkins C, Haluska BA et al. Association of outcome with
left ventricular parameters measured by two-dimensional and three-
dimensional echocardiography in patients at high cardiovascular risk. J Am
Soc Echocardiogr. 2014;27:65–73.
13. Yingchoncharoen T, Negishi T, Stanton T et al. Incremental value of
three-dimensional echocardiography in the evaluation of left ventricular
size in mitral regurgitation: A follow-up study after mitral valve surgery. J Am
Soc Echocardiogr. 2014;27:608–15.
14. Surkova E, Muraru D, Aruta P et al. Current clinical applications of
three-dimensional echocardiography: When the technique makes the
difference. Curr Cardiol Rep. 2016;18:109.
15. Muraru D, Niero A, Rodriguez-Zanella H et  al. Three-dimensional
speckle-tracking echocardiography: Benefits and limitations of integrating
myocardial mechanics with three-dimensional imaging. Cardiovasc Diagn
Ther. 2018;8:101–17.
16. Lang RM, Badano LP, Tsang W et al. EAE/ASE recommendations for
image acquisition and display using three-dimensional echocardiography.
Eur Heart J Cardiovasc Imaging. 2012;13:1–46.
17. Badano LP, Dall’Armellina E, Monaghan MJ et al. Real-time three-
dimensional echocardiography: Technological gadget or clinical tool? J
Cardiovasc Med (Hagerstown). 2007;8:144–62.
18. Medvedofsky D, Mor-Avi V, Byku I et  al. Three-dimensional
echocardiographic automated quantification of left heart chamber volumes
using an adaptive analytics algorithm: Feasibility and impact of image
quality in nonselected patients. J Am Soc Echocardiogr. 2017;30:879–85.
19. Addetia K, Badano LP, Lang RM. Routine assessment of the left
ventricle. In: Badano LP, Muraru D, Lang RM, eds. Textbook of Three-
dimensional Echocardiography, 2nd ed. Cham, Switzerland: Springer Nature;
2019, pp. 53–69.
20. Mor-Avi V, Sugeng L, Weinert L et al. Fast measurement of left ventricular
mass with real-time three-dimensional echocardiography: Comparison
with magnetic resonance imaging. Circulation. 2004;110:1814–8.
21. Badano LP, Muraru D, Rigo F et al. High volume-rate three-dimensional
stress echocardiography to assess inducible myocardial ischemia: A
feasibility study. J Am Soc Echocardiogr. 2010;23:628–35.
22. Chukwu EO, Barasch E, Mihalatos DG et al. Relative importance of errors
in left ventricular quantitation by two-dimensional echocardiography:
Insights from three-dimensional echocardiography and cardiac magnetic
resonance imaging. J Am Soc Echocardiogr. 2008;21:990–7.
23. Badano LP, Boccalini F, Muraru D et al. Current clinical applications of
transthoracic three-dimensional echocardiography. J Cardiovasc Ultrasound.
2012;20:1–22.
24. Shimada YJ, Shiota T. A meta-analysis and investigation for the source
of bias of left ventricular volumes and function by three-dimensional
echocardiography in comparison with magnetic resonance imaging. Am
J Cardiol. 2011;107:126–38.
25. Dorosz JL, Lezotte DC, Weitzenkamp DA et  al. Performance of
3-dimensional echocardiography in measuring left ventricular volumes and
ejection fraction: A systematic review and meta-analysis. J Am Coll Cardiol.
2012;59:1799–808.
26. Badano LP. The clinical benefits of adding a third dimension to assess
the left ventricle with echocardiography. Scientifica. 2014;2014:1–18.
27. Muraru D, Badano LP, Ermacora D et  al. Sources of variation and
bias in assessing left ventricular volumes and dyssynchrony using three-
dimensional echocardiography. Int J Cardiovasc Imaging. 2012;28:1357–68.
28. Mor-Avi V, Jenkins C, Kuhl HP et  al. Real-time 3-dimensional
echocardiographic quantification of left ventricular volumes: Multicenter
study for validation with magnetic resonance imaging and investigation of
sources of error. JACC Cardiovasc Imaging. 2008;1:413–23.
29. Chahal NS, Lim TK, Jain P et al. Population-based reference values for
3D echocardiographic LV volumes and ejection fraction. JACC Cardiovasc
Imaging. 2012;5:1191–7.
30. Aune E, Baekkevar M, Rodevand O et  al. Reference values for left
ventricular volumes with real-time 3-dimensional echocardiography. Scand
Cardiovasc J. 2010;44:24–30.
31. Fukuda S, Watanabe H, Daimon M et al. Normal values of real-time
3-dimensional echocardiographic parameters in a healthy Japanese
population: The JAMP-3D Study. Circ J. 2012;76:1177–81.
32. Muraru D, Badano LP, Peluso D et al. Comprehensive analysis of left
ventricular geometry and function by three-dimensional echocardiography
in healthy adults. J Am Soc Echocardiogr. 2013;26:618–28.
33. Bernard A, Addetia K, Dulgheru R et al. 3D echocardiographic reference
ranges for normal left ventricular volumes and strain: Results from the
EACVI NORRE study. Eur Heart J Cardiovasc Imaging. 2017;18:475–83.
34. Badano LP. Defining normative values for 3D LV volumes: The devil is
in the details. JACC Cardiovasc Imaging. 2013;6:530.
35. Nucifora G, Badano LP, Dall’Armellina E et al. Fast data acquisition
and analysis with real time triplane echocardiography for the assessment
of left ventricular size and function: A validation study [Validation Studies].
Echocardiography. 2009;26:66–75.
36. Malm S, Frigstad S, Sagberg E et al. Real-time simultaneous triplane
contrast echocardiography gives rapid, accurate, and reproducible
assessment of left ventricular volumes and ejection fraction: A comparison
with magnetic resonance imaging. J Am Soc Echocardiogr. 2006;19:1494–501.
37. Muraru D, Cecchetto A, Cucchini U et al. Intervendor consistency and
accuracy of left ventricular volume measurements using three-dimensional
echocardiography. J Am Soc Echocardiogr. 2018;31:158–68.
38. Soliman OI, Geleijnse ML, Theuns DA et al. Reverse of left ventricular
volumetric and structural remodeling in heart failure patients treated with
cardiac resynchronization therapy. Am J Cardiol. 2008;101:651–7.
39. Arai K, Hozumi T, Matsumura Y et al. Accuracy of measurement of
left ventricular volume and ejection fraction by new real-time three-
dimensional echocardiography in patients with wall motion abnormalities
secondary to myocardial infarction. Am J Cardiol. 2004;94:552–8.
40. Qin JX, Jones M, Shiota T et al. Validation of real-time three-dimensional
echocardiography for quantifying left ventricular volumes in the presence
of a left ventricular aneurysm: In vitro and in vivo studies. J Am Coll Cardiol.
2000;36:900–7.
41. Jenkins C, Bricknell K, Chan J et  al. Comparison of two- and three-
dimensional echocardiography with sequential magnetic resonance imaging
for evaluating left ventricular volume and ejection fraction over time in
patients with healed myocardial infarction. Am J Cardiol. 2007;99:300–6.
Left Ventricle  25
42. Hare JL, Jenkins C, Nakatani S et  al. Feasibility and clinical
decision-making with 3D echocardiography in routine practice. Heart.
2008;94:440–5.
43. Tsang W, Salgo IS, Medvedofsky D et  al. Transthoracic 3D
echocardiographic left heart chamber quantification using an automated
adaptive analytics algorithm. JACC Cardiovasc Imaging. 2016;9:769–82.
44. Otani K, Nakazono A, Salgo IS et  al. Three-dimensional
echocardiographic assessment of left heart chamber size and function with
fully automated quantification software in patients with atrial fibrillation. J
Am Soc Echocardiogr. 2016;29:955–65.
45. Tamborini G, Piazzese C, Lang RM et al. Feasibility and accuracy of
automated software for transthoracic three-dimensional left ventricular
volume and function analysis: Comparisons with two-dimensional
echocardiography, three-dimensional transthoracic manual method,
and cardiac magnetic resonance imaging. J Am Soc Echocardiogr.
2017;30:1049–58.
46. Kitano T, Nabeshima Y, Otsuji Y et  al. Accuracy of left ventricular
volumes and ejection fraction measurements by contemporary three-
dimensional echocardiography with semi- and fully automated software:
Systematic review and meta-analysis of 1881 subjects. J Am Soc Echocardiogr.
2019;32:1105–15.
47. Pieske B, Tschope C, de Boer RA et al. How to diagnose heart failure
with preserved ejection fraction: The HFA-PEFF diagnostic algorithm: a
consensus recommendation from the Heart Failure Association (HFA) of
the European Society of Cardiology (ESC). Eur Heart J. 2019;40:3297–317.
48. Flachskampf FA, Biering-Sorensen T, Solomon SD et  al. Cardiac
imaging to evaluate left ventricular diastolic function. JACC Cardiovasc
Imaging. 2015;8:1071–93.
49. Zeidan Z, Erbel R, Barkhausen J et  al. Analysis of global systolic
and diastolic left ventricular performance using volume-time curves by
real-time three-dimensional echocardiography. J Am Soc Echocardiogr.
2003;16:29–37.
50. Nakanishi K, Fukuda S, Watanabe H et al. The utility of fully automated
real-time three-dimensional echocardiography in the evaluation of left
ventricular diastolic function. J Cardiol. 2015;66:50–6.
51. Kirk JA, Kass DA. Electromechanical dyssynchrony and resynchronization
of the failing heart. Circ Res. 2013;113:765–76.
52. Cerqueira MD, Weissman NJ, Dilsizian V et al. Standardized myocardial
segmentation and nomenclature for tomographic imaging of the heart.
A statement for healthcare professionals from the Cardiac Imaging
Committee of the Council on Clinical Cardiology of the American Heart
Association. Circulation. 2002;105:539–42.
53. Kapetanakis S, Kearney MT, Siva A et al. Real-time three-dimensional
echocardiography: A novel technique to quantify global left ventricular
mechanical dyssynchrony. Circulation. 2005;112:992–1000.
54. Soliman OI, van Dalen BM, Nemes A et  al. Quantification of left
ventricular systolic dyssynchrony by real-time three-dimensional
echocardiography. J Am Soc Echocardiogr. 2009;22:232–9.
55. Marsan NA, Bleeker GB, Ypenburg C et al. Real-time three-dimensional
echocardiography permits quantification of left ventricular mechanical
dyssynchrony and predicts acute response to cardiac resynchronization
therapy. J Cardiovasc Electrophysiol. 2008;19:392–9.
56. Lau C, Abdel-Qadir HM, Lashevsky I et  al. Utility of three-
dimensional echocardiography in assessing and predicting response
to cardiac resynchronization therapy. Can J Cardiol. 2010;26:
475–80.
57. Becker M, Hoffmann R, Schmitz F et  al. Relation of optimal lead
positioning as defined by three-dimensional echocardiography to long-
term benefit of cardiac resynchronization. Am J Cardiol. 2007;100:1671–6.
58. Deplagne A, Lafitte S, Reuter S et al. Absence of additional improvement
in outcome of patients receiving cardiac resynchronization therapy paced at
the most delayed left ventricular region. Arch Cardiovasc Dis. 2009;102:641–9.
59. Miyazaki C, Redfield MM, Powell BD et  al. Dyssynchrony indices to
predict response to cardiac resynchronization therapy: A comprehensive
prospective single-center study. Circ Heart Failure. 2010;3:565–73.
60. Sonne C, Sugeng L, Takeuchi M et  al. Real-time 3-dimensional
echocardiographic assessment of left ventricular dyssynchrony: Pitfalls
in patients with dilated cardiomyopathy. JACC Cardiovasc Imaging.
2009;2:802–12.
26  3D Echocardiography
61. Mu Y, Chen L, Tang Q et  al. Real time three-dimensional
echocardiographic assessment of left ventricular regional systolic function
and dyssynchrony in patients with dilated cardiomyopathy. Echocardiography.
2010;27:415–20.
62. Takeuchi M, Jacobs A, Sugeng L et al. Assessment of left ventricular
dyssynchrony with real-time 3 -dimensional echocardiography:
Comparison with Doppler tissue imaging. J Am Soc Echocardiogr. 2007;​
20:1321–9.
63. Mor-Avi V, Lang RM. The use of real-time three-dimensional
echocardiography for the quantification of left ventricular volumes and
function. Curr Opin Cardiol. 2009;24:402–9.
64. Russo C, Jaubert MP, Jin Z et al. Intra- and interobserver reproducibility
of left ventricular mechanical dyssynchrony assessment by real time three-
dimensional echocardiography. Echocardiography. 2012;29:598–607.
65. Gorcsan J, 3rd, Abraham T, Agler DA et  al. Echocardiography for
cardiac resynchronization therapy: Recommendations for performance
and reporting—A report from the American Society of Echocardiography
Dyssynchrony Writing Group endorsed by the Heart Rhythm Society. J Am
Soc Echocardiogr. 2008;21:191–213.
66. Bacha EA, Zimmerman FJ, Mor-Avi V et al. Ventricular resynchronization
by multisite pacing improves myocardial performance in the postoperative
single-ventricle patient. Ann Thorac Surg. 2004;78:1678–83.
67. Cai Q, Ahmad M. Left ventricular dyssynchrony by three-dimensional
echocardiography: Current understanding and potential future clinical
applications. Echocardiography. 2015;32:1299–306.
68. Bluemke DA, Kronmal RA, Lima JA et  al. The relationship of left
ventricular mass and geometry to incident cardiovascular events: The
MESA (Multi-Ethnic Study of Atherosclerosis) study. J Am Coll Cardiol.
2008;52:2148–55.
69. Armstrong AC, Gidding S, Gjesdal O et  al. LV mass assessed by
echocardiography and CMR, cardiovascular outcomes, and medical
practice. JACC Cardiovasc Imaging. 2012;​5:837–48.
70. Devereux RB, Alonso DR, Lutas EM et al. Echocardiographic assessment
of left ventricular hypertrophy: Comparison to necropsy findings. Am J
Cardiol. 1986;57:450–8.
71. Shimada YJ, Shiota T. Meta-analysis of accuracy of left ventricular
mass measurement by three-dimensional echocardiography. Am J Cardiol.
2012;110:445–52.
72. Mizukoshi K, Takeuchi M, Nagata Y et al. Normal values of left ventricular
mass index assessed by transthoracic three-dimensional echocardiography.
J Am Soc Echocardiogr. 2016;29:51–61.
73. Marwick TH, Gillebert TC, Aurigemma G et  al. Recommendations
on the use of echocardiography in adult hypertension: A report from
the European Association of Cardiovascular Imaging (EACVI) and
the American Society of Echocardiography (ASE). J Am Soc Echocardiogr.
2015;28:727–54.
74. Chan SY, Mancini GB, Fu Y et al. Novel methodology for echocardiographic
quantification of cardiac shape. Can J Cardiol. 1997;13:153–9.
75. Mannaerts HF, van der Heide JA, Kamp O et al. Early identification
of left ventricular remodelling after myocardial infarction, assessed by
transthoracic 3D echocardiography. Eur Heart J. 2004;25:680–7.
76. Maffessanti F, Caiani EG, Tamborini G et  al. Serial changes in
left ventricular shape following early mitral valve repair. Am J Cardiol.
2010;106:836–42.
77. Opie LH, Commerford PJ, Gersh BJ et al. Controversies in ventricular
remodelling. Lancet. 2006;367:356–67.
78. Kaku K, Takeuchi M, Otani K et  al. Age- and gender-dependency
of left ventricular geometry assessed with real-time three-dimensional
transthoracic echocardiography. J Am Soc Echocardiogr. 2011;24:541–7.
79. Mor-Avi V, Lang RM, Badano LP et  al. Current and evolving
echocardiographic techniques for the quantitative evaluation of cardiac
mechanics: ASE/EAE consensus statement on methodology and indications
endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr.
2011;24:277–313.
80. Voigt JU, Pedrizzetti G, Lysyansky P et al. Definitions for a common
standard for 2D speckle tracking echocardiography: Consensus document
of the EACVI/ASE/Industry Task Force to standardize deformation
imaging. Eur Heart J Cardiovasc Imaging. 2015;16:1–11.
81. Mondillo S, Galderisi M, Mele D et al. Speckle-tracking echocardiography:
A new technique for assessing myocardial function. J Ultrasound Med.
2011;30:71–83.
82. Kocabay G, Muraru D, Peluso D et al. Normal left ventricular mechanics
by two-dimensional speckle-tracking echocardiography. Reference values
in healthy adults. Rev Esp Cardiol. 2014;67:651–8.
83. Sengupta PP, Krishnamoorthy VK, Korinek J et al. Left ventricular form
and function revisited: Applied translational science to cardiovascular
ultrasound imaging. J Am Soc Echocardiogr. 2007;20:539–51.
84. Jasaityte R, Heyde B, D’Hooge J. Current state of three-dimensional
myocardial strain estimation using echocardiography. J Am Soc Echocardiogr.
2013;26:15–28.
85. Wu VC, Takeuchi M, Otani K et  al. Effect of through-plane and
twisting motion on left ventricular strain calculation: Direct comparison
between two-dimensional and three-dimensional speckle-tracking
echocardiography. J Am Soc Echocardiogr. 2013;26:1274–81.
86. Kaku K, Takeuchi M, Tsang W et al. Age-related normal range of left
ventricular strain and torsion using three-dimensional speckle-tracking
echocardiography. J Am Soc Echocardiogr. 2014;27:55–64.
87. Muraru D, Cucchini U, Mihaila S et  al. Left ventricular myocardial
strain by three-dimensional speckle-tracking echocardiography in healthy
subjects: Reference values and analysis of their physiologic and technical
determinants. J Am Soc Echocardiogr. 2014;27:858–71.
88. Badano LP, Cucchini U, Muraru D et  al. Use of three-dimensional
speckle tracking to assess left ventricular myocardial mechanics: Inter-
vendor consistency and reproducibility of strain measurements. Eur Heart J
Cardiovasc Imaging. 2013;14:285–93.
Left Ventricle  27
 3 Stress Echocardiography
INTRODUCTION
Since the 1990s, stress echocardiography has become an
established tool for the diagnosis of myocardial ischemia
and for the stratification of the individual patient with
known coronary artery disease. Conventional 2D stress
echocardiography is based on the serial acquisition of
the typical four or five transthoracic image planes from
parasternal and apical echocardiography windows. The
acquisition is performed at rest and during the different
levels of either physical or pharmacological stress.
However, there are some significant limitations that
make it sometimes difficult to acquire data and to analyze
the images: transthoracic image quality with incomplete
visualization of left ventricular (LV) walls, probe positioning
difficulties resulting in inadequate image planes, and
the time-consuming serial acquisition of different image
planes that has to be performed in a narrow time window
during peak stress while wall motion abnormalities exist.
Even after successful data acquisition, the subjectivity of
image interpretation remains a problem leading to reduced
interobserver agreement and causing the well-known
examiner dependency. All factors together may result in
impaired test accuracy and a lower sensitivity to detect
regional myocardial ischemia. With the advent of real-time
3D echocardiography, several of the previously mentioned
limitations of conventional 2D stress echocardiography
might be solved.
ACQUISITION — TECHNICAL ASPECTS
Matrix array transducers allow different approaches to be
used to perform stress echocardiography. One image plane
can be rotated automatically without changing the probe
position (rotating monoplanar) and two (biplanar) or three
(triplanar) image planes can be acquired simultaneously.
Rotating mono-, bi-, and triplanar techniques, of course, do
not fulfill the definition of 3D echocardiography due to the
gaps between all image planes, but they may serve as a first step
toward “complete” full-volume 3D stress echocardiography.
In biplanar mode, the spatial relation of both image
planes can be varied in three directions: rotation around
a central stable longitudinal axis, elevation tilt, and lateral
tilt. Using the triplanar approach, three image planes are
rotated around a longitudinal axis with variable increments.
The default setting for the angle between the image planes is
60°. Spatial and time resolutions of bi- and triplanar data are
identical to the conventional 2D data that can be recorded
with matrix array transducers. However, the acquisition time
is potentially much shorter since two or three planes are
captured simultaneously.
In contrast, the acquisition of wide-angle 3D datasets
(full-volume 3D acquisition) is usually based on the serial
recording of four (up  to seven) narrow subvolumes in
28  3D Echocardiography
the corresponding number of consecutive heartbeats.
Immediately after acquisition, subsegments are combined
offline to a pyramidal 3D dataset with an overall angle
of maximally 120° by 120°. These 3D datasets are able
to encompass a complete left ventricular cavity from an
apical echocardiographic window. Spatial resolution of
full-volume datasets is somewhat smaller compared to
conventional 2D or bi- and triplanar images. However, full-
volume 3D data allow coverage and analysis of the complete
circumference of the left ventricular wall and not only two
or three selected 2D image planes that are always prone
to potential image plane positioning errors. Temporal
resolution depends on the number of acquired subvolumes
and segment depth, but regularly lies between 30 and 50
volumes per second.
The smaller the number or the wider the angle of the
acquired subsegments, the lower spatial and time resolution
will be. In contrast to triggered image acquisition, “single-
beat acquisition” of full-volume LV data is a more recent
and promising development to overcome artifacts due to
nonmatching subvolumes. As previously mentioned, a
certain trade-off regarding spatial and temporal resolution
of these systems has to be accepted (Figure 3.1).
ACQUISITION — WORKFLOW USING MATRIX
ARRAY TRANSDUCERS
Like conventional 2D techniques during stress
echocardiography, 3D echocardiography is performed
at rest, at low and peak stress, and during recovery. Both
physical stress (either bicycle or treadmill exercise) and
pharmacological stress (mainly dobutamine plus atropine,
but also adenosine and dipyridamole) can be used in
combination with 3D techniques.1–7
Left heart contrast agents can be applied for better
endocardial delineation as continuous infusion or using
bolus injections immediately before the acquisition of each
stress level.8–11 However, for full-volume datasets that are
acquired over several cardiac cycles, a continuous contrast
infusion is preferred so that the concentration of contrast
microbubbles remains constant during acquisition.6 Many
3D ultrasound systems have contrast-specific imaging
modalities, which should be used when contrast agents are
employed.
ROTATING MONOPLANAR, BIPLANAR,
AND TRIPLANAR MODES
Some vendors developed acquisition software that takes
advantage of matrix array’s potential to electronically rotate
an image plane. In consequence, the image plane can be
changed - as a rotation around a stable central axis - without
moving the transducer. Once the echocardiographic
window is found, the ultrasound probe can be held still,
which makes the acquisition easier for beginners but also
 A 80°–108° 80°–108°
Triggered
B 85°–90° 85°–90°
Single beat
Figure 3.1  Acquisition of full-volume 3D data. (A) Triggered
acquisition requires four to seven consecutive heartbeats. During
every beat a narrow subvolume is acquired and finally assembled
to a pyramidal 3D dataset of maximally 120° by 120°. (B) Single-beat
acquisition allows an acquisition of 3D datasets within one single
heartbeat avoiding stitching artifacts.
for experienced examiners. Nevertheless, serial acquisition
of all image planes remains time consuming.
Typically, biplanar mode from the parasternal
echocardiographic window allows the simultaneous
acquisition of a long axis and of an adapted short axis, and
from the apical echocardiographic window, a simultaneous
apical four-chamber and a two-chamber view. Finally,
using the rotation of one of the image planes, in a third
heartbeat the apical long axis can be acquired.12,13 Image
plane orientation can be stored in the echocardiographic
system as an individual setting so that after the acquisition
of all planes, side-by-side visualization and synchronization
are possible.
Acquisition of triplanar data typically is only performed
from a single apical echocardiographic window. In nearly
all patients, a default setting of 60° increments between
the three planes allows simultaneous visualization of four
and two chambers as well as of the apical long axis when
carefully adapted to the patient’s anatomy. Furthermore,
when omitting parasternal recording, triplanar scanning
facilitates a single transducer position for acquisition
of only one heartbeat at each stress stage. Loops from
all three image planes are stored separately and can
be presented and analyzed side by side comparable to
conventional 2D stress echocardiography.14
3D FULL-VOLUME MODE AND QUALITY CONTROL
In comparison to rotating mono-, bi-, and triplanar
techniques, the number of necessary heartbeats to acquire
a complete full-volume dataset is further decreased to
one up to four depending on the equipment in use. Stress
echocardiographic acquisition of full-volume data is
normally performed from a single apical echocardiographic
window. Parasternal full-volume recording in the majority
of patients is not able to cover the complete LV and thus
is not practical. At least one full-volume dataset should be
acquired at each stress level.1,15–20
The main difference between conventional 2D and
multiplanar or full-volume 3D stress echocardiography is a
significantly shorter scanning time. Full volume 3D data by
definition include a considerably higher amount of data on
LV wall motion.
Based on this faster acquisition, the narrow time
window at peak stress, especially in physical exercise
echocardiography, can be used more effectively. Performing
stress echocardiography in a bi- or triplanar approach has
already been shown to result in a higher heart rate during
exercise stress acquisition, a prerequisite for ischemia
detection.12
A full-volume 3D dataset incorporating the entire left
ventricle is required for analysis. In order to optimize
the time resolution, the size of the dataset should be
minimized by excluding extraneous structures such as the
right ventricle and left atrium. In addition, a setting with
maximal volume rate (perhaps by using more subvolumes)
should be chosen.
Single-beat full-volume acquisition is available on some
3D echocardiography systems. In case a reasonable volume
rate can be achieved, this technique removes one potential
source of artifacts and errors; subvolume stitching problems.
If the 3D dataset has been created using triggered
acquisition of more than one heartbeat with stitched
subvolumes, it is important to validate its integrity before
proceeding with analysis. This is achieved by cropping down
from the apex in a transverse plane to look for fault lines at
the joins between the subvolumes. These are usually caused
by translation errors resulting from transducer movement
during acquisition, patient respiration, or irregular R-R
intervals. Any dataset containing stitching artifacts cannot
be used for analysis (Figure 3.2).
DATA DISPLAY, ANALYSIS, AND
INTERPRETATION
Conventional 2D stress echocardiograms are analyzed by
displaying the same view at different stages side by side. It
is therefore more familiar for most users to display image
planes derived from stress 3D datasets in a similar way.21
Once the 3D dataset is acquired, image planes can be
created in every desired orientation by cropping into the 3D
dataset using multiplanar reconstruction (MPR) techniques
to create semiconventional 2D “slices” of the LV. Besides the
extraction of conventional two-, three-, and four-chamber
views, multiple parallel short-axis slices, usually six to nine
from base to apex of the LV, can be used for systematic
analysis of regional wall motion analysis. These slices can
be extracted manually or semiautomatically, as it is possible
in several commercially available 3D echocardiography
machines.20 Analysis of regional wall motion abnormalities
and contraction patterns in circular short-axis slices of the
Stress Echocardiography 29
 A B C

Figure 3.2  Typical artifacts limiting use of 3D data in stress echocardiography. (A) Endocardial borders of anteroseptal wall are not visible
(arrow). (B) Stitching artifacts (small arrows) are caused by relative motion between transducer and heart or different heart rates of consecutive
heartbeats during the triggered acquisition. (C) Left ventricular cavity is not completely included in the 3D dataset (arrow).

left ventricle - as we know it from cardiac magnetic resonance
imaging (MRI) - is somewhat easier than in long-axis views
(Figure 3.3).
The use of MPR with adjustment of the planes facilitates
geometric correction and ensures that no plane is off-axis,
which can be difficult to achieve during “live” stress image
acquisition. With 3D, every plane can be adjusted offline to
ensure that it is positioned geometrically correct and that it
correlates with other planes acquired at different stress stages.
Yet, this kind of manual cropping tends to be time consuming.
Therefore, today’s stress echocardiographic software
implemented into the latest 3D systems uses autocropping
features creating standard image planes presuming that
the apical full-volume dataset has been acquired using a
standard orientation. Of course, autocropped planes can be
readjusted manually. Some 3D stress software utilizes feature
extraction techniques that utilize preloaded 3D image
templates and pattern recognition algorithms.
In addition to creating “standard” 2D views from the 3D
dataset, it is also possible to continuously move or rotate any
of the views during playback to effectively create an infinite
number of planes. However, there is a certain risk to losing
more time with cropping the full-volume dataset than one
has saved during the acquisition.
The last step of stress echocardiographic analysis is
a side-by-side analysis of the extracted image planes at
different stress/exercise levels and is still based on subjective
interpretation of wall motion and thickening abnormalities
analogous to conventional 2D stress echocardiography.
Several advanced approaches based on modern image analysis
algorithms, such as speckle tracking in 3D, strain calculation,
parametric imaging, or quantitative analysis of wall motion
amplitudes, have been used in scientific studies to overcome
the subjectivity depending on the individual experience of
the echocardiographer (Figures 3.4 and 3.5).22–27
CLINICAL STUDIES ON 3D STRESS
ECHO - ADVANTAGES, PERSPECTIVES,
AND LIMITATIONS
Early studies using first-generation 3D equipment in the late
1990s already demonstrated that 3D volumetric imaging
could be used to analyze regional LV wall motion.28 Other
studies even claimed a high sensitivity and superiority

A B

Figure 3.3  Multislice imaging in 3D echocardiography. (A) Three orthogonal views extracted from the 3D dataset (green, red, and blue)
allow discovery of the correct alignment of the long axis and a set of parallel short-axis slices (two of them marked with yellow lines). The
example shows a 4 × 4 set of short-axis slices. (B) Example showing a 3 × 3 set of short-axis slices visualizing endocardial boundaries of the left.

30  3D Echocardiography
 A B C

Figure 3.4  Side-by-side visualization of multislice images. Side-by-side visualization of serially acquired data: (A) demonstrating the situation
at rest, (B) 3 × 3 set of the corresponding short-axis slices at low-dose dobutamine dose, (C) set of short-axis slices at peak dobutamine dose.

over conventional 2D stress echocardiography.29 However,
overall poor image quality and other technical limitations
of the purely 3D-dedicated echocardiographic system
prevented this first approach from becoming widespread
in clinical use.
Since the advent of the next generation of matrix array
transducers, several study groups used bi- and triplanar
techniques as a first step toward “complete” 3D stress
echocardiography. Others used full-volume 3D data
and performed comparative studies vs. conventional 2D
echocardiography, coronary angiography, and nuclear
imaging.1–3 These studies have demonstrated a comparable
image quality and a good correlation between conventional
2D and 3D stress echocardiography with a nearly identical
sensitivity, specificity, and overall accuracy.16 However, the main
difference in all studies was, not surprisingly, a significantly
shorter scanning time to acquire a 3D dataset covering the
complete LV compared to the serial scanning of three (or even
more) different 2D image planes. Importantly, the shorter
scanning time did obviously not reduce test accuracy (Figures
3.6 and 3.7).
As a consequence of these numerous studies, clinical
cardiologists may ask: If sensitivity and specificity are
equivalent, why should one use a matrix array transducer
at all and not continue to do a 2D stress echocardiogram?
However, there are more advantages of 3D imaging during
stress echocardiographic workflow than only a shorter
scanning time:
• There is no need to change the transducer position
during apical scanning once the echocardiographic
window is found. This makes acquisition easier and faster
for both beginner and expert echocardiographers.
Furthermore, image plane positioning errors
leading to false-positive or false-negative 2D stress
echocardiographic examinations might be avoided.

A B

Figure 3.5  Qualitative visualization of regional wall motion abnormalities. Based on rendered endocardial borders, a left ventricular cast
represents an end-diastolic (A) and an end-systolic (B) left ventricular volume. Regional wall motion abnormalities can easily be detected
and visualized qualitatively (arrow in Panel B) when the end-diastolic borders are kept as a wire mesh.

Stress Echocardiography 31
 90
p < .01
80

70

Acqisition time (s)

60

50

40

30

20

10
62 59 38 68 27 21 29 29
0
2D 3D

Figure 3.6  Reduction of scan time using 3D vs. 2D stress echocardiography. Acquisition times of 2D and 3D stress echocardiography based
on the published data of four comparative studies. 2D echocardiography needs significantly more time to acquire all image planes necessary
for an adequate examination than does 3D echocardiography.

• The narrow time window at peak stress, especially in
physical exercise echocardiography, can be used much
more effectively when acquiring a complete 3D dataset. A
shorter time needed for scanning at peak stress and a more
complete monitoring (more segments can be observed
online during stress testing) also reduce the potential
risk of prolonged myocardial ischemia for the individual
patient. Moreover, reduction of stress echocardiography
duration in the long run also may reduce costs and increase
throughput in the stress echocardiography laboratory.
• Finally, besides the advantages during image acquisition,
there seem to be advantages analyzing regional LV wall
motion abnormalities in short-axis slices, similar to
MRI.
PERSPECTIVES
The combination of 3D stress echocardiography with
contrast enhancement for an improved endocardial
delineation has been used in early studies to increase the
number of evaluable LV segments. Evaluation of myocardial
perfusion in three dimensions as an even more complex
combination of advanced modalities might increase
the sensitivity in the diagnosis of functionally relevant
coronary artery disease as has been demonstrated in some
smaller and preliminary studies.6,30 However, knowing the
difficulties of 2D myocardial perfusion imaging based on
the replenishment of myocardial contrast, it seems to be still
not ready for widespread use.
Another study tried to combine the advantages of 2D and
3D stress echocardiography by integrating 3D acquisition
into a routine stress echocardiography protocol. 31 This
integrated approach improved overall accuracy in the
diagnosis of coronary artery disease significantly in
comparison to 2D or 3D alone. This combined approach may
be an optimal way for the 3D echocardiography beginner to
get used to 3D stress echocardiography.

100
Sensitivity Specificity
95
95 93
89 89 90
90
86 87
85 84

80 78 78 78 78 77 76
75 73 73
72 72
68
70
67
65

60

55
50
3D 2D 3D 2D

Figure 3.7  Diagnostic accuracy of 2D and 3D stress echocardiography in comparative studies. Bar graph demonstrating sensitivity (left) and
specificity (right) of 3D and 2D stress echocardiography in comparison to nuclear imaging or coronary angiography as gold standard. Average
sensitivity and specificity over all studies were not different between 2D and 3D techniques, demonstrating the comparable diagnostic
accuracy of both methods.

32  3D Echocardiography
 Intraventricular dyssynchrony may also be a marker
for stress-induced ischemia. 3D echocardiography is one
of several techniques that have been demonstrated to
be capable of detecting dyssynchrony as represented by
segmental volume-time curves.32 3D stress echocardiographic
studies are currently underway to evaluate the potential of
this technique. Moreover, studies using dynamic maps of
contraction, which are derived from full-volume datasets,
appear promising to more accurately localize and estimate
the severity of stress-induced ischemia by identifying areas of
delayed contraction or even diastolic function.5,22,33
Even more advanced approaches based on modern image
analysis algorithms have been used in scientific studies to
quantitatively analyze wall motion abnormalities or regional
myocardial ischemia. Speckle tracking in 3D, calculation
of regional myocardial deformation, or even calculation of
regional stress-strain loops, although depending significantly
on an optimal temporal resolution of the underlying 3D
dataset, may be the ultimate goal for precise and sensitive
detection of small myocardial pathologies.22–27,34
LIMITATIONS
Despite the variety of potential advantages of 3D compared
to conventional 2D stress echocardiography, limitations
have to be mentioned. Although modern matrix array
transducers already provide a 2D image quality comparable
to high-end 2D transducers, overall image quality in full-
volume datasets still is worse compared to high-end 2D
equipment.17,31 This is especially true for short-axis slices
extracted from apically acquired 3D data due to the reduced
line density and lateral resolution. In addition, matrix
array probes of several vendors are still relatively large and
interfere with narrow intercostal spaces, thus resulting in
artifacts or dropouts. Therefore, some authors claimed in
the past that application of left heart contrast is mandatory
for adequate endocardial delineation when acquiring full-
volume 3D data,9,10 although the majority of more recent
studies use no contrast. This may be due to the difficulties
in achieving a homogenous contrast opacification over the
complete duration of a full-volume acquisition.
Sector size with regard to angle width in earlier days was
a problem especially in dilated LVs. Meanwhile, modern 3D
echocardiographic equipment allows wide-angle settings,
which normally will be sufficient to encompass even distorted
ventricles using off-axis scanning.
Temporal resolution plays an important role in stress
echocardiography. To increase time resolution without
losing angle width of the acquired pyramidal 3D dataset,
a certain trade-off in line density always has to be accepted
which results in reduced image quality. In a standard
setting, most 3D devices today allow a time resolution of
about 40–50 ms (20–25 volumes/s), even in single-beat
acquisition. Using the triggered mode (i.e., four to seven
beats) or reduced acquisition angle (e.g., 80° instead of
120°) and reduced depth will allow a significantly higher
time resolution up to 10 ms ( = 100 volumes per second).
However, the quality of triggered data always depends on
the stability of the heart rate, the patient’s breath-hold,
and probe position. Thus, the potential advantage of short
acquisition time in 3D stress echocardiography may be
reduced by the difficulties in getting an artifact-free dataset.
To date, even after years of commercially available 3D
echocardiographic systems, there is no adequate internal
software solution that allows an easy-to-use method aligning
data at rest and during stress levels. In conventional 2D stress
echocardiography, it is a standard technique to have side-by-
side visualization of the corresponding image planes at rest
and stress levels. With the completeness of 3D data, it becomes
a new task to find the same or at least a comparable image
plane during different stress levels. An improper selection of
image planes may add a new and unexpected source of error
in the interpretation of 3D stress echocardiography.
Finally, the interpretation of image planes generated from
the complete 3D dataset remains subjective. The addition of
more reliable and less subjective quantitative tools such as
speckle tracking or “3D strain,” at least at present, still is only
scientific and challenging. Unfortunately, these advanced and
proprietary techniques have not yet entered widespread clini-
cal routine.24–26,34 After several enthusiastic studies in the first
years of real-time 3D echocardiography, the lack of easy-to-use
analysis tools may be responsible for the low number of clinical
studies on 3D stress echocardiography over the last few years.
CONCLUSION
3D stress echocardiography has been shown to be feasible,
resulting in a test accuracy that is comparable to conventional
2D techniques. Besides the advantage of reduced acquisition
time covering the complete left ventricle without losing image
quality, it may be easier analyzing regional LV wall motion
abnormalities in short axis slices instead of conventional
long axis planes. In addition, image plane positioning
errors leading to false positive or negative 2D stress echo
examinations might be avoided.
However, to be realistic, up to now, a clinically relevant
and easy-to-use solution for the routine use of 3D in stress
echocardiography has not yet been established. On the long
run, real-time 3D stress echo will be the fastest and without
any doubt the best way to do a stress echo.
SUMMARY BOX
Advantages of 3D over 2D stress echocardiography
• Faster acquisition
• Complete left ventricle encompassed
• (Probably) easier interpretation of wall motion
abnormalities in short-axis views
Disadvantages of 3D compared to 2D stress
echocardiography
• Temporal and spatial resolution susceptible to
sector size and acquisition technique (triggered/
untriggered)
• Limited software solutions for side-by-side
viewing of rest and stress levels
Stress Echocardiography 33

REFERENCES
1. Matsumura Y, Hozumi T, Arai K. Non-invasive assessment of myocardial
ischemia using new real-time three-dimensional dobutamine stress
echocardiography: Comparison with conventional two-dimensional
methods. Eur Heart J. 2005;​26:1625–32.
2. Aggeli C, Ginnopoulos G, Misovoulos P, Roussakis G, Christoforatou
E, Kokkinakis C. Real-time three-dimensional dobutamine stress
echocardiography for coronary artery disease diagnosis: Validation with
coronary angiography. Heart. 2007;93:672–5.
3. Peteiro J, Pinon P, Perez R, Monserrat L, Perez D, Castro-Beiras A.
Comparison of 2- and 3-dimensional exercise echocardiography for the
detection of coronary artery disease. J Am Soc Echocardiogr. 2007;20:959–67.
4. Varnero S, Santagata P, Pratali L, Basso M, Gandolfo A, Bellotti P.
Head to head comparison of 2D vs. real time 3D dipyridamole stress
echocardiography. Cardiovasc Ultrasound. 2008;6:31.
5. Jenkins C, Haluska B, Marwick TH. Assessment of temporal heterogeneity
and regional motion to identify wall motion abnormalities using treadmill
exercise stress three-dimensional echocardiography. J Am Soc Echocardiogr.
2009;22(3):268–75.
6. Aggeli C, Felekos I, Roussakis G et al. Value of real-time three-dimensional
adenosine stress contrast echocardiography in patients with known or
suspected coronary artery disease. Eur J Echocardiogr. 2011;12(9):648–55.
7. Berbarie RF, Dib E, Ahmad M. Stress echocardiography using real-time
three-dimensional imaging. Echocardiography. 2018;35(8):1196–203.
8. Pulerwitz T, Hirata K, Abe Y et  al. Feasibility of using a real-time
3-dimensional technique for contrast dobutamine stress echocardiography.
J Am Soc Echocardiogr. 2006;19:540–45.
9. Takeuchi M, Shinichiro O, Weinert L, Spencer K, Lang R. Comparison
of contrast-enhanced real-time live 3-dimensional dobutamine stress
echocardiography with contrast 2-dimensional echocardiography for
detecting stress-induced wall-motion abnormalities. J Am Soc Echocardiogr.
2006;19(3):294–9.
10. Krenning BJ, Nemes A, Soliman OI et  al. Contrast-enhanced three-
dimensional dobutamine stress echocardiography: Between Scylla and
Charybdis? Eur J Echocardiogr. 2008;9(6):757–60.
11. Stergiopoulos K, Bahrainy S, Buzzanca L, Blizzard B, Gamboa J, Kort
S. Initial experience using contrast enhanced real-time three-dimensional
exercise stress echocardiography in a low-risk population. Heart Int.
2010;5(1):e8.
12. Sugeng L, Kirkpatrick J, Lang RM et al. Biplane stress echocardiography
using a prototype matrix-array transducer. J Am Soc Echocardiogr.
2003;16:937–41.
13. Yang H, Pellikka P, McCully R et  al. Role of biplane and biplane
echocardiographically guided 3 -dimensional echocardiography
during dobutamine stress echocardiography. J Am Soc Echocardiogr.
2006;19:1136–43.
14. Eroglu E, D’Hooge J, Herbots L, Thijs D, Dubois C, Sinnaeve P.
Comparison of real-time tri-plane and conventional 2D dobutamine stress
echocardiography for the assessment of coronary artery disease. Eur Heart
J. 2006;27:1719–24.
15. Sawada SG, Thomaides A. Three-dimensional stress echocardiography:
The promise and limitations of volumetric imaging. Curr Opin Cardiol.
2009;24(5):426–32.
16. Badano LP, Muraru D, Rigo F et al. High volume-rate three-dimensional
stress echocardiography to assess inducible myocardial ischemia: A
feasibility study. J Am Soc Echocardiogr. 2010;23(6):628–35.
17. Pratali L, Molinaro S, Corciu AI, Pasanisi EM, Scalese M, Sicari R.
Feasibility of real-time three-dimensional stress echocardiography:
Pharmacological and semi-supine exercise. Cardiovasc Ultrasound. 2010;8:10.
34  3D Echocardiography
18. Abusaid GH, Ahmad M. Real time three-dimensional stress
echocardiography advantages and limitations. Echocardiography.
2012;29(2):200–6.
19. Hoogslag GE, Joyce E, Bax JJ, Ajmone Marsan N, Delgado V. Assessment
of global left ventricular excursion using three-dimensional dobutamine
stress echocardiography to identify significant coronary artery disease.
Echocardiography. 2016;33(10):1532–8.
20. Yoshitani H, Takeuchi M, Mor-Avi V, Otsuji Y, Hozumi T, Yoshiyama
M. Comparative diagnostic accuracy of multiplane and multislice three-
dimensional dobutamine stress echocardiography in the diagnosis of
coronary artery disease. J Am Soc Echocardiogr. 2009;22:437–42.
21. Nemes A, Leung KY, van Burken G et  al. Side-by-side viewing of
anatomically aligned left ventricular segments in three-dimensional stress
echocardiography. Echocardiography. 2009;26(2):189–95.
22. Ahmad M, Dimmano M, Xie C. Advances in parametric 3D
echocardiography in quantitative estimation of dobutamine stress induced
ischemia. Circulation. 2008;118:S850–1.
23. Kort S, Mamidipally S, Madahar P et al. Segmental contribution to left
ventricular systolic function at rest and stress: A quantitative real time three-
dimensional echocardiographic study. Echocardiography. 2010;27(2):167–73.
24. Herz SL, Hasegawa T, Makaryus AN et  al. Quantitative three-
dimensional wall motion analysis predicts ischemic region size and location.
Ann Biomed Eng. 2010;38(4):1367–76.
25. Leung KY, van Stralen M, Danilouchkine MG et al. Automated analysis of
three-dimensional stress echocardiography. Neth Heart J. 2011;19(6):307–10.
26. Seo Y, Ishizu T, Enomoto Y, Sugimori H, Aonuma K. Endocardial
surface area tracking for assessment of regional LV wall deformation with
3D speckle tracking imaging. JACC Cardiovasc Imaging. 2011;4(4):358–65.
27. Parker KM, Clark AP, Goodman NC, Glover DK, Holmes JW. Comparison
of quantitative wall-motion analysis and strain for detection of coronary
stenosis with three-dimensional dobutamine stress echocardiography.
Echocardiography. 2015;32(2):349–60.
28. Collins M, Hsieh A, Ohazama CJ et  al. Assessment of regional wall
motion abnormalities with real-time 3-dimensional echocardiography. J
Am Soc Echocardiogr. 1999;12:7–14.
29. Ahmad M, Xie T, McCulloch M, Abreo G, Runge  M. Real-time
three-dimensional dobutamine stress echocardiography in assessment
stress echocardiography in assessment of ischemia: Comparison with
two-dimensional dobutamine stress echocardiography. J Am Coll Cardiol.
2001;37(5):1303–9.
30. Abdelmoneim SS, Bernier M, Dhoble A et al. Assessment of myocardial
perfusion during adenosine stress using real time three-dimensional and
two-dimensional myocardial contrast echocardiography: Comparison
with single-photon emission computed tomography. Echocardiography.
2010;27(4):421–9.
31. Johri AM, Chitty DW, Hua L, Marincheva G, Picard MH. Assessment
of image quality in real time three-dimensional dobutamine stress
echocardiography: An integrated 2D/3D approach. Echocardiography.
2015;32(3):496–507.
32. Kapetanakis S, Kearney MT, Siva A, Gall N, Cooklin  M, Monaghan
MJ. Real-time three-dimensional echocardiography: A novel technique to
quantify global left ventricular mechanical dyssynchrony. Circulation. 2005;​
112(7):992–1000.
33. Kort S, Mamidipally S, Madahar P, Dave S, Brown DL. Real time
three-dimensional stress echocardiography: A new approach for assessing
diastolic function. Echocardiography. 2011;28(6):676–83.
34. Pedrosa J, Duchenne J, Queirós S et  al. Non-invasive myocardial
performance mapping using 3D echocardiographic stress-strain loops. Phys
Med Biol. 2019;64(11):115026.
 4 Right Ventricle
INTRODUCTION
The shape of the right ventricle (RV) is complicated and
thus any 2D imaging cannot represent the entire RV as
seen in Figure 4.1 ( ). In the apical 2D echocardiographic
view, the RV looks triangular, while in the cross-sectional
view, it appears crescent in the normal condition.1 The RV
is composed of the following three components:
1. The inlet, which consists of the tricuspid valve (TV),
chordae tendineae, and papillary muscle
2. The trabecular apical myocardium
3. The infundibulum or conus, which refers to the smooth
myocardial outflow region
The infundibulum consists of 25%–30% of RV volume
shown by a 3D study.2
The three parts of the RV are not in the same plane
as seen in a 3D echocardiogram from a normal subject
(Figure 4.1). The RV inflow tract contracts earlier than
the infundibulum. The response of these three segments
to medications, sympathetic stimulation, and volume and
pressure overload may be different. For example, animal
and human studies suggested that the inotropic response
of the infundibulum may be greater than that of the inflow
tract.
RV has circumferential arrangement of the myofibers
in the subendocardium and longitudinal myofibers in the
subendocardium. RV contraction is greater longitudinally
than radially. It is no wonder that almost all the RV strain
and strain rate studies are focused on the longitudinal
ones, not radial or circumferential ones. For example, RV
free-wall longitudinal strain had a stronger correlation
with RV ejection fraction (EF) determined by magnetic
resonance imaging (MRI) than tricuspid annular plane
systolic excursion (TAPSE), RV fractional area change
(FAC), and tricuspid S′ in a heterogeneous group of
patients. 3
DETERMINANTS OF RIGHT HEART FUNCTION
2D ECHOCARDIOGRAPHIC ASSESSMENT OF RIGHT
VENTRICLE SIZE
RV volume estimation by 2D echocardiography has
historically employed several geometric models, including
elliptical, hemi-elliptical, ellipsoid, area-length, the
Simpson, triangular prism, and pyramid ones. Currently,
none of these 2D models is accepted for clinical use.
Moreover, unpredictable changes in the geometry of the
RV responding to volume and pressure overload create
further problems for the use of such geometric assumptions.
However, 2D echocardiography is widely used to judge the
size in daily cardiac practice. Normal values were suggested
by the American Society of Echocardiography (ASE) as
follows: 25–41 mm for RV basal diameter, 59–83 mm for
RV longitudinal diameter, and 21–35 mm for the right
ventricular outflow tract (RVOT) proximal diameter.4
Also, as a general guide, in the apical four-chamber and
parasternal long-axis view, normal RV size is approximately
two-thirds that of the left ventricle (LV). When the RV
appears larger than the LV and/or shares the apex, RV
dilation may be present.
2D ECHOCARDIOGRAPHIC METHODS FOR
DETERMINING RV SYSTOLIC FUNCTION
RV systolic function is a strong predictor of outcome in heart
failure patients. Systolic function is currently determined
by the following 2D echocardiography methods.4 The ASE
guideline has been upgraded from 2010 which was used
for the second edition of this textbook. Now in the new
ASE guideline, 3D echocardiography as well as 2D strain
by speckle tracking have been added as a measure for
evaluating RV systolic function.4
1. RV FAC. RV FAC is defined as (end-diastolic area –
end-systolic area)/end-diastolic area × 100. This value
is determined by RV endocardial tracing in the apical
four-chamber view. This method has been used in the
literature many times and is recommended by the ASE
as one of the quantitative methods for determining RV
systolic function. RV systolic dysfunction is suspected
when FAC is less than 35%.
  Although this method does not reflect RVOT, which
may react differently from RV inflow to medications,
pressure, and volume overload, it is still useful practically
AO
PV
TV
RV
Figure 4.1  3D TEE image of the right ventricle . (AO, aorta; PV,
pulmonary valve; RV, right ventricle; TV, tricuspid valve.)
Right Ventricle 35
 to roughly judge the RV systolic function.5 Not only is this
method quantitatively important but also, at the same
time, geometrical judgment of RV such as the McConnell
sign can be performed.6 Thus, this is a clinically
indispensable, easy 2D eyeball method although detailed
3D geometrical character of the McConnell sign and
segmental stain can be more specific and quantitatively
accurate for acute pulmonary embolism.7,8
. Tricuspid annular plane systolic motion (TAPSE, movement
2 general, the ASE suggested that RV systolic dysfunction
of the tricuspid annulus). The value is determined as the
distance of systolic TV annular motion in the M-mode
recording. The movement of the tricuspid annulus in a
standard apical four-chamber view is easy to recognize.
The normal value is greater than 16 mm. RV systolic
dysfunction is suspected when TAPSE is less than
17 mm.4 Although this method assumes that the TV
annular movement represents the entire RV function,
this assumption may not hold true when regional RV
PV
TV
PV
TV
EDV=78.3ml
Figure 4.2  (A) Determination of an absolute volume of the right ventricular (RV) cavity with 3D TTE (see text). (B) Software to determine
absolute RV volume from 3D TEE volume. (EDV, end-diastolic volume.)
36  3D Echocardiography
dysfunction exists. In busy clinical settings, however, the
combination of FAC and TAPSE is practical for quick
assessment of RV function in many cases.9
3. Peak systolic tricuspid annular velocity by pulsed and tissue
Doppler. The evaluation of peak systolic tricuspid
annular velocity using Doppler tissue imaging provides
a simple, rapid, and noninvasive tool for assessing
RV systolic function in patients with heart failure. In
is suspected when S′ velocity by pulsed Doppler less
than 9.5 cm/s and less than 6.0 cm/s by color Doppler.4
However, like TAPSE, this method assumes that the
TV annular velocity represents the entire RV function,
which may not hold true when regional RV dysfunction
exists.
. Myocardial function index or Tei index. The myocardial
4
performance index (MPI) or Tei index is considered an
index of global RV function. The value is determined
TV
PV
 as the ratio of the total isovolumic time (isovolumic
relaxation time and isovolumic contraction time) to
RV ejection time. Measurement can be performed with
6
pulsed Doppler and/or the tissue Doppler method.
This method is relatively simple and does not require
optimal RV imaging.
  RV systolic dysfunction is suspected when MPI is
greater than 0.43 by pulsed Doppler and MPI greater
than 0.54 by tissue Doppler.4 However, this method may
be inaccurate in patients with arrythmia and when RV
pressure is increased.
5. RV dp/dt. The rate of pressure rise can be estimated by
continuous-wave (CW) Doppler recording of tricuspid
regurgitation (TR) velocity. RV dp/dt is determined by the
ratio of the increase in pressure (12 mm Hg from 1 m/s
to 2 m/s of TR velocity) to time (from 1 m/s to 2 m/s).
RV dp/dt less than 400 mm  Hg/s may be considered
abnormal (if other findings are consistent). However,
this method is dependent on preload, less accurate in
severe TR, and relatively time consuming. Thus, it is not
routinely used clinically.
. Strain. RV free wall strain derived from speckle tracking
was recently added as a measure of RV function in the
ASE guideline.4 The global longitudinal RV free wall
strain by speckle tracking greater than –20 is considered
to be abnormal (e.g., –16 is abnormal and –25 is normal).
However, this value may depend on echocardiography
systems or vendors.4
7. 3D echocardiography. Considering the complex
geometry of the RV cavity, no 2D echocardiographic
methods as mentioned earlier can provide true RV
volumes. As compared to MRI, the 2D approach to RV
volume determination has been proven inaccurate.
3D echocardiography has been proposed as a better
method than 2D for determining RV volumes.4,10–14 3D
echocardiography can determine absolute cavity volumes
of an RV of any shape, which may depend on volume and
pressure overload (Figure 4.2).15

A Difference in RV EDV between 3D echocardiography and MRI

Publication
ID Author Weight Estimates [95%CI]
Year/Month
01 Vogel 1997.4 5.2% –4.50 [–6.51, –2.49]
02 Papavassiliou 1998.8 4.2% –9.60 [–18.03, –1.17]
03 Fujimoto 1998.12 4.8% –4.00 [–8.93, 0.93]
04 Prakasa 2006.3 4.7% –15.90 [–21.71, –10.09]
05 Nesser TEE 2006.9 4.3% –1.30 [–9.10, 6.50]
06 Nesser TTE 2006.9 4.3% –1.60 [–9.58, 6.38]
07 Kjaergaard 2006.12 3.8% 5.40 [–4.55,15.35]
08 Gopal DS 2007.5 5.2% –1.20 [–2.67, 0.27]
09 Gopal AR 2007.5 5.2% –16.00 [–18.11, –13.89]
10 Jenkins 2007.6 5.1% –3.00 [–5.77, –0.23]
11 Niemann 2007.10 5.2% 0.91 [0.15, 1.67]
12 Lu 2008.1 4.9% –7.00 [–11.16, –2.84]
13 Iriart 2009.1 4.5% –18.70 [–25.62, –11.78]
14 Khoo DS 2009.10 3.4% –45.74 [–58.03, –33.45]
15 Khoo AR 2009.10 3.5% –45.27 [–56.68, –33.86]
16 Khoo ABD 2009.10 3.5% –51.19 [–62.60, –39.78]
17 Khoo MAB 2009.10 3.7% –52.38 [–62.91, –41.84]
18 Grewal 2009.12 3.1% –25.00 [–38.72, –11.28]
19 Grapsa PAH 2010.1 4.4% –3.70 [–10.96, 3.56]
20 Grapsa NL 2010.1 5.1% –1.50 [–4.57, 1.57]
21 Sugeng 2010.1 3.1% –14.00 [–27.80, –0.20]
22 van der Zwaan 2010.2 4.0% –34.00 [–43.26, –24.74]
23 Leibundgut 2010.2 4.9% –10.20 [–14.63, –5.77]

All studies
–13.9 [–17.7, –10.1], p < 0.00001
Underestimation
Overestimation

–50 –40 –30 –20 –10 +10 +20 +30 +40 +50 (ml)

Figure 4.3  (A) Meta-analysis of right ventricular end-diastolic volume (RV EDV) by 3D echocardiography. (Continued)

Right Ventricle 37
 B Difference in RV EF between 3DE and MRI

Publication
ID Author Year/Month Weight Estimates [95%CI]
01 Vogel 1997.4 4.1% –6.60 [–9.03, –4.17]
02 Papavassiliou 1998.8 2.6% –3.35 [–7.39, 0.69]
03 Fujimoto 1998.12 3.4% 1.00 [–2.04, 4.04]
04 Prakasa 2006.3 5.9% –1.20 [–1.97, –0.43]
05 Nesser TEE 2006.9 2.4% –4.00 [–8.25, 0.25]
06 Nesser TTE 2006.9 2.5% –2.00 [–6.12, 2.12]
07 Kjaergaard 2006.12 2.6% –5.90 [–9.91, –1.89]
08 Gopal DS 2007.5 5.2% –0.70 [–2.20, 0.80]
09 Gopal AR 2007.5 5.5% 1.70 [0.49, 2.91]
10 Jenkins 2007.6 5.6% 2.00 [0.89, 3.11]
11 Niemann 2007.10 5.5% 0.16 [–1.04, 1.36]
12 Lu 2008.1 4.7% 0.30 [–1.59, 2.19]
13 Iriart 2009.1 4.8% –0.20 [–2.05, 1.65]
14 Khoo DS 2009.10 3.9% –0.50 [–3.06, 2.06]
15 Khoo AR 2009.10 4.2% –0.70 [–3.07, 1.67]
16 Khoo ABD 2009.10 4.3% –2.60 [–4.82, –0.38]
17 Khoo MAB 2009.10 3.9% 1.40 [–1.16, 3.96]
18 Grewal 2009.12 5.3% 2.00 [0.63, 3.37]
19 Grapsa PAH 2010.1 4.9% –1.30 [–3.07, 0.47]
20 Grapsa NL 2010.1 4.8% –1.30 [–3.10, 0.50]
21 Sugeng 2010.1 4.3% –2.00 [–4.27, 0.27]
22 van der Zwaan 2010.2 4.7% –4.00 [–5.91, –2.09]
23 Leibundgut 2010.2 5.1% –0.40 [–1.97, –1.17]

All studies –0.9 [–1.8, –0.1], p=0.03

Underestimation Overestimation
–4 –2 +2 +4 (%)

Figure 4.3 (Continued)  (B) Meta-analysis of right ventricle ejection fraction (RV EF) by 3D echocardiography.

Figure 4.4  A pitfall of right ventricular (RV) volume determination with 3D echocardiography. Unclear borderline (arrows) is a cause of an
erroneous estimation of RV volume (see text).

38  3D Echocardiography
 A

Figure 4.5  (A) Preoperative transesophageal echocardiography (TEE), showing severe tricuspid regurgitation (TR) and dilated right ventricle
and right atrium. (B) Postoperative 2D TEE, showing smaller RV without residual TR.

NORMAL VALUES OF RV VOLUMES AND EJECTION
FRACTION BY 3D ECHOCARDIOGRAPHY
NORMAL VALUES OF RV VOLUMES WERE REPORTED15,16
There were significant differences in RV end-diastolic
volume (EDV) between men and women (129 ± 25 vs.
102 ± 33 mL, P < .01).16,17 However, adjusting to lean body
mass (but not the body surface area or height) eliminated
this difference (2.1 ± 0.5 vs. 2.2 ± 0.4 mL/kg, P = not
significant).17 Normal upper limit values are for men
87 mL/m2 for EDV and 44 mL/m2 for end-systolic volume
(ESV) and for women 74 mL/m2 for EDV and 36 mL/m2
for ESV.4
Clinical validation of 3D RV volume determination with
MRI has been reported many times. In vitro studies repeatedly
confirmed the accuracy of real-time 3D echocardiography
for determining RV volume, stroke volume, and/or EF.1,18–21
In contrast to nonhuman validation studies, however, in
clinical studies, there has been consistent underestimation
of MRI-derived RV volumes by 3D echocardiography.
Our meta-analysis showed RV volumes were slightly
underestimated by 3D echocardiography as compared to

Right Ventricle 39
 A

pre
PV

TV

EDV=238.3ml PV
TV

post

PV TV

PV
TV

PV
TV

EDV=151.0ml

Figure 4.6  (A) Right ventricular (RV) volume by presurgical 3D TEE. (B) RV volume by postsurgical 3D TEE. (EDV, end-diastolic volume; PV,
pulmonary valve; TV, tricuspid valve.)

MRI (Figure 4.3).22 Normal values of RV EF are reported
by multiple authors. Our meta-analysis showed that EF was
slightly underestimated (0.9%) by 3D echocardiography as
compared to MRI (Figure 4.3).22 RV systolic dysfunction is
suspected when 3D RV EF is less than 44%.4
PITFALLS OF 3D ECHOCARDIOGRAPHY MEASUREMENT
Inclusion of the entire RV is not automatic. In 40
patients who planned for a routine 2D transthoracic
echocardiography (TTE), parasternal, apical, and subcostal
views were used for 3D echocardiography. In this study, RV
was adequately visualized in only 12 (30%) patients by 3D
echocardiography.23 Tracing of the RV endocardium may
be erroneous, although the typical views such as the apical
four-chamber view show an optimal RV image for tracing.
Inclusion and exclusion of the moderator band may create
confusion (Figure 4.4).
ADDITIONAL TESTING BASED ON
LIMITATIONS OF ECHOCARDIOGRAPHIC DATA
MRI is the gold standard for determining RV volume and
function. This method should be considered when the
image quality of 3D echocardiography is not good enough
for evaluation (Table 4.1).

40  3D Echocardiography
Table 4.1  Comparison between 2D Echocardiography and 3D Echocardiography and Magnetic Resonance
Imaging
Magnetic Resonance
2D Echocardiography 3D Echocardiography Imaging

RV Size Relatively simple to measure in
multiple views and provide a visual
assessment
RV Volume Area-length or Simpson method
RV Function Fractional area change TAPSE, TVA
velocity (pulsed and tissue Doppler),
MPI or Tei index, CW dp/dt, strain
and strain rate
CW, continuous wave; EF, ejection fraction; FAC, fractional area change; MPI, myocardial performance index; RV, right ventricle; TAPSE, tricuspid annular
plane systolic motion; TVA, tricuspid valve annulus.
Easy to apply but not quantitative,
moderate accuracy
Not accurate
All indices are limited due to
localized information, combination
of FAC and TAPSE can be applied
for rough assessment
Better estimate than 2D Gold standard, but not for
echocardiography, need more daily practice
time to measure, may
underestimate RV volumes
Needs more time Accurate
Better estimate than 2D Accurate RV EF, not used in
echocardiography, may daily practice
underestimate RV EF

widely accepted, visualization of unique RV remodeling

CLINICAL IMPLICATIONS OF RV
VOLUME, FUNCTION, AND GEOMETRY
DETERMINED BY 3D ECHOCARDIOGRAPHY
In a clinical feasibility study, at least one good 3D
acquisition of the RV was achieved in all subjects in a
mean time of 3 ± 1 minutes, and the RV image quality
was good in most subjects (85%). 24 A newer type of
real-time 3D system has further improved these results
since the publication of this study. In patients with
diverse backgrounds, RV EF determined by 3D TTE was
independently associated with cardiac outcomes. 25 Real-
time 3D TTE revealed that patients with arrhythmogenic
RV cardiomyopathy had a decreased RV EF as compared
with controls. 26 In another study, 3D echocardiography-
derived RV EF correlated negatively with 2D-derived
pulmonary arterial systolic pressure and positively with
tricuspid annular plane systolic excursion, peak systolic
velocity, and fractional shortening area. 24
In a recent publication, 3D echocardiographic assessment
of LV and RV volumes and shape are reported to be useful
for describing the impact of the left ventricular assist device
(LVAD) on the heart.27 The 3D echocardiography-derived
RV EF and RV free wall strain are associated with RV failure
and long-term outcome in patients undergoing LVAD
implantation. These parameters have the potential to be future
predictors for right heart failure in LVAD surgery.28 Real-time
3D echocardiography is a promising tool to offer insights into
the morphology of the RV in a variety of patients, including
arrhythmogenic RV dysplasia, Epstein malformation, and
tetralogy of Fallot.29–33 These clinical studies demonstrate
unique images of the RV and RV-related cardiac abnormalities
only possible with 3D echocardiography.
As a new methodology of 3D echocardiography, 3D
speckle tracking is developed and reported to determine
RV volume and RV EF.8 This methodology seems promising,
as the values of RV volume and EF were comparable with
cardiac magnetic resonance measurements. Interestingly,
regional RV wall motion with heterogeneous segmental
deformations could be demonstrated by this 3D
methodology.8 Although the speckle tracking 3D is not yet
and regional wall motion abnormality in patients
with pulmonary hypertension by this method was also
reported.34,35
As for real-time 3D TEE assessment of RV volumes and
function in surgical patients with normal and dilated
RVs, its feasibility was reported with improvement of the
quantitative evaluation of RV function. 36 In a practical
sense, however, 3D echocardiographic measurement of RV
volume and EF may be cumbersome in the operating room
or catheterization laboratory. Based on recent publications
with the use of 3D echocardiography, 2D-based FAC or
visual assessment of RV systolic function in the operating
room appeared to be reliable. 5,37 RV volume was not
accurate by visual assessment in this study. 37 Thus, we
must choose wisely on what method should be used in a
variety of clinical settings, from visual 2D assessment to
3D measurement of RV volume and EF with and without
speckle tracking.
CASE PRESENTATION
This patient was in a car accident recently and subsequently
had shortness of breath and leg edema. 2D TEE (Figure 4.5)
showed severe TR and dilated RV with normal systolic
function. Real-time 3D TEE analysis showed RV EDV of
238 mL and EF of 61% (Figure 4.6). After the TV repair,
2D TEE showed no residual TR and reduced RV size and
systolic function (Figure  4.5). No reliable quantification
was possible with 2D echocardiography. 3D TEE analysis
demonstrated reduced RV EDV of 151 and EF of 52% after
the surgery (Figure 4.6).
CONCLUSION
Because of its unique geometry, RV evaluation by 2D
methods is difficult and requires including multiple factors
such as RV FAC and TAPSE. 3D echocardiography is not only
theoretically ideal, but also announced as a measure of RV
volume and function in the new ASE guideline. Continued
technological improvement to easily determine RV volume
and function in a variety of pathological conditions is still
desired to improve clinical outcomes.

Right Ventricle 41

REFERENCES
1. Shiota T, Jones M, Chikada M et  al. Real-time three-dimensional
echocardiography for determining right ventricular stroke volume in an
animal model of chronic right ventricular volume overload. Circulation.
1998;97(19):1897–900.
2. Nesser HJ, Tkalec W, Patel AR et al. Quantitation of right ventricular
volumes and ejection fraction by three-dimensional echocardiography in
patients: Comparison with magnetic resonance imaging and radionuclide
ventriculography. Echocardiography. 2006;23(8):666–80.
3. Focardi M, Cameli M, Carbone SF et  al. Traditional and innovative
echocardiographic parameters for the analysis of right ventricular
performance in comparison with cardiac magnetic resonance. Eur Heart J
Cardiovasc Imaging. 2015;16(1):47–52.
4. Lang RM, Badano LP, Mor-Avi V et al. Recommendations for cardiac
chamber quantification by echocardiography in adults: An update from the
American Society of Echocardiography and the European Association of
Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28(1):1–39.e14.
5. Imada T, Kamibayashi T, Ota C et al. Intraoperative right ventricular
fractional area change is a good indicator of right ventricular contractility:
A retrospective comparison using two- and three-dimensional
echocardiography. J Cardiothorac Vasc Anesth. 2015;29(4):831–5.
6. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee
RT. Regional right ventricular dysfunction detected by echocardiography
in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469–73.
7. Vitarelli A, Barilla F, Capotosto L et al. Right ventricular function in acute
pulmonary embolism: A combined assessment by three-dimensional and
speckle-tracking echocardiography. J Am Soc Echocardiogr. 2014;27(3):329–38.
8. Ishizu T, Seo Y, Atsumi A et al. Global and regional right ventricular
function assessed by novel three-dimensional speckle-tracking
echocardiography. J Am Soc Echocardiogr. 2017;30(12):1203–13.
9. Jones N, Burns AT, Prior DL. Echocardiographic assessment of the right
ventricle-state of the art. Heart Lung Circ. 2019;28(9):1339–50.
10. Niemann PS, Pinho L, Balbach T et al. Anatomically oriented right
ventricular volume measurements with dynamic three-dimensional
echocardiography validated by 3-Tesla magnetic resonance imaging. J Am
Coll Cardiol. 2007;50(17):1668–76.
11. Sugeng L, Mor-Avi V, Weinert L et  al. Multimodality comparison of
quantitative volumetric analysis of the right ventricle. JACC Cardiovasc
Imaging. 2010;3(1):10–8.
12. Schattke S, Wagner M, Hattasch R et al. Single beat 3D echocardiography
for the assessment of right ventricular dimension and function after
endurance exercise: Intraindividual comparison with magnetic resonance
imaging. Cardiovasc Ultrasound. 2012;10:6.
13. Ostenfeld E, Flachskampf FA. Assessment of right ventricular volumes
and ejection fraction by echocardiography: From geometric approximations
to realistic shapes. Echo Res Pract. 2015;2(1):R1–R11.
14. Wu VC, Takeuchi M. Echocardiographic assessment of right ventricular
systolic function. Cardiovasc Diagn Ther. 2018;8(1):70–9.
15. Tamborini G, Marsan NA, Gripari P et al. Reference values for right
ventricular volumes and ejection fraction with real-time three-dimensional
echocardiography: Evaluation in a large series of normal subjects. J Am Soc
Echocardiogr. 2010;23(2):109–15.
16. Gopal AS, Chukwu EO, Iwuchukwu CJ et al. Normal values of right
ventricular size and function by real-time 3-dimensional echocardiography:
Comparison with cardiac magnetic resonance imaging. J Am Soc Echocardiogr.
2007;20(5):445–55.
17. Kjaergaard J, Sogaard P, Hassager C. Quantitative echocardiographic
analysis of the right ventricle in healthy individuals. J Am Soc Echocardiogr.
2006;19(11):1365–72.
18. Ota T, Fleishman CE, Strub M et  al. Real-time, three-dimensional
echocardiography: Feasibility of dynamic right ventricular volume
measurement with saline contrast. Am Heart J. 1999;137(5):958–66.
42  3D Echocardiography
19. Schindera ST, Mehwald PS, Sahn DJ, Kececioglu D. Accuracy of real-
time three-dimensional echocardiography for quantifying right ventricular
volume: Static and pulsatile flow studies in an anatomic in vitro model. J
Ultrasound Med. 2002;21(10):1069–75.
20. Chen G, Sun K, Huang G. In vitro validation of right ventricular volume
and mass measurement by real-time three-dimensional echocardiography.
Echocardiography. 2006;23(5):395–9.
21. Hoch M, Vasilyev NV, Soriano B, Gauvreau K, Marx GR. Variables
influencing the accuracy of right ventricular volume assessment by real-
time 3-dimensional echocardiography: An in vitro validation study. J Am Soc
Echocardiogr. 2007;20(5):456–61.
22. Shimada YJ, Shiota M, Siegel RJ, Shiota T. Accuracy of right ventricular
volumes and function determined by three-dimensional echocardiography
in comparison with magnetic resonance imaging: A meta-analysis study. J
Am Soc Echocardiogr. 2010;23(9):943–53.
23. Ostenfeld E, Shahgaldi K, Winter R, Willenheimer R, Holm J.
Comparison of different views with three-dimensional echocardiography:
Apical views offer superior visualization compared with parasternal and
subcostal views. Clin Physiol Funct Imaging. 2008;28(6):409–16.
24. Tamborini G, Brusoni D, Torres Molina JE et al. Feasibility of a new
generation three-dimensional echocardiography for right ventricular
volumetric and functional measurements. Am J Cardiol. 2008;102(4):499–505.
25. Nagata Y, Wu VC, Kado Y et al. Prognostic value of right ventricular
ejection fraction assessed by transthoracic 3D echocardiography. Circ
Cardiovasc Imaging. 2017;10(2).
26. Kjaergaard J, Hastrup Svendsen J, Sogaard P et al. Advanced quantitative
echocardiography in arrhythmogenic right ventricular cardiomyopathy. J
Am Soc Echocardiogr. 2007;20(1):27–35.
27. Addetia K, Uriel N, Maffessanti F et al. 3D morphological changes in
LV and RV during LVAD ramp studies. JACC Cardiovasc Imaging. 2018;11(2
Pt 1):159–69.
28. Magunia H, Dietrich C, Langer HF et al. 3D echocardiography derived
right ventricular function is associated with right ventricular failure and
mid-term survival after left ventricular assist device implantation. Int J
Cardiol. 2018;272:348–55.
29. Acar P, Abadir S, Roux D et al. Ebstein’s anomaly assessed by real-time
3-D echocardiography. Ann Thorac Surg. 2006;82(2):731–3.
30. Vettukattil JJ, Bharucha T, Anderson RH. Defining Ebstein’s
malformation using three-dimensional echocardiography. Interact
Cardiovasc Thorac Surg. 2007;6(6):685–90.
31. van Noord PT, Scohy TV, McGhie J, Bogers AJ. Three-dimensional
transesophageal echocardiography in Ebstein’s anomaly. Interact
Cardiovasc Thorac Surg. 2010;10(5):836–7.
32. Karsenty C, Hadeed K, Acar P. [Congenital heart disease: Recent
technical advances in three-dimensional echocardiography]. Presse Med.
2017;46(5):482–9.
33. Lakatos B, Kovacs A, Tokodi M, Doronina A, Merkely B. [Assessment of
the right ventricular anatomy and function by advanced echocardiography:
Pathological and physiological insights]. Orv Hetil. 2016;157(29):1139–46.
34. Ryo K, Goda A, Onishi T et al. Characterization of right ventricular
remodeling in pulmonary hypertension associated with patient outcomes
by 3-dimensional wall motion tracking echocardiography. Circ Cardiovasc
Imaging. 2015;8(6).
35. Moriyama H, Murata M, Kataoka M et  al. Right ventricle-specific
three-dimensional wall motion tracking for visualization of regional wall
motion abnormality in patients with pulmonary arterial hypertension. Circ
Cardiovasc Imaging. 2019;12(4):e008795.
36. Fusini L, Tamborini G, Gripari P et  al. Feasibility of intraoperative
three-dimensional transesophageal echocardiography in the evaluation
of right ventricular volumes and function in patients undergoing cardiac
surgery. J Am Soc Echocardiogr. 2011;24(8):868–77.
37. Magunia H, Schmid E, Hilberath JN et  al. 2D echocardiographic
evaluation of right ventricular function correlates with 3D volumetric models
in cardiac surgery patients. J Cardiothorac Vasc Anesth. 2017;31(2):595–601.
 5 Left Atrium
INTRODUCTION
The left atrium (LA) is one of the four chambers of the
heart receiving oxygen-rich blood from the lungs through
the pulmonary veins before filling the left ventricle. The LA
is routinely imaged by cardiac magnetic resonance (CMR)
imaging, computed tomography (CT) scan, or more often by
transthoracic echocardiography (TTE) with transesophageal
echocardiography (TEE) giving a higher accurate resolution
owing to the proximity of the LA. The LA has a complex
anatomy and function, and 3D echocardiography enables
an easier, accurate, and reproducible interpretation
of the LA, overcoming the intrinsic limitations of
conventional echocardiography. One major advantage
of 3D echocardiography is the en face view giving realistic
appreciation of the normal anatomy and diseased LA from
an unprecedented perspective while the heart is beating.
Another benefit is the LA time-varying volume measurement
with a high level of accuracy and reproducibility with limited
geometric assumptions. The production of C-planes from
any perspective within the 3D volume acquisition is another
improvement of the appreciation of LA anatomy and function
but is less utilized in clinical practice.
3D ECHOCARDIOGRAPHY AND 3D PRINTING
TO UNDERSTAND LEFT ATRIAL ANATOMY
The global 3D printing market is expected to expand as a
response to growing demand for prototyping in various fields
including health care. In the medical field, 3D printing allows
for the creation of patient-specific organs and touchable
replicas that students can use to learn and surgeons can use
to practice on before performing complicated operations. A
3D printing of the left atrium is obtained from layer-by-layer
addition of specific material to form an object referring to a 3D
LAA
LA
LAA closure
device
Figure 5.1  Two different views simulating left atrial appendage (LAA) closure. Device implantation should be based on accurate operation
obtained using a simulated cast before an attempt on a human. (Courtesy of Dr. Ciobotaru Vlad, 3DHeartModeling.com, Hôpital Privé Les
Franciscaines, Nîmes, FR, Cardiac Imaging Department.)
file postprocessed from a regular CT scan, magnetic resonance
imaging (MRI), or less frequently 3D echocardiography with
the help of software and a 3D printer ( ). Some publications
highlight the use of 3D printing for sizing and selecting
left atrial appendage closure devices,1,2 illustrating and
closing atrial septal defect (ASD).3,4 Figure 5.1 is a versatile
method that enables a more comprehensive study of LA
structures, especially complex anatomy and simulated device
implantation.
GUIDELINES FOR USE OF
3D ECHOCARDIOGRAPHY IN
THE EVALUATION OF LEFT ATRIUM
When assessing the LA using 3D echocardiography,
acquisition should be focused on the structure as outlined
in the European Association of Echocardiography
and the American Society of Echocardiography (ASE)
recommendations.5
LEFT ATRIAL VOLUME MEASUREMENT
Accurate quantitative assessment of LA volume is crucial
for clinical decision making, particularly when managing
patients with atrial fibrillation, diastolic function, or
mitral valve disease. Although the left atrium is seen
in all standard ultrasound windows, the transthoracic
apical approach is the most appropriate one to obtain
the entire LA volume. As the left atrium does not have
particular thickness, high-contrast images are preferred
to better delineate the endocardium. To guarantee LA
volume measurement, the protocol may use two different
acquisition modalities. The use of simultaneous biplane
(Figure 5.2A) or triplane (Figure 5.2B) acquisition gives
two or three real-time images with equiangulation or
adjustable angulation of the LA while volume-gated
LAA
LA
LAA closure
device
Left Atrium  43
 A C
LA
LA LA
LA
LA LA
LA
LA LA
Figure 5.2  Apical imaging gives both dimension and functional information of the left atrium, thus it should be widely employed. (A) and
(B) provide two and three simultaneous views of the left atrium (LA) at 90° and 60° increments, respectively. In the same beat, the left atrium
is sliced into nine equidistant cutting planes from the apical view (C).
acquisition (Figure 5.2C) during a breath-hold provides
a full dataset in which the LA can be cut in long-axis or
short-axis view and sometimes arbitrary slices to recreate
virtual 2D planes. Gated datasets are most challenging
in patients with atrial fibrillation; thus, the simultaneous
multiplane mode is preferred.
LEFT ATRIAL ANATOMY
Both the anatomy and the pathology of LA are best
visualized from 3D TEE using volume-rendered acquisition.
The interatrial septum including the upper right pulmonary
veins is fully imaged from midesophageal 30° views ( ), while
at 90° the mitral valve is visible. The left upper pulmonary
vein or the two left pulmonary veins can be shown with
a slight tear and counterclockwise rotation  ( ). A 90°
rotation toward the septum followed by a slight down-to-up
angulation gives both right upper and lower pulmonary
veins. Accurate descriptive assessment of LA anatomy is
pivotal for the diagnosis of congenital heart diseases, like
ASD, evidence of LA mass including left trial appendage
thrombosis, and to guide new procedures like left atrial
appendage closure and MitraClip delivery.
GLOBAL LEFT ATRIAL FUNCTION
MEASUREMENT
Because M-mode anterior-posterior diameter or left atrial
area misclassify 57% and 70% of patients, respectively,6 LA
volume measurement must include volumes and shape by
3D echocardiography. The images can be reviewed online
44  3D Echocardiography
LA LA LA
LA LA LA
LA LA
and offline. Standard 2D views from the 3D dataset of
LA volumes are measured using the biplane or triplane
Simpson disk summation, the most preferred method
when compared to the ellipsoid or area-length model. 5
Frames corresponding to the largest LA (just before the
mitral valve opening), the smallest LA (just after the mitral
valve closure), and before atrial contraction (P wave on the
electrocardiogram [ECG]) are selected. The endocardial
borders of the LA are then manually traced on all images
while excluding the left atrial appendage and the pulmonary
veins ostia from tracing (Figure 5.3A and B). At the end
of the process, volumes are automatically provided. Left
atrial volumes are directly influenced by several extrinsic
factors like gender, age, and patient phenotype, meaning
that LA volumes should always be normalized to body-size
area before interpretation and report.7
The largest LA volume is widely used in the literature
to stratify patients at risk for cardiovascular events. A
LA volume index greater than 34 mL/m2 dichotomizes
patients with normal and dilated volume (Table 5.1). MRI
systematically overestimates LA volumes measured by 3D
echocardiography, meaning the cut-off of 34 mL/m2 must
be interpreted only in a context of ultrasound acquisition.8
The upper normal limit for echocardiographic LA
volume index of 34 mL/m2 has direct application in the
field diastolic function assessment. 9,10 Combined with
peak tricuspid regurgitation velocity, E/e′ ratio, and
transmitral E/A ratio, the largest LA volume greater than
34 mL/m2 dichotomizes patients with normal and high left
ventricular filling pressure as well as patients with normal
 A B

Figure 5.3  The left atrium (LA) at end diastole, realigned so that the two (A) or three apical (B) views share the same longitudinal axis, which
passes through the LA cavity center. Manually traced, the endocardial contouring provides area and volume .

Left atrial volume (ml)

Reservoir
Table 5.1  Body Surface Area Corrected Left Atrial function Conduit
Volume function
Pump
function
Normal Mildly Moderately Severely
Range Dilated Dilated Dilated Filling phase Filling phase
Left Atrial Maximal 16–34 35–41 42–48 >48 (mL/
Volume Index (mL/m2) (mL/m2) (mL/m2) m 2) Time

Table 5.2  Volume-Derived Indexes of Left Atrial

Functional Assessment
Normal
Volume Fraction Fraction

LA Reservoir Function LAVmax − LAVmin (LAVmax − LAVmin)/ 70%

LAVmax
LA Conduit Function LAVmax − LAVpreA (LAVmax − LAVpreA)/ 44%
LAVmax
LA Kick Function LAVpreA − LAVmin (LAVpreA − LAVmin)/ 47%
LAVpreA Figure 5.4  The time-varying left atrial (LA) 3D volume curve is
obtained from frame-to-frame manual tracing or automated border
LA Global Function (LAEF × LVOT-VTI)/
LAVimin detection. The largest LA volume, the pre-A LA volume and the small-
est LA volume provide LA conduit, reservoir, and pump function .
LA, left atrium; LAEF, left atrial ejection fraction; LVOT, left ventricular out-
flow tract; VTI, velocity time integral.

LEFT ATRIAL APPENDAGE BY

and different degrees of diastolic dysfunction, however
with a degree of uncertainty.11
From a more exploratory approach, volume-derived
indexes of LA functional assessment can be calculated by
3D echocardiography (Table  5.2, ). Those indexes have
been investigated in various diseases and pathophysiological
conditions. For instance, LA kick progressively increases
with age to compensate for the decline of LA conduit
function, while the reservoir function remains unchanged.
In dilated cardiomyopathy, both LA reservoir and conduit
function decrease while LA kick function increases at
an early stage of the disease. A more comprehensive
approach of atrial function is given by the time-varying 3D
echocardiography LA volume change (Figure 5.4). In this
condition, LA volumes can be corroborated to additional
3D strain investigation.
3D ECHOCARDIOGRAPHY
The left atrial appendage (LAA) is one of the major
anatomical parts of the LA. The anatomy of the LAA has
been recently extensively revisited by 3D echocardiography
as a response of the enthusiastic percutaneous LAA closure
procedure for patients with atrial fibrillation who are at an
increased risk for stroke and contraindicated for long-term
oral anticoagulation.
The appropriate way and the proper position to image
the LAA is the high midesophageal view with anteflexion of
the transesophageal probe at 0°, 45°, 90°, and 135° during
an end-expiratory breath-hold. In zoomed modality, real-
time 3D echocardiography gives an en face view  of  LAA
with its orifice and may help to differentiate spontaneous
echocardiographic contrast, thrombi to pectinate muscle .

Left Atrium  45
Figure 5.5  Different shapes of the left atrial appendage as assessed with biplane 3D echocardiography.

Video 5.6 ( ) is an example of a thrombus provided by 3D
echocardiography. Turning on the 3D biplane imaging
around 45° (aortic short-axis view) is a unique instance to
simultaneously obtain two orthogonal planes illustrating
the complex LAA morphology (Figure 5.5). Moving the
lateral plane may help to better align with appendage lobes.
The 3D patterns are cauliflower, windsock, multilobular,
and chicken wing (Figure 5.5) with a direct effect on embolic
risk in patients with atrial fibrillation.12 The cropping plane
in full-volume modality may reconsider LA anatomy from
different perspectives, while extra planes can be adjusted to
obtain depth and cross-sectional area in single or multiple
displays (Figure 5.6).
3D guided echocardiography is routinely utilized to guide
percutaneous interventions. Images obtained from 3D TEE
facilitates the correct sizing and placement of percutaneous
LAA. Figure 5.7 summarizes the road map for LAA sizing
before device implantation. Two consecutive biplanes 3D
echocardiography at 0° and 45° giving two simultaneous
orthogonal planes at 90° and 135°, respectively, are acquired

Le atrium
Le atrium

LAA
LAA

LAA

Figure 5.6  TEE evaluation of the left atrial appendage (LAA). The LAA is assessed in biplane 3D TEE views (examples, 90° and 120°). The
diameter (solid yellow arrow) of the LAA is shown at a depth of 10 mm from the ostium, representing the lobe landing zone.

46  3D Echocardiography
 LAA
A LAA B C

Le atrium

LAA

D E F

Le atrium

LAA

LAA
LAA occluder device

Figure 5.7  Road map for LAA sizing before device implantation. Two consecutive biplanes obtained by 3D echocardiography at 0° and 45°
giving, respectively, two simultaneous orthogonal planes at 90° and 135°, are acquired to obtain the largest LAA measurements (diameter
and depth) mandatory to select the prosthesis (A). The 3D pyramidal dataset from full-volume acquisition helps the positioning of different,
better-aligned short- and long-axis planes (B). Data obtained from the reconstructed planes include LAA long- and short-orifice diameters
that should be more accurate than those obtained from 3D echocardiography biplane imaging, while en face view with direct on-image LAA
diameter measurement should be interpreted with much caution (C). Thorough selection of appropriate prostheses contributes to successful
results as shown in (D,E,F) .

to obtain the largest LAA measurements (diameter and
depth) mandatory to select the prosthesis (Figure 5.7A). The
3D pyramidal dataset from full-volume acquisition helps the
positioning of different better-aligned short- and long-axis
planes (Figure 5.7B). Data obtained from the reconstructed
planes include LAA long- and short-orifice diameters that
should be more accurate than those obtained from 3D
echocardiography biplane imaging, while an en face view
with direct on-image LAA diameter measurement should be
interpreted with a lot of caution (Figure 5.7C).13 Thorough
selection of appropriate prostheses contribute to successful
results as shown in Figure 5.7D through F .
FOCUS ON THE INTERATRIAL SEPTUM BY
3D ECHOCARDIOGRAPHY
A number of published papers have reinforced the role of 3D
echocardiography spanning diagnosis, detailed anatomical
assessment, device sizing and selection, periprocedure
guidance, and postdevice surveillance in the management
of ASD.14
Regarding ASD, Nanda and colleagues were the first to
image interatrial abnormality using 3D TEE.15 A few years
later, Acar et al. demonstrated that TTE was as accurate
as 3D TEE by imaging and sizing ASDs in children.16
Along with diameter, many different anatomical shapes
were described: round, ovoid, racket configuration, and
multiperforated ASD. 3D echocardiography was judged
useful to detail the relationship between environmental
structures and ASD such as aortic root and tricuspid valve.
When the rims surrounding the defect were too slight,
a transcatheter atrial septal approach was inadequate
for closure. More recently, ASD demonstrated dynamic
changes throughout the cardiac cycle.17,18 From those
3D studies, it appeared that a unique, round with good
rims, and less contractile ASD was the most appropriate
configuration for percutaneous closure.
Another field of exploration is the patent foramen ovale
(PFO). Cryptogenic stroke in patients younger than 60
years of age is a new area of application for transcatheter
procedures with the CLOSE trial and recent meta-
analysis suggesting the occlusion of remnant congenital
circulation.19,20 PFO is a congenital cardiac trait that
frequently persists in 25%–30% of individuals. The defect
most commonly is at the anterior superior border adjacent
to the aortic root and appears as a tunnel-like defect
between a thicker, less-compliant septum secundum and a
thinner, more-compliant septum primum. The septum may
be flaccid and aneurysmal. 21 The 3D echocardiography
has potential in investigating the PFO in size, anatomy,
and function. Interatrial septal focus is obtained after
rotating the probe at midesophageal short-axis view. From
full-volume acquisition, the cropping plane is adjusted to
obtain an en face view of the PFO ( ). Real-time rendering
volume provides crucial information about remnant PFO
and function of the adjacent interatrial septum. It is

Left Atrium  47
 A B
PFO
PFO
Right atrium
PFO
PFO
Figure 5.8  Various still images of patent foramen ovale from biplane 3D echocardiography to en face view
suggested that when PFO is associated with atria septum
aneurysm, defined as atrial septal excursion of greater than
15 mm, larger prostheses are preferred, like in video ( ).1 ​
Venturini et  al. reports that both PFO width and depth
are correlated with the size of the prosthesis. From a 3D
echocardiography dataset acquisition, width is accessible
after aligning planes at the tip of the PFO ( ). The length
of the PFO, which is also correlated with prosthesis sizing,
is measured at 30° using 2D echocardiography derived
from biplane 3D echocardiography (Figure 5.8). This
unique view provides simultaneously the two determinant
parameters from a single beat.
INTERATRIAL SEPTAL PUNCTURE BY
3D ECHOCARDIOGRAPHY
Indications of interatrial septal puncture under TEE are
well documented. 22 As common examples, it includes
radiofrequency atrial fibrillation ablation, mitral stenosis
dilation, ASD, and PFO closure and more recently
deployment of device in left atrial appendage or edge-to-
edge mitral valve repair. The failure to cross the septum by
TEE is uncommon, and one paper reports the intramural
location of the guidewire detected by 3D echocardiography
in a patient undergoing edge-to-edge mitral valve repair.23
The question that arises during transseptal puncture is what
should be the exact needle location, and interventional
cardiologists often spend more time crossing the septum
than positioning the clip. Specifically, the site of septal
puncture (EVEREST 2) is slightly superior in the bicaval
view (around 90°–110°) and central in the commissural
view (around 60°). It is normally achieved by 2D TEE, but
the use of biplane 3D echocardiography is requested by
implanters in all cases in our institution. Figure 5.9 presents
an example of biplane 3D echocardiography showing the
proper positioning of the needle that is always confirmed by
an en face view from LA perspective between 12 and 2 o’clock
(Figure 5.10). Distance between a virtual line perpendicular
to the septal tenting and the mitral annulus is then
measured using regular 2D TEE at 0° and is expected to be
48  3D Echocardiography
Le atrium PFO
.
between 3.5 and 4 cm to ensure proper orientation of the
steerable catheter during the next step. Needle relocation
is sometimes needed using the same echocardiography
protocol. From this 3D protocol, we increase the accuracy
of the puncture site and facilitate the tenting septum to the
mitral annulus distance measurement.
LEFT ATRIAL MASS BY 3D ECHOCARDIOGRAPHY
Only a few cases of LA tumors are reported in the literature.24–27
3D echocardiography addresses connections and anatomical
relations between structures, facilitates volume measurement,
and is adapted to follow-up in case of specific therapeutic
needs. In the literature, LA tumors were scanned from both
transesophageal and transthoracic approaches.25,27 For LA
myxoma, 3D echocardiography navigation easily locates the
point of insertion and displays adhesion to multiple regions,
whereas 3D reconstruction clarifies whether the tumor
adheres the mitral valve or the left atrium and hems in the
left ventricle ( ).28 Recently, live 3D echocardiography has
proven to more confidently diagnose myxoma by identifying
isolated echolucent areas consistent with hemorrhage/
necrosis by using a section plane of the tumor mass ( ). A
patient with a hemangioma showed much more extensive
and closely packed echolucencies consistent with a highly
vascularized tumor by live 3D echocardiography.24
Generally speaking, real-time TTE has a poor sensitivity
for the detection of LA thrombosis until it attains a definite
dimension. Again, the TEE approach appears to be more
consistent, but the literature is limited to few case reports.
Rotational 3D echocardiography was employed to evidence
large LA appendage thrombosis, but recently, Ieva et  al.
reports the usefulness of live 3D TTE in a typical case
of large thrombus floating in the left atrium. We report
here an example of LA thrombus after the resection of
the LA posterior wall (Figure 5.11). The thrombus could
be easily viewed from the sides along with its morphology
and the site of attachment. In this case, by cropping the 3D
images sequentially, the degree and extent of lysis within
the thrombus which may have potential therapeutic and
 Le atrium
Needle

Right atrium

Figure 5.9  An example of biplane 3D echocardiography showing the proper needle positioning during a MitraClip procedure.

A B

Figure 5.10  Proper positioning of needle before septal puncture confirmed by en face view from left atrial perspective between 12 and
2 o’clock during a MitraClip procedure.

prognostic implications could be comprehensively assessed

after the anticoagulation is started. Finally, real-time 3D
echocardiography provided information about thrombus
mobility, which has prognostic implications ( ).

Le atrial
thrombosis CONCLUSION
3D imaging has the ability to assess LA volume and
function more accurately than does 2D imaging. By freely
navigating in a volume dataset and giving an en face view of
any volume-rendered reconstruction, 3D echocardiography
Figure 5.11  Rendered volume of left atrial (LA) thrombus after the offers a true inside and outside vision of the heart,
resection of LA posterior wall by 3D TTE. similar to a surgical view. Online reconstruction is one

Left Atrium  49
of the most fascinating capabilities helping surgeons and
interventional cardiologists to deliver the best therapy in a
safer environment.
REFERENCES
1. Venturini JM, Retzer EM, Estrada JR et al. A practical scoring system
to select optimally sized devices for percutaneous patent foramen ovale
closure. J Struct Heart Dis. 2016;2:217–23.
2. Le Bras A. Interventional cardiology: 3D printing of personalized
implants for left atrial appendage occlusion. Nat Rev Cardiol. 2018;15:​
134–5.
3. Bramlet M, Olivieri L, Farooqi K, Ripley B, Coakley M. Impact of three-
dimensional printing on the study and treatment of congenital heart
disease. Circ Res. 2017;120:904–7.
4. Thakkar AN, Chinnadurai P, Breinholt JP, Lin CH. Transcatheter
closure of a sinus venosus atrial septal defect using 3D printing and image
fusion guidance. Catheter Cardiovasc Interv. 2018;92:353–7.
5. Lang RM, Badano LP, Tsang W et al. EAE/ASE recommendations for
image acquisition and display using three-dimensional echocardiography.
J Am Soc Echocardiogr. 2012;25:3–46.
6. Badano LP, Pezzutto N, Marinigh R et al. How many patients would be
misclassified using M-mode and two-dimensional estimates of left atrial size
instead of left atrial volume? A three-dimensional echocardiographic study.
J Cardiovasc Med. 2008;9:476–84.
7. Badano LP, Miglioranza MH, Mihaila S et al. Left atrial volumes and
function by three-dimensional echocardiography: Reference values,
accuracy, reproducibility, and comparison with two-dimensional
echocardiographic measurements. Circ Cardiovasc Imaging. 2016;9(7).
8. Rodevan O, Bjornerheim R, Ljosland M, Maehle J, Smith HJ, Ihlen H. Left
atrial volumes assessed by three- and two-dimensional echocardiography
compared to MRI estimates. Int J Cardiac Imaging. 1999;15:397–410.
9. Nagueh SF, Smiseth OA, Appleton CP et al. Recommendations for the
evaluation of left ventricular diastolic function by echocardiography:
An update from the American Society of Echocardiography and the
European Association of Cardiovascular Imaging. J Am Soc Echocardiogr.
2016;29:277–314.
10. Ponikowski P, Voors AA, Anker SD et al. 2016 ESC guidelines for the
diagnosis and treatment of acute and chronic heart failure: The task
force for the diagnosis and treatment of acute and chronic heart failure
of the European Society of Cardiology (ESC). Developed with the special
contribution of the Heart Failure Association (HFA) of the ESC. Eur J
Heart Fail. 2016;18:891–975.
11. Lancellotti P, Galderisi M, Edvardsen T et al. Echo-Doppler estimation
of left ventricular filling pressure: Results of the multicentre EACVI Euro-
Filling study. Eur Heart J Cardiovasc Imaging. 2017;18:961–8.
12. Beigel R, Wunderlich NC, Ho SY, Arsanjani R, Siegel RJ. The left atrial
appendage: Anatomy, function, and noninvasive evaluation. JACC Cardiovasc
Imaging. 2014;7:1251–65.
50  3D Echocardiography
13. Zhang J, Cui CY, Huang DQ et al. Evaluation of the left atrial appendage
by real time three-dimensional transesophageal echocardiography online.
Echocardiography. 2018;35:​991–8.
14. Silvestry FE, Cohen MS, Armsby LB et  al. Guidelines for the
echocardiographic assessment of atrial septal defect and patent foramen
ovale: From the American Society of Echocardiography and Society for
Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015;28:910–58.
15. Nanda NC, Ansingkar K, Espinal M et  al. Transesophageal three-
dimensional echo assessment of sinus venosus atrial septal defect.
Echocardiography. 1999;16:835–7.
16. Acar P, Dulac Y, Roux D, Rouge P, Duterque D, Aggoun Y.
Comparison of transthoracic and transesophageal three-dimensional
echocardiography for assessment of atrial septal  defect diameter in
children. Am J Cardiol. 2003;91:500–2.
17. Xie MX, Fang LY, Wang XF et al. Assessment of atrial septal defect area
changes during cardiac cycle by live three-dimensional echocardiography.
J Cardiol. 2006;47:181–7.
18. Handke M, Schafer DM, Muller G, Schochlin A, Magosaki E, Geibel
A. Dynamic changes of atrial septal defect area: New insights by three-
dimensional volume-rendered echocardiography with high temporal
resolution. Eur J Echocardiogr. 2001;2:46–51.
19. Mas JL. Closure of patent foramen ovale and “cryptogenic” stroke: What’s
new, what’s next? Arch Cardiovasc Dis. 2019;112:145–9.
20. Mas JL, Derumeaux G, Guillon B et  al. Patent foramen ovale
closure or anticoagulation vs. antiplatelets after stroke. New Engl J Med.
2017;377:1011–21.
21. Marshall AC, Lock JE. Structural and compliant anatomy of the patent
foramen ovale in patients undergoing transcatheter closure. Am Heart J.
2000;140:303–7.
22. Silvestry FE, Kerber RE, Brook MM et al. Echocardiography-guided
interventions. J Am Soc Echocardiogr. 2009;22:213–31; quiz 316-217.
23. Swaans MJ, Post MC, Van den Branden BJ, Van der Heyden JA. A
complicated transseptal puncture during MitraClip procedure: Saved by
3D-TEE. Eur J Echocardiogr. 2011;12:E45.
24. Borges AC, Witt C, Bartel T, Muller S, Konertz W, Baumann G. Preoperative
two- and three-dimensional transesophageal echocardiographic assessment
of heart tumors. Ann Thorac Surg. 1996;61:1163–7.
25. Salustri A, Roelandt J. Images in cardiovascular medicine. Left atrial
myxoma visualized by transesophageal rotoplane echocardiographic
computed tomography. Circulation. 1995;91:2290.
26. Greco C, Romano P, Di Segni M, Prati PL. Three-dimensional
transesophageal echocardiographic evaluation of a left atrial myxoma. G
Ital Cardiol. 1998;28:193.
27. Mehmood F, Nanda NC, Vengala S et  al. Live three-dimensional
transthoracic echocardiographic assessment of left atrial tumors.
Echocardiography. 2005;22:137–43.
28. Harada T, Ohtaki E, Sumiyoshi T, Hosoda S. Successful three-
dimensional reconstruction using transesophageal echocardiography in a
patient with a left atrial myxoma. Jpn Heart J. 2001;42:789–92.
 6 Hypertrophic Cardiomyopathy

cardiomyopathy. Advances in 3D echocardiography have

INTRODUCTION brought this technique to the clinical field of hypertrophic
Hypertrophic cardiomyopathy is a cardiovascular disease cardiomyopathy where the abnormal and particular
defined by the presence of unexplained left ventricular (LV) geometry of the hypertrophic ventricle prove challenging
hypertrophy associated with nondilated ventricular chambers to assess with classical 2D approaches.
in the absence of another cardiac or systemic disease that itself
would be capable of producing the magnitude of hypertrophy; M-MODE ECHOCARDIOGRAPHY
it is caused by a genetic disorder in one of at least ten genes
M-mode echocardiography was the first echocardiographic
that encode the proteins of the cardiac sarcomere. This disease
technique used for the diagnosis of this disease. Typically,
has a unique potential for clinical presentation during any
M-mode scans through the LV in the long parasternal
phase of life from infancy to old age and may be expressed
view allow the detection of a thickened wall (>15 mm)
in a wide range of phenotypical forms, from severe symmetric
and a reduced cavity of the LV. The hypertrophy can be of
LV hypertrophy to massive hypertrophy of asymmetrical
concentric or asymmetric distribution, usually affecting the
distribution.
septal wall (Figures 6.1 and 6.2), with a septal-to-posterior
Physiopathological mechanisms underlying hypertrophic
wall ratio greater than 1.3. 2 Care must be taken when
cardiomyopathy are complex and not clearly understood
using M-mode to avoid oblique cuts of the interventricular
but include dynamic LV outflow obstruction, mitral
septum or incorrect identification of echoes from the
regurgitation, and diastolic dysfunction. These may all
right side of the septum that may lead to overestimation
lead to shortness of breath and limited functional capacity,
of LV hypertrophy. M-mode echocardiography can also
angina, and syncope; however, although most patients are
determine the existence, degree, and duration of an
asymptomatic throughout their lives, there is a risk for
abnormal anterior movement of the mitral valve during
sudden cardiac death probably associated with arrhythmia
systole (systolic anterior motion [SAM]), related to several
and progression to advanced heart failure with LV systolic
factors such as abnormalities in the mitral valve apparatus
dysfunction. The main causes of adverse clinical outcomes
(i.e., posterior to anterior leaflet mismatch and abnormal
are shown in Table 6.1.
disposition of the subvalvular apparatus), reduced left
Diagnosis of hypertrophic cardiomyopathy is now
ventricular outflow tract (LVOT) dimensions, and the
mainly based on cardiac imaging methods, including 2D
Venturi effect of the abnormally accelerated LV outflow. The
echocardiography, magnetic resonance (MR), and multislice
duration of the contact of the mitral valve with the septal
computed tomography (CT) scanning. LV thickening is
wall allows the classification of the severity of the SAM,3
associated with a nondilated cavity with hyperdynamic
given the high temporal resolution of M-mode scans across
motion and, usually, systolic chamber obliteration. Typically,
the mitral valve in the parasternal long axis (Figures 6.3
the diagnosis is made on the presence of a maximal LV wall
and 6.4). Additionally, M-mode interrogation of the aortic
thickness of at least 15 mm in the absence of any other
valve leaflets provides indirect hemodynamic information
disease capable of inducing such a degree of LV hypertrophy
about the existence of LV outflow obstruction, as the early
noted by 2D echocardiography.1
closing of an otherwise normally appearing aortic valve can
Hypertrophic cardiomyopathy can be classified into
be detected during midsystole (Figure 6.5). This midsystolic
various hemodynamic subgroups. Patients may present
closure or notching of the aortic valve must be differentiated
with nonobstructive or obstructive disease; the latter may
from other causes of severe LV hypertrophy, such as the
be subclassified into latent or provocable (resting gradient
presence of a subaortic fixed stenosis (subaortic membrane),
<30 mm Hg and >30 mm Hg after provocation) and resting
where the abnormal closure of the aortic valve occurs in
obstructive hypertrophic cardiomyopathy (resting gradient
early systole, or a valvular aortic stenosis, where the valve
>30 mm Hg).1
does not open properly throughout the whole systole and
2D echocardiography has been classically the most
thickening of the aortic leaflets is present.
commonly used imaging technique to evaluate hypertrophic

Table 6.1  Causes of Adverse Outcomes in Hypertrophic 2D ECHOCARDIOGRAPHY

Cardiomyopathy
• Sudden death/ventricular arrhythmia
• Refractory heart failure symptoms
• Left ventricular outflow tract obstruction
• Diastolic dysfunction
• Systolic dysfunction (left ventricular remodeling)
• Complications related to atrial fibrillation (embolic stroke)
2D echocardiography provides a powerful tool to evaluate
patients with hypertrophic cardiomyopathy with more
anatomical information of the cardiac cavities (Figure 6.6).
2D echocardiography also allows a better understanding
of the distribution of the hypertrophy than M-mode
echocardiography, especially in those rare presentations
affecting localizations other than the septal or the posterior

Hypertrophic Cardiomyopathy  51
Figure 6.1  M-mode scan across the basal level of the left ventricle
in the parasternal long-axis view showing asymmetric septal
hypertrophy with severe hypertrophy of the septum (top arrow) and
mild hypertrophy of the posterior wall (bottom arrow) with a ratio
greater than 1.5/1.
wall, such as the LV inferior or lateral wall4 (Table 6.2). The
distribution of LV hypertrophy may be determined by the
use of 2D echo in the short-axis view of the LV, where the
whole transversal section of the LV wall and cavity can be
examined in most cases (Figure 6.7A–C). From this view,
this technique may also be able to detect right ventricular
involvement (Figure 6.8). Finally, 2D echocardiography may
be of particular utility in diagnosing infrequent forms of
apical distribution, especially with the use of contrast agents
that are helpful in delineating the endocardial border and
opacify the ventricular cavity. This phenotypical expression
of the disease is less frequent but has a high prevalence in
Japanese populations and typically is not associated with
LVOT obstruction but with cavity obliteration, showing a
“spade-like” LV appearance in systole 5 (Figure 6.9). For
Figure 6.2  M-mode scan across the basal level of the left ventricle
in the parasternal long-axis view showing symmetric hypertrophy
with severe hypertrophy of both the septum and the posterior wall
(arrows) with a ratio close to 1/1.
52  3D Echocardiography
Figure 6.3  M-mode scan across the mitral valve in the parasternal
long-axis view demonstrating systolic anterior motion (SAM) of the
mitral valve during the whole systole with complete contact of the
valve and the septum (arrow).
this reason, it has to be differentiated from other diseases
that may occupy the apex, such as the hypereosinophilic
syndrome or the presence of an intraventricular thrombus.
Other rare presentations of hypertrophic cardiomyopathy
include those affecting the posterolateral LV wall and
those with midventricular location with cavity obstruction
at this level.6
In cases of symmetric, concentric LV hypertrophy,
hypertrophic cardiomyopathy has to be differentiated from
that “physiological” LV hypertrophy related to physical
training (athlete’s heart); in the case of severe concentric
hypertrophy, differential diagnosis has to be made with
infiltrative disease such as amyloidotic cardiomyopathy or
genetic diseases (see later).
In an upper level at the short-axis view or in the
parasternal long-axis view, the LV outflow may sometimes
Figure 6.4  M-mode scan across the mitral valve in the parasternal
long-axis view demonstrating systolic anterior motion (SAM) of the
mitral valve during the whole systole with complete contact of the
valve and the septum (arrows).

Figure 6.5  M-mode scan across the aortic valve guided by 2D TEE in
a patient with hypertrophic obstructive cardiomyopathy depicting
abnormal early closure of the aortic valve during midsystole
(arrows).
Figure 6.6  2D apical four-chamber view depicting severe left
ventricular hypertrophy involving the whole septal wall and the
apex. Lateral wall and right ventricle are much less affected.
Table 6.2  Distribution of Hypertrophic
Cardiomyopathy in the Left Ventricle
Asymmetrical:
 Septal 90%
 Midventricular 1%
 Apical 3%
  Posterolateral wall 1%
Symmetrical (concentric) 5%
be evaluated with virtual occlusion during systole in those
cases of concomitant LV outflow obstruction.
Also, from the apical views, 2D echocardiography
allows for evaluation of the distribution of the LV
hypertrophy that may affect mostly the basal septum but
can also involve the whole septal wall. In elderly patients,
LV hypertrophy is usually located at the level of the basal
septum that maintains its normal curvature leading to an
ovoid-shaped LV cavity (Figure 6.10). In younger patients,
LV hypertrophy usually involves the whole septal wall that
shows a convex curvature toward the cavity (reversed
abnormal septal curvature), leading to a crescent-shaped
LV cavity (Figure 6.6).
In those patients with obstructive disease (around 25% of
patients with hypertrophic cardiomyopathy), LV hypertrophy
is often accompanied by SAM, which is noticeable with 2D
scans by the systolic contact of the mitral valve and the
septal wall (Figure  6.11A and B). SAM may be caused
by the anterior movement of the anterior leaflet (10%) or
the posterior leaflet (31%) or more commonly, both (58%).
In a few cases, SAM is noted only at the chordal structure,
which usually does not translate into significant obstruction
to LV outflow. The mitral leaflets are significantly longer,
and mismatch between the anterior and posterior leaflets
has also been demonstrated in patients with obstructive
hypertrophic cardiomyopathy.7 Lesions in the mitral
valve are also frequently associated with hypertrophic
cardiomyopathy (around 20%) and can be evaluated with
2D echocardiography; accordingly, calcification of the
mitral annulus, thickening of the valves, and less frequently,
leaflet prolapse, can be detected.8
Left atrial (LA) dimension, an index of chronic diastolic
dysfunction and mitral regurgitation which are both
usually observed in these patients, can also be assessed
with 2D echocardiography, mainly from the apical views.
Finally, 2D echocardiography permits the estimation
of LV systolic function as in any cardiac disease. In most
cases, the hypertrophied LV moves hyperdynamically in
systole resulting in cavity obliteration, clearly seen from all
parasternal and apical views. However, few patients develop
severe systolic dysfunction9 which can be detected by 2D
echocardiography during follow-up, even requiring heart
transplantation in rare situations; development of systolic
dysfunction occurs in around 10% of patients and has
been related to fibrotic changes in the intracellular matrix,
ischemia, infarction, and small vessels.10
COLOR DOPPLER ECHOCARDIOGRAPHY
Color Doppler 2D echocardiography detects the presence
of a turbulent flow in the LVOT in the case of LV
obstruction (Figure  6.12). Obstruction in hypertrophic
cardiomyopathy may occur at three levels: LVOT,
midventricular, and apical; it occurs most frequently at the
outflow tract (Table 6.3). However, distinguishing the three
levels of obstruction may sometimes be challenging. The
presence of a flow convergence area in the LVOT points to
the existence of obstruction at this level probably due to an
associated SAM, while visualization of a turbulent flow in
the mid or apical cavity may help in the diagnosis of these
less frequent forms of hypertrophic cardiomyopathy.12
Midventricular obstruction may also develop secondary
to apical myocardial infarction in the presence of
angiographically normal coronary arteries or in patients
with coronary artery disease and diffuse involvement of
ventricular hypertrophy.11,13
Hypertrophic Cardiomyopathy  53
 A B

Figure 6.7  2D short-axis view of the left ventricle at the papillary muscle level demonstrating atypical asymmetric left ventricular hypertrophy
affecting predominantly the anterior septum (A) or more unfrequently the posterior septum and the inferior wall (B). 2D short-axis view of
the left ventricle at the papillary muscle level demonstrating typical concentric left ventricular hypertrophy with similar wall thickness at the
septum and posterior and lateral walls (C).

Also, color Doppler diagnoses the presence of mitral
regurgitation as a consequence of the SAM and/or the
coexistence of organic valve disease.14,15 The quantification
of mitral regurgitation in the presence of LVOT obstruction
may be cumbersome and of particular difficulty as both
turbulent flows get merged together, making it difficult
to clearly visualize the flow convergence of the mitral
regurgitant jet. Additionally, the mitral regurgitant jet is
usually eccentric and directed posterolaterally to the LA
(Figure 6.12).

Figure 6.8  2D TEE: Short-axis view of the left (LV) and right ventricle (RV) depicting right ventricular hypertrophy (arrows) that induces
outflow obstruction as suggested by the systolic color flow turbulence seen in the right panel (arrow).

54  3D Echocardiography
Figure 6.9  Contrast-enhanced 2D echocardiography: four-chamber apical view of the left ventricle which shows a typical “spade-like”
appearance due to the presence of apical hypertrophy. The thickness of the basal and midsegments of the left ventricle is normal, while the
apex is collapsed by the wall hypertrophy existing at this level (arrows).

LVOT obstruction and secondary mitral regurgitation with

PULSED- AND CONTINUOUS-WAVE DOPPLER
Pulsed-wave Doppler cannot always be reliably applied in
patients with hypertrophic cardiomyopathy as flow velocity
is increased in the LV cavity and aliasing occurs. However, in
the presence of LV outflow or midcavity obstruction, pulsed-
wave Doppler may be of particular interest, allowing the
detection of the level at which the obstruction is produced
by mapping flow velocity from the apex to the outflow
tract.16 Additionally, pulsed-wave Doppler is useful to
evaluate diastolic LV function, mostly impaired in patients
with hypertrophic cardiomyopathy.17 Abnormal, delayed
relaxation is the most frequent diastolic pattern found.
Pseudonormalization is also often seen in patients with
increased LA pressure (Figure 6.13A). Also, a restrictive
pattern may be seen as an effect of increased chamber
stiffness causing both rapid atrial-ventricular pressure
equilibration (rapid deceleration time) and compensatory
increases in LA pressure (increased E-wave velocity)18–21
(Figure 6.13B). Finally, pulsed-wave Doppler of the LV
inflow combined with velocities of the mitral annulus
determined with pulsed tissue Doppler, may also provide
accurate estimates of LV filling pressures.22,23
Continuous-wave Doppler is an essential tool for
the complete evaluation of patients with hypertrophic
cardiomyopathy. It allows the estimation of the severity
of intraventricular obstruction. Excellent correlation has

Figure 6.10  2D echocardiographic four-chamber apical view of a 70-year-old patient with hypertrophic cardiomyopathy affecting mainly the
basal septum, where thickness was 17 mm while in the other left ventricular segments was 13 (anterior wall) and 12 mm (posterolateral wall).

Hypertrophic Cardiomyopathy  55
 A B

Figure 6.11  (A) 2D parasternal long-axis view showing systolic contact of the mitral valve with the septum (arrow) due to the anterior
movement of the former during systole (arrow over electrocardiogram) . (B) 2D four-chamber apical view showing systolic contact of the
mitral valve with the septum due to the anterior movement of the former during systole.

been demonstrated between pressure gradients determined
from continuous-wave Doppler and cardiac catheterization
in different subsets of patients with hypertrophic
cardiomyopathy.12,24–28 Typically, the spectral continuous-
wave Doppler shows a dagger-shaped gradient across the
LVOT (Figure 6.14) that may be confounded with the spectral
signal of mitral regurgitation, usually more round shaped,
but sometimes really difficult to differentiate. Usually,
mitral regurgitant flow reaches peak velocities at about 5 or
6 m/s, while intraventricular obstruction rarely overcomes
those values.27 It is important to interrogate the LVOT with
continuous-wave Doppler at both the resting state and
after a provocation maneuver, either Valsalva or handgrip
maneuver, physical exercise, pharmacological stress, or amyl
nitrite administration (Figure 6.15A and B). Evaluation of
the intraventricular gradient with this technique is the main
imaging tool to evaluate the efficacy of a given therapy in
patients with hypertrophic cardiomyopathy. However, its
unpredictable variability even throughout the same day is
also reported.28
As previously mentioned, intraventricular obstruction
in hypertrophic cardiomyopathy may take place at three
levels, and their differentiation may not be easy. With
continuous-wave Doppler, each has the typical concave
“dagger-shaped” systolic Doppler waveform, but the highest
velocities generally occur with LVOT obstruction, and the
peak velocity occurs later in systole for midventricular and
cavity obliteration.12,25

Figure 6.12  2D parasternal long-axis view of a patient with nonobstructive hypertrophic cardiomyopathy. Right and left panels show the
same view without and with color Doppler, respectively. Color Doppler shows turbulent flow at the left outflow tract (full arrow), suggesting
the presence of a significant increase in flow velocity at this level and mitral regurgitation with an eccentric jet directed posterolaterally
(dotted arrow).

56  3D Echocardiography
 A B
Figure 6.13  Spectral pulsed-wave Doppler of the left ventricular inflow in two patients with hypertrophic cardiomyopathy. Patient shown
in (A) demonstrates early (E wave) to late (A wave) peak diastolic velocities with a ratio (E/A) of approximately 1 but with a prolonged
deceleration time of the E wave (290 ms), suggesting an abnormal relaxation. Patient shown in (B) has an elevated E/A ratio of 1.89, suggesting
diastolic dysfunction with a restrictive filling pattern.
Table 6.3  Causes of Left Ventricular Systolic
Obstruction
• Obstruction at the left ventricular outflow tract:
• Septal hypertrophy and systolic anterior motion
• Discrete subaortic stenosis
• Mitral valve replacement (position of the strut)
• Mitral valve repair with systolic anterior motion
• Anomalous mitral valve apparatus:
• Abnormal papillary muscles
• Mitral accessory tissue
• Midventricular obstruction:
• Midventricular hypertrophic cardiomyopathy
• Apical hypertrophic cardiomyopathy
• Apical myocardial infarction with hyperdynamic contraction of the
basal and midventricular segments
• Cavity obliteration:
• Apical hypertrophic cardiomyopathy (apical cavity obliteration)
• Hyperdynamic state
• Hypovolemia
• Concentric left ventricular hypertrophy (secondary to
hypertension, aortic stenosis)
ROLE OF 3D ECHOCARDIOGRAPHY IN
HYPERTROPHIC CARDIOMYOPATHY
Table 6.4 summarizes the potential utility of 3D
echocardiography among patients with hypertrophic
cardiomyopathy.
DISTRIBUTION AND QUANTIFICATION OF LEFT
VENTRICULAR HYPERTROPHY
3D echocardiography provides a complete volume of the left
and right ventricles, which may be useful to better evaluate the
distribution of hypertrophy, particularly in those asymmetrical
presentations or in the apical form.29 Postprocessing of the 3D
images allows any given slice across the LV cavity to be obtained
without the problem of misalignment typically observed with
M-mode and 2D echocardiography that may show tangential
slices of the LV wall giving, therefore, the false diagnosis of
wall hypertrophy (Figure 6.16, ). Also in this regard,
3D techniques may allow for the location and quantification of
the maximum thickness of the myocardium. This parameter
has been shown to have prognostic implications in terms of
risk of cardiac sudden death.1
Left and right ventricular volumes can be accurately
estimated with 3D echocardiography according to
several studies that have compared the results of 3D
echocardiography and magnetic resonance imaging (MRI),
phantoms, or electromagnetically derived volumes. 30–32
The abnormal geometry of the cavity of a hypertrophied
ventricle may be a good substrate to be evaluated with 3D
echocardiography, as geometric assumptions are not needed
and consequently eliminated (Figure 6.17, ). Similarly,
LV mass may also be measured with more reliability and
accuracy with the use of this technique.31
Different studies have validated the estimation of
LV mass with M-mode or 2D echocardiography against
postmortem specimen based on different geometric
models. However, these geometrical assumptions
may not always hold true in the case of hypertrophic
cardiomyopathy, often leading to erroneous calculation
of LV mass. Early reconstructive 3D echocardiographic
techniques demonstrated that accuracy was improved
and reproducibility reduced for LV mass measurement
with the use of 3D echocardiography in comparison with
M-mode and 2D echocardiography. 34,35 More recently,
real-time 3D echocardiography has also shown the ability
to increase the accuracy of LV mass estimation in vivo and
in vitro with a standard error of 8.5 g. 33,36 Accuracy was
especially improved in those cases of asymmetrical LV.
With developing technologies to improve spatial resolution
Hypertrophic Cardiomyopathy  57
 A B

Figure 6.14  (A) Continuous-wave spectral Doppler scan of the left ventricular outflow tract demonstrating normal velocities in a patient
with nonobstructive hypertrophic cardiomyopathy. (B) A patient with obstructive hypertrophic cardiomyopathy with the presence of a typical
dagger-shaped Doppler pattern at rest corresponding to the obstruction in the left ventricular outflow tract.

A B

Figure 6.15  (A) Continuous-wave spectral Doppler scan of the left ventricular outflow tract demonstrating elevated velocities at rest in a
patient with obstructive hypertrophic cardiomyopathy. (B) The Valsalva maneuver further increases outflow tract velocities, which can be
considered a confirmation of the obstructive nature of the disease.

an index of the severity and chronicity of both mitral

Table 6.4  3D Echocardiography in Hypertrophic
Cardiomyopathy
• Distribution of LV hypertrophy
• LV mass assessment
• Assessment of left atrium
• Evaluation of LVOT
• Effect of interventional therapies
LV, left ventricular; LVOT, left ventricular outflow tract.
and visualization, real-time 3D echocardiography may
become the imaging technique of choice for LV mass
determination in clinical studies looking at hypertrophy
regression in hypertrophic cardiomyopathy, arterial
hypertension, or aortic stenosis.
EVALUATION OF LEFT ATRIAL SIZE
Assessment of LA size and function may be of importance
in patients with hypertrophic cardiomyopathy due to
several reasons. As previously mentioned, it may be
regurgitation and diastolic dysfunction. 37,38 Also, it may
constitute a risk factor for atrial fibrillation that usually
induces hemodynamic and clinical worsening of patients
with hypertrophic cardiomyopathy. Because the LA
has a complex shape, requiring a full 3D analysis, 3D
echocardiography could be used as a reliable method for
measuring LA volume. Similar to what has been formerly
discussed for the evaluation of the LV volumes and mass,
the 3D methodology avoids any geometric assumption,
making it a method of choice to measure LA volume. 39
By the use of real-time 3D echocardiography, it has been
proved that LV thickness is the most important determinant
of LA dilation, followed by LV end-diastolic pressure and
outflow tract obstruction.40
LA size has been demonstrated to decrease after septal
reduction therapies, either surgical myectomy or alcohol
septal ablation (ASA).19,37 3D echocardiography may also
become a useful tool for the evaluation of the results of
these techniques and their impact on LA size and function.

58  3D Echocardiography
 A B

C D

Figure 6.16  (A) A triplane 2D acquisition from the apical position showing asymmetric hypertrophy of the interventricular septum in a patient
with hypertrophic cardiomyopathy . (B–D) show the same three apical views using 3D echocardiography .

LA function can be comprehensively analyzed with the
use of 3D echocardiography allowing for the evaluation of
conduit, reservoir, and contractile features (Figure 6.18).41
EVALUATION OF LEFT VENTRICULAR OUTFLOW
TRACT AREA
As previously mentioned, some patients with hypertrophic
cardiomyopathy have obstruction in the LVOT due to
multifactorial causes such as vigorous ejection fraction and
alterations in chamber geometry and morphology. The
narrowed outflow tract results from the septal hypertrophy
of the LV and the anterior displacement of the mitral
valve apparatus and papillary muscles.42–44 Severe LVOT
obstruction may contribute to the development of dyspnea,
syncope, and angina in these patients.45 Consequently,
treatment of such patients with obstructive hypertrophic
cardiomyopathy should be directed to reduce LV outflow
obstruction. For this purpose, negative inotropic drugs such

A B

Figure 6.17  Measurement of the left ventricular volume using a dedicated software to analyze transthoracic 3D echocardiography images.
Left ventricular volume is determined by tracking of the endocardial border throughout the cardiac cycle. A volume curve is generated with
the number of points corresponding to the frame rate of the acquired image. End-diastolic and end-systolic volumes are calculated together
with the stroke volume, cardiac output, and ejection fraction (A) . Volume meshes can be reconstructed in end systole (B) and end diastole
(C), enabling 3D visualization of the left ventricular shape.

Hypertrophic Cardiomyopathy  59
 A B

Figure 6.18  Measurement of the left atrial volume with a dedicated software using 3D TTE images. The left atrial endocardial border is
tracked through the whole cardiac cycle and a left atrial volume curve can be generated. Accordingly, the atrial volume can be assessed in
specific time points (end diastole, end systole and after P wave), allowing for the assessment of the components of atrial function: reservoir
(atrial filling), conduit (blood passing from pulmonary veins toward the left ventricle during early relaxation and passive ventricular loading),
and pump function (atrial emptying and active filling of the left ventricle after atrial contraction in patients with sinus rhythm). Volume
meshes can be constructed, enabling 3D visualization of the left atrium.

as beta-blockers or calcium channel blockers have been
proposed with efficacy rates around 70% when maximum
titration can be tolerated.1 Dual-chamber pacing has
also been used as an alternative to reduce outflow tract
obstruction with controversial results.46–48
Both surgical myectomy or ASA effectively reduce LVOT
obstruction in patients with hypertrophic obstructive
cardiomyopathy.49–53 The former surgically eliminates
(direct scission) a part of the hypertrophied septal
muscle, while the latter chemically induces the necrosis

Figure 6.19  2D echocardiography in a patient with obstructive hypertrophic cardiomyopathy who underwent percutaneous septal alcohol
ablation 6 months ago. (Left Panel) Parasternal long-axis view showing mild anterior displacement of the mitral chordae toward the septum
without contacting it (thin arrow) and a focal thinning of the basal septum where the necrosis was chemically induced (thick arrow).
Interrogation with color Doppler (Right Panel) confirms the absence of turbulent flow in the outflow tract and, therefore, the elimination
of obstruction at this level.

60  3D Echocardiography
 A B

Figure 6.20  3D TTE from the apical view showing the aortic valve and the left ventricular outflow tract in early diastole (A) and systole (B) .
2D images of the short-axis and long-axis views on the left side enable orientation indicating the direction from which the 3D image is
observed. Yellow arrows point in the direction the user is observing, while the yellow target indicates the viewer is observing directly from
a vertical 90° angle. 3D views enable assessment of valve morphology and can show obstruction of the left ventricular outflow tract due to
septal wall thickening (white arrow).

of the basal septal myocardium by injecting ethanol
in one septal coronary artery branch. Significant and
sustained reductions in LVOT pressure gradients have
been reported after ASA with a reasonable safety profile
in the long-term follow-up. 53 Outcomes are also very good
after surgical myectomy in specialized centers, with high
rates of abolition of outflow obstruction. 51,54,55
Measurement of the efficacy of these treatments is usually
based on indirect signs of obstruction such as the presence
of significant pressure gradients through the LVOT (Figure
6.19). Evaluation of the LVOT anatomy is difficult with 2D
imaging methods due to the complex and 3D nature of
the outflow tract anatomy. 3D imaging techniques such
as 3D echocardiography or MRI theoretically provide
better information about this structure and the complex
relationship between the mitral valve, the septum, and the
LVOT (Figure 6.20A, and B and Figure 6.21A and B).
The degree of the outflow obstruction is usually determined
by continuous-wave Doppler through the LVOT guided by
2D imaging. However, as noted earlier, concomitant mitral
regurgitation may cause uncertainty of this measurement
despite typical dagger-shaped continuous-wave Doppler
profiles of the LVOT obstruction. Direct, real-time 3D
visualization of the narrowed LVOT area would provide
the adequate cut-off values to diagnose the real severity
or magnitude of LV outflow obstruction and the extent
of SAM56 (Figure 6.22A–C, ). In addition, when ASA
or myectomy is performed, direct 3D visualization of
the opened or widened LVOT would be not only visually
impressive, but also important for knowing the location and
extent of the septal reduction.
A few studies have reported the capability of 3D
echocardiography to assess the LV tract area. 57–59 With
reconstructed images from 3D TTE, it was determined that
patients with hypertrophic cardiomyopathy have a more
elliptical LVOT than normal subjects; also, asymmetry of the
outflow tract was highest in patients with outflow obstruction
at rest, indicating that for similar cross-sectional area, the
asymmetry of the LVOT may play a role in the presence
of significant obstruction. 57,58 3D echocardiography can
provide precise quantitative assessment of the minimal cross-
sectional area of the LVOT as well of its temporal changes,60
which is a determinant of systolic outflow obstruction.61
Accordingly, real-time 3D echocardiographic studies have
demonstrated a significant relationship between LVOT areas
and pressure gradients.60,62 In this sense, an area of less than
0.85 cm2 provided sensitivity of 87% and specificity of 77%
to predict significant resting pressure gradients across the

A B

Figure 6.21  Apical view in 3D TTE exam in end diastole (A) and midsystole (B) showing the anterior movement of the mitral valve toward
the septum and partially obstructing the left ventricular outflow tract during systole (arrow).

Hypertrophic Cardiomyopathy  61
 A B

Figure 6.22  3D TEE: View from the left atrium on the mitral valve and the left ventricular outflow tract (LVOT). In a healthy patient, the LVOT
is clearly seen during the whole cardiac cycle. (A) A still frame taken during midsystole . In a patient with hypertrophic cardiomyopathy and
anterior motion of the mitral valve (SAM), still frames taken at early (B) and midsystole (C) show that the LVOT disappears in midsystole
indicating significant LVOT obstruction. (LAA, left atrial appendage.)

LVOT (>50 mm Hg); also, an area below 2.0 cm2 provided

sensitivity of 81% and specificity of 90% for diagnosing
obstruction.56
Additionally, with the 3D technique, the location of
systolic anterior motion of the mitral valve, which is not
constantly produced from the center of the anterior
leaflet, can be precisely determined by moving the 2D
short-axis plane across the LVOT in the 3D space or even
with the use of the transesophageal approach from direct
visualization from the left atrium60,62 (Figure 6.23, ). 2D
echocardiography may underestimate the severity of SAM
of the mitral valve because of errors in the image plane
and misalignment. Recognition of the asymmetry of mitral
systolic anterior motion and septal hypertrophy may be of
special interest for the surgeon in determining the exact
location of resection and whether concomitant mitral valve
surgery is necessary to eliminate obstruction.
Also, multiplane TEE with 3D reconstruction provided Figure 6.23  3D TEE: View from the left atrium on the mitral valve and
evidence of a significant increase of the LVOT area in the left ventricular outflow tract (LVOT) showing an anterior systolic
11 patients undergoing myectomy. 58 With real-time 3D motion of the mitral valve (SAM) that starts from the midanterior
echocardiography, these results have been confirmed, part of the valve, leaving the posteromedial part of the LVOT less
and also, an increased outflow tract area has been obstructed .

62  3D Echocardiography
 A B C

Figure 6.24  A TEE study of the left ventricular outflow tract of a patient with obstructive hypertrophic cardiomyopathy before (Top Row)
and after (Bottom Row) surgical myectomy and aortic valve replacement. (A) 2D echocardiography shows the left ventricular outflow tract
narrowing before (Top Row) and the notable widening after (Bottom Row) septal myectomy. (B) Color Doppler investigation demonstrates
turbulent flow at the obstruction point before (Top Row) and normalization of flow after surgery (Bottom Row) . (C) 3D echocardiography
shows the left ventricular outflow tract as seen from the left ventricle. Obstruction caused by the septal hypertrophy is notable in the top
row .

demonstrated after alcohol septal ablation. Indeed, it area. 66 – 68 Accordingly, real-time 3D color Doppler
was found that although both techniques are effective in echocardiography has been shown to provide unique
reducing LVOT obstruction, the increase in LVOT area information about the flow convergence zone geometry,
was greater for myectomy than alcohol septal ablation.62 resulting in accurate estimates of mitral regurgitant
These results are in accordance with other findings volume and orifice area in experimental and clinical
showing that the effect of myectomy on LVOT obstruction models. 3D color Doppler echocardiography also provides
may be more definitive than alcohol septal ablation. 52 unique information about the origin, direction, and flow
Therefore, 3D echocardiography should be included as an pattern of the regurgitant jet (Figure 6.25, ); several
imaging technique of choice in patients with obstructive studies have showed good correlation with angiographic
hypertrophic cardiomyopathy to diagnose obstruction
and to evaluate the effect of therapies, particularly those
involving septal reduction either chemically (alcohol
ablation) or mechanically (myectomy). This may even
be applied in the operating room, with the epicardial
approach or with a 3D echocardiographic transesophageal
probe 63–65 (Figure 6.24A–C, ).
Additionally, early detection of iatrogenic ventricular
septal defect could be facilitated intraoperatively with the
use of color Doppler 3D echocardiography, as the eccentric
and tortuous path of the abnormal shunting flow may be
detected more easily with this technique.

ASSESSMENT OF MITRAL REGURGITATION

Mitral regurgitation due to SAM of the mitral valve
generates eccentric regurgitant jets, and as previously
mentioned, it is usually difficult to quantify the severity
of the regurgitation. 3D color Doppler echocardiography
may be useful to better quantify mitral regurgitant Figure 6.25  Transesophageal 3D color-Doppler echocardiography
jets in these patients either by assessment of the full showing a double flow: An eccentric mitral regurgitation (MR) jet
volume of the regurgitant f low or by more accurate and another jet of left ventricular outflow tract (LVOT) obstruction
visualization and measurement of the flow convergence with a unique flow convergence (FC) area .

Hypertrophic Cardiomyopathy  63
 A B

Figure 6.26  (A) In a patient with hypertrophic cardiomyopathy, tissue Doppler imaging in apical triplane acquisiton mode enables
simultaneous deformation analysis in three apical planes. Images are stopped in end systole, where the red color represents maximal
deformation at aortic valve closure. Notable regions of impaired deformation (white arrows) coincide with regions of abnormal wall
thickening. (B) By analyzing deformation in selected areas of interest in the basal-inferoseptum (yellow marker), mid-inferoseptum (green
marker), and apical-inferoseptum (red marker), it can be seen that parts of the mid-inferoseptum that demonstrate notable deformational
impairment are surrounded by normal or subnormal deformation - a finding characteristic of hypertrophic cardiomyopathy.

grading of mitral regurgitation. 67,69 Finally, it may also
be helpful in locating the origin of the obstruction as it
allows visualization of the entire flow convergence area.
DEFORMATION MYOCARDIAL IMAGING IN
HYPERTROPHIC CARDIOMYOPATHY
The assessment of myocardial deformation either
by tissue Doppler myocardial imaging or 2D and 3D
echocardiography (speckle tracking) may be used to
differentiate hypertrophic myopathies with similar
phenotypic appearance (i.e., myocardial hypertrophy) but
with very different genotype and underlying etiology such
as hypertrophic cardiomyopathy, amyloidosis, hypertensive
cardiomyopathy, or Fabry disease.70 The differentiation
of such pathologies is important as they have different
prognostic and therapeutical implications.
The most typical pattern of deformation in hypertrophic
cardiomyopathy is in showing segments where no myocardial
deformation is present, surrounded by regions of only
slightly reduced deformation. This can be demonstrated
with tissue Doppler imaging in triplane acquisition mode,
which enables simultaneous deformation analysis in three
apical planes (Figure 6.26A and B), or 2D and 3D speckle
tracking (Figure 6.27A and B), which offer a segmental
overview of cardiac deformation based on a 17- or

A B

Figure 6.27  (A) Global longitudinal strain and a 17-segment left ventricle model with deformation values (“bull’s-eye plot”), can be calculated
and generated with longitudinal strain deformation data available from 2D speckle tracking in three apical planes (four-chamber, three-
chamber, and two-chamber views). Strain curves show impaired deformation in the basal and midseptal and inferior myocardial segments,
which can be seen as abnormally thick in this patient with hypertrophic cardiomyopathy. The bull’s-eye deformation plot visualizes the
distribution of impairment in the 17-segment model. (B) Similar output can be obtained with 3D speckle tracking analysis, showing a similar
distribution of deformational impairment.

64  3D Echocardiography
Table 6.5  Differential Diagnosis of Hypertrophic Myopathies with Deformation Imaging
Deformation Physiological Hypertrophy
Parameters (e.g., Athletes) Pressure Overload
Global deformation Normal or supranormal Reduced and
postsystolic thickening
Longitudinal function Normal or supranormal Impaired (basal
segments)
Extent of involvement Diffuse Regional
Affected segments Diffuse Basal, septum
Source: Modified from Cikes M et al. Nat Rev Cardiol. 2010;7:384–96.
18-segment model of the LV, also called a bull’s-eye plot, as an
easily understandable output useful for interpreting disease-
specific patterns of deformational impairment. Conversely,
in amyloidotic disease, a reduction in longitudinal systolic
strain can be seen globally, though most prominently in the
basal segments. The cardiac apex is the last to be affected,
which is often referred to as “apical sparing” - a deformation
pattern highly suggestive of amyloidosis with reduced
longitudinal strain at basal and midventricular segments and
more preserved at the apical segments. Additionally, in early
hypertensive cardiomyopathy, longitudinal deformation
is mostly preserved in all ventricular segments except in
the basal septum where deformation is low, and typically,
postsystolic thickening is observed. Finally, longitudinal
deformation is most affected in inferolateral segments of
the LV in patients with Fabry disease (Table 6.5). 3D strain
echocardiography could provide a more comprehensive
assessment of the whole geometrical deformation of
hypertrophic myocardiopathies with easier interpretation
of deformation data by simple visualization of all ventricular
segments and better differentiation of these diagnoses.71
A nother potential application of myocardial
deformation imaging is the prediction of the risk of
ventricular arrythmias in patients with hypertrophic
cardiomyopathy. It has been demonstrated that the
presence of more than 3 LV segments with longitudinal
systolic strain greater than -10% represented an
independent predictor of nonsustained ventricular
tachycardia, which is associated in turn with the presence
of myocardial fibrosis.72
Finally, deformation imaging has also been used to evaluate
LA dysfunction; lower peak systolic strain rate of the LA has
been reported in patients with hypertrophic cardiomyopathy
and correlated with heart failure symptoms.73
CONCLUSION
Echocardiography has played a pivotal role in the diagnosis
of hypertrophic cardiomyopathy and in the evaluation of
the effect of therapy in patients with obstructive disease.
The abnormalities in cardiac geometry of this cardiac
abnormality make it suitable to be studied with a 3D imaging
technique not depending on geometrical assumptions. 3D
echocardiography is therefore a powerful tool to evaluate
these patients in the clinical setting.
Hypertropic Amyloidosis
Cardiomyopathy Fabry Disease Disease
Reduced and Reduced and Severely impaired
postsystolic thickening postsystolic thickening
Absent in affected Impaired Severely impaired
regions
Regional Diffuse Diffuse
Predominantly basal Inferolateral Diffuse
and midseptum
REFERENCES
1. Maron BJ, McKenna WJ, Danielson GK et  al. American College of
Cardiology/European Society of Cardiology clinical expert consensus
document on hypertrophic cardiomyopathy. A report of the American
College of Cardiology Foundation Task Force on Clinical Expert Consensus
Documents and the European Society of Cardiology Committee for Practice
Guidelines. J Am Coll Cardiol. 2003;42:1687–713.
2. Afonso LC, Bernal J, Bax JJ, Abraham TP. Echocardiography in
hypertrophic cardiomyopathy: The role of conventional and emerging
technologies. J Am Coll Cardiol Cardiovasc Imaging. 2008;1:787–800.
3. Gilbert BW, Pollick C, Adelman AG, Wigle ED. Hypertrophic
cardiomyopathy: Subclassification by M-mode echocardiography. Am J
Cardiol. 1980;45:861–72.
4. Maron BJ, Gottdiener JS, Epstein SE. Patterns and significance of
distribution of left ventricular hypertrophy in hypertrophic cardiomyopathy.
A wide angle, two-dimensional echocardiographic study of 125 patients. Am
J Cardiol. 1981;48:418–28.
5. Yamaguchi H, Ishimura T, Nishiyama S et  al. Hypertrophic
nonobstructive cardiomyopathy with giant negative T waves (apical
hypertrophy): Ventriculographic and echocardiographic features in 30
patients. Am J Cardiol. 1979;44:401–12.
6. Falicov RE, Resnekov L, Bharati S, Lev M. Mid-ventricular obstruction: A
variant of obstructive cardiomyopathy. Am J Cardiol. 1976;37:432–7.
7. Schwammenthal E, Nakatani S, He S et  al. Mechanism of mitral
regurgitation in hypertrophic cardiomyopathy: Mismatch of posterior to
anterior leaflet length and mobility. Circulation. 1998;98:856–65.
8. Grigg LE, Wigle ED, Williams WG, Daniel LB, Rakowski H.
Transesophageal Doppler echocardiography in obstructive hypertrophic
cardiomyopathy: Clarification of pathophysiology and importance in
intraoperative decision making. J Am Coll Cardiol. 1992;20:42–52.
9. Spirito P, Maron BJ. Absence of progression of left ventricular
hypertrophy in adult patients with hypertrophic cardiomyopathy. J Am Coll
Cardiol. 1987;9:1013–7.
10. Kitaoka H, Kubo T, Okawa M, Hitomi N, Furuno T, Doi YL. Left
ventricular remodeling of hypertrophic cardiomyopathy: Longitudinal
observation in rural community. Circulation J. 2006;70:1543–9.
11. Fighali S, Krajcer Z, Edelman S, Leachman RD. Progression of
hypertrophic cardiomyopathy into a hypokinetic left ventricle: Higher
incidence in patients with midventricular obstruction. J Am Coll Cardiol.
1987;9:288–94.
12. Schwammenthal E, Block M, Schwartzkopff B et al. Prediction of the
site and severity of obstruction in hypertrophic cardiomyopathy by color
flow mapping and continuous wave Doppler echocardiography. J Am Coll
Cardiol. 1992;20:964–72.
13. Webb JG, Sasson Z, Rakowski H, Liu P, Wigle ED. Apical hypertrophic
cardiomyopathy: Clinical follow-up and diagnostic correlates. J Am Coll
Cardiol. 1990;15:83–90.
14. Roberts CS, Gertz SD, Klues HG et al. Appearance of or persistence
of severe mitral regurgitation without left ventricular outflow obstruction
after partial ventricular septal myotomy-myectomy in hypertrophic
cardiomyopathy. Am J Cardiol. 1991;68:1726–8.
15. Rakowski H, Sasson Z, Wigle ED. Echocardiographic and Doppler
assessment of hypertrophic cardiomyopathy. J Am Soc Echocardiogr.
1988;1:31–47.
Hypertrophic Cardiomyopathy  65
16. Sasson Z, Yock PG, Hatle LK, Alderman EL, Popp RL. Doppler
echocardiographic determination of the pressure gradient in hypertrophic
cardiomyopathy. J Am Coll Cardiol. 1988;11:752–6.
17. Spirito P, Maron BJ, Chiarella F et  al. Diastolic abnormalities in
patients with hypertrophic cardiomyopathy: Relation to magnitude of
left ventricular hypertrophy. Circulation. 1985;72:310–6.
18. Spirito P, Maron BJ. Relation between extent of left ventricular
hypertrophy and diastolic filling abnormalities in hypertrophic
cardiomyopathy. J Am Coll Cardiol. 1990;15:808–13.
19. Sitges M, Shiota T, Lever HM et  al. Comparison of left ventricular
diastolic function in obstructive hypertrophic cardiomyopathy in patients
undergoing percutaneous septal alcohol ablation versus surgical myotomy/
myectomy. Am J Cardiol. 2003;91:817–21.
20. Nihoyannopoulos P, Karatasakis G, Frenneaux M, McKenna WJ,
Oakley CM. Diastolic function in hypertrophic cardiomyopathy: Relation
to exercise capacity. J Am Coll Cardiol. 1992;19:536–40.
21. Elliott PM, Brecker SJ, McKenna WJ. Diastolic dysfunction in hypertrophic
cardiomyopathy [editorial; comment]. Eur Heart J. 1998;19:1125–7.
22. Nagueh SF, Lakkis NM, Middleton KJ, Spencer WH , Zoghbi WA,
Quinones MA. Doppler estimation of left ventricular filling pressures in
patients with hypertrophic cardiomyopathy. Circulation. 1999;99:254–61.
23. Nishimura RA, Appleton CP, Redfield MM, Ilstrup DM, Holmes
DR Jr, Tajik AJ. Noninvasive Doppler echocardiographic evaluation of
left ventricular filling pressures in patients with cardiomyopathies: A
simultaneous Doppler echocardiographic and cardiac catheterization
study. J Am Coll Cardiol. 1996;28:1226–33.
24. Stewart WJ, Schiavone WA, Salcedo EE, Lever HM, Cosgrove DM,
Gill CC. Intraoperative Doppler echocardiography in hypertrophic
cardiomyopathy: Correlations with the obstructive gradient. J Am Coll
Cardiol. 1987;10:327–35.
25. Panza JA, Petrone RK, Fananapazir L, Maron BJ. Utility of continuous
wave Doppler echocardiography in the noninvasive assessment of left
ventricular outflow tract pressure gradient in patients with hypertrophic
cardiomyopathy. J Am Coll Cardiol. 1992;19:91–9.
26. Schwammenthal E, Schwartzkopff B, Block M et  al. Doppler
echocardiographic assessment of the pressure gradient during bicycle
ergometry in hypertrophic cardiomyopathy. Am J Cardiol. 1992;69:1623–8.
27. Yock PG, Hatle L, Popp RL. Patterns and timing of Doppler-detected
intracavitary and aortic flow in hypertrophic cardiomyopathy. J Am Coll
Cardiol. 1986;8:1047–58.
28. Kizilbash AM, Heinle SK, Grayburn PA. Spontaneous variability
of left ventricular outflow tract gradient in hypertrophic obstructive
cardiomyopathy. Circulation. 1998;97:461–6.
29. Frans EE, Nanda NC, Patel V et al. Live three-dimensional transthoracic
contrast echocardiographic assessment of apical hypertrophic
cardiomyopathy. Echocardiography. 2005;22:686–9.
30. Hubka M, Bolson EL, McDonald JA, Martin RW, Munt B, Sheehan
FH. Three-dimensional echocardiographic measurement of left and right
ventricular mass and volume: In vitro validation. Int J Cardiovasc Imaging.
2002;18:111–8.
31. Qin JX, Jones M, Shiota T et al. New digital measurement methods for left
ventricular volume using real-time three-dimensional echocardiography:
Comparison with electromagnetic flow method and magnetic resonance
imaging. Eur J Echocardiogr. 2000;1:96–104.
32. Schmidt MA, Ohazama CJ, Agyeman KO et  al. Real-time three-
dimensional echocardiography for measurement of left ventricular
volumes. Am J Cardiol. 1999;84:1434–9.
33. Qin JX, Jones M, Travaglini A et al. The accuracy of left ventricular mass
determined by real-time three-dimensional echocardiography in chronic
animal and clinical studies: A comparison with postmortem examination
and magnetic resonance imaging. J Am Soc Echocardiogr. 2005;18:1037–43.
34. Gopal AS, Schnellbaecher MJ, Shen Z, Akinboboye OO, Sapin PM, King
DL. Freehand three-dimensional echocardiography for measurement of
left ventricular mass: In vivo anatomic validation using explanted human
hearts. J Am Coll Cardiol. 1997;​30:802–10.
35. Gopal AS, Keller AM, Shen Z et al. Three-dimensional echocardiography:
In vitro and in vivo validation of left ventricular mass and comparison with
conventional echocardiographic methods [see comments]. J Am Coll Cardiol.
1994;24:504–13.
36. Schmidt MA, Freidlin RZ, Ohazama CJ et al. Anatomic validation of a
novel method for left ventricular volume and mass measurements with use of
real-time 3-dimensional echocardiography. J Am Soc Echocardiogr. 2001;14:1–10.
66  3D Echocardiography
37. Sanada H, Shimizu M, Sugihara N, Shimizu K, Ino H, Takeda R.
Increased left atrial chamber stiffness in hypertrophic cardiomyopathy. Br
Heart J. 1993;69:31–5.
38. Nagueh SF, Lakkis NM, Middleton KJ et al. Changes in left ventricular
filling and left atrial function six months after nonsurgical septal reduction
therapy for hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol.
1999;34:1123–8.
39. Bauer F, Shiota T, Qin JX, White RD, Thomas JD. Measurement of
left atrial and ventricular volumes in real-time 3D echocardiography.
Validation by nuclear magnetic resonance. Arch Mal Coeur Vaiss. 2001;​
94:31–8.
40. Bauer F, Shiota T, White RD et al. Determinant of left atrial dilation
in patients with hypertrophic cardiomyopathy: A real-time 3-dimensional
echocardiographic study. J Am Soc Echocardiogr. 2004;17:968–75.
41. Montserrat S, Sitges M, Calvo N et al. Effect of repeated radiofrequency
catheter ablation on left atrial function for the treatment of atrial
fibrillation. Am J Cardiol. 2011;108(12):1741–6.
42. Maron BJ. Hypertrophic cardiomyopathy. Lancet. 1997;350:127–33.
43. Spirito P, Maron BJ. Significance of left ventricular outflow tract
cross-sectional areal in hypertrophic cardiomyopathy: A two-dimensional
echocardiographic assessment. Circulation. 1983;67:1100–8.
44. Klues HG, Maron BJ, Dollar AL, Roberts WC. Diversity of structural
mitral valve alterations in hypertrophic cardiomyopathy. Circulation.
1992;85:1651–60.
45. Chikamori T, Counihan PJ, Doi YL et  al. Mechanisms of exercise
limitation in hypertrophic cardiomyopathy. J Am Coll Cardiol. 1992;​
19:507–12.
46. Fananapazir L, McAreavey D. Therapeutic options in patients with
obstructive hypertrophic cardiomyopathy and severe drug-refractory
symptoms. J Am Coll Cardiol. 1998;31:259–64.
47. Nishimura RA, Trusty JM, Hayes DL et al. Dual-chamber pacing for
hypertrophic cardiomyopathy: A randomized, double-blind, crossover
trial. J Am Coll Cardiol. 1997;29:435–41.
48. Tascon JC, Albarran A, Hernandez F et al. Obstructive myocardiopathic
hypertrophy and sequential atrioventricular stimulation. Immediate
results and long-term follow-up. Seven years’ experience. Rev Esp Cardiol.
2000;53:1028–39.
49. Hess OM, Sigwart U. New treatment strategies for hypertrophic
obstructive cardiomyopathy: Alcohol ablation of the septum: The new gold
standard? JAm Coll Cardiol. 2004;44:2054–5.
50. Maron BJ, Dearani JA, Ommen SR et al. The case for surgery in obstructive
hypertrophic cardiomyopathy. J Am Coll Cardiol. 2004;44:2044–53.
51. Merrill WH, Friesinger GC, Graham TP Jr   et al. Long-lasting
improvement after septal myectomy for hypertrophic obstructive
cardiomyopathy. Ann Thor Surg. 2000;69:1732–5; discussion 1735–6.
52. Qin JX, Shiota T, Lever HM et al. Outcome of patients with hypertrophic
obstructive cardiomyopathy after percutaneous transluminal septal
myocardial ablation and septal myectomy surgery. J Am Coll Cardiol.
2001;38:1994–2000.
53. Lakkis NM, Nagueh SF, Dunn JK, Killip D, Spencer WH 3rd.
Nonsurgical septal reduction therapy for hypertrophic obstructive
cardiomyopathy: One-year follow-up. J Am Coll Cardiol. 2000;36:852–5.
54. Heric B LB, Miller DP, Rosenkranz ER, Lever HM, Cosgrove DM.
Surgical management of hypertrophic obstructive cardiomyopathy. Early
and late results. J Thorac Cardiovasc Surg. 1995;110:195–206.
55. McCully RB, Nishimura RA, Tajik AJ, Schaff HV, Danielson GK. Extent
of clinical improvement after surgical treatment of hypertrophic obstructive
cardiomyopathy. Circulation. 1996;94:467–71.
56. Fukuda S, Harra ML, William JS et  al. Diagnostic value of left
ventricular outflow area in patients with hypertrophic cardiomyopathy: A
real time three-dimensional echocardiography study. J Am Soc Echocardiogr.
2008;21:789–95
57. Salustri A, Kofflard MJ, Roelandt JR et  al. Assessment of left
ventricular outflow in hypertrophic cardiomyopathy using anyplane and
paraplane analysis of three-dimensional echocardiography. Am J Cardiol.
1996;78:462–8.
58. Franke A, Schondube FA, Kuhl HP et al. Quantitative assessment of the
operative results after extended myectomy and surgical reconstruction of the
subvalvular mitral apparatus in hypertrophic obstructive cardiomyopathy
using dynamic three-dimensional transesophageal echocardiography. J Am
Coll Cardiol. 1998;31:1641–9.
59. Mihara H, Shibayama K, Harada K, Berdejo J, Itabashi Y, Shiota
T. LV outflow tract area in discrete subaortic stenosis and hypertrophic
obstructive cardiomyopathy: A real-time 3-dimensional transesophageal
echocardiography study. JACC Cardiovasc Imaging. 2014;7(4):425–8.
60. Qin JX, Shiota T, Lever HM et al. Impact of left ventricular outflow
tract area on systolic outflow velocity in hypertrophic cardiomyopathy: A
real-time three-dimensional echocardiographic study. J Am Coll Cardiol.
2002;39:308–14.
61. Sherrid MV, Chu CK, Delia E, Mogtader A, Dwyer EM Jr. An
echocardiographic study of the fluid mechanics of obstruction in
hypertrophic cardiomyopathy. J Am Coll Cardiol. 1993;22:816–25.
62. Sitges M, Qin JX, Lever HM et  al. Evaluation of left ventricular
outflow tract area after septal reduction in obstructive hypertrophic
cardiomyopathy: A real-time 3-dimensional echocardiographic study. Am
Heart J. 2005;150:852–8.
63. Nash PJ, Agler DA, Shin JH et al. Images in cardiovascular medicine.
Epicardial real-time 3-dimensional echocardiography during septal
myectomy for obstructive hypertrophic cardiomyopathy. Circulation.
2003;108:e54–5.
64. Willert JL, Shook D, D’Ambra MN. 3D Transesophageal
echocardiography: Systolic anterior motion with hypertrophic
obstructive cardiomyopathy. Anesth Analg. 2006;​102:1361–2.
65. Nampiaparampil RG, Swistel DG, Schlame M, Saric M, Sherrid
MV. Intraoperative two- and three-dimensional transesophageal
echocardiography in combined myectomy-mitral operations for
hypertrophic cardiomyopathy. J Am Soc Echocardiogr. 2018;31(3):275–88.
66. Sitges M, Jones M, Shiota T et al. Real-time three-dimensional color
doppler evaluation of the flow convergence zone for quantification of mitral
regurgitation: Validation experimental animal study and initial clinical
experience. J Am Soc Echocardiogr. 2003;16(1):38–45.
67. Irvine T, Derrick G, Morris D, Norton M, Kenny A. Three-dimensional
echocardiographic reconstruction of mitral valve color Doppler flow
events. Am J Cardiol. 1999;84:1103–6, A10.
68. Shiota T, Sinclair B, Ishii M et al. Three-dimensional reconstruction
of color Doppler flow convergence regions and regurgitant jets: An in vitro
quantitative study. J Am Coll Cardiol. 1996;27:1511–8.
69. De Simone R, Glombitza G, Vahl CF, Albers J, Meinzer HP, Hagl S.
Three-dimensional color Doppler: A clinical study in patients with mitral
regurgitation. J Am Coll Cardiol. 1999;33:1646-54.
70. Cikes M, Sutherland GR, Anderson LJ, Bijnens BH. The role of
echocardiographic deformation imaging in hypertrophic myopathies. Nat
Rev Cardiol. 2010;7:384–96.
71. Baccouche H, Maunz M, Beck T et al. Differentiating cardiac amyloidosis
and hypertrophic cardiomyopathy by use of three-dimensional speckle-
tracking echocardiography. Echocardiography. 2012;29:668–77.
72. Di Salvo GPG, Limongelli G, Baldini L, Rea A, Verrengia M, D’Andrea
A. Non-sustained ventricular tachycardia in hypertrophic cardiomyopathy
and new ultrasonic derived parameters. J Am Soc Echocardiogr.
2010;23:581–90
73. Rosca M, Bogdan AP, Beladan C et  al. Left atrial dysfunction as a
correlate of heart failure symptoms in hypertrophic cardiomyopathy. J Am
Soc Echocardiogr. 2010;23:1090–98.
Hypertrophic Cardiomyopathy  67
7A Primary Mitral Regurgitation
INTRODUCTION
Comprehensive understanding of mitral valve (MV)
anatomy, function, and lesions is essential for the assessment
of primary or organic mitral regurgitation (MR) and for the
planning of MV interventions.1 Although conventional 2D
transthoracic (TTE) or transesophageal echocardiography
(TEE) continues to be the standard approach for the
assessment of MR and prediction of MV repair, the
development of real-time 3D TTE and TEE has greatly
enhanced the assessment of the complex MV anatomy and
function and understanding of MV pathologies.1 Multiple
advantages of 3D include the ability to provide en face view
of the MV in real time, to crop the volume in any plane and
to perform accurate quantification of the MV components
with the help of sophisticated softwares.2–4 3D TEE color
Doppler also provides better quantification of MR.4 Finally,
3D TEE has become over the recent years an essential tool
for planning and guiding transcatheter MV interventions
as well as for pre- and postoperative assessment of surgical
MV repair.5–8
3D ASSESSMENT OF THE MITRAL VALVE
COMPONENTS
The different components of the MV can be adequately
examined using real-time 3D TTE or TEE3–5 (Table 7A.1).
Assessment of the MV can be performed with all 3D
imaging modes. The type of information required mainly
determines the choice of the 3D imaging mode. The modes
“3D Zoom” and “Full Volume” are the most frequently
used for the capture of the entire MV and for studying its
anatomy and function. Real-time modalities such as zoom
mode and live 3D have the advantage to avoid stitch artifacts
that may occur during multibeat acquisition. 3D zoom mode
is the primary mode for assessing the MV morphology and
function and for procedural guidance during transcatheter
interventions. To obtain 3D zoom view, the MV should be
centered in the acquisition boxes in two orthogonal views,
with optimization of the width and depth of the 3D volume
in order to include the aortic valve, left atrial appendage,
and interatrial septum. The multibeat “Full Volume” mode
provides the best spatial and temporal resolution.4 It is the
ideal mode for quantitative measurements and the use of 3D
color Doppler. Its main limitation is the possibility of stitching
artifacts created by respiratory motion or arrhythmias. “Live
3D” is the best imaging mode for analyzing the anatomical
details of the MV.3–4
ASSESSMENT OF MITRAL VALVE LEAFLETS
Unlike 2D techniques, which require multiple tomographic
views to examine the different segments of the MV leaflets,
68  3D Echocardiography
3D en face view from the left atrium (LA) perspective provides
comprehensive assessment of the MV in only one view (Figure
7A.1, ).2–4 This view is classically reoriented to reproduce the
“surgical” view similar to the view obtained by the surgeon
in the operative room, with the aortic valve displayed at 11
o’clock.2–4 The en face view of the MV from the LA provides a
complete visualization of anterior mitral leaflet and posterior
mitral leaflet, the coaptation zone, and the commissures. In
this view, the three scallops of the posterior valve (P1, P2,
and P3) can be clearly identified according to Carpentier
classification, separated by two marked indentations.9 By
analogy to the posterior leaflet, and despite the absence of
indentations, the anterior leaflet scallops facing the posterior
ones are classified as A1, A2, and A3.9 It is important to note
that anatomical variations in the number and location of
segments can occur, especially in cases of Barlow disease.
The coaptation line shows in systole an upward concavity
joining the two commissures. The anterolateral commissure
(ALC) is situated next to the A1-P1 scallops and the left atrial
appendage. The posteromedial commissure (PMC) is situated
next to the A3-P3 scallops, close to the interatrial septum.4–5
Some anatomical lesions often missed by 2D TEE, such as deep
indentations of the posterior leaflet, can be easily identified
by the 3D en face view.10 By tilting the 3D volume from the
previous view, the MV can be viewed from the left ventricular
(LV) perspective with the same orientation. Both views can
be visualized simultaneously in real time in the most recent
systems (Figure 7A.2, ).
In addition to real-time 3D views, new imaging tools have
been recently developed to simultaneously display the 3D
view and 2D biplane or multiplane cut planes, with or without
color Doppler. The availability of these multiple imaging
views in real time or in review mode is particularly useful for
the assessment of detailed segmental MV morphology and
function and guidance of percutaneous MV interventions.7,8
Advanced 3D analysis of the MV can be performed using
dedicated 3D reconstruction software. This software allows
precise quantification of multiple parameters regarding
the MV leaflets (area and dimensions of anterior and
posterior leaflet, segmentation, coaptation line), which
are useful in the planning of MV repair.4,7,8 Semiautomatic
software allows for the generation of a realistic model
of the MV leaflets, helping localize MV prolapse and
improving communication with surgeons or interventional
cardiologists (Figure 7A.3).4,10,11
ASSESSMENT OF MITRAL ANNULUS
Early 3D echocardiography studies demonstrated that the
mitral valve annulus (MVA) is a nonplanar saddle-shaped
structure with two anterior and posterior high points and two
medial and lateral points closest to the apex.5,12 This shape
explains the possibility of a false diagnosis of prolapse of the
MV in an apical four-chamber view.12 Although the global
Table 7A.1  Advantages and Limitations of 3D and 2D Echocardiography
2D TEE 3D TEE

Advantages Limitations Advantages Limitations

Morphology Multiplane assessment Requires multiple views; En face view of the MV; multiplane Lower spatial and temporal
of MV leaflet segments; requires experienced reconstruction of MV leaflets and resolution than 2D TEE
high spatial and temporal operator MV annulus
resolution
Mechanisms Accurate identification of Challenging assessment of Better assessment of complex and multiple Tissue dropout/stitching
“simple” prolapse complex or commissural prolapse; quantitative assessment of artifacts simulating
prolapse; less accurate prolapse using multiplane reconstruction perforation; additional views
identification of MV and 3D automated software tools; easier (angled views, longitudinal
perforation communication; best assessment of MV 2D cutting planes) needed in
perforation, with 3D color Doppler complex prolapse
Quantification Reference technique; Challenging quantification Direct assessment of vena contracta area Color Doppler frame rate;
of MR multiparametric approach in eccentric MR jets using multiplane reconstruction; no stitching artifacts in multibeat
(geometric assumption) geometric assumption acquisition mode

MR, mitral regurgitation; MV, mitral valve; TEE, transesophageal echocardiography.

ASSESSMENT OF SUBVALVULAR APPARATUS

3D echocardiographic assessment of the sub-valvular
apparatus involves careful analysis of integrity of chordal
insertion, and pathologic changes such as chordal thickening,
rupture or elongation. Chordae tendinae are best assessed in
“Zoom” mode or wide angle acquisition from the LV side,
from long- and short-axis planes using TTE parasternal views
or TEE transgastric views.14

Figure 7A.1  3D TEE zoom en face view of the mitral valve from the
left atrium providing a complete visualization of the anterior and
posterior mitral leaflets, the line of coaptation and commissures, and
the scallops of the anterior leaflet (A1, A2, A3) and posterior leaflet
(P1, P2, P3) with indentations . (ALC, anterolateral commissure; AV,
aortic valve; LAT, lateral; LAA, left atrial appendage; MED, medial;
PMC, posteromedial commissure.)
3D ASSESSMENT OF MITRAL
REGURGITATION
MECHANISMS AND ETIOLOGIES
Primary or organic MR differentiates from secondary MR by
the presence of structural abnormalities of the leaflets or the
subvalvular apparatus.1 Comprehensive echocardiographic
assessment of MR includes description of mechanisms, and
etiologies, precise localization of structural lesions, and
accurate MR quantification. It is important to differentiate
mechanisms from etiologies of MR. A given etiology can
induce MR by different or several mechanisms.1 In addition,
identification of complex or multiple mechanisms/lesions,
less favorable for repair, may have significant influence
on the decision to intervene, especially in asymptomatic
patients.15 Although 2D TTE and TEE remain the reference
methods for MV analysis and quantification of MR, 3D TEE
has been shown to add significant information especially in
patients with complex lesions.16–18

shape of MVA can be grossly assessed with 3D en face views, the
saddle shape and MV annular geometry, as well as assessment
of the dynamic variations of size, are best assessed offline
using dedicated reconstruction softwares.4,11,13 3D studies
have shown that the mitral area decreases by about 25% in
systole. Reference values for the normal MVA in humans have
been recently reported using 3D TEE.13 Key associates of the
MVA area were body surface area and indexed LA and LV
systolic volumes (SVs).13
MECHANISMS
The Carpentier functional classification describes three
major mechanisms of MR according to leaflets movement9:
type I, normal leaflet movement (e.g., MR caused by annulus
dilatation or leaflet perforation); type II, excessive leaflet
movement (e.g., MV prolapse); and type III, restricted leaflet
motion (IIIa and IIIb in diastole and systole, respectively).
Type I MR: Annular dilation is frequently encountered in
different etiologies of MR and often associated with other
mechanisms.1 3D TEE studies have shown that MV prolapse

Primary Mitral Regurgitation  69

 A B

Figure 7A.2  3D TEE zoom en face view of the mitral valve from the left atrium (A) and from the left ventricle (B) . (ANT, anterior; AV, aortic
valve; LAT, lateral; MED, medial; POST, posterior.)

and regurgitation are associated with a markedly enlarged
annulus, more marked in cases of Barlow disease than
in fibroelastic disease.11 In addition to annular dilation,
flattening of the systolic annular shape and decreased
annular motion have been demonstrated in decompensated
late-stage degenerative MV disease19 and might be a risk
marker for the progression of leaflet lesions and occurrence
of chordal rupture.20 Moreover, the dynamics of the mitral
annulus differ significantly across the different mechanisms
of MR (functional MR [FMR], degenerative MR [fibroelastic
deficiency and Barlow disease]) and may have important
implications for MR quantification.21
MV perforation is generally secondary to endocarditis.
Eccentric MR jets with 2D TTE or TEE generally suggest
this mechanism. Although 2D TTE and TEE may visualize
the perforation, precise localization is more challenging. In
contrast, 3D TEE en face view of the mitral leaflets with color
Doppler allows direct visualization and precise anatomical
localization of the perforation22 (Figure 7A.4).
Type II MR: Excessive mobility of MV leaflets is present
in prolapse and flail. MV prolapse (displacement of
the free edge of one or both leaflets beyond the plane
of the annulus) and flail (complete eversion of the free
edge of the valve leaflet in the LA) are the most frequent
mechanisms of primary MR and also the most frequent
indication for MV repair.1 Accurate knowledge of the
severity, extent, and location of prolapse is essential for
preprocedural planning of surgical or percutaneous

Figure 7A.3  3D reconstruction of the mitral valve with volume-rendered 3D representation of prolapse as seen from the left atrium in a
patient with P2 prolapse (arrow). The region of prolapse is clearly visualized in red scale (Bottom Right).

70  3D Echocardiography
 A B

C D

Figure 7A.4  Mitral regurgitation secondary to mitral valve perforation. (A–B) Cross-sectional 3D TEE reconstruction planes demonstrating
the perforation leak of the anterior leaflet (arrow). (C) 3D color “full-volume” mode showing the perforation jet (arrow). (D) 3D en face view
assessing the exact location and extent of perforation in the A2 segment (arrow).

interventions.7,11,16,18 Although 2D TTE and TEE using
standardized multiple imaging planes remain the standard
methods of assessment for localization of prolapsed or
flailed scallops, accurate identification of complex lesions
involving bileaflet or commissural prolapse remains
challenging and dependent on operator expertise.1
In contrast to 2D techniques, 3D TEE en face view (“surgical”
view) allows immediate characterization of leaflet prolapse
and flail segments as protrusion or bulging of one or more
segments (Figure 7A.5, ).17,23 Although the 3D TTE en face
view of the MV has been shown to be feasible and accurate
in identifying the location of MV prolapse when the quality
of images is sufficient,24 3D TEE provides the highest quality
of imaging. Multiple studies have shown that when compared
with surgical inspection, the accuracy of 3D TEE in assessing
MV prolapse was excellent, superior to 2D TEE.16,17 3D TEE
provides a more comprehensive and accurate identification
of individual segments and improves the assessment of
the exact localization and extent of prolapsing segments
(Figure 7A.6).16–19 The added value of 3D TEE is particularly
important in complex prolapse, involving multiple leaflet
segments and in commissural lesions.17,24–27 However, the
benefit of 3D imaging for the assessment of MV prolapse
is not limited to the 3D en face view, which sometimes fails
to give the full perspective of the severity of the prolapse.
Additional longitudinal planes, obtained either by biplane
imaging or multiplanar reconstruction, are particularly
helpful to assess precisely the different valve segments,
facilitating the assessment of complex MV prolapse (Figure
7A.7). In addition, angled 3D TEE views are also very useful to
assess the extent of the prolapse from another perspective or
to identify small prolapse, commissural prolapse, or chordal
rupture (Figure 7A.8, ).27
In addition to qualitative assessment, 3D TEE also
provides more precise quantification of MV prolapse than
2D TEE.28 The circumferential extent and length of the
prolapsing tissue can be measured online directly on
the 3D image. 8 Dedicated 3D multiplane reconstruction
software allows measurement of quantitative parameters of
MV prolapse such as annular area, leaflet length, prolapse
width, and leaflet gap (Figure 7A.9). These quantification
parameters have been shown to be well correlated with
surgical measurements and determine the complexity of
MV repair.26
Other advantages of 3D TEE over 2D TEE are the gain of
time during TEE examination and the increased confidence
and communication for planning MV repair.
Using dedicated quantitative software, a parametric
map of the mitral valve can be derived, transforming the
3D image of MV into a color-encoded topographic display
(Figure 7A.3). Use of parametric images has been shown to
improve the diagnostic accuracy of less-experienced readers

Primary Mitral Regurgitation  71

 A B C

Figure 7A.5  2D and 3D TEE images of a P2 prolapse. Multiple 2D TEE standardized views are necessary to identify the flail of P2 (A to C) with
ruptured chordae (arrow). (D) 3D TEE en face view showing in one view the localization and extent of P2 prolapse .

A AV B
AV
C AV

D E F

Figure 7A.6  Examples of 3D TEE en face view of mitral valve prolapse: (A) isolated P2 prolapse (arrow), (B) large P2P3 prolapse (arrow),
(C) commissural prolapse (arrow) , (D) anterior A2 prolapse (arrow), (E) anterior A3 prolapse (arrow), (F) multiple segments posterior
prolapse in Barlow disease (arrow) .

72  3D Echocardiography
Figure 7A.7  3D TEE assessment of the prolapsing and flail segments using 3D TEE and biplane imaging. (Left) 3D TEE en face view of the
mitral valve showing a P2 prolapse in the central A2/P2 region and the cutting planes (red dotted lines, A,B,C) used for biplane imaging.
(Right) Starting from a primary intercommissural view, biplane imaging sweep from lateral to medial provides the orthogonal left ventricular
outflow tract view showing A1P1 (A); A2P2 (B), and A3P3 (C).

A B C

* *

D E F

*
* * *

* *

Figure 7A.8  Examples of 3D TEE angled views to offer better visualization of mitral valve prolapse and ruptured chordae (arrows), P2
prolapse (A to C), large P2-P3 prolapse (*) (C to D) , (E to F) .

Primary Mitral Regurgitation  73

 A B

+
+

C D

Figure 7A.9  3D TEE multiplanar reconstruction of the mitral valve (MV) allowing measurement of the flail width (A) and gap (B) of a P2
prolapse, and 3D measurement of MV area (C). Direct measurement of the width of the prolapse on the 3D image (D).

and to improve the communication between members of
the heart team in the perspective of MV repair.29 The use of
a semiautomated algorithm using anatomical intelligence to
generate these parametric images has been recently shown
to improve further the accuracy and efficiency of parametric
maps in localizing MV prolapse.30
Type III MR: Restrictive movement of the MV may be
caused by calcification or rheumatic disease, radiotherapy,
or inflammatory or drug-induced valve disease. Real-
time 3D TTE and 3D TEE allow precise assessment of the
restrictive movement of the leaflets by a combination of
longitudinal and short-axis planes.
ETIOLOGIES
3D echocardiography may also provide specific information
about MR etiology. 3D en face views, from both the LA and
LV perspectives, allow a detailed morphological assessment
of any anatomical lesions, such as presence of leaflet
thickening, calcifications, cleft, vegetations, and ruptured
chordae. It also provides the exact location of these lesions.
In MV prolapse, it has been shown that 3D measurements
of the MV, such as billowing height, may distinguish Barlow
disease from fibroelastic deficiency.24
In rheumatic MR, 3D TTE and 3D TEE provide
important additional information about the presence of
commissural fusion and MV area, when mitral stenosis
coexists with MR.31
QUANTIFICATION OF MITRAL REGURGITATION
Accurate grading of MR severity is crucial for appropriate
management and to define the timing of surgical
intervention.15 The current guidelines recommend
an integrated approach for the evaluation of the MR
severity including qualitative and quantitative 2D Doppler
parameters as well as LV size and function.1,32
However, in clinical practice, significant limitations
remain for accurate and reproducible quantification. 33
In particular, commonly used 2D-derived MR severity
parameters such as vena contracta (VC) width and proximal
isovelocity surface area (PISA) based on geometric
assumptions (i.e., circular regurgitant orifice [RO] or
hemispheric proximal flow region) are not always valid in
clinical practice.1,33
3D color Doppler provides more accurate information
about MR jet and PISA geometric characteristics34,35 and
has clearly demonstrated that the true proximal flow
convergence region is usually more hemi-elliptical than
hemispheric, especially in FMR.34,36,37
In addition, 3D color Doppler is able to provide a
direct measurement of the VC area without geometric
assumption.36,37 A 3D en face view of the VC perpendicular to
the jet direction can be obtained even in eccentric jets using
multiplanar reconstruction, allowing direct planimetry of
the VC area36–40 (Figure 7A.10). This method is especially
useful when orifice shape is noncircular or when there are
multiple MR jets. 39,40 An excellent correlation has been
shown between regurgitant volume (RV) calculated from
3D vena contracta area (VCA) and that calculated by cardiac
magnetic resonance.38
Other 3D approaches for quantification of effective
regurgitant orifice area (EROA) are the measurement of the
3D surface of the proximal flow region without geometric
assumption, or the measurement of the largest radius of the
PISA after multiplane reconstruction.37

74  3D Echocardiography
Figure 7A.10  3D TEE color Doppler quantitative assessment of the vena contracta area (VCA3D) on the en face view (Bottom Left) derived
by multiplanar reconstruction in a 3D color Doppler dataset.
Although the accuracy of these 3D color Doppler EROA
measurements has been demonstrated in several studies,
some limitations persist to make these tools useful in the
daily routine (narrow sector, low volume rate [often inferior
to 10 Hz] and poor temporal resolution, stitched artifacts
with multiple cardiac cycles acquisition). However, recent
technological improvements allowing large-volume color,
single-beat, real-time, 3D color Doppler imaging with an
increased volume rate have made these measurements more
efficient and user friendly.1
Another 3D echocardiographic method to quantify MR
uses the difference between LV stroke volume obtained from
a 3D acquisition of the LV and aortic SV measured using
the Doppler method to calculate the RV and regurgitant
fraction.39
Finally, a new transthoracic 3D approach has been
recently reported using automatic quantification of color
Doppler velocity data and area obtained from 3D color
Doppler acquisitions at the mitral and aortic valves to
calculate SV at each orifice.41 These techniques require
further clinical validation.
TREATMENT OF MITRAL REGURGITATION
SURGICAL MANAGEMENT
Intraoperative 2D/3D echocardiography is key for the
success of mitral valve repair. In pre-pump analysis, it
permits determination of valve analysis and predicts
techniques to be used; in post-pump analysis, it is used to
assess the immediate results as a safety net for surgeons. 3D
echocardiography permits facilitation of communication
between surgeons and echocardiographists42 with the
unique ability to show the dynamic surgeon’s view from
the LA.
Pre-Pump: Road Map for Repair
The feasibility of valve repair depends on valve analysis and
surgical expertise based on volume.43 It requires team effort
with a common language based on the pathophysiological
triad and the functional approach. There has to be a clear
distinction in the echocardiographic report between
etiology (i.e., cause of the disease), lesions (i.e., result from
the disease), and dysfunction (i.e., result from lesions).
Dysfunction is an essential element because it is the basic
principle of the functional approach that permits simplified
decision making, and it is well assessed by echocardiography
because it is based on leaflet motion (type I, normal; type
II, excessive or prolapse; type III, restrictive in diastole IIIa
or in systole IIIb). The echocardiographist also has the duty
to localize the dysfunction (segmental analysis) in order to
determine which scallop is involved. 2D echocardiography is
appropriate to define the type of dysfunction. 2D but overall
real-time 3D TEE is a spectacular tool to determine segmental
analysis, particularly for commissural prolapse (Figure
7A.11). For the frequent P2 prolapse, 3D echocardiography
permits evaluation of the width and height of prolapse
and the width of the indentations (Figure 7A.12). The
main goal and objective of the surgeon planning a valve
repair is to correct the dysfunction. Echocardiography
is not the best tool to diagnose lesions such as chordal
rupture or elongation; in fact, chordal elongation is often
undiagnosed. Lesional analysis is evaluated visually by the
surgeon. This analysis is essential to choose the appropriate
techniques according to Carpentier’s “one lesion, one
technique” principle. The  following measurements must
also be made: height of A2, which correlates with ring size
and etiology (>34 mm for Barlow) and tricuspid annulus
diameter in diastole to determine if tricuspid repair will be
necessary (above 40 mm in deep four-chamber view with
Primary Mitral Regurgitation  75

Figure 7A.11  3D mitral surgeon’s view of posteromedial commissural
prolapse with chordal rupture (arrow) (endocarditis).
coronary sinus as the landmark) (Figure 7A.13). According
to the extent of dysfunction, localized (Figure 7A.14, )
or extensive prolapse (Figure 7A.15, ), the surgeon can
evaluate the difficulty of repair based on his or her own skill
and experience.
Post-Pump Control: Safety Net for Surgeons
Intraoperative TEE is mandatory and systematic for all MV
repairs. It permits evaluation of immediate functional results:
residual MR, reoperation factors, systolic anterior motion,
and other complications such as LV dysfunction, circumflex
coronary artery injury, aortic cusp stitch, or atrial septal
defect. Residual MR is an unacceptable result except for
mild and central regurgitation due to leaflet irregularities.
Beyond severity, the objective of the echocardiography is
to determine the precise mechanism and particularly to
identify leaflet jet and segmental analysis; real-time 3D color
TEE has clear superiority over 2D analysis for this purpose
(Figure 7A.16, ).
Atrial Ventricular
Figure 7A.12  3D atrial and ventricular view of indentation (P2-P3)
width (arrow).
76  3D Echocardiography
CS
Figure 7A.13  Tricuspid annulus diameter measurement in deep,
four-chamber view with coronary sinus (CS) landmark.
PERCUTANEOUS MANAGEMENT
Percutaneous mitral valve repair (PMVR) has been
developed during the recent years as an alternative to
surgery for the treatment of severe MR in patients with high
surgical risk.44 The edge-to-edge leaflet repair using the
MitraClip (Abbott Vascular Structural Heart, Menlo Park,
California) is currently the only device approved by the U.S.
Food and Drug Administration specifically for primary or
degenerative MR. Other transcatheter or percutaneous
techniques are currently under development, such as
mitral annuloplasty techniques (Cardioband, Edwards Life
Science), coronary sinus annuloplasty systems, artificial
chord implantation, and transcatheter MV replacement.
The success of these techniques is highly dependent on
the quality of imaging before and during intervention. In
addition to other imaging modalities, 3D TEE has greatly
enhanced the capabilities of assessment, planning, and
guidance of these complex MV procedures.
MITRACLIP
The MitraClip edge-to-edge mitral repair procedure is
the most developed PMVR technique for both primary
and secondary MR in high surgical risk patients.44,45
This technique mimics the surgical approach previously
described by Alfieri and results in a double mitral orifice by
positioning a clip on the MV using a transseptal approach.
The feasibility and safety profile of the MitraClip device has
been shown to be favorable in the EVEREST I and II trials.45
Preprocedural Assessment
Echocardiographic selection relies on a detailed
characterization of MV anatomy and function.44 Although
comprehensive TTE remains the first step to assess the
mechanisms and severity of MR, TEE is mandatory for the
assessment of MV anatomy and suitability for clipping.45,46
The systematic use of 3D TEE and biplane imaging
has significantly improved the quality of the screening
process.47–49 3D and biplane TEE provide an accurate
assessment of the localization and extent of the prolapsing
and flail segments, which is key for successful planning of
Figure 7A.14  Full-volume 3D atrial view of localized (P2) prolapse with two chordal rupture (Left)
Figure 7A.15  Full-volume 3D atrial and ventricular view of extensive
(A2P3) prolapse with A2 chordal rupture .
P1 P3
P2
Figure 7A.16  Surgical 3D color view to precise localization of residual
jet after repair (in the line of P2 resection) (arrow) . result assessment.47,49
and correlation with surgical findings (Right).
the procedure.48 Accurate measurements of the flail gap
and width of the prolapse, as well as mitral valve area,
can be performed directly on the 3D image or by using
multiplane reconstruction (Figure 7A.9).46 In addition, 3D
TEE is able to identify abnormalities associated with an
unsuccessful procedure, such as MV leaflet cleft, or deep
indentations of the posterior leaflet. Finally, 3DTEE greatly
facilitates communication between echocardiographers
and interventionists during the screening and planning
process.45,47
Based on the EVEREST II trial, optimal echocardiographic
criteria for edge-to-edge repair were a regurgitant jet
originating centrally, associated with an A2-P2 prolapse, a
flail gap less than 10 mm, and a flail width less than 15 mm.45
More recently, it has been shown that patients with more
complex valve pathology, outside the EVEREST criteria, can
be successfully treated in experienced high-volume centers,46
although the need for reintervention is higher in these
patients.50 Less or unsuitable candidates are patients with
commissural or multisegment prolapse, calcification in the
grip zone, and a mitral diastolic valve area less than 3 cm2.46
Procedural Guidance
2D/3D TEE are essential to guide the MitraClip
procedure.7,8,47,49 Because optimal communication is
essential to facilitate procedural guidance, the fluoroscopic
and echocardiographic images should be simultaneously
displayed on a screen for both interventionists and
echocardiographers.46 As compared to 2D TEE, 3D TEE
greatly facilitates guidance and navigation by providing
a comprehensive visualization of catheters, devices, and
cardiac structures in 3D space. 3D TEE has been shown to
shorten the time needed to clip deployment and reduce the
procedure time.51
During the MitraClip procedure, biplane and 3D TEE
views have a complementary role, providing accurate spatial
orientation and guidance, precise clip positioning, and
Primary Mitral Regurgitation  77
 A B C D

SUP
POST LA LA
LA
ANT

Av

RA ANT INF SUP POST

Av #
RA
INF

Figure 7A.17  Echocardiography-guided transseptal puncture. (A and B) Biplane view showing the tenting of the septum (arrow) in the short-
axis view (A) and bicaval view (B). These two views are used to adapt the position of the needle (see text). (C) Four-chamber midesophageal
TEE view showing the height of the puncture (see text). (D) The en face view of the interatrial septum from the right atrial perspective.
The fossa is clearly depicted (#). (ANT, anterior; Av, aortic valve; INF, inferior; LA, left atrium; POST, posterior; RA, right atrium; SUP, superior.)

Transseptal Puncture
Transseptal (TS) puncture is a crucial step during
MitraClip therapy. The location of the puncture is
generally superior and posterior, at a depth of 4–5 cm
above the MV annulus plane to allow the capture of the
prolapsed leaflet. An inadequate puncture site will lead
to difficulties in positioning the clip, aortic hugging if
the puncture is too anterior, and difficulties in pulling
back the clip if the puncture is too low. In addition to
standard 2D TEE planes (bicaval view for superior
inferior orientation, short-axis view for anteroposterior
orientation, and midesophageal four-chamber view for
depth assessment), 3D TEE may provide good visualization
of the fossa ovalis from the right atrial perspective,
helping the surgeon to reach the appropriate location in
difficult cases 49 (Figure 7A.17).
Clip Steering and Positioning of the Clip above the Mitral Valve
After the TS puncture, 3D TEE provides excellent
visualization and spatial orientation of the clip delivery
system (CDS) within the LA. 3D TEE and biplane mode
are used to monitor the positioning of the CDS in the
appropriate position toward the MV (Figure 7A.18). Biplane
imaging allows simultaneous display of two standardized
planes (intercommissural view at 60° and LV outflow tract
view at 120°–150°) to assess the trajectory and proper
positioning of the clip. After correct positioning, the clip
is opened and aligned perpendicular to the line of MV
coaptation, which is essential to ensure proper grasping of
the leaflets. The 3D TEE en face view from the LA provides
the best assessment of perpendicular orientation of the clip.
Fine adjustments of the position of the clip can be made
while using the 3D TEE en face view (Figure 7A.19,  ).

A B C D

Figure 7A.18  Real-time 3D TEE guidance of the MitraClip procedure. (A) The 3D-TEE identifies crossing of the interatrial septum (IAS) and
assesses the correct position of the guide catheter in the left atrium (LA). (B) The 3D-TEE is used to guide the advancement of the clip delivery
system (arrow) in the left atrium. (C,D) The clip delivery system is oriented toward the mitral valve (MV).

78  3D Echocardiography
 A B
E
D F
Figure 7A.19  2D TEE (A,B,C) and real-time 3D TEE (D,E,F) assessment of the alignment of the clip perpendicular to the line of leaflet
coaptation . Real-time 3D TEE en face view is the best modality to check the perpendicular orientation and correct position of the clip
between the target scallops.
Grasping the Leaflets
Perpendicular orientation of the clip is checked again with
3D TEE after the clip has passed into the LV, using the en
face view of the MV from the LV side. If the 3D TEE view
from the LA side is used, gain should be reduced to see the
clip below the leaflets. Biplane imaging is the best imaging
modality to assess the capture of the leaflets. 3D TEE is
generally not used during this step because of its lower
spatial resolution.
Immediate Assessment of the Result
Before clip release, careful 2D and 3D TEE assessment is
crucial to confirm adequate leaflet capture, residual MR,
and absence of mitral stenosis.
The 3D TEE en face view is the best technique to assess the
correct position of the clip between the middle scallops, the
final appearance of a double orifice, and the assessment of
residual regurgitant jets and their relationship to anatomy
(Figure 7A.20, ).
Immediately after clip release, the presence and degree
of residual MR are reassessed as well as the position and
stability of the clip and the evaluation of the MV area.
Residual MR severity after percutaneous repair is not only
a determinant of procedural success but a major prognostic
factor. To date, no single echocardiographic method has
been recommended for postprocedural MR quantification,
C
with the evaluation currently relying on a multiparametric
approach. 52 Summation of the 3D TEE VCA of MR color
jets has been shown to be a useful adjunct for this difficult
assessment of residual MR, and it provides prognostic
information. 52–54 A VCA threshold of 0.27 cm2 has been
defined for the identification of moderate or greater MR,
with good diagnostic accuracy and good negative predictive
value.54
Assessment of mitral stenosis after MitraClip relies on
the measurement of Doppler mitral gradient and MV area.
However, 2D planimetry and the pressure half-time method
to assess MV area may be inaccurate in this setting. 52
Cumulative planimetry of the residual MV orifice with
individually optimized cut planes for each orifice allows
for the best quantification of the residual MV area 52,55,56
(Figure 7A.21). The 3D TEE intraprocedural assessment of
MV area has been shown to predict hemodynamic response
and postprocedural prognosis after MitraClip.56 In a recent
study using 3D TEE postprocedural MV area 1.94 cm2 or
less was predictive for adverse outcomes, independent of
transmitral gradient.56
CONCLUSION
3D echocardiography, especially 3D TEE, is an imaging
modality that greatly improves the morphological and
Primary Mitral Regurgitation  79
 A B C

D E F

Figure 7A.20  2D TEE visualization of the clip crossing the mitral valve (A,B) and grasping the leaflets (C). 3D TEE en face visualization of the
double orifice after clip deployment (D), long-axis view after cropping to assess the capture of the leaflets inside the clip (E); 3D-TEE en face
final double-orifice aspect (*) (F) .

MEDIAL ORIFICE PLANIMETRY LATERAL ORIFICE PLANIMETRY

LA LA LA LA

LV

MED LAT

Figure 7A.21  3D mitral valve area (MVA) measurement immediately after MitraClip implantation. After multiplanar reconstruction, the cut
planes are individually optimized for each orifice. Lateral and medial orifice areas can be measured and summed up to obtain a final MVA.

functional assessment of the MV. 3D TEE provides unique

anatomical views of the MV in real time, allows accurate
identification of MV pathology and quantification of the
MV components, and improves the quantification of MR. 3D
TEE has become a standard practice for planning surgical
and percutaneous MV interventions. Finally, 3D TEE has
become an invaluable tool in the operating room and for
the guidance of percutaneous MV procedures in the cardiac
catheterization laboratory.
REFERENCES
1. Lancellotti P, Moura L, Pierard LA et  al. European Association of
Echocardiography recommendations for the assessment of valvular
regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve
disease). Eur J Echocardiogr. 2010;4:307–32.
2. Lang RM, Badano LP, Tsang W et al. American Society of Echocardiography;
European Association of Echocardiography EAE/ASE recommendations for
image acquisition and display using three-dimensional echocardiography.
J Am Soc Echocardiogr. 2012;1:3–46.

80  3D Echocardiography
3. Sugeng L, Coon P, Weinert L et  al. Use of real-time 3-dimensional
transthoracic echocardiography in the evaluation of mitral valve disease. J
Am Soc Echocardiogr. 2006;4:413–21.
4. Salcedo EE, Quaife RA, Seres T et  al. A framework for systematic
characterization of the mitral valve by real-time three-dimensional
transesophageal echocardiography. J Am Soc Echocardiogr. 2009;10:1087–99.
5. Valocik G, Kamp O, Visser CA. Three-dimensional echocardiography in
mitral valve disease. Eur J Echocardiogr. 2005;6:443–54.
6. Ben Zekry S, Nagueh SF, Little SH et al. Comparative accuracy of two- and
three-dimensional transthoracic and transesophageal echocardiography
in identifying mitral valve pathology in patients undergoing mitral valve
repair: Initial observations. J Am Soc Echocardiogr. 2011;10:1079–85.
7. Wunderlich NC, Beigel R, Ho SY et al. Imaging for mitral interventions:
Methods and efficacy. JACC Cardiovasc Imaging. 2018;6:872–901.
8. Faletra FF, Pedrazzini G, Pasotti E et al. 3D TEE during catheter-based
interventions. JACC Cardiovasc Imaging. 2014;7:292–308.
9. Carpentier A. Cardiac valve surgery—The “French correction.” J Thorac
Cardiovasc Surg. 1983;86:323–37.
10. Guerreiro C, Fonseca C, Ribeiro J, Fontes-Carvalho R. Isolated cleft of
the posterior mitral valve leaflet: The value of 3DTEE in the evaluation of
mitral valve anatomy. Echocardiography. 2016;33:1265–6.
11. Maffessanti F, Marsan NA, Tamborini G et  al. Quantitative analysis
of mitral valve apparatus in mitral valve prolapse before and after
annuloplasty: A three-dimensional intraoperative transesophageal study.
J Am Soc Echocardiogr. 2015;4:405–13.
12. Levine R, Handschumacher M, Sanfilippo AJ et al. Three-dimensional
echocardiographic reconstruction of the mitral valve, with implications for
the diagnosis of mitral valve prolapse. Circulation. 1989;80:589–98.
13. Ring L, Dutka DP, Boyd J et al. The normal mitral valve annulus in
humans defined using 3-dimensional transesophageal echocardiography.
JACC Cardiovasc Imaging. 2018;11:510–2.
14. Obase K, Jeevanandam V, Saito K et al. Visualization and measurement
of mitral valve chordae tendineae using three-dimensional transesophageal
echocardiography from the transgastric approach. J Am Soc Echocardiogr.
2015;28:449–54.
15. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for
the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.
16. Grewal J, Mankad S, Freeman WK et al. Real-time three-dimensional
transesophageal echocardiography in the intraoperative assessment of
mitral valve disease. J Am Soc Echocardiogr. 2009;1:34–41.
17. La Canna G, Arendar I, Maisano F et al. Real-time three-dimensional
transesophageal echocardiography for assessment of mitral valve functional
anatomy in patients with prolapse-related regurgitation. Am J Cardiol.
2011;107:1365–74.
18. Faletra F, Demertzis S, Pedrazzini G et  al. Three-dimensional
transesophageal echocardiography in degenerative mitral regurgitation.
J Am Soc Echocardiogr. 2015;28:437–48.
19. Chen TE, Ong K, Suri RM et al. Three-dimensional echocardiographic
assessment of mitral annular physiology in patients with degenerative
mitral valve regurgitation undergoing surgical repair: Comparison
between early- and late-stage severe mitral regurgitation. J Am Soc
Echocardiogr. 2018;31:1178–89.
20. Lee APW, Hsiung MC, Salgo IS et al. Quantitative analysis of mitral
valve morphology in mitral valve prolapse with realtime 3-dimensional
echocardiography. Circulation. 2013;127:832–41.
21. Van Wijngaarden SE, Kamperidis V, Regeer MV et al. Three-dimensional
assessment of mitral valve annulus dynamics and impact on quantification
of mitral regurgitation. Eur Heart J Cardiovasc Imaging. 2018;19:176–84.
22. Thompson KA, Shiota T, Tolstrup K, Gurudevan SV, Siegel RJ. Utility
of three-dimensional transesophageal echocardiography in the diagnosis
of valvular perforations. Am J Cardiol. 2011;107:100–2.
23. Manda J, Kesanolla SK, Hsuing MC et al. Comparison of real time
two-dimensional with live/real time three-dimensional transesophageal
echocardiography in the evaluation of mitral valve prolapse and chordae
rupture. Echocardiography. 2008;10:1131–7.
24. Pepi M, Tamborini G, Maltagliati A et al. Head-to-head comparison
of two- and three-dimensional transthoracic and transesophageal
echocardiography in the localization of mitral valve prolapse. J Am Coll
Cardiol. 2006;48:2524–30.
25. Biaggi P, Jedrzkiewicz S, Gruner C et al. Quantification of mitral valve
anatomy by three-dimensional transesophageal echocardiography in mitral
valve prolapse predicts surgical anatomy and the complexity of mitral valve
repair. J Am Soc Echocardiogr. 2012;7:758–65.
26. Chandra S, Salgo IS, Sugeng L et al. Characterization of degenerative
mitral valve disease using morphologic analysis of real-time three-
dimensional echocardiographic images: Objective insight into complexity
and planning of mitral valve repair. Circ Cardiovasc Imaging. 2011;1:24–32.
27. Biaggi P, Gruner C, Jedrzkiewicz S et  al. Assessment of mitral valve
prolapse by 3D TEE angled views are key. JACC Cardiovasc Imaging.
2011;1:94–7.
28. Izumo M, Shiota M, Kar S et  al. Comparison of real-time three-
dimensional transesophageal echocardiography to  two-dimensional
transesophageal echocardiography for  quantification of mitral valve
prolapse in patients with severe mitral regurgitation. Am J Cardiol. 2013;​
111:588–94.
29. Addetia K, Mor-Avi V, Weinert L, Salgo IS, Lang RM. A new definition
for an old entity: Improved definition of mitral valve prolapse using three-
dimensional echocardiography and color-coded parametric models. J Am
Soc Echocardiogr. 2014;27:8–16.
30. Jin CN, Salgo IS, Schneider RJ et al. Using anatomic intelligence to
localize mitral valve prolapse on three-dimensional echocardiography. J
Am Soc Echocardiogr. 2016;29:938–45.
31. Dreyfus J, Brochet E, Lepage et  al. Real-time 3D transoesophageal
measurement of the mitral valve area in patients with mitral stenosis. Eur J
Echocardiogr. 2011;10:750–5.
32. Zoghbi WA, Adams D, Bonow RO et  al. Recommendations for
noninvasive evaluation of native valvular regurgitation: A report from the
American Society of Echocardiography developed in collaboration with
the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr.
2017;30:303–71.
33. Grayburn PA, Weissman NJ, Zamorano JL. Quantitation of mitral
regurgitation. Circulation. 2012;126:2005–17.
34. Yosefy C, Levine RA, Solis J et al. Proximal flow convergence region
as assessed by real-time 3-dimensional echocardiography: Challenging the
hemispheric assumption. J Am Soc Echocardiogr. 2007;20:389–96.
35. Sitges M, Jones M, Shiota T et al. Real-time three-dimensional color
Doppler evaluation of the flow convergence zone for quantification of
mitral regurgitation: Validation experimental animal study and initial
clinical experience. J Am Soc Echocardiogr. 2002;16:38–45.
36. Kahlert P, Plicht B, Schenk IM et al. Comparison of direct planimetry of
mitral valve regurgitation orifice area by three-dimensional transesophageal
echocardiography to effective regurgitant orifice area obtained by proximal
flow convergence method and vena contracta area determined by color
Doppler echocardiography. J Am Soc Echocardiogr. 2008;8:912–21.
37. Altiok E, Hamada S, van Hall S et al. Comparison of direct planimetry of
mitral valve regurgitation orifice area by three-dimensional transesophageal
echocardiography to effective regurgitant orifice area obtained by proximal
flow convergence method and vena contracta area determined by color
Doppler echocardiography. Am J Cardiol. 2011;107:452–8.
38. Shanks M, Siebelink HM, Delgado V et  al. Quantitative assessment
of mitral regurgitation: Comparison between three-dimensional
transesophageal echocardiography and magnetic resonance imaging. Circ
Cardiovasc Imaging. 2010;3:694–700.
39. Little SH, Pirat B, Kumar R et al. Three-dimensional color Doppler
echocardiography for direct measurement of vena contracta area in mitral
regurgitation. JACC Cardiovasc Imaging. 2008;1:695–704.
40. Berdejo J, Shiota M, Mihara H et al. Vena contracta analysis by color
Doppler three-dimensional transesophageal echocardiography shows
geometrical differences between prolapse and pseudoprolapse in eccentric
mitral regurgitation. Echocardiography. 2017;34:683–9.
41. Hoe R, Son JW, Ó Hartaigh B et  al. Clinical implications of three-
dimensional real-time color Doppler transthoracic echocardiography in
quantifying mitral regurgitation: A comparison with conventional two-
dimensional methods. J Am Soc Echocardiogr. 2017;4:393–40.
42. Berrebi A. Mitral valve repair: Echocardiography is its best friend. Rev
Esp Cardiol. 2011;64:554–6.
43. Chikwe J, Toyoda N, Anyanwu AC et  al. Relation of mitral valve
surgery volume to repair rate, durability, and survival. J Am Coll Cardiol.
2017;69:2397–406.
Primary Mitral Regurgitation  81
44. Nyman CB, Mackensen GB, Jelacic S et al. Transcatheter mitral valve
repair using the edge-to-edge. Clip J Am Soc Echocardiogr. 2018;31:434–53.
45. Feldman T, Kar S, Elmariah S et  al. Randomized comparison of
percutaneous repair and surgery for mitral regurgitation: 5-year results of
EVEREST II. J Am Coll Cardiol. 2015;66:2844–54.
46. Boekstegers P, Hausleiter J, Baldus S et al. Percutaneous interventional
mitral regurgitation treatment using the Mitra-Clip system. Clin Res Cardiol.
2014;103:85–96.
47. Wunderlich NC, Siegel RJ. Peri-interventional echo assessment for the
MitraClip procedure. Eur Heart J Cardiovasc Imaging. 2013;14:935–49.
48. Wallenborn J, Herrmann S, Hansen M et  al. Systematic
echocardiographic evaluation of mitral valve regurgitation for
transcatheter edge-to-edge repair. Echocardiography. 2016;33:1069–79.
49. Faletra FF, Berrebi A, Pedrazzini G et  al. 3D transesophageal
echocardiography: A new imaging tool for assessment of mitral
regurgitation and for guiding percutaneous edge-to-edge mitral valve
repair. Prog Cardiovasc Dis. 2017;60:305–21.
50. Lesevic H, Karl M, Braun D et al. Long-term outcomes after MitraClip
implantation according to the presence or absence of EVEREST inclusion
criteria. Am J Cardiol. 2017;​119:1255–61.
82  3D Echocardiography
51. Biner S, Perk G, Kar S, Rafique AM et  al. Utility of combined two-
dimensional and three-dimensional transesophageal imaging for catheter-
based mitral valve clip repair of mitral regurgitation. J Am Soc Echocardiogr.
2011;6:611–7.
52. Altiok E, Hamada S, Brehmer K et al. Analysis of procedural effects of
percutaneous edge-to-edge mitral valve repair by2D and 3D echocardiog-
raphy. Circ Cardiovasc Imaging. 2012;5:748–55.
53. Dietl A, Prieschenk C, Eckert F et  al. 3D vena contracta area after
MitraClip procedure: Precise quantification of residual mitral regurgitation
and identification of prognostic information. Cardiovasc Ultrasound.
2018;16:1–10.
54. Avenatti E, Burkhard Mackensen G, El-Tallawi KC et al. Diagnostic value
of 3-dimensional vena contracta area for the quantification of residual
mitral regurgitation after MitraClip procedure JACC. Cardiovasc Interv.
2019;12:582–91.
55. Biaggi P, Felix C, Gruner C et al. Assessment of mitral valve area during
percutaneous mitral valve repair using the MitraClip system: Comparison of
different echocardiographic methods. Circ Cardiovasc Imaging. 2013;6:1032–40.
56. Utsunomiya H, Itabashi Y, Kobayashi S et al. Effect of percutaneous
edge-to-edge repair on mitral valve area and its association with pulmonary
hypertension and outcomes. Am J Cardiol. 2017;120:662–9.
7B Secondary Mitral Regurgitation
INTRODUCTION
Secondary mitral regurgitation (SMR) is relatively
frequent. It occurs in roughly 20%–25% of patients
following myocardial infarction (MI) and 50% of those
with chronic heart failure (CHF).1 Any degree of SMR in
patients with left ventricular (LV) dysfunction conveys
adverse prognosis, with a graded relationship between
severity of regurgitation and reduced survival.2 Moreover,
SMR can be progressive, resulting in adverse remodeling
and poor clinic outcomes despite guideline-directed
therapy in heart failure patients. 3 The increase in the
prevalence of both MI and CHF in the last decades is
likely to lead to an increase in the prevalence of SMR.
Surgical techniques used for mitral valve (MV) repair
(i.e., undersized annuloplasty) are not able to abolish SMR
in most patients.4 Recurrence of SMR after undersized
annuloplasty has been reported in as much as 60% of them.4
A better understanding of the complex 3D morphology of
the MV before surgery in each individual patient, possible
today with the use of 3D echocardiography, might improve
surgical results after MV repair. 3D echocardiography is
superior to 2D in the assessment of the morphology of
the MV apparatus because it does not depend on mental
reconstruction of the gathered images and allows direct
visualization of the MV morphology from any angle. Some
interesting animal studies using 3D echocardiography
and addressing the mechanisms of SMR came up with
innovative solutions that efficiently reduced the severity of
SMR. 5–7 Hence, 3D echocardiography is a very useful tool
in the evaluation of patients with SMR, especially when
MV repair is contemplated, although the incremental
benefit of 3D over standard 2D measurements at outcome
prediction still requires further studies.8
PHYSIOPATHOLOGY OF SECONDARY MITRAL
REGURGITATION
The concept of SMR emerged from 2D echocardiographic
studies, but most of our current knowledge regarding this
entity improved with the use of 3D echocardiography.9,10
The central mechanism of SMR is the tethering of the
MV leaflets during systole toward the LV cavity 9–12 (Figure
7B.1, Panels A and B). This leads to a restricted systolic
motion of the MV leaflets, an apical displacement of the
MV leaflets coaptation line relative to the mitral annular
plane, a tenting of the MV leaflets during systole, and a
decrease in the coaptation surface of the leaflets. Excessive
systolic tethering of the MV leaflets is a consequence of LV
remodeling (change in LV shape or/and volume). This is why
SMR is considered a disease of the LV with consequences
on MV function and not a disease of the valve itself, the
MV leaflets being structurally intact. In this situation, the
LV remodeling leads to apical and outward displacement
of the papillary muscles (PMs). These changes in the 3D
morphology of the PM’s position relative to MV annulus and
leaflets contribute to SMR genesis.
Two patterns of tethering of the MV have been
described: symmetric and asymmetric.13 Following MI,
especially after posteroinferior MI, there is a regional LV
remodeling involving the posterior and inferior LV wall,
with apical and medial displacement of the posteromedial
PM. This leads to posterior leaflet restriction with
asymmetric tethering of the MV leaflets and to an eccentric
SMR jet that is usually oriented posteriorly into the left
atrium. When remodeling involves the entire LV, both
PMs are displaced apically and outwardly, both leaflets
are restricted, and the tethering on the MV apparatus is
symmetric, leading to a central MR jet.
Another consequence of LV remodeling is the change
in geometry and function of the mitral annulus. With LV
remodeling, as 3D echocardiography studies have proven,
there is dilation and flattening of the mitral annulus
which contributes to MV leaflets tethering and SMR14,15
(Figure  7B.2, Panel A ; Figure 7B.3). Mitral annulus
dilation by pulling away the mitral leaflets favors the
development of SMR. However, mitral annular dilation
is only a secondary mechanism in SMR.16 Mitral annulus
dilation alone does not lead to significant SMR, but in the
presence of leaflet tethering exerted by LV remodeling,
mitral annular dilation significantly worsens SMR severity
by enhancing leaflet tethering.16 Flattening of the mitral
annulus, which has a saddle shape in normal individuals,17
leads to an increase in the systolic stress exerted on the
MV leaflets in patients with SMR. Also, in SMR the mitral
annulus diminishes its sphincteric function (the capacity to
contract - reduce its surface - during systole), contributing
to SMR18.
Furthermore, the severity of SMR depends on the balance
between the forces that pull the mitral leaflets toward the
LV apex, that is, tethering forces, and the forces that work
to push the mitral leaflets toward the atrioventricular plane,
that is, closing forces.19 The presence of annular dilatation
and deformation, a decrease in the closing forces of the
LV (i.e., LV systolic dysfunction and/or dyssynchrony), and
a high left atrial pressure during systole20 will favor SMR.
Conversely, an increase in LV closing forces21 and mitral
leaflet enlargements, as response to chronic stretch, will aim
to prevent SMR.22,23
LV dysfunction alone does not lead to significant SMR.9
However, in the presence of augmented tethering generated
by LV distortion, LV dysfunction greatly contributes to SMR.9
Conversely, an increase of the LV contractility will lead to a
decrease in SMR. LV dyssynchrony contributes also to SMR
by altering the effectiveness of the LV closing forces.21,24
Secondary Mitral Regurgitation  83
 A B
Figure 7B.1  Tethering of the mitral valve leaflets during systole with apical displacement of leaflet coaptation line relative to the mitral
annular plane (Panel A). Apical and outward papillary muscle displacement in the context of global left ventricular remodeling with tethering
on the mitral valve leaflets during systole (Panel B).
A B
C D
Figure 7B.2  Offline reconstruction of the mitral annulus (Panels
A, B, C, and D) in a patient with secondary mitral regurgitation
with measurement of different parameters describing mitral
annulus deformation: antero-posterior diameter (Panels A, D),
intercommissural diameter (Panels A, C), the sphericity index,
nonplanar angle, annular circumference and area (Panel A).
Remodeling of the mitral annulus with marked flattening in a patient
with secondary mitral regurgitation (Panel A) . (A, anterior; AL,
anterolateral; Ao, aortic annulus; P, posterior; PM, posteromedial.)
Reduction in SMR after cardiac resynchronization therapy
is associated with favorable changes in MV geometry and an
increase in closing forces.21
MECHANISM AND ETIOLOGY OF SECONDARY
MITRAL REGURGITATION
There are two described types of SMR, ischemic and
nonischemic, depending on the underlying cause of
myocardial disease that leads to LV remodeling. LV
remodeling after MI leads to ischemic SMR. Dilated
cardiomyopathy of nonischemic etiology leads to
84  3D Echocardiography
A B
Figure 7B.3  Mitral annulus reconstruction showing a saddle-
shaped annulus in a patient with a normal mitral valve and no mitral
regurgitation (Panel B) vs. a remodeled mitral annulus with marked
flattening in a patient with secondary mitral regurgitation (Panel A).
(A, anterior; AL, anterolateral; Ao, aortic annulus; P, posterior; PM,
posteromedial.)
nonischemic SMR. The most frequent of all is,
undoubtedly, ischemic SMR. The Carpentier classification
is the most common classification used to describe the
SMR mechanism. Type I: Simple annular dilatation is an
exceptional mechanism in secondary MR. However, it may
be observed in the setting of isolated basilar myocardial
infarction or in primary mitral annular dysfunction. Type
IIIb: SMR results in most cases from a systolic restriction
of leaflet motion due to significant LV remodeling and PM
displacement. Of note, the restriction touches on both
leaflets.
MITRAL VALVE MORPHOLOGY
3D echocardiography, through the en face view allows
direct examination of the atrial surface of both MV
leaflets, coaptation line, and of the two commissures
of the MV leaflets. In SMR, due to the tethering of the
leaflets, the geometry of the valve changes markedly, and
when examined from the left atrium, the MV has a funnel
shape, with the lowest points of the funnel at the level of
the coaptation line (Figure 7B.4, Panels A–C ). In this
 A B C

Figure 7B.4  En face view of the mitral valve in a patient with secondary mitral regurgitation and asymmetric tethering of the mitral valve leaflets:
End diastole (Panel A), midsystole (Panel B), and early diastole (Panel C). Marked change in geometry of the mitral valve with apical displacement
of the coaptation line and “funnel” configuration of the valve (Panel B). (AML, anterior mitral leaflet; PML, posterior mitral leaflet.)

case, the coaptation line, which normally has an upward
concavity, expresses an even more pronounced upward
concavity (symmetric tethering, Figure 7B.5, Panel A)
or completely changes its shape pointing toward the LV
cavity (asymmetric tethering, Figure 7B.5, Panel B). 3D
echocardiography enables visualization of mitral leaflet
tenting patterns in SMR. Differences in symmetric and
asymmetric tenting patterns result in differences in mitral
valve geometry, which in turn affects the degree of MR.
Asymmetric tenting is associated with smaller and higher
annulus, greater posterior-to-anterior leaflet tethering
angle, smaller tenting volume, and the coaptation line
is more posteriorly displaced, compared to symmetric
tenting.25
Real-time 3D echocardiography, together with dedicated
valve segmentation and modeling algorithms have been shown
to predict the risk of recurrent ischemic MR after undersized
ring annuloplasty. A preoperative P3 leaflet tethering angle
of 29.9° or greater was associated with postoperative MR
recurrence, thus favoring chord-sparing valve replacement
over than valve repair in this group of patients.26
An important indicator of mitral leaflet tethering available
through 3D echocardiography is the tenting volume, which
is the volume enclosed between the MV leaflets and the
annular plane in midsystole. This parameter is closely
related to SMR severity and is a reliable marker of tethering
severity. Tenting volume shape can be reconstructed through
offline analysis from 3D acquired datasets. Examining the

A1 A2 A3

B1 B2 B3

Figure 7B.5  En face view of the mitral valve in patients with secondary mitral regurgitation. Valve motion is followed through the cardiac
cycle (end diastole, Panels A1, B1; midsystole, Panels A2, B2; early diastole, Panels A3, B3). Symmetric tethering on the mitral leaflets in
midsystole (Panel A2) vs. asymmetric tethering with predominant posterior leaflet midsystolic restriction (Panel B2). (AML, anterior mitral
leaflet; PML, posterior mitral leaflet.)

Secondary Mitral Regurgitation  85

tenting volume shape makes it easy to identify the pattern
of tethering on the MV leaflets, asymmetric tethering
exhibiting a tenting volume deformed toward the most
tethered segment of the leaflet, pointing out the part of
the leaflet that is predominantly stretched. In some cases
of severe SMR, with lack of adequate coaptation, an orifice,
representing the anatomic regurgitant area, can be directly
visualized from the en face view (Figure 7B.6). This orifice
Figure 7B.6  Lack of coaptation in a patient with asymmetric
tethering of the mitral valve leaflets and secondary mitral
regurgitation (arrow). The anatomical regurgitant orifice area can
be measured by planimetry in this patient.
represents the zone of noncoaptation of the leaflets and
indicates “the weak points” of the MV, where tethering is
most severe and the closing forces are overwhelmed.
3D echocardiography enables offline reconstruction of
the MV leaflets and annulus (Figures 7B.2, 7B.3, 7B.7). This
allows a more accurate evaluation of the mitral annulus
shape and dimensions, as it has a complex geometry,
including an asymmetric elliptical shape curved to form a
saddle-like structure.17 One of the major limitations of 2D
echocardiography is that the sonographer cannot accurately
identify the largest diameter of the mitral annulus. Moreover,
2D echocardiography cannot provide enough information
regarding the shape of the mitral annulus, as the annulus is an
inherent 3D structure. SMR has been shown to be associated
with a rigid annulus, which dilates and flattens during systole.27
Conversely, 3D echocardiography can accurately evaluate the
anteroposterior diameter, the intercommissural diameter, and
the sphericity index of the mitral annulus, thus establishing the
largest diameter of the annulus, and gives insights regarding
the change in its shape, irrespective of the severity of annular
remodeling (Figures 7B.2 and 7B.7). 3D echocardiography
allows calculation of the true perimeter of the mitral annulus,
without grossly geometric assumptions, and length of each
annular segment (anterior annulus length vs. posterior annulus
length). The height of the annulus, that is, the distance between
the highest and the lowest points on the annulus, can be
measured, giving information on its degree of deformation.
Studies that analyzed annular remodeling in SMR have shown
that, as compared to normal subjects, the annular perimeter
and area are increased and that the annulus is less elliptical
and more flattened14,15,28 (Figure 7B.3). These studies have also
pointed out that the degree of mitral annular deformation in
ischemic SMR is more pronounced following anterior MI than

A B

C D

Figure 7B.7  Offline measurement of the anteroposterior diameter of the mitral annulus (Panels A, B), of the anterior (Panel C) and posterior
mitral leaflet (Panel D) surface in a patient with secondary mitral regurgitation.

86  3D Echocardiography
inferior MI.29 Owing to 3D echocardiography, an attenuation
of the sphincter function of the mitral annulus has been
described as one of the mechanisms promoting SMR.18 The
annular area change between diastole and systole, a marker of
sphincter function of the mitral annulus, is decreased in these
patients15,30. 3D echocardiography has also proven that in
healthy individuals, systolic caudal displacement of the mitral
annulus occurs and is more accentuated in the posterior region,
while in patients with SMR, this displacement is reduced, most
notably in the posterior region.15
Secondary MR varies throughout the cardiac cycle as
a result of dynamic changes in the mitral apparatus and
the complex valvular-ventricular interplay. Real-time 3D
echocardiography, coupled with dedicated quantitative
software enable the study of mitral annular shape, dimensions,
and motion throughout the cardiac cycle. Study has shown
that the loss of mitral annular contraction along the
intercommissural line contributes to early systolic SMR, while
asymmetric papillary muscle position was associated with
mid-to-late systolic SMR.31 The eSie Valves (Siemens Medical
Solutions, Malvern, Pennsylvania), an automated quantitative
analysis software that enables rapid and reproducible analysis
with minimal user interaction, has been shown to reliably
depict mitral annular geometry change and distinguish the
etiology of MR under 5 minutes.32
3D reconstruction of the MV also allows the assessment
of the mitral leaflet surface (Figure 7B.7). This made possible
the identification of another important mechanism aiming
to prevent SMR, which is leaflet elongation in response to
the chronic mechanical stress exerted by leaflet tethering.
3D echocardiographic studies on animal models elegantly
showed that MV leaflets are not completely inert structures
and that they are capable to enlarge in order to increase
their coaptation surface, explaining at least in part, why
even in cases with significant tethering SMR may be only
of mild severity.22
3D echocardiography also allows a comprehensive
evaluation of the MV subvalvular apparatus and its position
relative to the mitral annular plane. The distance between
each PM tip and its ipsilateral or contralateral commissure,
the inter-PM distance, the distance between each PM tip and
a point located in the center of a plane with least deviation
of annular hinge point about it, are all several methods to
describe the severity and pattern of the MV tethering. One
of the most relevant parameters that can be evaluated with
the use of 3D echocardiography is the tethering distance
measured between the medial trigone (medial junction of
aortic and mitral annuli) and the head of the posteromedial
PM. This parameter proved to be a reliable indicator of the
severity of distortion on the MV apparatus and a strong
predictor of SMR after MI.9,16 In addition, persistent
tethering of the papillary muscle post mitral annuloplasty,
as defined by displacement of the PM outside of the mitral
annular ring has been shown to be associated with MR
recurrence.33 The advantage of 3D echocardiography over
2D echocardiography is not only that it can accurately
identify PM tips closest to the base of the heart, making a
more reliable measurement of all the tethering distances, but
it also enables measurements of MV deformation otherwise
impossible with 2D echocardiography. Patients with SMR has
been shown to have normal chordal length, measured from
3D TEE transgastric view, as compared to those with primary
MR, who have elongated primary chords.34
3D QUANTIFICATION OF SECONDARY
MITRAL REGURGITATION
2D echocardiography is the cornerstone approach for
grading SMR. However, 2D echocardiography seems to
underestimate the real effective regurgitant orifice area
(EROA) as well as the real regurgitant volume in SMR.35
Conventionally, SMR is considered severe when the 2D
EROA is greater than 20 mm2 and/or when regurgitant
volume (RV) is 30 mL,36–38 although higher cutoff values of
EROA 40 mm2 or more by 2D proximal isovelocity surface
area (PISA) and regurgitant volume of 60 mL or more have
been proposed by the American College of Cardiology/
American Heart Association39 and the American Society
of Echocardiography.40 3D derived cut-off values for EROA
and RV severity are not yet established, but with the rapid
improvement of 3D transthoracic echocardiography (TTE),
they will probably be available soon. A recent study of patients
with SMR on optimal medical therapy demonstrated a linear
increment of risk as the severity of MR increases. The highest
risk group was denoted by an EROA of 30 mm2 or more and
RV of 40 mL or more. In the intermediate risk group (EROA
of 20 to 20 mm2 and RV of 30 to 44 mL), a regurgitant fraction
of 50% or more was also associated with poor outcome.41
Recommended and validated methods for assessing SMR
severity in 2D echocardiography are the measurement of vena
contracta (VC) width and the measurement of EROA and
RV through the PISA method.36 However, there are several
limitations of the PISA method and VC width, as assessed by
2D echocardiography, that should be acknowledged and that
might be overcome by 3D echocardiography. One of these
limitations is that it is awkward to acquire the VC width from
a plane perpendicular to the direction of the regurgitant
jet, especially in eccentric jets. In addition, VC is not always
circular and in cases with elliptical VC, its width might be
underestimated if measured from the plane perpendicular
to its long axis or overestimated if measured in its long axis
(Figure 7B.8, Panel A). 3D echocardiography can overcome
these limitations because it can provide the surface of the VC with
no geometric assumptions, by direct planimetry, measuring
VC area in the plane perpendicular to the direction of the
regurgitant jet. The 3D VC area is independent of flow rate
as it is predominantly determined by regurgitant orifice size.
The 3D-derived VC area has been shown to correlate more
closely with Doppler-derived EROA than 2D VC width.42 In
addition, direct measurement and summation of multiple 3D
VC areas have been shown to correlate well with EROA derived
from 3D left ventricular volume and thermodilution data.
It is especially useful in patients with multiple regurgitant
jets.43 There are several caveats to the 3D VC method. The
size of the 3D color Doppler is influenced by tissue and color
gain settings, as well as the write-priority algorithm of the
image display software.44 The PISA method, as assessed by 2D
echocardiography, assumes that the flow convergence area
Secondary Mitral Regurgitation  87
 A B

Figure 7B.8  Vena contracta area as assessed by 3D echocardiography showing that the vena contracta of the regurgitant jet can be elliptic.
3D echocardiography allows correct alignment perpendicular to the jet direction and accurate measurement of the vena contracta area (Panel
A). Complex 3D geometry of the proximal isovelocity surface area as assessed by 3D echocardiography (Panel B).

is hemispherical. As demonstrated by 3D, flow convergence
area is frequently hemi-elliptic in SMR,45 and applying the PISA
radius method in this case might lead to underestimation of
EROA and RV (Figure 7B.8, Panel B). 3D echocardiography
serves not only to identify cases in which the 2D PISA radius
method underestimates the severity of SMR, but also to enable
the calculation of the real 3D surface of proximal isovelocity
layers without raw geometric assumptions. Instantaneous
“full-volume” 3D echocardiography with the ACUSON
SC2000 volume imaging ultrasound system provides an
innovative technology that allows a new quantitative method
of 3D PISA calculation46. With this system, the EROA and
RV are derived from the same equations applied in 2D
Doppler echocardiography but with the advantage of PISA
being directly measured as a 3D structure (Figure 7B.9  ).
The problem of multiple jets might also be solved by this
particular technique. This approach was validated against
in vitro phantoms with impressive results, showing higher
accuracy when compared with results obtained from the
conventional spherical approximation.
Several automated approaches have been employed
to quantify MR from real-time 3D volumetric data. The
automated 3D PISA method segments the regurgitant
surface area from 3D color Doppler data after optimizing

Figure 7B.9  Instantaneous “full-volume” 3D echocardiography with the assessment of the effective regurgitant orifice area and regurgitant
volume of the mitral insufficiency by direct 3D measurement of proximal isovelocity surface area .

88  3D Echocardiography
the proximal flow convergence region. The EROA and peak
regurgitant volume can be calculated from the largest PISA, Table 7B.2  Morphological Suitability Criteria for
while the integrated PISA and total regurgitant volume MitraClip Intervention Based on the Expansion of the
account for regurgitant jets from all frames. 3D regurgitant EVEREST Criteria and Crossroads Training Experience
volume derived from integrated PISA has been shown to Challenging Unsuitable
be more accurate than the peak PISA technique due to the Optimal Morphology Morphology Morphology
dynamic nature of the regurgitant orifice in patients with Central pathology, A2/ Peripheral pathology, A1/ Ceft or perforation
SMR. Both the peak and integrated 3D PISA techniques P2 P1 or A3/P3
have been shown to correlate well with cardiac magnetic No leaflet calcification Calcification not in Calcification in
resonance imaging.47 grasping zone grasping zone
Another automated software utilizes real-time 3D full- MVA >4 cm2 MVA 3–4 cm2 MVA <3 cm2 or
volume color Doppler (3D FVCD) data to quantify MR MG ≥5 mm Hg
using the volumetric method. It employs 3D hemispheric Posterior leaflet Posterior leaflet 7–10 mm Posterior leaflet
≥10 mm <7 mm
flow sampling planes at the mitral annulus and LV outflow
Tenting height Tenting height ≥11 mma
tract that detect flow volumes throughout the cardiac
<11 mm and
cycle. The 3D FVCD method has been shown to correlate coaptation length
better with cardiac magnetic resonance imaging than >2 mm
2D PISA or the 2D quantification method. 3D FVCD was Carpentier II Carpentier IIIB Carpentier IIIA
especially useful in cases with multiple MR jets and dilated Flail gap <10 mm and Flail width >15 mm with Multisegment flail,
left ventricle, as the 2D methods tend to underestimate flail width <15 mm sufficient valve area to Barlow syndrome
MR severity.48 tolerate >1 clipa
Recent studies in animal models have also shown the Source: Adapted from Boekstegers P, Hausleiter J, Baldus S et al. Clin Res
utility of a novel 3D color Doppler algorithm based on field Cardiol. 2014;103:85–96.
optimization methods to calculated EROA.49,50 a Consider MitraClip XTR (Abbot Vascular, Abbot Park, Illinois).

ROLE OF 3D DURING MITRACLIP THERAPY consists of symmetrical malapposition of structurally normal

The first step of the echocardiographic approach in patients
planned for a MitraClip therapy is the evaluation of the
extent of MV morphological changes that could affect the
device implantation (Tables 7B.1 and 7B.2).
APPROPRIATE MITRAL VALVE MORPHOLOGY
The MitraClip therapy is facilitated by an adequate match
between the varying anatomical characteristics of the MV
apparatus (leaflet length, intercommissural extension of the
culprit lesion) and fixed arm device properties (7 mm arm
length and 4 mm width, respectively, for the NTR device,
while the XTR device boosts 3 mm additional arm length
and 5 mm wider grasping width). The next-generation
MitraClip system not only promises to improve steering,
navigation, and deployment capabilities, but it may also
expand the reach of the clip in patients with complex
anatomy. According to EVEREST criteria, the suitability of
MitraClip therapy can be established by analyzing the leaflet
apposition-coaptation shape. 51,52 The ideal valve lesion
Table 7B.1  Incremental Value of 3D TEE in Defining
MitraClip Therapy Suitability in Patients with Secondary
Mitral Regurgitation
3D Echocardiographic Parameters
Intercommissural shape of target lesion
• Loss of coaptation extension
• Asymmetrical tethering extension
• Regurgitant jet extension
• Interscallop diastasis
• Leaflet hypoplasia
leaflets with preserved systolic coaptation (Figures 7B.10
through 7B.12). The symmetrical leaflet malapposition
with preserved systolic coaptation (at least 2 mm coaptation
length, and less than 11 mm depth) is considered favorable
for successful MitraClip implantation.51–53 Extreme leaflet
hypoplasia, due to fibrotic retraction, suggests an anatomical
condition of valve lesion/MitraClip mismatch, leading to
inefficacious or complicated capture. MitraClip therapy,
although mimicking the surgical edge-to-edge technique,
does not include prosthetic ring implantation, which can
affect its long-term results. 54 Consequently, complete
intercommissural extended loss of systolic leaflet coaptation,
owing to noncompensated LV tethering forces and/or
isolated annular dilation, should be considered suboptimal/
adverse functional anatomy. However, 2D echocardiography
may be affected by a limited cutting plane, leading to
the possible incompleteness of functional anatomy and
coaptation loss assessment along the whole intercommissural
plane. Indeed, if the 2D cutting plane crosses a limited
coaptation loss, especially on the site of cleft diastasis, the
valve lesion might be considered potentially unsuitable
for MitraClip implantation. Real-time 3D TEE provides
comprehensive analysis of leaflet apposition-coaptation
along the intercommissural plane, together with color
flow mapping of valve regurgitation. Consequently, we can
accurately map the target lesion on the intercommissural plane.
Analyzing 3D images, with change of image orientation or
cut and crop, a multiplanar reconstruction (MPR) of all MV
segments on a longitudinal plane may be obtained. Based
on volume-rendered images, MPR can be used to optimize
interpretation and quantify the displacement of facing MV
segments above the anteroposterior annular plane along

Secondary Mitral Regurgitation  89

 A B

C D E

Figure 7B.10  (A,B) 2D TEE showing severe mitral regurgitation owing to symmetrical malapposition with preserved leaflet coaptation. (C,D)
Real-time 3D TEE confirms the preserved leaflet coaptation along the intercommissural plane and moderately extended central regurgitant
jet. (E) Real-time 3D TEE following MitraClip implantation showing double orifice with mild residual regurgitation.

A C

B D

Figure 7B.11  (A) 2D TEE showing severe mitral regurgitation, due to leaflet malapposition with loss of coaptation. (B) Real-time 3D TEE
indicating a loss of coaptation (arrow) of moderate intercommissural extension (line). The patient underwent double clip implantation
without residual stenosis according to mitral valve area estimation (3 cm2) using the smallest value deriving from 3D TEE (C).

90  3D Echocardiography
the intercommissural coaptation surface. The restricted
motion can be recognized, relative to the leaflet-annular
hinge points, using a modifiable cutting plane to carry out
an MPR long-axis view with a segment-by-segment analysis
perpendicular to the intercommissural line (Figure 7B.13).
In addition, 3D color regurgitant jet analysis, together with
B
A
D residual MV area after clip implantation. 53,55,56 Providing
C a comprehensive anatomical view, real-time 3D TEE
E
F facilitates procedural guidance. In the setting of SMR,
E
Figure 7B.12  2D and 3D TEE in a patient with secondary mitral
regurgitation owing to extended leaflet asymmetrical malapposition
with loss of coaptation. (A) 2D TEE asymmetrical malapposition and
loss of coaptation with extreme tethering and hypoplasia of posterior
leaflet. (B) 2D TEE color flow mapping showing severe regurgitation. (C)
3D TEE showing extended malcoaptation and hypoplasia of posterior
leaflet involving middle and medial scallops (D,E). (F) 3D TEE color flow
mapping showing intercommissural extended regurgitant jet.
functional malapposition and coaptation shape of mitral
leaflets, provides an ultimate evaluation of the target valve
lesion in terms of coaptation maintenance, or extension
of coaptation loss, along the intercommissural plane. This
information might be useful to predict unsuitability, or a
technically demanding procedure, including the need for
and sequence of additional clips and postprocedural mitral
valve stenosis.
MONITORING DURING IMPLANTATION
Both 2D and 3D TEE are established methods to
monitor the MitraClip procedure, including transseptal
puncture site, guidance of the delivery system toward
the MV, adjustment of opened clip perpendicular to
commissures in the left atrium and LV, MitraClip system/
target MV lesion matching, grasping and leaflet insertion,
effectiveness on MR downgrading, and assessment of
enhances overall 2D capability for MitraClip monitoring. A
fusion imaging platform, for example, the EchoNavigator
system (Philips Healthcare), that allows simultaneous
display of 3D echocardiographic and fluoroscopic images,
further improves spatial relation understanding and
appropriate MitraClip orientation may be facilitated,
targeting grasping in the culprit zone outside the possible
interscallop diastasis. In addition, real-time 3D TEE
provides a clear assessment of coaptation gap extension to
plan the optimal site for clip implantation. For instance,
if the coaptation loss shows a limited intercommissural
extension, the MitraClip device may first be implanted into
the adjacent zone with maintained coaptation, in order to
improve the subsequent capture of the leaflet gap using
an additional clip. Successful MitraClip therapy is based
on abolishing regurgitation without residual valve stenosis.
Real-time 3D TEE provides accurate identification of the
site of residual regurgitation to guide additional clip
implantation. Subsequent MV area assessment, in addition

Figure 7B.13  (Left) 3D multiplanar reconstruction (MPR) is the most precise method to calculate mitral valve area preprocedurally, without
the ambiguity inherent with 2D measurement as it is challenging to determine the level of the leaflet tip on 2D. (Right) 3D MPR is especially
useful when the leaflet pathology or the intended grasping site is off-centered. The leaflet length of the correct posterior scallop can be
measured off 3D MPR.

Secondary Mitral Regurgitation  91

Figure 7B.14  3D multiplanar reconstruction should be considered while measuring postprocedural mitral valve area, as the orifices cannot
be on the same plane.

Figure 7B.15  3D multiplanar reconstruction is useful at measuring residual mitral regurgitation as the jets can be complex, composed of
multiple smaller jets that are asymmetric, crisscrossing, and not on the same plane.

92  3D Echocardiography
to transvalvular gradient, can help predict stenosis
following additional clip implantation. Using 3D TEE, the
smallest valve area can be accurately assessed before clip
delivery. Study has shown that a mitral valve area of less
than 4.1 cm2 on preinterventional 3D TEE was associated
with a diastolic transmitral mean gradient of 5 mm Hg or
higher after MitraClip. 57 The prediction and recognition
of MitraClip-related MV stenosis is crucial in patients
with severe pulmonary hypertension in the setting of end-
stage cardiomyopathy to avoid left atrial pressure increase
despite successful treatment of valve regurgitation.
The postprocedural residual MR assessment requires an
integrative, multiparametric approach due to its complexity.
Residual MR jets can arise from either or both orifice(s), of
different planes and severity. Also, the presence of the clip
or tissue bridge hinders the formation of a hemispheric flow
convergence zone, rendering the PISA method unreliable.40
3D TEE enables assessment of residual MR from each orifice
of the double-orifice mitral valve post MitraClip (Figures
7B.14 and 7B.15). Direct planimetry of the vena contracta
areas from the medial and lateral regurgitant jets has been
shown to be useful and correlates well with CMR, although
further validation in this cohort is required.58,59
CONCLUSION
3D echocardiography is an indispensable tool in the
evaluation of patients with secondary MR. It is the
only technique available that enables complete 3D live
visualization of the mitral valve in a beating heart. Not only
3D echocardiography enables complete morphological
assessment and complete description of the mechanism of
valve dysfunction, but it is also the key exam for procedure
planning (surgical vs. transcatheter repair) and guiding
in SMR.60
REFERENCES
1. Bursi F, Enriquez-Sarano M, Nkomo VT et al. Heart failure and death
after myocardial infarction in the community: The emerging role of mitral
regurgitation. Circulation. 2005;111:295–301.
2. Grigioni F, Enriquez-Sarano M, Zehr KJ et  al. Ischemic mitral
regurgitation: Long-term outcome and prognostic implications with
quantitative Doppler assessment. Circulation. 2001;103:1759–64.
3. Bartko PE, Pavo N, Pérez-Serradilla A et al. Evolution of secondary mitral
regurgitation. Eur Heart J Cardiovasc Imaging. 2018;19:622–9.
4. McGee EC, Gillinov AM, Blackstone EH et  al. Recurrent mitral
regurgitation after annuloplasty for functional ischemic mitral
regurgitation. J Thorac Cardiovasc Surg. 2004;128:916–24.
5. Hung J, Solis J, Guerrero JL et al. A novel approach for reducing ischemic
mitral regurgitation by injection of a polymer to reverse remodel and
reposition displaced papillary muscles. Circulation. 2008;118:S263–9.
6. Fattouch K, Murana G, Castrovinci S et al. Mitral valve annuloplasty and
papillary muscle relocation oriented by 3-dimensional transesophageal
echocardiography for severe functional mitral regurgitation. J Thorac
Cardiovasc Surg. 2012;143:38–42.
7. Liel-Cohen N, Guerrero JL, Otsuji Y et al. Design of a new surgical approach
for ventricular remodeling to relieve ischemic mitral regurgitation:
Insights from 3-dimensional echocardiography. Circulation. 2000;
​101:2756–63.
8. Lancellotti P, Zamorano JL, Vannan MA. Imaging challenges in
secondary mitral regurgitation unsolved issues and perspectives. Circ
Cardiovasc Imaging. 2014;7:735–46.
9. Otsuji Y, Handschumacher MD, Liel-Cohen N et  al. Mechanism of
ischemic mitral regurgitation with segmental left ventricular dysfunction:
Three-dimensional echocardiographic studies in models of acute and
chronic progressive regurgitation. J Am Coll Cardiol. 2001;37:641–8.
10. Otsuji Y, Handschumacher MD, Schwammenthal E et al. Insights from
three-dimensional echocardiography into the mechanism of functional
mitral regurgitation: Direct in vivo demonstration of altered leaflet
tethering geometry. Circulation. 1997;96:1999–2008.
11. Godley RW, Wann LS, Rogers EW et  al. Incomplete mitral leaflet
closure in patients with papillary muscle dysfunction. Circulation. 1981;​
63:565–71.
12. Ogawa S, Hubbard FE, Mardelli TJ et  al. Cross-sectional
echocardiographic spectrum of papillary muscle dysfunction. Am Heart J.
1979;97:312–21.
13. Agricola E, Oppizzi M, Maisano F et al. Echocardiographic classification
of chronic ischemic mitral regurgitation caused by restricted motion
according to tethering pattern. Eur J Echocardiogr. 2004;5:326–34.
14. Watanabe N, Ogasawara Y, Yamaura Y et al. Geometric deformity of
the mitral annulus in patients with ischemic mitral regurgitation: A
real-time three-dimensional echocardiographic study. J Heart Valve Dis.
2005;14:447–52.
15. Ahmad RM, Gillinov AM, McCarthy PM et al. Annular geometry and
motion in human ischemic mitral regurgitation: Novel assessment with
three-dimensional echocardiography and computer reconstruction. Ann
Thorac Surg. 2004;78:2063–8.
16. Otsuji Y, Kumanohoso T, Yoshifuku S et al. Isolated annular dilation does
not usually cause important functional mitral regurgitation: Comparison
between patients with lone atrial fibrillation and those with idiopathic or
ischemic cardiomyopathy. J Am Coll Cardiol. 2002;39:1651–6.
17. Levine RA, Handschumacher MD, Sanfilippo AJ et al. Three-dimensional
echocardiographic reconstruction of the mitral valve, with implications for
the diagnosis of mitral valve prolapse. Circulation. 1989;80:589.
18. Daimon M, Gillinov AM, Liddicoat JR et al. Dynamic change in mitral
annular area and motion during percutaneous mitral annuloplasty for
ischemic mitral regurgitation: Preliminary animal study with real-time
3-dimensional echocardiography. J Am Soc Echocardiogr. 2007;20:382–8.
19. He S, Fontaine AA, Schwammenthal E et al. Integrated mechanism for
functional mitral regurgitation: Leaflet restriction versus coapting force: In
vitro studies. Circulation. 1997;96:1826–34.
20. Maréchaux S, Pinçon C, Poueymidanette M et al. Elevated left atrial
pressure estimated by Doppler echocardiography is a key determinant
of mitral valve tenting in functional mitral regurgitation. Heart.
2010;96:289–97.
21. Hung J, Solis J, McCarty D et  al. Mechanism of decrease in mitral
regurgitation after cardiac resynchronization therapy: Optimization of the
force-balance relationship. Circ Cardiovasc Imaging. 2009;2:444–50.
22. Chaput M, Handschumacher MD, Tournoux F et  al. Mitral leaflet
adaptation to ventricular remodeling occurrence and adequacy in patients
with functional mitral regurgitation. Circulation. 2008;118:845–52.
23. Chaput M, Handschumacher MD, Guerrero JL et  al. Mitral leaflet
adaptation to ventricular remodeling prospective changes in a model of
ischemic mitral regurgitation. Circulation. 2009;120:99–103.
24. Lancellotti P, Mélon P, Sakalihasan N et  al. Effect of cardiac
resynchronization therapy on functional mitral regurgitation in heart
failure. Am J Cardiol. 2004;94:1462–5.
25. Zeng X, Nunes MCP, Dent J et  al. Asymmetric versus symmetric
tethering patterns in ischemic mitral regurgitation: Geometric differences
from three-dimensional transesophageal echocardiography. J Am Soc
Echocardiogr. Epub ahead of print 2014. DOI: 10.1016/j.echo.2014.01.006.
26. Bouma W, Lai EK, Levack MM et al. Preoperative three-dimensional
valve analysis predicts recurrent ischemic mitral regurgitation after mitral
annuloplasty. Ann Thorac Surg. 2016;101:567–75.
27. Levack MM, Jassar AS, Shang EK et  al. Three-dimensional
echocardiographic analysis of mitral annular dynamics: Implication for
annuloplasty selection. Circulation. 2012;126(11 Suppl 1):S183–8.
28. Khabbaz KR, Mahmood F, Shakil O et  al. Dynamic 3-dimensional
echocardiographic assessment of mitral annular geometry in patients with
functional mitral regurgitation. Ann Thorac Surg. 2013;95:105–10.
29. Watanabe N, Ogasawara Y, Yamaura Y et  al. Mitral annulus flattens
in ischemic mitral regurgitation: Geometric differences between
inferior and anterior myocardial infarction—A real-time 3-dimensional
echocardiographic study. Circulation. 2005;112:458–62.
Secondary Mitral Regurgitation  93
30. De Simone R, Wolf I, Mottl-Link S et al. A clinical study of annular
geometry and dynamics in patients with ischemic mitral regurgitation:
New insights into asymmetrical ring annuloplasty. Eur J Cardiothorac Surg.
2006;29:355–61.
31. Topilsky Y, Vaturi O, Watanabe N et  al. Real-time 3-dimensional
dynamics of functional mitral regurgitation: A prospective quantitative
and mechanistic study. J Am Heart Assoc. 2013;2:1–7.
32. Aquila I, Fernández-Golfín C, Rincon LM et  al. Fully automated
software for mitral annulus evaluation in chronic mitral regurgitation by
3-dimensional transesophageal echocardiography. Medicine (Baltimore).
2016;95:e5387.
33. Hung J, Solis J, Handschumacher MD et  al. Persistence of mitral
regurgitation following ring annuloplasty: Is the papillary muscle outside
or inside the ring? J Heart Valve Dis. 2012;21:218–24.
34. Obase K, Komeda M, Saito K et al. Visualization of submitral structure
by three-dimensional transesophageal echocardiography. Echocardiography.
2013;30(8):945–51.
35. Marsan NA, Westenberg JJM, Ypenburg C et  al. Quantification of
functional mitral regurgitation by real-time 3D echocardiography.
Comparison with 3D velocity-encoded cardiac magnetic resonance. JACC
Cardiovasc Imaging. 2009;11:1245–52.
36. Lancellotti P, Tribouilloy C, Hagendorff A et  al. Recommendations
for the echocardiographic assessment of native valvular regurgitation:
An executive summary from the European Association of Cardiovascular
Imaging. Eur Heart J Cardiovasc Imaging. 2013;14:611–44.
37. Vahanian A, Alfieri O, Andreotti F et  al. The joint task force on
the management of valvular heart disease of the European Society of
cardiology (ESC) and the European Association for Cardio-Thoracic
Surgery (EACTS). Eur J Cardiothorac Surg. 2012;33:2451–96.
38. Baumgartner H, Falk V, Bax J et al. 2017 ESC/EACTS Guidelines for
the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.
39. Nishimura RA, Otto CM, Bonow RO et al. 2017 AHA/ACC Focused
Update of the 2014 AHA/ACC Guideline for the Management of Patients
With Valvular Heart Disease: A Report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. J Am Coll Cardiol. 2017;70(2):252–89.
40. Zoghbi WA, Asch FM, Bruce C et al. Guidelines for the Evaluation of
Valvular Regurgitation After Percutaneous Valve Repair or Replacement:
A Report from the American Society of Echocardiography Developed
in Collaboration with the Society for Cardiovascular Angiography and
Interventions, Japanese Society of Echocardiography, and Society for
Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2019;32:431–75.
41. Bartko PE, Arfsten H, Heitzinger G et al. A unifying concept for the
quantitative assessment of secondary mitral regurgitation. J Am Coll Cardiol.
2019;73:2506–17.
42. Yosefy C, Hung J, Chua S et al. Direct measurement of vena contracta
area by real-time 3-dimensional echocardiography for assessing severity of
mitral regurgitation. Am J Cardiol. 2009;104:978–83.
43. Hyodo E, Iwata S, Tugcu A et al. Direct measurement of multiple vena
contracta areas for assessing the severity of mitral regurgitation using 3D
TEE. JACC Cardiovasc Imaging. 2012;5:669–76.
44. Little SH. The vena contracta area: Conquering quantification with a
3D cut? JACC Cardiovasc Imaging. 2012;5:677–80.
94  3D Echocardiography
45. Matsumura Y, Fukuda S, Tran H et  al. Geometry of the proximal
isovelocity surface area in mitral regurgitation by 3-dimensional color
Doppler echocardiography: Difference between functional mitral
regurgitation and prolapse regurgitation. Am Heart J. 2008;155:231–8.
46. Grady L, Datta S, Kutter O et al. Regurgitation quantification using 3D
PISA in volume echocardiography. Lect Notes Comput Sci (including Subser Lect
Notes Artif Intell Lect Notes Bioinformatics). 2011;14:512–9.
47. Thavendiranathan P, Liu S, Datta S et al. Quantification of chronic
functional mitral regurgitation by automated 3-dimensional peak and
integrated proximal isovelocity surface area and stroke volume techniques
using real-time 3-dimensional volume color Doppler echocardiography:
In vitro and clinical validation. Circ Cardiovasc Imaging. 2013;6:125–33.
48. Heo R, Son JW, ó Hartaigh B et  al. Clinical implications of three-
dimensional real-time color Doppler transthoracic echocardiography in
quantifying mitral regurgitation: A comparison with conventional two-
dimensional methods. J Am Soc Echocardiogr. 2017;30:393–403.e7.
49. Tan TC, Zeng X, Jiao Y et  al. Three-dimensional field optimization
method: Clinical validation of a novel color Doppler method for quantifying
mitral regurgitation. J Am Soc Echocardiogr. 2016;29:926–34.
50. Pierce EL, Rabbah JPM, Thiele K et  al. Three-dimensional field
optimization method: Gold-standard validation of a novel color Doppler
method for quantifying mitral regurgitation. J  Am Soc Echocardiogr.
2016;29:917–25.
51. Feldman T, Foster E, Glower DG et al. Percutaneous repair or surgery
for mitral regurgitation. N Engl J Med. 2011;364:1395–406.
52. Feldman T, Wasserman HS, Herrmann HC et al. Percutaneous mitral
valve repair using the edge-to-edge technique: Six-month results of the
EVEREST phase I clinical trial. J Am Coll Cardiol. 2005;46:2134–40.
53. Zamorano JL, Badano LP, Bruce C et al. EAE/ASE recommendations
for the use of echocardiography in new transcatheter interventions for
valvular heart disease. Eur Heart J. 2011;32:2189–214.
54. Rogers JH, Franzen O. Percutaneous edge-to-edge MitraClip therapy
in the management of mitral regurgitation. Eur Heart J. 2011;32:2350–7.
55. Wunderlich NC, Siegel RJ. Peri-interventional echo assessment for the
MitraClip procedure. Eur Heart J Cardiovasc Imaging. 2013;14:935–49.
56. Faletra FF, Berrebi A, Pedrazzini G et  al. 3D transesophageal
echocardiography: A new imaging tool for assessment of mitral
regurgitation and for guiding percutaneous edge-to-edge mitral valve
repair. Prog Cardiovasc Dis. 2017;60:305–21.
57. Altiok E, Hamada S, Brehmer K et  al. Analysis of procedural
effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D
echocardiography. Circ Cardiovasc Imaging. 2012;5(6):748–55.
58. Gruner C, Herzog B, Bettex D et al. Quantification of mitral regurgitation
by real time three-dimensional color Doppler flow echocardiography
pre- and post-percutaneous mitral valve repair. Echocardiography.
2015;32(7):1140–6.
59. Avenatti E, Mackensen GB, El-Tallawi KC et  al. Diagnostic value of
3-dimensional vena contracta area for the quantification of residual
mitral regurgitation after MitraClip procedure. JACC Cardiovasc Interv.
2019;12(6):582–91.
60. Boekstegers P, Hausleiter J, Baldus S et al. Percutaneous interventional
mitral regurgitation treatment using the Mitra-Clip system. Clin Res Cardiol.
2014;103:85–96.
 8 Mitral Stenosis
INTRODUCTION
The management of patients with rheumatic mitral valve
(MV) stenosis relies on clinical data, morphological
evaluation, and accurate assessment of the mitral valvular
orifice area (MVA). Echocardiography is the main
diagnostic imaging modality to evaluate MV obstruction
and to assess the severity and the hemodynamic
consequences of mitral stenosis (MS), as well as valve
morphology and extent of the disease. Classic methods
to determine MVA have many limitations. The display
of cardiac anatomy in 3D from any perspective has clear
advantages and provides an insight into the functional
and anatomical properties of cardiac structures. The
benefits of 3D echocardiography are particularly useful
to the study of mitral valve disease. 3D echocardiography
provides not only different and superior evaluation of the
MV apparatus structure but also the optimal plane of the
smallest MV orifice and allows a more accurate assessment
of MVA. The development of a fully sampled matrix array
transducer has enabled easy and fast acquisition of real-
time volumetric imaging from the transthoracic approach
(RT3DE). It has sparked a great interest in using this
methodology in clinical practice.
MORPHOLOGICAL ASSESSMENT
Evaluation of the MV anatomy and pathology is a major aspect
of the echocardiographic workup because this identifies
the best treatment options. Rheumatic mitral valve stenosis
(MS) is a disease associated with progressive morphological
changes of the MV apparatus. Chronic scarring of the
valve leaflets converts a translucent, pliable valve into a
stiff, thickened structure leading to fusion of the leaflet
commissures and thickening, fibrosis, and calcification of the
leaflet cusps. These changes are progressive over time and
result in funnel-shaped stenotic MV. Rheumatic involvement
of the subvalvular apparatus includes fusion, thickening,
retraction, shortening, and calcification. Choosing the
patients favorable for percutaneous mitral valvuloplasty
(PMV) requires precise evaluation of the MV apparatus.
Unfavorable results of catheter-based interventions are
largely due to unfavorable morphology of the valve
apparatus. Commissural fusion is the requisite lesion for
PMV to be effective. Thus, only the rheumatic etiology is
appropriate for PMV. In degenerative MS, mitral annular
calcification is the main lesion and commissural fusion is
not present; thus, these cases are generally not well suited
for PMV. Contraindications to PMV should also be excluded
(MVA >1.5 cm2, left atrial thrombus, mitral regurgitation
more than mild, severe or bicommissural calcification,
severe concomitant valve disease, or concomitant coronary
artery disease requiring bypass surgery).
2D echocardiography plays an important role in diagnosis
and selection of the best therapeutic strategy in patients
with MS. Apart from estimation of the transmitral pressure
gradient and MVA, 2D echocardiography is essential in
the selection of patients for PMV. Morphology of the MV
is considered as the main predictor of a successful PMV;
hence, a MV scoring system using echocardiography is
of crucial importance.1 Among all available MV scoring
systems, Wilkins’s score is the most commonly used.2 This
score evaluates MV thickness, mobility, leaflet calcification,
and the degree of subvalvular apparatus thickening. A
favorable Wilkins’s score (<8 points) is highly predictive
of a good outcome after PMV.3 More recently, it has been
shown that other factors, such as commissural fusion
and calcification, are also strong predictors of outcomes
after PMV.4–6 However, 2D echocardiography is limited
by the ability to distinguish calcification and subvalvular
involvement.
The morphological assessment of the MV apparatus by
3D echocardiography becomes more accurate. Stereoscopic
views of the MV apparatus can easily be obtained, as can
surgical and en face views from either the left atrium or the left
ventricle (Figure 8.1, ). The position and degree of fusion
and thickening of the leaflet and chordae tendineae can all
be visualized clearly on 3D echocardiography (Figure 8.2, ).
A previous work of our group demonstrated interobserver
variability of Wilkins’s score by using 2D echocardiography
and RT3DE.7 The RT3DE assessment showed the better inter-
and intraobserver agreement for the morphological evaluation
of the rheumatic MV. The improvement of RT3DE probe
technology raised the need to construct a scoring system using
RT3DE, proposed by Anwar et al.8,9 They divided each leaflet
into three scallops. Thickness, mobility, and calcification
for each MV scallop were scored separately. The subvalvular
apparatus was also divided into three cut sections: Proximal
(valve level), middle, and distal (papillary muscle level). The
individual RT3DE score points of leaflets and subvalvular
apparatus were summed to calculate the total RT3DE
score, ranging from 0 to 31 points. A total score of mild MV
involvement was defined as less than 8 points, moderate MV
involvement as 8–13 points, and severe MV involvement as 14
points or more. The new proposed RT3DE score was feasible
and reproducible and compared favorably with Wilkins’s score.
They also found that calcification by RT3DE score was the
only predictor of the development of grade 2 or higher mitral
regurgitation after PMV; not only because of calcification
extent, but also because of the calcification site, because this
complication was more common when the calcification was
detected at the commissural segments of the MV leaflets by
RT3DE. The 3D score has many potential benefits compared
to 2D scores. By RT3DE, visualization and assessment of the
lengths of both leaflets are possible through a single image
plane, and leaflet mobility can be assessed. The whole leaflet
Mitral Stenosis  95
 A B
Figure 8.1  En face view of mitral valve from either the left atrium (A)
Figure 8.2  Subvalvular mitral apparatus assessment by 3D TTE
length could not be evaluated by a single 2D echocardiography
image, especially for the posterior leaflet, which is short and
naturally less mobile than the anterior leaflet. Scoring of leaflet
calcification using Wilkins’s score depends on the bright areas
and the extension of calcification along the leaflet length.
Multiple cut planes are needed for detecting calcification
in all scallops of both MV leaflets. RT3DE could assess the
extent and distribution of calcification in each scallop from
a single short-axis cut plain. The new RT3DE score described
calcification at the commissural parts of the leaflet by a higher
score than the middle leaflet calcification because it is one of
the strong predictors of outcome after PMV. In addition, the
RT3DE score includes the chordal thickness and separation,
which is a good independent predictor for PMV outcome.
Compared to Wilkins’s score, the RT3DE score is simple and
more helpful, particularly for less-experienced operators, and
can be applied using both transthoracic and transesophageal
approaches because the image orientation and interpretation
are the same.
The usefulness of 3D echocardiography has also been
described in rare clinical entities such as parachute mitral
96  3D Echocardiography
or the left ventricle (B) by 3D TTE in a patient with mitral stenosis.
valve,10 double-orifice mitral valve,11 radiation-induced MV
stenosis,12 or systemic lupus erythematosus–related MS,13
where immunoglobulin and complement deposition in the
valvular structure consequently leads to valve thickening
and formation of Libman-Sacks vegetations.
FUNCTIONAL ASSESSMENT
In the past, the gold standard method to determine MVA
has been invasive evaluation, using the catheter-based
data and the Gorlin equation. However, this method is
invasive, can result in complications, and has important
limitations. Most notably, it is inaccurate when significant
valvular regurgitation is present. 2D echocardiography
. has been the usual method to determine MVA in routine
clinical practice. MVA can be assessed indirectly by the
pressure half-time (PHT) method, or by direct planimetry.
2D planimetry of the MVA is performed in a parasternal
short-axis view at the tip of the leaflets when maximal
excursion of the leaflets is seen. The inner edge of the MV
orifice is traced in mid-diastole. PHT is obtained by tracing
the deceleration slope of the E-wave on Doppler spectral
display of transmitral inflow. The MVA can be calculated
from the following simplified formula: 220/PHT. These
methods have several limitations. PHT-derived MVA can
be obtained easily, but may be influenced by hemodynamic
factors (heart rate, cardiac rhythm, cardiac index, left
ventricular systolic and diastolic dysfunction, left ventricular
and atrium compliance, left ventricular hypertrophy, and
concomitant valvular disease).14,15 The main advantage of
planimetry is that it provides a relatively hemodynamic-
independent assessment of the MVA. In the past, direct
measurements of the MVA only could be performed using
planimetry traced on 2D echocardiography images, but this
method has several limitations - the most important is that
there is no controlled sectioning of the mitral funnel orifice.
Measurements of the MVA are made in the short-axis view
with no simultaneous independent imaging to verify that
Figure 8.3  3D echocardiography allows simultaneous display of more than one 2D view. The advantage of this is the ability to confirm that
the parasternal short-axis view of the mitral orifice is in fact at the tip of the mitral leaflets.
the imaging plane corresponds to the smallest and most
perpendicular view of the MV orifice. Because of it, this
method requires significant experience and operator skill
to obtain the correct imaging plane that displays the true
MV orifice. In addition, 2D echocardiography planimetry
is limited to patients with favorable image quality from a
parasternal window.
The assessment of patients with MV stenosis is one of the
most promising clinical applications of 3D echocardiography.
3D echocardiography shows not only the anatomical
structure of MV (commissural splitting and leaflet tears)
but also the optimal plane of the smallest MV orifice, and it
can thus accurately assess the MVA. 3D echocardiography
provides unique orientations of the cardiac structures not
obtainable by routine 2D echocardiography. The short-
axis cut plane is further positioned at the MV cusp tips,
which is selected for MVA measurement by planimetry, and
errors due to malpositioning can be obviated (see Figure
8.3). In addition, planimetry using 3D echocardiography
is not limited to the parasternal window and allows MVA
measurement from an apical window. The introduction of
a full matrix-array transducer has enabled online RT3DE
and rendering. It became possible to rapidly evaluate
the MV structure and MVA. The utility of RT3DE in the
evaluation of MS and accuracy of MVA measurements has
been established by multiple studies. Our group conducted
a study where RT3DE was compared with current 2D
echocardiography methods for the assessment of MVA in
patients with rheumatic MS (2D planimetry, PHT method,
and proximal isovelocity surface area [PÌSA] method).2 The
gold standard method assumed was the MVA, which was
invasively determined using the Gorlin equation. RT3DE
planimetry was performed en face at the ideal cross section of
the MV during its greatest diastolic opening. The ideal cross
section was defined as the most perpendicular view on the
plane with the smallest MV orifice. Analysis showed better
agreement when comparing the invasively determined
MVA with RT3DE determined MVA than when comparing
it with the current 2D echocardiography methods. Similar
results have been reported in other works.16–18 Kasliwal et al.
compared the MVA obtained by 3D echocardiography with
the true mitral orifice measured directly at operation. The
comparison achieved a high degree of agreement.19 There
is sufficient evidence that 3D echocardiography is superior
to 2D echocardiography and can be routinely used in the
quantification of the MVA in MS.2,16–18 The exceptional
quality of the images of the MV suggests that this modality
is the new gold standard for the MVA quantification.
Gorlin’s method has several pitfalls, such as using the
assumption that a properly confirmed wedge pressure
accurately reflects left atrial pressure, the misalignment of
the pulmonary capillary wedge and left ventricular pressure
tracings, and the calibration errors. In addition, significant
mitral regurgitation and the presence of an atrial septal
defect may confound measurements of transmitral volume
flow. A previous work was evaluated if RT3DE planimetry
is more accurate than the Gorlin method to measure the
MVA.20 A median value of the MVA, obtained from the
measurements of three classical noninvasive methods (2D
planimetry, PHT and PISA method), was used as the gold
standard. This value was compared with RT3DE planimetry
and the Gorlin method. Analysis showed that the accuracy
Mitral Stenosis  97
Figure 8.4  Mitral valve navigation (MVN) software allows tracing of the MV orifice, including the commissures.
of RT3DE planimetry is superior to the accuracy of the
invasive Gorlin method for assessing MVA when the median
(or composite dataset) was used as the standard. Thus, we
should keep in mind the fact that RT3DE planimetry may
be a better reference method than the Gorlin method
to assess the severity of rheumatic MS. In addition, the
Gorlin method is invasive and may result in complications
and inaccuracies for the patient. In addition, the use of
RT3DE by the transesophageal approach allows excellent
visualization of the MV orifice and leaflets, enabling a
more accurate MVA measurement by 3D planimetry.21,22
Due to the nonplanar nature of the MV orifice, the actual
MVA may be underestimated, and Mahmoud Elsayed
et  al. have proposed the use of a mitral valve navigation
(MVN) software that traces the MV orifice including the
commissures23 (Figure 8.4). At present, RT3DE may be
considered the gold standard for the quantification of the
MVA and may eventually make routine preoperative cardiac
catheterization unnecessary.
Recent works have proposed a new method to assess MVA
based on PISA by 3D color Doppler echocardiography.24,25
The conventional 2D PISA method is based on the
principles of the continuity equation, and the preservation
of mass method is based on the assumption of hemispheric
98  3D Echocardiography
symmetry of PISA. However, PISA can be variable depending
on the shape of the orifice, leading to a discrepancy between
MVA calculated with the hemispheric assumption and the
actual area.26 A further limitation of the conventional PISA
method is related to the requirement of an angle correction
factor (the funnel angle formed by the mitral leaflets).27
Because it is a difficult and time-consuming technique, the
conventional 2D PISA method is the least popular for the
calculation of MVA. The recently developed modality of
single-beat real-time 3D color Doppler imaging can provide
the actual geometry of the flow convergence and allows
direct measurement of PISA without geometric assumptions
or the requirement of an angle correction factor, so it
should reduce the errors in calculating MVA present in the
conventional 2D method (Figure 8.5). This novel method
has been shown to be more accurate than 2D methods and
has high agreement with 3D planimetry.24,25 Table 8.1 shows
a detailed comparison of the different methods to evaluate
a rheumatic mitral stenosis. Cardiac magnetic resonance
(CMR) is an excellent method that provides evaluation of
cardiac anatomy and function noninvasively and may be
an alternative method when the echocardiography images
are inadequate to evaluate MVA or 3D transesophageal
echocardiography (TEE) cannot be performed (Figure 8.6).
Figure 8.5  Example of 3D proximal isovelocity surface area volume automatic calculation for determining mitral valve area using dedicated
software.

Table 8.1  Advantages and Limitations of the Different

Methods Used to Evaluate the Mitral Valve Area
Influence of Acoustic Useful
Hemodynamic Window after Invasive
Method Conditions Needed PMV Technique

2D planimetry − ++ + −
PHT ++ ++ − −
2D/3D PISA + +++ + −
RT3DE − ++ ++ −
GORLIN ++ − ++ ++
PHT, pressure half-time; PISA, proximal isovelocity surface area; PMV,
­percutaneous mitral valvuloplasty; RT3DE, real-time 3D echocardiography.

One study compared the planimetric MVA assessed by 3D

TEE and CMR in rheumatic MS patients and obtained an
excellent correlation.28
MONITORING PERCUTANEOUS MITRAL
VALVULOPLASTY
PMV is a safe and effective treatment for MS and has evolved
as the preferred treatment option for selected symptomatic
patients with rheumatic MS. Because thrombi can develop and
enlarge rapidly in the setting of MS and stasis within the left
atrium and left atrial appendage, the presence of intracardiac
thrombi should be excluded before PMV. 3D TEE is helpful
to guide the balloon into the MV, and to determine the best
position of the balloon between the mitral leaflets by using
X-plane views. It is critical to avoid inflation of the balloon in
Figure 8.6  Mitral valvular area assessment by cardiac magnetic
resonance.
the subvalvular region as this can result in chordal rupture,
tearing of the valve leaflet at a site other than the commissures,
and even damage to and tearing of the papillary muscle. 3D
echocardiography can provide additional information to pre-
PMV and post-PMV. Previous studies have demonstrated large
discrepancies in the immediate post-PMV period between
MVA measurements obtained using the PHT method and
those derived invasively in the catheterization laboratory.29,30
The reasons for this inaccuracy include (1) the development of
an atrial septal defect in many patients after PMV and (2) the
PHT method assumes that the left atrial and left ventricular

Mitral Stenosis  99

Figure 8.7  Commissural tearing assessment after percutaneous
mitral valvuloplasty by real-time 3D echocardiography .
compliances remain stable; this assumption is not valid in the
immediate period following PMV because rapid changes in the
left atrial pressure and left ventricular filling occur, affecting
the compliance of both the left atrium and left ventricle.31
2D planimetry of MVA is less dependent on hemodynamic
variables32 and theoretically should be more accurate than
PHT after PMV, but it is not exempt from limitations.
Following PMV, the mitral orifice becomes irregular and is
technically difficult to trace, particularly if calcium is present,
and due to the variable geometry of the MV orifice, correct
plane orientation frequently is difficult. By means of 3D
echocardiography, it is possible to assess the morphology of
the MV also in PMV, which is important in the evaluation
of the mechanism and success of the procedure. By volume-
rendered 3D echocardiography, dynamic reconstructions can
be performed of the MV structure en face of either a left atrial or
a left ventricular perspective, including a detailed visualization
of the commissures, leaflets, and subvalvular structures not
seen with 2D echocardiography. The easy acquisition and
online review of RT3DE facilitates immediate assessment of
the MV commissural splitting, stretching, or tearing after
PMV in the cardiac catheterization laboratory (Figure 8.7, ).
In a work of our group, we examined the problem of the MVA
evaluation immediately after a PMV.33 The gold standard
method was the MVA invasively determined. RT3DE was
the most accurate technique for measuring MVA, with a
better pre- and postprocedural agreement with the invasively
(Gorlin) derived MVA. Post-PMV the agreement with the
Gorlin-derived MVA was much better than 2D planimetry and
PHT-derived MVA. In conclusion, RT3DE is also a very suitable
technique for monitoring the efficacy of the PMV, with a
better accuracy compared to 2D planimetry and PHT-derived
MVA. Messika-Zeitoun compared MVA measurements using
RT3DE with those obtained using 2D echocardiography in
experienced and less-experienced operators before and after
PMV.34 They found RT3DE provides a better accuracy than
2D echocardiography for less-experienced operators, but it
100  3D Echocardiography
Figure 8.8  En face view of mitral valve by 3D TEE .
does not provide a real advantage for experienced operators.
The  reason that may explain these findings is that MVA
planimetry with 2D echocardiography must be performed at
the tips of the leaflets with the correct plane orientation and
therefore it requires a great experience. Thus, RT3DE seems
particularly helpful for less-experienced operators.
In recent years, 3D TEE has become a valuable
complementary tool guiding PMV35–37 and accurately
managing and diagnosing possible complications. Real-time
3D TEE supplies superior imaging quality (Figure 8.8, ) and
is capable of facilitating interventions with unprecedented
detail and ease. Real-time 3D TEE provides wide fields
of view with superior depth resolution allowing a safe
navigation by monitoring the spatial relationships between
cardiac structures and interventional devices simultaneously.
Positioning of the interatrial transseptal puncture is essential
for minimizing the risk of cardiac tamponade and successfully
navigating the balloon catheter toward the mitral orifice
(Figure 8.9, ).38 Fine corrections in position and alignment
are more easily performed with 3D TEE, as seen in navigating
the balloon catheter just beyond the plane of MV coaptation.
The distal half of the balloon must be placed just beyond the
MV plane of coaptation, inflated, and then retracted against
the MV prior to full inflation (Figure 8.10, ). Appreciation
of incorrect positioning in the left ventricle may be helpful in
avoiding potential complications. After inflating the balloon,
success can be assessed using 3D TEE to confirm commissural
fissuring and to search for possible leaflet tears.
Recently, real-time echocardiographic and fluoroscopic
fusion imaging have emerged for guidance of structural
heart interventions as, for example, in PMV (Figure 8.11, .
This technology provides simultaneous visualization of fine
catheter manipulations under fluoroscopic guidance with
detailed cardiac structural anatomy and color Doppler
hemodynamic information provided by echocardiography.39
Echocardiographic-f luoroscopic fusion imaging is
compatible with 2D echocardiographic imaging with or
without color Doppler, simultaneous multiplane, and 3D
echocardiographic imaging modes. The fused images are
 A B
Figure 8.9  Interatrial transseptal puncture guided by 3D TEE using X-plane mode (Panel A) and 3D zoom mode (Panel B
Figure 8.10  Monitoring of percutaneous mitral valvuloplasty by 3D
transesophageal echocardiography using live 3D zoom mode .
Figure 8.11  Monitoring of percutaneous mitral valvuloplasty by
echocardiographic and fluoroscopic fusion imaging .
).
automatically displayed from the perspective of the frontal
fluoroscopic C arm. 3D volume datasets can also be displayed
as the complete volume of data, which can be cropped in
the plane of the fluoroscopic image to display soft tissue
anatomy relevant to the procedure. The system also allows the
placement of fiducial markers within the echocardiographic
space that can be visualized on the live fluoroscopic image.
In the future, this new tool will have a main role guiding
structural heart interventions.
CONCLUSION
The benefits of 3D echocardiography are particularly well suited
to the study of MV stenosis. The en face view of the MV allows
direct planimetry and thus accurate estimation of the MVA. 3D
TEE has emerged as a valuable complementary tool monitoring
PMV, and accurately diagnosing possible complications. In
the future, 3D echocardiography might become the “gold
standard” method for MV stenosis assessment.
REFERENCES
1. Pan M, Medina A, Suarez de Lezo J et al. Factors determining late success
after mitral balloon valvulotomy. Am J Cardiol. 1993;71:1181–5.
2. Wilkins GT, Weyman AE, Abascal VM et  al. Percutaneous balloon
dilatation of the mitral valve: An analysis of echocardiographic variables
related to outcome and the mechanism of dilatation. Br Heart J.
1988;60:299–308.
3. Padial LR, Freitas N, Sagie A et al. Echocardiography can predict which
patients will develop severe mitral regurgitation after percutaneous mitral
valvulotomy. J Am Coll Cardiol. 1996;27:1225–31.
4. Cannan CR, Nishimura RA, Reeder GS et  al. Echocardiographic
assessment of commissural calcium: A simple predictor of outcome after
percutaneous mitral balloon valvotomy. J Am Coll Cardiol. 1997;29:175–80.
5. Fatkin D, Roy P, Morgan JJ et al. Percutaneous balloon mitral valvotomy
with the Inoue single-balloon catheter: Commissural morphology as a
determinant of outcome. J Am Coll Cardiol. 1993;21:390–7.
6. Sutaria N, Shaw TR, Prendergast B et  al. Transoesophageal
echocardiographic assessment of mitral valve commissural morphology
predicts outcome after balloon mitral valvotomy. Heart. 2006;92:52–7.
7. Zamorano J, Cordeiro P, Sugeng L et al. Real-time three-dimensional
echocardiography for rheumatic mitral valve stenosis evaluation. J Am Coll
Cardiol. 2004;43:2091–6.
Mitral Stenosis  101
8. Anwar AM, Attia WM, Nosir YF et  al. Validation of a new score for
the assessment of mitral stenosis using real-time three-dimensional
echocardiography. J Am Soc Echocardiogr. 2010;23:13–22.
9. Soliman OI, Anwar AM, Metawei AK et al. New scores for the assessment
of mitral stenosis using real-time three-dimensional echocardiography.
Curr Cardiovasc Imaging Rep. 2011;4:370–7.
10. Wierzbowska-Drabik K, Kasprzak JD. Parachute-like mitral valve with
symptomatic stenosis—Imaging with transthoracic and transesophageal
three-dimensional echocardiography and treatment implications.
Echocardiography. 2016;33:496–8.
11. Taramasso M, La Canna G, Alfieri O. Three-dimensional
echocardiographic imaging of double-orifice mitral valve determining
severe mitral stenosis: Diagnosis and intraoperative aspect of a very rare
clinical entity. Eur Heart J. 2011;33(16):1988.
12. Malanca M, Cimadevilla C, Brochet E et  al. Radiotherapy-induced
mitral stenosis: A three-dimensional perspective. J  Am Soc Echocardiogr.
2010;23:108.e1–2.
13. Plastiras SC, Pamboucas CA, Tzelepis GE et al. Assessing mitral valve
stenosis by real-time 3-dimensional echocardiography in systemic lupus
erythematosus: A look inside the heart. J Rheumatol. 2009;36:1843–5.
14. Hatle L, Angelsen B, Tromsdal A. Noninvasive assessment of
atrioventricular pressure half-time by Doppler ultrasound. Circulation.
1979;60:1096–104.
15. Rodriguez L, Thomas JD, Monterroso V et al. Validation of the proximal
flow convergence method: Calculation of orifice area in patients with mitral
stenosis. Circulation. 1993;88:1157–65.
16. Binder TM, Rosenhek R, Porenta G et al. Improved assessment of mitral
valve stenosis by volumetric real-time three-dimensional echocardiography.
J Am Coll Cardiol. 2000;36:1355–61.
17. Xie MX, Wang XF, Cheng TO et al. Comparison of accuracy of mitral valve
area in mitral stenosis by real-time, three-dimensional echocardiography
versus two-dimensional echocardiography versus Doppler pressure half-
time. Am J Cardiol. 2005;95:1496–9.
18. Sebag IA, Morgan JG, Handschumacher MD et al. Usefulness of three-
dimensionally guided assessment of mitral stenosis using matrix-array
ultrasound. Am J Cardiol. 2005;96:1151–6.
19. Kasliwal R, Trehan N, Mittal S. A new “gold standard” for the
measurement of mitral valve area? Surgical validation of volume rendered
three-dimensional echocardiography. Circulation. 1996;94(Suppl.):355.
20. Perez de Isla L, Casanova C, Almeria C et al. Which method should be
the reference method to evaluate the severity of rheumatic mitral stenosis?
Gorlin’s method versus 3D-echo. Eur J Echocardiogr. 2007;8:470–3.
21. Dreyfus J, Brochet E, Lepage L et al. Real-time 3D transoesophageal
measurement of the mitral valve area in patients with mitral stenosis. Eur J
Echocardiogr. 2011;12:750–5.
22. Schlosshan D, Aggarwal G, Mathur G et al. Real-time 3D transesophageal
echocardiography for the evaluation of rheumatic mitral stenosis. JACC
Cardiovasc Imaging. 2011;4:580–8.
23. Mahmoud Elsayed HM, Hassan M, Nagy M et al. A novel method to
measure mitral valve area in patients with rheumatic mitral stenosis using
three-dimensional transesophageal echocardiography: Feasibility and
validation. Echocardiography. 2018;35:368–74.
102  3D Echocardiography
24. de Agustin JA, Mejia H, Viliani D et  al. Proximal flow convergence
method by three-dimensional color Doppler echocardiography for mitral
valve area assessment in rheumatic mitral stenosis. J Am Soc Echocardiogr.
2014;27:838–45.
25. Sampaio F, Ladeiras-Lopes R, Almeida J et  al. Three-dimensional
proximal flow convergence automatic calculation for determining mitral
valve area in rheumatic mitral stenosis. Echocardiography. 2017;34:1002–9.
26. Shandas R, Gharib M, Liepman D et al. Studies to define geometry of the
flow convergence region. Echocardiography. 1992;9:43–50.
27. Rodriguez L, Thomas JD, Monterroso V et al. Validation of the proximal
flow convergence method; calculation of orifice area in patients with mitral
stenosis. Circulation. 1993;88:1157–65.
28. Uygur B, Celik O, Ustabasioglu FE et  al. Three-dimensional
transesophageal echocardiography vs. cardiac magnetic resonance in the
assessment of planimetric mitral valve area in rheumatic mitral stenosis.
Echocardiography. 2018;35:1621–5.
29. Reid CL, Rahimtoola SH. The role of echocardiography/Doppler
in catheter balloon treatment of adults with aortic and mitral stenosis.
Circulation. 1991;84(Suppl I):240–9.
30. Vahanian A, Michel PL, Cormier B et  al. Results of percutaneous
mitral commissurotomy in 200 patients. Am J Cardiol. 1989;63:
847–52.
31. Thomas JD, Wilkins GT, Choong CY et al. Inaccuracy of mitral pressure
half-time immediately after percutaneous mitral valvotomy. Dependence on
transmitral gradient and left atrial and ventricular compliance. Circulation.
1988;78:980–93.
32. Faletra F, Pezzano A Jr, Fusco R et al. Measurement of mitral valve area
in mitral stenosis: Four echocardiographic methods compared with direct
measurement of anatomic orifices. J Am Coll Cardiol. 1996;28:1190–7.
33. Zamorano J, Pérez de Isla L, Sugeng L et al. Non-invasive assessment of
mitral valve area during percutaneous balloon mitral valvuloplasty: Role of
real time 3D echocardiography. Eur Heart J. 2004;25:2086–91.
34. Messika-Zeitoun D, Brochet E, Holmin C et  al. Three-dimensional
evaluation of the mitral valve area and commissural opening before and
after percutaneous mitral commissurotomy in patients with mitral stenosis.
Eur Heart J. 2007;28:72–9.
35. Dobarro D, Gomez-Rubin MC, Lopez-Fernandez T et al. Real time three-
dimensional transesophageal echocardiography for guiding percutaneous
mitral valvuloplasty. Echocardiography. 2009;26:746–8.
36. Shin JJ, Alfirevic A, Navia JL. Complications of percutaneous mitral
balloon valvotomy: Usefulness of real-time 3-dimensional technology. J
Cardiothorac Vasc Anesth. 2013;27:546–8.
37. Eng MH, Salcedo EE, Quaife RA et al. Implementation of real time
three-dimensional transesophageal echocardiography in percutaneous
mitral balloon valvuloplasty and structural heart disease interventions.
Echocardiography. 2009;26:958–66.
38. Wang A, Bashore TM. Cardiac perforation and tamponade: Being at the
wrong place but at predictable times during balloon mitral commissurotomy.
Cathet Cardiovasc Diagn. 1997;42:149–50.
39. Thaden JJ, Sanon S, Geske JB et al. Echocardiographic and fluoroscopic
fusion imaging for procedural guidance: An overview and early clinical
experience. J Am Soc Echocardiogr. 2016;29:503–12.
 9 Aortic Stenosis
INTRODUCTION
Aortic stenosis (AS) is now the most frequent type of
valvular heart disease in Europe and North America. The
main etiology leading to hemodynamically significant AS
is calcific AS. In adults with advanced age (>65 years),
calcific AS is found in approximately 2%–7% of the general
population.1,2 The second most frequent etiology, which
dominates in the younger age group, is congenital AS,
whereas rheumatic AS has now become uncommon in
Western countries but remains frequently encountered in
developing countries.
Evaluation of AS is one of the major applications of
clinical echocardiography.3 It provides not only detailed
anatomical and functional information about the aortic
valve but also clues toward quantification of AS severity
and its consequences on left heart chambers and the
pulmonary vascular bed. In addition, echocardiography
largely contributes to risk stratification and decision
making regarding the need for aortic valve replacement.
2D echocardiography remains the cornerstone in the
evaluation of AS severity. However, 3D echocardiography
can provide additional information regarding aortic valve
morphology and can overcome some of the inherent
limitations of 2D echocardiography in the assessment of AS
severity4 (Figure 9.1, ).
3D IMAGING OF THE AORTIC VALVE AND
ANNULUS
The aortic valve consists of a complex of structures
surrounding the aortic orifice along the outflow tract of the
left ventricle (LV).5 Typically, the valve has three leaflets,
which are semilunar in shape. The cups are inserted into
a fibrous connective tissue sleeve, which is attached to the
aorta media above (the Valsalva sinuses and the sinotubular
junction). Below, the cusps are attached to the myocardium
of the LV outflow tract and to the anterior mitral leaflet
(virtual basal ring), below the anatomical ventriculo-aortic
junction. Hence, the true anatomical aortic annulus is
not actually the ring projected at the most basal leaflet
insertion - as usually defined and measured with various
imaging techniques - but a crown-like 3D structure.
Of note, the size of the aortic annulus and the root is
influenced by inner pressure and is dynamically changing
during the cardiac cycle by 12% and 16%, respectively.6
Each cusp is attached along its curved edge, and the cusps
meet at three commissures that are equally spaced along
the circumference of the sleeve at the supra-aortic ridge.
In a normal aortic valve, the cups are symmetrical, mobile,
and free at the commissures, with equal overlap on closure.
The cusps are called left coronary, right coronary, and
noncoronary cusps based on the location of the coronary
ostia.7
Owing to the complex 3D structure of the aortic valve,
assessment of its morphology by 2D echocardiography
might be cumbersome because of the need for multiple
plane scans in a narrow volume (the aortic root and leaf-
lets are small structures as compared to other cardiac
chambers and valves) and the need for mental reconstruc-
tion of the acquired images. 3D echocardiography allows
rapid and straightforward visualization of the entire aortic
root, of each semilunar cusp and their attachments to the
aortic wall defining the sinuses of Valsalva. Hence, with
3D echocardiography, the understanding of aortic valve
morphology and to a certain extent, pathology, becomes
less laborious. In practice, both 3D transthoracic echocar-
diography (TTE) and transesophageal echocardiography
(TEE) can be used to assess AS, often in a complementary
manner to conventional 2D echocardiography.
The common approaches for imaging the aortic valve
by 3D TTE are the parasternal and apical windows; the
latter may display lower resolution for cusp morphology,
but may adequately identify bicuspid morphology or
delineate aortic tumors/vegetations or LV outflow tract
(LVOT) anatomy (Figure 9.2, ). As a rule of thumb, the
best acoustic window in each patient is usually chosen.
3D TEE allows visualization of the aortic valve and root
from the upper esophageal view. It is usually the preferred
technique, providing better image quality than 3D TTE
due to better spatial resolution. (The probe is closer to
the imaged cardiac structures, and higher frequencies are
used.) It is the method of choice when a definite diagnosis
cannot be made by 2D and 3D TTE.
3D data acquisition often starts with biplane imaging of
the aortic valve that allows visualization of the aortic leaflets
from two planes, one in the long axis of the aortic root and
the other (the lateral plane) perpendicular to the long-axis
plane. The latter can be moved laterally along the long-axis
plane in order to obtain the best view of the aortic leaflets
opening (Figure 9.3, ). This type of acquisition and display
are very useful in the rapid assessment of aortic anatomical
valve area (AVA) by planimetry. Real-time 3D TTE or TEE
allows acquisition of a full-volume dataset focused on the
aortic valve and root. The acquired 3D datasets can be
cropped and rotated for a dynamic 3D rendering of the
aortic valve, which can be visualized from both the aortic
(en face) and ventricular perspectives, as well as sliced in
any desired longitudinal or oblique plane. The en face
view of the aortic valve from the aortic perspective allows
rapid assessment of aortic valve morphology; it can only be
obtained with 3D echocardiography.
Aortic Stenosis  103
 A
B

C D

Figure 9.1  En face view of the aortic valve in 3D TEE in systole (Panel A) and diastole (Panel B) that allows rapid assessment of aortic leaflet
morphology. (Panels C,D) 3D TEE view of the aortic valve in a patient with aortic stenosis .

Figure 9.2  Left ventricular outflow tract hypoplasia in a patient with elevated systolic transaortic pressure gradient. 3D echocardiography
helped make the diagnosis by showing a very narrow left ventricular outflow tract with midsystolic obstruction. (CV, chamber view.)

Such morphological assessments are of great importance,

USEFULNESS OF 3D IN AORTIC STENOSIS
AORTIC VALVE/ANNULUS MORPHOLOGY
For morphological assessment of the aortic valve/annulus
complex, the image acquisition can be done as real-time, real-
time zoomed, or electrocardiogram (ECG)-gated (“stitched”
volumes) 3D images. 3D echocardiography provides useful
information regarding the shape and morphology of the
aortic annulus and its dynamic changes; the presence, extent,
and asymmetry of aortic calcifications; the number of cusps
and their opening (central or eccentric) (Figure 9.4,  ); and the
relationship between aortic annulus and the coronary ostia.
particularly in the setting of transcatheter aortic valve
replacement (TAVR). For instance, although TAVR has been
successfully performed in bicuspid aortic valve, the presence of
an elliptical valvular orifice may cause asymmetric deployment
of the prosthesis and increase the risk of perivalvular leak or
of compression of the coronary arteries.8
In daily practice, the evaluation of the aortic annulus/
LVOT shape and size is crucial because it intervenes in the
assessment of the AVA and dictates the eligibility for TAVR
and the optimal prosthetic size. 2D echocardiography has
been the most commonly used imaging modality for this

104  3D Echocardiography
 A B Anatomic AVA =0.85 cm²

Sll frame in midsystole,

cung plane at the level
of AV ps

Figure 9.3  Biplane from 3D TTE. (A) Long-axis view of the left ventricular tract and aorta. (B) Cross section of the aortic valve in a short-axis
view at the level of the aortic annulus. The yellow arrow shows that the aortic valve area (AVA) is planimetered in early systole. The dashed
line represents the position of the perpendicular plane at the edges of the aortic cusps in systole that gives the short-axis image of the aortic
valve from which the AVA is planimetered .

Figure 9.4  En face view of the aortic valve leaflets in diastole in a patient with a type 1 bicuspid aortic valve according to the presence and
location of the raphe. The gray arrow indicates the presence of a raphe, otherwise difficult to visualize by 2D echocardiography .

purpose. However, 3D imaging using computed tomography
(CT) has demonstrated an ellipsoid geometry of the aortic
valve annulus. 8 Such a noncircular shape of the aortic
annulus results in a larger diameter in the coronal direction
and a smaller diameter in the sagittal direction (Figure 9.5, ).
Hence, any 2D imaging technique allowing analysis of the
annulus diameter in just one view is at risk of underestimating
the maximal valve annulus diameter. 3D echocardiography
has the advantage of allowing analysis of cardiac structures
in any view similar to CT. After acquisition, the 3D volume
can be cropped to obtain an en face view of the aortic annulus
and a correct measurement of the maximum and minimum
annular diameters by examining both the coronal and the
sagittal planes10,11 (Figure 9.6, ). Recent studies have shown
that 3D-TEE automated/semiautomated software analyses
of aortic annulus area and perimeter are feasible, reliable,
and can be used in clinical practice as an alternative to
multidetector row computed tomography (MDCT) for
aortic annulus assessment although major diameter, area,
and perimeter values remain underestimated compared
with the respective MDCT measurements12–18 (Table 9.1).
However, to date, measurement of the aortic annulus pre-
TAVR is based on cardiac CT, but in patients with severe
renal failure, 3D TEE is the alternative.
PLANIMETRY OF THE ANATOMICAL AORTIC VALVE
AREA
Direct measurement of the aortic valve anatomical orifice
area avoids the hemodynamic and geometric assumptions of
the continuity equation (CE). However, due to the complex
orientation of the stenotic aortic valve orifice, adjusting the
exact 2D plane for valve area planimetry (no real control
of plane position at the narrowest orifice) is challenging.
In addition, the dynamic movement of the aortic annulus
during the cardiac cycle may result in misalignment of
the true cross-sectional view.19 The aortic annulus moves

Aortic Stenosis  105

 17.5 mm

17.5 mm

23 mm

Figure 9.5  Elliptical left ventricular outflow tract (LVOT) in a patient with aortic stenosis. 3D TTE is able to detect the shape of the LVOT
during systole or diastole (here midsystole) in order to measure its maximal and minimal diameters and compute the surface of the LVOT,
irrespective of its shape. The surface of the LVOT calculated this way may be introduced in the continuity equation for optimization of aortic
effective orifice area calculation .

A B CSA = 3.4 cm²

Sagial plane

C D

Coronal plane

Figure 9.6  Multiplanar assessment of the aortic annulus using 3D TEE . (A,C) Long-axis views of the aortic valve, (B) short-axis view
orthogonal to the long-axis views showing an irregular annular shape with maximum and minimum diameters, and (C) coronal plane.

cranially during early systole, caudally during the remaining
of the systole, and isovolumic relaxation and back to cranial
position during diastole. The degree of displacement is
larger for the anterior part of the annulus.4 This makes 2D
echocardiography less optimal to assess the aortic valve
opening area (anatomical valve area): First, because of the
through-plane motion of these structures during systole, and
second, because of the tilting of both aortic annulus and
leaflets during systole (anterior part of the annulus shows a
larger displacement) causing an oblique alignment of the 2D
cross-sectional view.19
However, real-time 3D TEE/TTE can overcome this
limitation by rendering a comprehensive and dynamic
visualization of the entire aortic valve. It allows tracking
of the anatomical valve area throughout systole, and by
cropping and plane adjustments, en face alignment of the
cut plane to the aortic valve orifice irrespective of its spatial
orientation in regard to the surrounding structures. This

106  3D Echocardiography
Table 9.1  Aortic Annular Measurements Derived from Different Methods and Imaging Techniques
3D TEE AAA (mm ) 2
Stella et al.18 Manual −16
Semiautomated −18
Prihadi et al.17 Automated −10
Podlesnikar et al.16 Automated −12
Khalique et al.15 Manual −14
Semiautomated −8
Utsunomiya et al.14 Manual −37
Vaquerizo et al.13 Manual −81
Jilaihawi et al.12 Manual −45
AAA, aortic annulus area; MDCT, multidetector row computed tomography; TEE, transthoracic echocardiography.
way, the smallest AVA can be accurately identified. 3D
planimetered AVA has good agreement with AVA by CE
or CT, while it moderately agrees with Gorlin’s formula
at catheterization. 3D TEE planimetry showed superior
accuracy than 2D TEE, which significantly overestimated
the AVA.20–22
When there is an associated obstruction at subvalvular
level and Doppler methods cannot be reliably applied, orifice
planimetry by 3D echocardiography can provide critical
information about stenosis severity for both valvular and
subvalvular narrowing. After comparison with 3D-guided
aortic valve orifice planimetry, it has been hypothesized
that the optimal 2D short-axis view of the aortic cusps for
the calculation of anatomical AVA is the one that provides
visualization of the aortic cusps only during systole, but not
during diastole.19
Of note, planimetry of the AVA has some drawbacks.
Planimetry may overestimate the severity of AS in low
cardiac output patients, as the anatomical area of aortic
valve opening is reduced. Moreover, heavily calcifications
of the aortic valve leaflets (shadowing or reverberations)
and poor image quality make the orifice area difficult to
planimeter with either 2D or 3D echocardiography.21
EFFECTIVE AORTIC VALVE AREA
In AS, quantification of effective AVA is currently based
on the determination of the pressure gradients across
the aortic valve - flow-dependent parameters - and
the assessment of the AVA by the CE - a relatively flow-
independent parameter. 2,23 By applying the CE, AVA
calculation requires the evaluation of LV stroke volume
at the level of LVOT, which is calculated by multiplying the
cross-sectional area derived from the LVOT diameter by
the pulsed-wave Doppler time-velocity integral (TVI) of
flow in the LVOT. However, stroke volume calculation by
this method assumes a circular and regular LVOT shape
and a laminar LVOT flow profile. 23
THREE-DIMENSIONALLY DERIVED LEFT VENTRICULAR
OUTFLOW TRACT/ANNULAR DIMENSION
LVOT/annular diameter is the greatest potential source
of error in the CE. Off-axis measurement may lead to
underestimation of AVA. Any error of 1 mm in the LVOT
Paired Difference (MDCT vs. 3D TEE)
Perimeter (mm) Major Diameter (mm) Minor Diameter (mm)
−1.3 −3.0 0.2
−3.3 −2.0 0.1
−0.2 −0.8 −0.2
−2.7 −1.8 0.5
– –
– – –
– −2.0 −0.8
−6.5 −2.7 −0.7
−4.9 −2.4 −0.9
diameter will lead to an error in AVA estimation of 0.1 cm2.
Practically, LVOT diameter measurement is obtained from a
2D parasternal long-axis zoomed view with the 2D imaging
cut-plane parallel to the LVOT direction. Careful angulation
of the transducer is performed to find maximal LVOT
diameter. However, the presence of an elliptical or irregular-
shaped LVOT may result in some degree of imprecision in
AVA calculation.9–11
Despite assuming a circular LVOT shape in the CE,
2D echocardiography remains the standard for the
measurement of AS severity because these parameters have
been shown to be strong predictors of clinical outcomes.23
In most patients, the sagittal LVOT diameter does not
change much in the 1 cm proximal to the aortic valve.24
However, in patients with a “sigmoid septum,” the LVOT
diameter measured 0.5–1 cm apically from the annulus
with 2D TTE/TEE will often appear smaller than the
flow area (cropped from a 3D dataset) at the annulus.
In addition, when LVOT velocity is measured 0.5–1 cm
below the aortic annulus owing to flow convergence, the
velocity profile may no longer be flat but rather skewed
with the highest velocities present at the septum.23 Hence,
Doppler estimation of stroke volume by the CE has a risk
of both over- and underestimation of AS severity. 3D TEE
provides measurements of aortic annulus diameters similar
to those obtained by CT, while 2D imaging techniques,
providing only a sagittal view, underestimate aortic
annulus diameters.9 3D TEE measurements of the distances
between aortic annulus and coronary ostia correlated very
well with the measurements obtained by CT (reference
technique)9 (Figure 9.7, ). Direct planimetry of the LVOT/
annulus areas by 3D TEE showed the best agreement with
computed tomography, while the calculations based on the
diameter measured by 2D or 3D TEE led to significant area
underestimation. Hence, for patients categorized by 2D
echocardiography as having severe AS, 10% and 25% can be
recategorized into “moderate” AS using the calculated 3D
TEE circular LVOT/annular area and planimetered 3D TEE
area, respectively.25 Thus, by avoiding the assumptions about
LVOT geometry needed for the calculation of AVA in 2D
echocardiography, direct planimetry of the LVOT available
with 3D echocardiography might improve precision of the
AVA calculation by the CE. However, it has to be emphasized
Aortic Stenosis  107
Figure 9.7  Multiplanar assessment of the aortic annulus using 3D TEE examining the relationship between aortic annulus and the coronary
ostia . (LCA, left coronary artery; RCA, right coronary artery.)
that studies using hybrid methods for calculating effective
AVA (LVOT cross-sectional area with 3D imaging CT or
TEE) have suggested that an effective AVA less than 1.2 cm2
may be the threshold to apply to consider AS severe. Hence,
care is to be taken if effective AVA calculated with the
hybrid method is between 1 and 1.2 cm2, as these values
may actually indicate severe AS.
THREE-DIMENSIONALLY DERIVED CONTINUITY
EQUATION (VOLUMETRIC METHOD)
Another source of error in the calculation of 2D LVOT-
derived stroke volume relates to LVOT flow determination,
which is performed using another echocardiographic
window and so differs in timing and location relative to
the LVOT diameter measurement. Flow velocity varies
Figure 9.8  3D volumetric assessment of the stroke volume
LV, left ventricle; PW, pulsed wave.)
108  3D Echocardiography
within the LVOT, having a nonuniform pattern with higher
velocities toward the septum.23 Such limitations may be
overcome by the 3D volumetric assessment of the stroke
volume using semiautomated LV border detection (TTE
apical full volume acquisition). 3D stroke volume (end-
systolic volume minus end-diastolic volume) is thus used at
the numerator of the CE (Figure 9.8, ). In asymptomatic
AS, the CE-derived stroke volume index has been reported
to be larger compared to the 2D-/3D-derived stroke
volume index with modest correlations.26 In the study of
Gutierrez-Chico et al., the 3D assessment had the best linear
association and absolute agreement with Gorlin’s equation.27
Observer agreements for 3D-derived AVA were better than
agreements for CE-derived AVA. The 3D assessment was
. (Ao, aorta; AS, aortic stenosis; AVA, aortic valve area; CW, continuous wave;
 (a)
LV
(b)
DIASTOLE
Figure 9.9  (a) Positioning of the Edwards Sapien valve at the level of the aortic valve annulus
Sapien valve .
also more accurate than CE and 2D volumetric methods to
calculate AVA and grade AS severity.
THREE-DIMENSIONALLY DERIVED COLOR DOPPLER
FLOW
3D color Doppler can also overcome the inaccuracies of
spectral Doppler for stroke volume calculation by directly
measuring stroke volume–derived velocities within one
imaging window. This approach circumvents any assumptions
about the LVOT shape and velocity profiles.28 Practically, a
3D hemispheric sampling curve captures velocities within the
LVOT during the entire systole. After offline computation of
velocities, a reproducible measurement of the LVOT flow is
obtainable. Measurements of stroke volume by using 3D color
Doppler have been shown to be feasible with good agreement
with CMR phase contrast imaging.29 In patients, AVA derived
from 2D CE correlated only modestly with that derived from
3D color Doppler. Such significant discrepancies between
both methods were predicted by the presence of distorted
LVOT geometry. Of note, there was better agreement of
3D-derived AVA using color Doppler with AVA guided by
planimetry, an independent anatomical standard. Hence,
3D echocardiography color Doppler–derived LVOT stroke
volume in the calculation of AVA by CE has potential
advantages compared to 2D CE.
Ao
SYSTOLE
. (b) En face 3D TEE assessment of the Edwards
IMAGING DURING TRANSCATHETER AORTIC
VALVE REPLACEMENT
Echocardiography is critical for pre-, per-, and postprocedural
evaluation of TAVR, providing both anatomical and
hemodynamic information.8,30 Preprocedural assessment
of candidates for TAVR was covered earlier, especially
the problems relative to the accurate sizing of the aortic
annulus. Periprocedural imaging evaluation during TAVR
can contribute to balloon and prosthesis positioning, to
confirm prosthesis function after implantation, and to
rapidly detect complications. 3D TEE guidance has been
associated with less contrast use31 and lower incidence of
periprocedural paravalvular regurgitation-related events.32
During the intervention, real-time 3D TEE enables
improved navigation of catheters and prostheses, which
can be stereoscopically depicted. 3D TEE is especially useful
during TAVR to ensure coaxial catheter alignment in the
LVOT and the aortic root, to guide prosthesis deployment,
and to examine its relationship with the anterior mitral
leaflet (Figures 9.9, ). Immediately after deployment, 3D
TEE is essential to confirm that all prosthetic cusps are
moving well, that the valve stent has a circular shape, and
to exclude any aortic regurgitation, which if severe and
paraprosthetic, may prompt balloon reinflation.
Aortic Stenosis  109

CONCLUSION
3D TTE and TEE offer additional information of the aortic
valve morphology and function and should be incorporated,
when available, in the assessment of AS, especially in cases
when 2D echocardiography provides conflicting results.
3D echocardiographic study is also recommended for
identification of bicuspid aortic valves and measurement of
the aortic annulus size before TAVI procedures.
REFERENCES
1. Nkomo VT, Gardin JM, Skelton TN et  al. Burden of valvular heart
diseases: A population-based study. Lancet. 2006;368:1005–11.
2. Osnabrugge RL, Mylotte D, Head SJ et al. Aortic stenosis in the elderly:
Disease prevalence and number of candidates for transcatheter aortic
valve replacement: A meta-analysis and modeling study. J Am Coll Cardiol.
2013;62:1002–12.
3. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS Guidelines for the
management of valvular heart disease. Eur Heart J. 2017;38:2739–91.
4. Lang RM, Badano LP, Tsang W et al. EAE/ASE recommendations for
image acquisition and display using three-dimensional echocardiography.
Eur Heart J Cardiovasc Imaging. 2012;13:1–46.
5. Lancellotti P, Tribouilloy C, Hagendorff A et al. European Association
of Echocardiography recommendations for the assessment of valvular
regurgitation. Part 1: Aortic and pulmonary regurgitation (native valve
disease). Eur J Echocardiogr. 2010;11:223–44.
6. Hamdan A, Guetta V, Konen E et  al. Deformation dynamics and
mechanical properties of the aortic annulus by 4-dimensional computed
tomography. J Am Coll Cardiol. 2012;59:119–27.
7. Anderson RH. Clinical anatomy of the aortic root. Heart. 2000;84:670–3.
8. Zamorano JL, Badano LP, Bruce C et al. EAE/ASE recommendations for
the use of echocardiography in new transcatheter interventions for valvular
heart disease. Eur Heart J. 2011;32:2189–214.
9. Altiok E, Koos R, Schroder J et  al. Comparison of two-dimensional
and three-dimensional imaging techniques for measurement of aortic
annulus diameters before transcatheter aortic valve implantation. Heart.
2011;97:1578–84.
10. Messika-Zeitoun D, Serfaty JM, Brochet E et al. Multimodal assessment
of the aortic annulus diameter: Implications for transcatheter aortic valve
implantation. J Am Coll Cardiol. 2010;55:186–94.
11. Paelinck BP, Van Herck PL, Rodrigus I et al. Comparison of magnetic
resonance imaging of aortic valve stenosis and aortic root to multimodality
imaging for selection of transcatheter aortic valve implantation candidates.
Am J Cardiol. 2011;108:92–8.
12. Jilaihawi H, Doctor N, Kashif M et  al. Aortic annular sizing for
transcatheter aortic valve replacement using cross-sectional 3-dimensional
transesophageal echocardiography. J Am Coll Cardiol. 2013;61:908–16.
13. Vaquerizo B, Spaziano M, Alali J et  al. Three-dimensional
echocardiography vs. computed tomography for transcatheter aortic valve
replacement sizing. Eur Heart J Cardiovasc Imaging. 2016;17:15–23.
14. Utsunomiya H, Mihara H, Itabashi Y et  al. Geometric changes in
ventriculoaortic complex after transcatheter aortic valve replacement
and its association with post-procedural prosthesis-patient mismatch: An
intraprocedural 3D-TEE study. Eur Heart J Cardiovasc Imaging. 2017;18:1–10.
15. Khalique OK, Hamid NB, White JM et  al. Impact of methodologic
differences in three-dimensional echocardiographic measurements of the
aortic annulus compared with computed tomographic angiography before
transcatheter aortic valve replacement. J Am Soc Echocardiogr. 2017;30:414–21.
16. Podlesnikar T, Prihadi EA, van Rosendael PJ et  al. Influence of the
quantity of aortic valve calcium on the agreement between automated
3-dimensional transesophageal echocardiography and multidetector row
computed tomography for aortic annulus sizing. Am J Cardiol. 2018;121:86–93.
110  3D Echocardiography
17. Prihadi EA, van Rosendael PJ, Vollema EM, Bax JJ, Delgado V, Ajmone
Marsan N. Feasibility, accuracy, and reproducibility of aortic annular
and root sizing for transcatheter aortic valve replacement using novel
automated three-dimensional echocardiographic software: Comparison
with multi-detector row computed tomography. J Am Soc Echocardiogr.
2018;31:505–14.
18. Stella S, Italia L, Geremia G et al. Accuracy and reproducibility of aortic
annular measurements obtained from echocardiographic 3D manual and
semi-automated software analyses in patients referred for transcatheter
aortic valve implantation: Implication for prosthesis size selection. Eur Heart
J Cardiovasc Imaging. 2019;20:45–55.
19. Nakai H, Takeuchi M, Yoshitani H, Kaku K, Haruki N, Otsuji Y. Pitfalls
of anatomical aortic valve area measurements using two-dimensional
transoesophageal echocardiography and the potential of three-
dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2010;
11:369–76.
20. 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.
21. Muraru D, Badano LP, Vannan M, Iliceto S. Assessment of aortic valve
complex by three-dimensional echocardiography: A framework for its
effective application in clinical practice. Eur Heart J Cardiovasc Imaging.
2012;13:541–55.
22. Machida T, Izumo M, Suzuki K et al. Value of anatomical aortic valve area
using real-time three-dimensional transoesophageal echocardiography in
patients with aortic stenosis: A comparison between tricuspid and bicuspid
aortic valves. Eur Heart J Cardiovasc Imaging. 2015;16:1120–8.
23. Baumgartner H, Hung J, Bermejo J et al. Recommendations on the
echocardiographic assessment of aortic valve stenosis: A focused update
from the European Association of Cardiovascular Imaging and the
American Society of Echocardiography. Eur  Heart J Cardiovasc Imaging.
2017;18:254–75.
24. Caballero L, Saura D, Oliva-Sandoval MJ et  al. Three-dimensional
morphology of the left ventricular outflow tract: Impact on grading aortic
stenosis severity. J Am Soc Echocardiogr. 2017;30:28–35.
25. Ng AC, Delgado V, van der KF et al. Comparison of aortic root dimensions
and geometries before and after transcatheter aortic valve implantation by
2- and 3-dimensional transesophageal echocardiography and multislice
computed tomography. Circ Cardiovasc Imaging. 2010;3:94–102.
26. Nabeshima Y, Nagata Y, Negishi K et al. Direct comparison of severity
grading assessed by two-dimensional, three-dimensional, and Doppler
echocardiography for predicting prognosis in asymptomatic aortic stenosis.
J Am Soc Echocardiogr. 2018;31:1080–90.
27. Gutierrez-Chico JL, Zamorano JL, Prieto-Moriche E et  al. Real-
time three-dimensional echocardiography in aortic stenosis: A novel,
simple, and reliable method to improve accuracy in area calculation.
Eur Heart J. 2008;29:1296 –306.
28. Poh KK, Levine RA, Solis J et  al. Assessing aortic valve area in
aortic stenosis by continuity equation: A novel approach using real-
time three-dimensional echocardiography. Eur Heart J. 2008;29:
2526–35.
29. Thavendiranathan P, Liu S, Datta S et al. Automated quantification
of mitral inflow and aortic outflow stroke volumes by three-dimensional
real-time volume color-flow Doppler transthoracic echocardiography:
Comparison with pulsed-wave Doppler and cardiac magnetic resonance
imaging. J Am Soc Echocardiogr. 2012;25:56–65.
30. Tamburino C, Capodanno D, Ramondo A et  al. Incidence and
predictors of early and late mortality after transcatheter aortic valve
implantation in 663 patients with severe aortic stenosis. Circulation. 2011;
123:299–308.
31. Bagur R, Rodés-Cabau J, Doyle D et  al. Usefulness of TEE as the
primary imaging technique to guide transcatheter transapical aortic valve
implantation. JACC Cardiovasc Imaging. 2011;4:115–24.
32. Hayek SS, Corrigan FE III, Condado JF et al. Paravalvular regurgitation
after transcatheter aortic valve replacement: Comparing transthoracic
versus transesophageal echocardiographic guidance. J Am Soc Echocardiogr.
2017;​30:533–40.
 10 Aortic Regurgitation
INTRODUCTION
During the two last decades, surgical techniques to repair
the aortic valve have emerged as a valuable alternative
to replacement in case of aortic regurgitation. Besides
the tremendous advantage of avoiding complications
related to anticoagulation, and offering a lower risk for
endocarditis, these techniques required more surgical skills
and perfect comprehension of the mechanism leading to
aortic regurgitation. This may explain the growing interest
in understanding the mechanism underlying aortic
regurgitation and the interaction of the different aortic root
components. Careful echographic assessment plays a key
role in identifying the mechanism of aortic regurgitation
and thus guiding the surgical procedure.1
FUNCTIONAL ANATOMY OF THE AORTIC
VALVE AND THE AORTIC ROOT
The aortic root is the portion of the ascending aorta that
lies between the sinotubular ridge superiorly and the bases
of the valve leaflets inferiorly. The aortic root must be
considered as a single functional entity.2–4 This includes the
sinuses, the aortic valve leaflets, the commissures, and the
interleaflet triangles (Figure 10.1). The leaflets are attached
in a semilunar fashion at the upper boundary of the root
called the sinotubular junction. Their lower part located
below the anatomical ventriculoarterial junction defines the
base of the aortic root. From a hemodynamic point of view,
they represent the separation between the left ventricle
and the aorta. The sinuses are the expended portion of
the root below the sinotubular junction. They are named
Figure 10.1  3D view of the different components of the aortic root: The sinotubular junction (black line), the crown-like insertion of the
aortic cusps (red line), the anatomical ventriculoaortic junction (green line), the aortic annulus (blue line). (Adapted from Muraru D, et al.
Eur Heart J Cardiovasc Imaging. 2012;13:541–55.)
according to the coronary arteries arising: right coronary,
left coronary, and noncoronary sinus. The definition of the
annulus varies. The imaging “annulus,” frequently called
the virtual ring, corresponds to the most basal insertion of
the leaflet and is considered as the reference measurement,
for determination of aortic size does not correspond to
the true anatomical “annulus” referring to a semilunar
crown-like structure demarcated by the hinges of the
aortic leaflets.5 Because the anatomical ventriculoarterial
junction could not be delineated by imaging, frequently, the
measurement at the level of the virtual ring is considered as
the ventriculoarterial measurement.6
The normal aortic valve has three cusps of similar
dimensions with three commissures of normal equal
height. The coronary ostia are below the level of the
commissures. The number of commissures of normal height
determines the number of cusps.4 Cusps are characterized
by the effective height that represents the height difference
between the nadir of the free margins and the annular
insertion plane, and by the geometric height that represents
the curved length of the cusp during diastole between the
aortic insertion and the nadir of the free margin.
The coaptation length of the cusps is defined by the
height of adjacent cusp tissue in diastole. Normal coaptation
length is about 2–5 mm (Figure 10.2).7,8
The measurements of the different parts of the aortic
root are linked together by geometrical relationship. For
example, the diameter of the sinotubular junction is 10%–
15% smaller than the diameter of the annulus.9 Preservation
of these relations is important when considering aortic
valve repair to ensure the correct function of the aortic
valve.
Aortic Regurgitation  111

Figure 10.2  Coaptation length of the cusp.
The functional anatomy of the aortic valve is more
complex than it seems just looking at the opening of
the cusp. During the systole, when the left ventricular
pressure exceeds the aortic pressure, the aortic valve opens
allowing left ventricular ejection. With the decrease of
left ventricular pressure, the valve closes when the aortic
pressure surpasses the left ventricular pressure. The upper
portion of the aortic root is exposed to aortic pressure
change, and the proximal part of the root complex is
exposed to ventricular change. Thus, the sizes of the aortic
annulus and root are dynamically changing during the
cardiac cycle by 12% and 16%, respectively.10,11 The sinuses
play an important role, when the leaflets are open. Early
in systole, vortices form between the leaflet and the aortic
wall; they allow some space between the leaflets and the
coronary ostia so the leaflet opening does not occlude the
coronary ostia. After peak systole, they will help in leaflet
closure. The sinus ridge and the shape certainly play a role
in this mechanism.
MECHANISM OF AORTIC REGURGITATION
Aortic regurgitation may be due to abnormalities of the
aortic valve, aortic root, or a combination of both. Because
of the tight relation between the component of the aortic
Figure 10.3  Functional classification of aortic valve regurgitation.
112  3D Echocardiography
root and the aortic valve dilatation of the root, sinotubular
junction or sinus will displace the valve commissures so
the leaflets could not properly coapt during diastole and
may lead to aortic regurgitation. Moreover, the sizes of the
aortic root and annulus change during the cardiac cycle
with the largest dimensions obtained during the first third
of systole and the smallest during isovolumic relaxation.12
Morphological valve abnormalities (see Section “Assessment
of Aortic Valve”) could also lead to aortic regurgitation.
To provide a functional description of aortic lesions
and help the surgeon to choose the most appropriate
technique to restore a normal functioning valve, functional
classification of the aortic regurgitation assessing the lesion
of the regurgitant aortic valve and root is proposed as
follows13 (Figure 10.3):
Type 1: Normal leaflet motion, dilatation of the aortic root
Type 2: Leaflet prolapse or commissural disruption or
fenestration
Type 3: Restricted leaflet motion
TECHNICAL CONSIDERATION FOR
IMAGING THE AORTIC VALVE AND ROOT
MORPHOLOGY BY 3D ECHOCARDIOGRAPHY
3D TRANSTHORACIC ECHOCARDIOGRAPHY
Obtaining a correct image from the aortic valve by 3D
transthoracic echocardiography (TTE) is certainly more
difficult than imaging the mitral valve. This may be explained
by the structure of the valve leaflet (form, thickness of the
cusp) and the position inside the ultrasound beam. Very
thin leaflets could lead to a significant dropout in the image
of the leaflet body.
The common approaches for imaging the aortic valve
by 3D TTE are from the parasternal and apical views.14 For
morphological assessment, the acquisition can be done as
electrocardiogram (ECG) gated full-volume, or real-time
3D image or real-time 3D zoomed images. In addition,
a 3D color volume for assessment of the regurgitant jet
will be acquired. Acquisition will be performed using the
smaller volume required to increase temporal resolution.
Figure 10.4  Cropped 3D dataset to examine the aortic valve morphology from the ventricular and the aortic perspective.
Figure 10.5  Cropped 3D dataset showing long- and short-axis views of the aortic valve and root.
For better results, the gain/compression must be set in
the midrange.15
The 3D echocardiography datasets obtained from the
aortic valve and root can be sliced in any longitudinal or
oblique plane. They can also be cropped and rotated to
examine the aortic valve morphology from the ventricular
or the aortic perspective (Figure 10.4). This 3D method
seems to be the best suited to assess valve morphology.16
The ventricular view allows exact visualization of the left
ventricular outflow tract area. The apical approach allows
visualization of the aortic valve by 3D echocardiography
when the parasternal approach is unsatisfactory. Despite
lower spatial resolution compared to the parasternal view,
precise evaluation of the morphology of the aortic valve and
root could be obtained in some cases with this approach.
3D TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Despite improvement in 3D TTE, the examination will be
inconclusive in some patients. In these cases or simply to
obtain more precise anatomical details, a 3D transesophageal
echocardiography (TEE) examination will be performed.
The examination begins with the 2D multiplane modality
of the probe. The side-by-side display of the short-axis and
long-axis views of the valve allows visualization of the leaflets
displayed on the long-axis view. Using a conventional 2D
echocardiography long-axis view (±120°), the lower cusp is
always the right coronary cusp, but it may be difficult to
identify if the upper cusp is the left or the noncoronary
cusp. This limitation disappears by the use of the multiplane
3D echocardiography approach, which allows identification
of the cusps displayed on the long-axis plane.
The reference planes for the acquisition of a real-time
3D dataset or 3D full-volume ECG triggered are the ±60°
midesophageal short axis and the ±120° midesophageal long
axis.14 After optimization of the bidimensional image, a narrow
angle can be used to optimize the 3D acquisition and to
examine the aortic valve and root anatomy. After acquisition of
full volume or zoomed volumes, the datasets could be cropped
to obtain the short- or long-axis plane or the aortic valve and
root (Figure 10.5). The cutting plane could be moved on the
plane of the left ventricular outflow tract, sinuses of Valsalva,
or sinotubular junction to obtain respective cross-sectional
planes (Figures 10.6A–D and 10.7,  ).
A 3D full-volume dataset with color Doppler will complete
the dataset acquisitions.
ASSESSMENT OF AORTIC ROOT
Usually, the aortic root is assessed by 2D TTE and TEE in
the parasternal long axis. Measurements are performed at
the level of the “annulus,” sinuses, sinotubular junction,
and tubular ascending aorta. 2D echocardiography may
be limited in this assessment by several factors: First, only
one plane could be imaged and some measurements may
Aortic Regurgitation  113
 A ASSESSMENT OF AORTIC VALVE
B documented during surgery.22 The regurgitant aortic valve
C displacement of an aortic leaflet (of part of it) toward the
D
Figure 10.6  Cropped 3D dataset showing multiple manually chosen
tomographic slices across the left ventricular outflow tract (A), the
aortic valve and the sinuses of Valsalva (B) , the sinotubular junction
(C), and the ascending aorta (D).
be oblique; and second, it is sometimes difficult to obtain
all the measurements in the same plane. All of these
difficulties could be overcome using 3D echocardiography.
The aortic annulus morphology was considered as circular
based on the bidimensional echocardiographic approach;
the tomographic techniques teach us that frequently the
shape of the annulus is closer to an oval than a circle17
(Figure 10.8). On 3D echocardiography, the elliptical
shape of the annulus is clearly appreciated from the en face
views with more accurate and reproducible measurements
compared with bidimensional echocardiography.18
Normal values for the aortic root have been recently
published.19,20 Other imaging modalities (computed
tomography, magnetic resonance imaging) are frequently
used for the assessment of the aortic root.
114  3D Echocardiography
The first step is to identify the morphology of the aortic
valve: number of leaflets, leaflet prolapsed/perforation, or
commissural fusion. Initial study using an early generation
3D TEE probe found that adequate aortic valve assessment
was possible in 81% of patients. 21 In a study comparing
bidimensional TEE and epicardial 3D echocardiography
against surgical findings, epicardial 3D echocardiography
was more sensitive to detect the valve abnormalities
could be tricuspid, bicuspid, or more rarely quadricuspid
(Figures 10.9 through 10.12, ).
Like for the mitral valve, an excess of aortic tissue may
also lead to severe aortic regurgitation. This represents the
class II aortic root dysfunction in the classification proposed
earlier. 3D echocardiography allows precise identification
of the location of the leaflet prolapse. By analogy with
the mitral valve, an aortic prolapse is defined as diastolic
left ventricle beyond the plane of the aortic annulus in
diastole.23 Several forms of prolapse could be recognized:
• Flail leaflet: There is no more coaptation and the leaflet
is freely “floating” in the outflow tract as shown on 3D
echocardiography as a typical spoon appearance.
• Prolapse: A leaflet is displaced below the level of the
annulus reducing the coaptation length.
• Partial leaflet prolapse: Only part of the leaflet is
prolapsing; frequently, the leaflet is divided into two
parts by a fibrous band and only the free margin portion
is prolapsed.
By cutting through the volume dataset of the aortic root, it
is easy to clearly demonstrate the location of the prolapse and
the kind of prolapse (Figure 10.13A–C, ). Dilatation of the
aortic root could also be assessed by 3D echocardiography
and full volume could be cropped as desired to analyze the
dimension of the root (Figure 10.14, ).
3D echocardiography allows measurement of parameters
that reflect the spatial relationships of structures in the aortic
root: Intercommissural distance, free leaflet edge lengths,
and so on. These measurements could not be obtained by
bidimensional echocardiography and could be useful when
choosing the tube graft size in valve-sparing root surgery.24
One other advantage of 3D echocardiography is his ability
to measure distance between the annulus and leaflet tips to
the coronary ostia.
Some tools have been developed and experimented
to quantify the geometry of the aortic root. They
demonstrated good correlation with measurement made
by computed tomography. This may aid in valve-sparing
root operation and transcatheter intervention. 25
QUANTIFICATION OF AORTIC VALVE
REGURGITATION
Numerous methods have been proposed to quantify the
severity of aortic regurgitation. Most of these methods are
based on Doppler measurement and rely on geometric
 A B C

A D E F

G H I

Figure 10.7  Cropped 3D dataset showing consecutive, automatically generated tomographic slices across the left ventricular outflow tract,
aortic valve, sinuses of Valsalva, sinotubularjunction, and ascending aorta (A–I) .

Figure 10.8  Aortic annulus morphology.

Figure 10.9  Cropped 3D full-volume dataset showing an en face view Figure 10.10  Cropped 3D full-volume dataset showing an en face
of a normal tricuspid aortic valve from the aortic perspective . view (aortic perspective) of a bicuspid aortic valve .

Aortic Regurgitation  115


Figure 10.11  Cropped 3D dataset showing slice across a quadricuspid
aortic valve .
A B
Figure 10.12  Cropped 3D dataset showing short- (A) and long-axis (B,C) slices across a quadricuspid aortic valve.
A B
Figure 10.13  Cropped 3D dataset showing tomographic slices across the different cusp (A, B, C) allowing identification of the location of
the fenestration/prolapse and coaptation height at different level. Panel C shows a cut between non-coronary and right coronary cusp (red
line), demonstrating fenestration and prolapse .
116  3D Echocardiography
assumption (proximal isovelocity surface area [PISA]
method). 26 3D echocardiography can be helpful for
accurate quantification of aortic regurgitation. An
earlier animal experimental study has demonstrated
that the volume of aortic regurgitation measured by 3D
echocardiography correlated well with electromagnetic flow
meter measurement.27
Measurement of vena contracta is one of the popular
methods to quantitative aortic regurgitation. The cross-
sectional area of the vena contracta could be used as a
surrogate of the effective regurgitant orifice area. However,
quantification of the vena contracta using conventional
bidimensional color Doppler can result in incorrect
estimates resulting from geometric assumptions that the
regurgitant orifice shape is always planar and round, when
in reality its geometry can be variable or several regurgitant
jets could be present.
A color 3D volume dataset acquired from the apical
or parasternal window could be cropped with dedicated
software. Multiple transversal planes perpendicular to the
direction of the regurgitant jet could be sliced giving a
direct en face view of the regurgitant jet just below the aortic
C
C
 A
A B
D E
G H
Figure 10.14  Cropped 3D dataset showing tomographic slices across the aortic root to analyze the dimension of the different part of the
root (A–I) Sinotubularjunction (E), ascending aorta (G–I) .
valvular plane. This view allows direct planimetry of the
vena contracta area at the level of the smallest color jet area
(Figures 10.15 and 10.16, ). This approach was validated in
animal models.28 Human studies confirm that frequently the
vena contracta area was not circular and that severity of aortic
regurgitation assessed by 3D echocardiography correlated
well with surgical finding or with angiographic grade.29,30
More recently, a study in patients with chronic aortic
regurgitation found that the vena contracta area computed
I
C
F
I
by 3D echocardiography correlated better with measurement
of aortic regurgitation by cardiac magnetic resonance than
traditional echocardiography-Doppler methods.31
Other 3D echocardiography methods have also been
proposed for the assessment of aortic regurgitation. Aortic
regurgitation could be quantified by using the difference
between right ventricular and left ventricular stroke
volumes.32 It is also possible to measure directly the PISA
with 3D echocardiography.33
Aortic Regurgitation  117

Figure 10.15  Cropped 3D color dataset showing the size and
shape of the vena contracta in a patient with a single aortic valve
regurgitation jet . 11. Brewer RJ, Deck JD, Capati B et al. The dynamic aortic root. Its role in
Figure 10.16  Cropped 3D color dataset showing the size and shape of
the vena contracta in a patient with multiple aortic valve regurgitation
jets .
CONCLUSION
3D echocardiography is part of the assessment of the patient
with aortic regurgitation, especially if aortic valve repair
surgery is contemplated. It facilitates assessment of the
mechanism of aortic regurgitation and could also be used
to evaluate the severity of the aortic regurgitation.
118  3D Echocardiography
REFERENCES
1. Vanoverschelde JL, van Dyck M, Gerber B et  al. The role of
echocardiography in aortic valve repair. Ann Cardiothorac Surg. 2013;2:65–72.
2. Sutton JP, Ho SY, Anderson RH. The forgotten interleaflet triangles:
A review of the surgical anatomy of the aortic valve. Ann Thorac Surg.
1995;59:419–27.
3. Underwood MJ, El Khoury G, Deronck D et al. The aortic root: Structure,
function, and surgical reconstruction. Heart 2000;83:376–80.
4. Ho SY. Structure and anatomy of the aortic root. Eur J Echocardiogr.
2009;10:i3–i10.
5. Anderson RH, Devine WA, Ho SY et  al. The myth of the aortic
annulus: The anatomy of the subaortic outflow tract. Ann Thorac Surg
1991;52:640–6.
6. Hagendorff A, Evangelista A, Fehske W et  al. Improvement in the
assessment of aortic valve and aortic aneurysm repair by 3-dimensional
echocardiography. J Am Coll Cardiol Imaging. 2019;12:2225–44.
7. Bierbach BO, Aicher D, Abu Issa O et al. Aortic root and cusp configuration
determine aortic valve function. Eur J Cardiothorac Surg. 2010;38:400–6.
8. Schäfers HJ, Schmied W, Marom G et al. Cusp height in aortic valves. J
Thorac Cardiovasc Surg. 2013;146:269–74.
9. Kunzelman KS, Grande KJ, David TE et  al. Aortic root and valve
relationships. Impact on surgical repair. J Thorac Cardiovasc Surg
1994;107:162–70.
10. Hamdan A, Guetta V, Konen E et  al. Deformation dynamics and
mechanical properties of the aortic annulus by 4-dimensional computed
tomography. J Am Coll Cardiol. 2012;59:119–27.
aortic valve function. J Thorac Cardiovasc Surg. 1976;72:413–7.
12. Veronesi F, Corsi C, Sugeng L et al. A study of functional anatomy of aortic-
mitral valve coupling using 3D matrix transesophageal echocardiography.
Circ Cardiovasc Imaging. 2009;2:24–31.
13. El Khoury G, Glineur D, Rubay J et al. Functional classification of aortic
root/valve abnormalities and their correlation with etiologies and surgical
procedures. Curr Opin Cardiol. 2005;20:115–21.
14. Lang RM, Badano LP, Tsang W et al. EAE/ASE recommendations for
image acquisition and display using three-dimensional echocardiography.
J Am Soc Echocardiogr. 2012;25:3–46.
15. Hung J, Lang R, Flachskampf F et al. 3D echocardiography: A review of
the current status and future directions J Am Soc Echocardiogr. 2007;20:213–33.
16. Muraru D, Badano LP, Vannan M et  al. Assessment of aortic valve
complex by three-dimensional echocardiography: A framework for its
effective application in clinical practice. Eur Heart J Cardiovasc Imaging.
2012;13:541–55.
17. Messika-Zeitoun D, Serfaty JM, Brochet E et al. Multimodal assessment
of the aortic annulus diameter: Implications for transcatheter aortic valve
implantation. J Am Coll Cardiol 2010;55:186–94.
18. Doddamani S, Bello R, Friedman MA et  al. Demonstration of left
ventricular outflow tract eccentricity by real time 3D echocardiography:
Implications for the determination of aortic valve area. Echocardiography.
2007;24:860–6.
19. Lang RM, Badano LP, Mor-Avi V et al. Recommendations for cardiac
chamber quantification by echocardiography in adults: An update from
the American Society of Echocardiography and the European Association
of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015;16:233–70.
20. Rodríguez-Palomares JF, Teixido-Tura G, Galuppo V et al. Multimodality
assessment of ascending aortic diameters: Comparison of different
measurement methods. J Am Soc Echocardiogr. 2016;29:819–26.
21. Kasprzak JD, Salustri A, Roelandt JR et  al. Three-dimensional
echocardiography of the aortic valve: Feasibility, clinical potential, and
limitations. Echocardiography. 1998;15:127–38.
22. Vida VL, Hoehn R, Larrazabal LA et al. Usefulness of intra-operative
epicardial three-dimensional echocardiography to guide aortic valve repair
in children. Am J Cardiol. 2009;103:852–6.
23. Flachkampf FA, Wouters P, Edvarsen Th et al. Recommendations for
transoesophageal echocardiography: Update 2014. Eur J Cardiovasc Imaging.
2014;15:353–65.
24. Otani K, Takeuchi M, Kaku K et al. Assessment of the aortic root using
real-time 3D transesophageal echocardiography. Circ J. 2010;74:2649–57.
25. Calleja A, Thavendiranathan P, Ionasec RI et al. Automated quantitative
3-dimensional modeling of the aortic valve and root by 3- dimensional
transesophageal echocardiography in normals, aortic regurgitation, and
aortic stenosis: Comparison to computed tomography in normal and
clinical implications. Circ Cardiovasc Imaging. 2013;6:99–108.
26. Lancellotti P, Tribouilloy Ch, Hagendorff A et al. European Association
of Echocardiography recommendations for the assessment of valvular
regurgitation. Part 1: Aortic and pulmonary regurgitation (native valve
disease). Eur J Echocardiogr. 2010;11:223–44.
27. Acar Ph, Jones M, Shiota T et al. Quantitative assessment of chronic
aortic regurgitation with 3-dimensional echocardiographic reconstruction:
Comparison with electromagnetic flowmeter measurements. J Am Soc
Echocardiogr. 1999;12:138–48.
28. Mori Y, Shiota T, Jones M et al. Three-dimensional reconstruction of the
color Doppler-imaged vena contracta for quantifying aortic regurgitation:
Studies in a chronic animal model. Circulation. 1999;99:1611–7.
29. Fang L, Hsiung MC, Miller AP et  al. Assessment of aortic
regurgitation by live three-dimensional transthoracic echocardiographic
measurements of vena contracta area: Usefulness and validation.
Echocardiography. 2005;22:775–81.
30. Chin CH, Chen CH, Lo HS. The correlation between three-dimensional
vena contracta area and aortic regurgitation index in patients with aortic
regurgitation. Echocardiography. 2010;27:161–6.
31. Perez de I, Zamorano J, Fernandez-Golfin C et al. 3D color-Doppler
echocardiography and chronic aortic regurgitation: A novel approach for
severity assessment. Int J Cardiol. 2013;166:640–5.
32. Li X, Jones M, Irvine T et al. Real-time 3-dimensional echocardiography
for quantification of the difference in left ventricular versus right ventricular
stroke volume in a chronic animal model study: Improved results using
C-scans for quantifying aortic regurgitation. J Am Soc Echocardiogr
2004;17:870–5.
33. Pirat B, Little SH, Igo SR et  al. Direct measurement of proximal
isovelocity surface area by real-time three-dimensional color Doppler
for quantitation of aortic regurgitant volume: An in vitro validation. J
Am Soc Echocardiogr. 2009;22:306–13.
Aortic Regurgitation  119
 11 Tricuspid Regurgitation
INTRODUCTION
Tricuspid regurgitation (TR) has an important impact on
patient prognosis, as demonstrated in large epidemiology
studies,1,2 in various disease states, 3–7 and after left heart
surgical and transcatheter therapies.8–11 Awareness of the
dramatic impact on patient survival and morbidity has
raised significant interest in TR pathophysiology, imaging
diagnosis, and percutaneous treatment solutions.12,13
Assessment of the morphology and geometry of the
tricuspid valve (TV) apparatus is the first step of the diagnosis,
as the management of functional TR (FTR) differs from that
of organic TR (OTR).14,15 Echocardiography is the modality of
choice for the initial evaluation of the etiology and the severity
of TR. Cardiac magnetic resonance and multislice computed
tomography are important adjunctive imaging modalities. By
integrating volumetric rendering with motion in real time,
3D echocardiography has become an essential technique
for assessing the morphology and dynamic function of the
TV. The rapidly advancing 3D echocardiography technology
allows us today to perform a virtual “dissection” of the heart
intra vitam and to discover unprecedented, impressive views
of cardiac valves in just a few minutes16 (Figure 11.1, ).
Although 2D echocardiography and Doppler imaging
remain the standard methods to evaluate TR and quantify
its severity, several limitations inherent to 2D echocardiog-
raphy modality frequently preclude an accurate character-
ization of TV anatomy and function:
1. Compared to the mitral valve (MV), the TV has a
greater variability in leaflet morphology, particularly
at the inferomural region (from two up to six leaflets
have been described)17–19 (Figure 11.2, ); as only two
of the three leaflets are routinely imaged in a single 2D
view, the precise identification of leaflets is challenging
by 2D echocardiography depending on the variable
angulations and rotations of the transducer relative to
the leaflet orientation20 (Figure 11.3, ).
2. The maximal dimensions and spatial configuration of the
complex, saddle-shaped tricuspid annulus (TA) cannot
be precisely and reproducibly quantified by a single linear
measure (usually performed by 2D echocardiography as
the mediolateral diameter of TA in apical four-chamber
view)21 (Figures 11.4 and 11.5).
3. TV leaflet commissures and their spatial relationship with
cardiac implantable electronic devices (CIEDs, such as
pacemaker wires, etc.) (Figure 11.6, ), malcoaptation
orifice, or valve area planimetry (Figure 11.7, ; Figure
11.8, ; and Figure 11.9) are generally difficult to assess
by 2D echocardiography, either from a transthoracic or
a transesophageal approach, since an en face view of the
entire valve (usually obtainable for mitral or aortic valve,
but rarely feasible for TV by conventional 2D echocar-
diography) is required for these purposes.22
120  3D Echocardiography
4. Doppler quantitative methods for grading FTR severity
have several limitations, due to unverified geometric
assumptions about the shape of regurgitant orifice and
proximal convergence area23 (Figures 11.10, and 11.11, ).
In contrast, 3D echocardiography is especially suited for
the assessment of the 3D configuration of TV apparatus
and the anatomical complexity of the right ventricle
(RV).13,24,25 3D echocardiography has unique capabilities
to display en face the nonplanar TV leaflets and annulus,
the subvalvular apparatus, and their spatial relationships
with the surrounding structures. The complementary use
of 3D color Doppler flow adds information about valve
integrity and enables the quantitation of TV regurgitation.
Consequently, transthoracic 3D echocardiography has
become an essential technique to noninvasively assess TV
morphology and function in daily practice.26
ANATOMY OF TRICUSPID VALVE APPARATUS
The TV apparatus comprises several components: leaflets
(anterior, posterior, and septal), their annular attachment
at the aortic valve junction, chordae tendinae, papillary
muscles, and ventricular and atrial walls. TV competence
depends on the structural integrity and effective functional
coordination of all these components.
The three leaflets are unequal in size, and the commissures
are not equidistant. Circumferentially, the anterior TV leaflet
is the largest, while the posterior is the smallest and has
multiple scallops27 (Figure 11.1). The septal leaflet is inserted
10 mm or less more apically than the MV, and it is the shortest
and the least mobile among TV leaflets, having chordal
attachment to the interventricular septum.28,29 Compared to
MV leaflets, TV leaflets are thinner, more translucent, and
fragile, and consequently are more challenging to image
and repair. Normal coaptation of the TV valve leaflets takes
place during systole either at the level of the annulus or just
below it. The difference between the total leaflet area and
the annular area represents the coaptation surface (extent of
leaflet overlapping) and characterizes the coaptation reserve
of the TV.30 A reduced coaptation reserve due to significant
annular dilatation will lead to FTR.31
The TA is a complex (less symmetric than the “saddle-
shaped” mitral annulus) nonplanar, highly dynamic structure
that changes in shape and size during the cardiac cycle due
to contraction of the surrounding myocardium. The TA
saddle shape has two high “horns” toward the right atrium
(RA) (i.e., anteroseptal and posterolateral), and two lower
“horns” toward the right ventricle (RV) (i.e., posteroseptal
and anterolateral) (Figure 11.4). The TA is larger and more
dynamic than the mitral annulus. The normal diameter of
the TA annulus by 2D echocardiography depends on the
view and timing of measurement; recently, it was reported
that normal maximal TA diameter measures 33 ± 5 mm or
 A B

Figure 11.1  3D imaging of the tricuspid valve by transesophageal approach at midesophageal level: (A) Ventricular view
and (B) atrial view . (ANT, anterior leaflet; AV, aortic valve; MV, mitral valve; POST, posterior leaflet; SEP, septal leaflet.)

A B C

Figure 11.2  Anatomical variability of tricuspid valve leaflets: (A) Bicuspid, (B) tricuspid, and (C) quadricuspid .

A B

Figure 11.3  Variability of imaging tricuspid valve leaflets in 2D four-chamber view: (A) Cropping plane (yellow line on 3D rendered image)
crosses septal and anterior leaflet and (B) cropping plane crosses septal and posterior leaflet. Note the visualization of adjacent structures
(AML, anterior mitral leaflet; CS, coronary sinus) depending on the relative position of the cropping plane.

19 ± 2 mm/m2 in the RV-focused four-chamber view in early
diastole, with men having larger absolute annulus size than
women.21 The TA upper limit of normality is 23 mm/m2 and
larger than previously described.21,32 The normal TA area in
midsystole is 7.6 ± 1.7 cm2/m2, and the TA area shortens by
35 ± 10% during the cardiac cycle.27 In patients with FTR,
TA becomes larger, rounder, flatter, and less contractile.33,34
As opposed to mitral annulus, the TA does not have a well-
defined annulus fibrosus, it only has a single right fibrous
trigone and is in contact with myocardium over a larger part
of its circumference.35–37 Thus, as the RV free wall expands
outward, dilatation of the TA occurs primarily in its free wall
aspect, while the septal aspect is relatively fixed. Histologically,
the TA is mostly made of fat, and its lower amount of fibrotic

Tricuspid Regurgitation  121


Figure 11.4  3D, saddle-shaped geometry of tricuspid annulus and
reconstruction of leaflets, allows assessment of the tenting volume.
tissue might explain why the TA is more prone to dilate along
with the adjacent chamber than the mitral annulus.
The papillary muscles and chordae form the “tensor
apparatus” of the TV and are pivotal to maintain leaflet
competence during systole.38 The papillary muscles are
different than those supporting the MV, smaller, often
multiple and widely separated. The largest and most consistent
is the anterior papillary muscle with chordae supporting the
anterior and posterior leaflets. RV dilation and remodeling
may displace the anterior papillary muscle attached to the
anterolateral RV wall and contribute to malcoaptation of the
TV leaflets. Accessory chordae may attach to the RV free wall
and to the moderator band, and many third-order chordae
are attached directly to the septum, playing a significant role
in leaflet tethering in FTR.39,40

Figure 11.5  Elliptical shape of tricuspid annulus (as seen from the right atrial perspective, Upper Left Panel). Yellow line corresponds to
the plane position of standard four-chamber view. One can appreciate that the diameter displayed in the four-chamber view, as well as the
orthogonal diameter (corresponding to the white line), underestimates the true largest dimension of the tricuspid annulus.

A B

Figure 11.6  Two examples of severe tricuspid regurgitation in the presence of a pacemaker lead. (A) In the first case, the catheter is in a
central position (arrow) and does not interfere with leaflet mobility . (B) In the second case, the catheter is impinging the septal leaflet
(arrow), limiting its normal coaptation with the other two leaflets. (IVS, interventricular septum .)

122  3D Echocardiography
 A B

C D

Figure 11.7  Mixed tricuspid valve dysfunction (stenosis and organic regurgitation) due to rheumatic heart disease. (A) Right ventricular
focused four-chamber view, displaying the typical leaflet thickening with restricted opening (“doming”) . (B) Doppler tracing across the
tricuspid valve showing mild stenosis (diastolic mean gradient of 5 mm Hg) and a triangular shape of tricuspid regurgitation profile suggestive
of severe regurgitation. (C) 3D reconstruction of stenotic tricuspid valve, showing leaflet thickening, commissural fusion, lack of coaptation
during systole, and restricted opening during diastole, allowing to measure planimetric valve area of 2.1 cm2 ; (D) 3D color Doppler of
tricuspid regurgitation with two longitudinal cut-planes and six transversal slices across the jet for measuring vena contracta area (1.5 cm2).

Figure 11.8  Multislice display of tricuspid valve apparatus by transthoracic 3D echocardiography, for a better appreciation of characteristic
features of rheumatic tricuspid valve involvement and illustration of smallest valve orifice for planimetry .

Tricuspid Regurgitation  123

 A B C

Figure 11.9  Carcinoid valve disease. (A) Thick, rigid tricuspid leaflets fixed in open position, visualized in right ventricular focused four-
chamber view by 2D echocardiography. (B) Free tricuspid regurgitation by 2D color Doppler. (C) 3D visualization of tricuspid valve from
ventricular perspective, showing leaflet thickening, with “frozen” aspect in semiopen position, and restricted diastolic leaflet opening leading
to mild stenosis and severe regurgitation.

A B

Figure 11.10  (A and B) Asymmetry of regurgitation orifice in functional tricuspid regurgitation by 2D color Doppler echocardiography. Note
the differences between the dimensions of the vena contracta and the shape of proximal convergence zone between apical four-chamber
(A) and parasternal long-axis view (B) .

A B C

Figure 11.11  Organic tricuspid regurgitation due to tricuspid valve flail after endomyocardial biopsy in heart transplant recipient. (A) Four-
chamber view by 2D echocardiography showing septal leaflet flail . (B) Severe tricuspid regurgitation with highly eccentric jet, suggestive of
organic etiology . (C) 3D visualization from atrial perspective of a segmental flail localized in anteroseptal position .

The diastolic opening of the valve along with an effective valve closure; however, a trivial or mild TR is
corresponding TA expansion provide a TV orifice area detectable using Doppler echocardiography in 80%–90%
of 7–9 cm2. The systolic narrowing of the orifice provides of normal subjects.41,42

124  3D Echocardiography
 A B

C D

Figure 11.12  Patient with functional tricuspid regurgitation. (A,B) 2D views of tricuspid leaflets, showing annular dilation and leaflet
tethering . (C,D) 3D views of tricuspid valve, illustrating structurally normal leaflets with three-leaflet configuration with significant
tethering . (ATL, anterior tricuspid leaflet; AV, aortic valve; MV, mitral valve; PTL, posterior tricuspid leaflet; RVOT, right ventricular
outflow tract; STL, septal tricuspid leaflet.)

TV is often best achieved from an apical approach, using

IMAGING THE TRICUSPID VALVE BY either an RV-focused or a foreshortened four-chamber
3D ECHOCARDIOGRAPHY view16 (Figures 11.12, and 11.13, ). In order to optimize
the spatial resolution, the TV should be located in the
Transthoracic 3D echocardiography is the preferred
center of the pyramidal volume acquisition. The volume
modality to image the TV. Due to the close proximity of the
size and depth are then adjusted in order to include the
TV to the anterior chest wall, and the position of the leaflets
entire TV complex in the dataset and remove unnecessary
perpendicular to the direction of ultrasound beams during
neighboring structures (i.e., MV, left ventricle, etc.).
systole, an optimal 3D echocardiography acquisition of the

A B C

Figure 11.13  Tricuspid valve endocarditis in drug abuser. (A) Right ventricular (RV) focused four-chamber view - displaying the septal and
posterior leaflets - did not show the vegetation attached to the anterior leaflet, which was better depicted in parasternal RV inflow-outflow
view (B, arrow) and optimally visualized in terms of size, shape, and location by 3D echocardiography (C, arrow) .

Tricuspid Regurgitation  125

 Due to its anatomical position, 3D transesophageal (3D
TEE) imaging of the TV is more challenging than of the
mitral valve. TV can be optimally visualized from a single
midesophageal four-chamber view (Figure 11.1) only in
11% of patients, largely because this valve is anteriorly
located, at a farther distance from the TEE transducer, is
associated with a less favorable angle of insonation, and
has thinner leaflets compared with the mitral valve.43 Low-
esophageal views with lateral angulation of the probe and
transgastric views allow better quality images to be achieved
of TV leaflets in systole and diastole, respectively, than the
standard midesophageal views.
The two most commonly used 3D echocardiography
acquisition modes are real-time and multibeat full-volume
modes, with or without color Doppler.26 Real-time single-
beat 3D echocardiography acquisition has the advantage
of not being limited by motion artifacts (i.e., respirophasic
or patient movement) or electrocardiographic cyclic
variability (i.e., arrhythmias). This acquisition modality
is recommended for intraprocedural guidance of TV
interventional procedures or for assessing respiratory
variations of the regurgitant orifice size. The number of
cardiac cycles to acquire during multibeat acquisition
depends on patient characteristics (cardiac rhythm, ability
to cooperate for breath-holding, etc.), the size of the volume
needed to include the TV apparatus, and the acquisition
depth. For quantitative analyses, a TV dataset should have
a temporal resolution of at least 20 volumes per second.16
FUNCTIONAL TRICUSPID REGURGITATION
FTR is the most common cause of RV dysfunction in the
Western world and has a very high mortality.44 TA dilatation
and leaflet tethering are the main underlying mechanisms of
functional TV regurgitation12 (Figures 11.10 and 11.12). The
extent of TA dilatation may be a more reliable indicator of
TV pathology than the degree of regurgitation.45 TA dilation
is invariably described as secondary to RV dilation and
dysfunction,12,46 which, in turn, distort the normal geometry
and spatial relationships of leaflets, papillary muscles, and
chordae leading to FTR, which further exacerbates RV and
TA remodeling in a vicious circle.46,48 In atrial fibrillation
(AF), RA enlargement may result in TA dilation and FTR,
even in the absence of RV dilation or dysfunction.49,50
Using 3D echocardiography, two independent groups33,52
were able to show that the increase of the TA mediolateral
distance was greater than that of the anterior-posterior
distance with worsening of TV regurgitation, as the TA dilates
preferentially along its free wall. Matsunaga and colleagues53
demonstrated that preoperative TA dilation was associated
with the development of late postoperative TR after the repair
of ischemic mitral regurgitation. Dreyfus and colleagues45
reported that the long-term outcome of the patients improved
when the decision to perform tricuspid annuloplasty was
based on the extent of TA dilation rather than on the degree
of TR at the time of surgery. Reference measures for TV
repair include TA size greater than 2.1 cm/m2 and tricuspid
annulus fractional shortening less than 25%.54 However,
both Matsunaga and Dreyfus used 2D echocardiography
126  3D Echocardiography
for surgery decision making, and this may have led to some
inaccuracies in measuring the true annular size.
Anwar and colleagues 55 demonstrated that 2D
echocardiography systematically underestimated the actual
TA size (Figure 11.5). As a consequence, 65% of patients
with normal TA diameter at 2D echocardiography showed
grades 1–2 FTR compared with 30% of patients with normal
TA size at 3D echocardiography.55 Conversely, calculation of
TA fractional shortening yielded the same results using 2D
echocardiography and 3D echocardiography, because there
is a comparable extent of underestimation of TA diameter
by 2D echocardiography in both diastole and systole.
In addition to TA shape, size, and function, 3D
echocardiography enables the assessment of TV leaflet
geometry in FTR (Figure 11.4). Sukmawan et al.56 reported
that in patients with pulmonary hypertension (i.e., right
ventricular to right atrium gradient ≥30 mm Hg), the
FTR coexists with the tethering of tricuspid leaflets into
the RV. The measured TV tenting volume was linearly
correlated with RV volume and with TV regurgitant jet
area. Min and colleagues57 evaluated the TV apparatus
using 3D echocardiography to predict residual TR after
surgical annuloplasty. Tenting volume and anteroposterior
tricuspid annulus diameter before surgery emerged as
independent preoperative predictors of short-term residual
TR. In addition, the tenting angle between TA plane and
septal leaflet was the most powerful predictor of successful
operative correction of the regurgitation. The authors also
assessed the geometric changes occurring after surgery and
found that annuloplasty led not only to the reduction of TA
size, but also to the worsening of leaflet tenting due to the
inward displacement of the TA. Chen et al.58 have also shown
that TV leaflet geometry and coaptation status assessed by 3D
echocardiography preoperatively enabled the prediction of
the prognosis in patients undergoing surgical annuloplasty
during left-sided heart valve surgery. Thus, tenting volume
greater than or equal to 3.9 mL and ratio of leaflet length to
closure length less than or equal to 1.13 provide important
predictive values for adverse events at 1-year follow-up.
Finally, 3D echocardiography can help in estimating
the severity of TV regurgitation using Doppler color flow.
Velayudhan et al.59 reported a good feasibility for obtaining
the vena contracta area of the TR jet from cropping the 3D
echocardiography color Doppler dataset by imaging planes
exactly parallel to the TV orifice. The authors also found a
poor correlation between the vena contracta area obtained
by 3D echocardiography and its width measured by 2D
echocardiography, supporting the concept that, similar
to mitral regurgitation, the vena contracta of the TR jet
has a complex geometry. However, they found reasonable
correlations between the vena contracta area measured
with 3D echocardiography and the conventional estimates
of TR severity by 2D echocardiography color Doppler (i.e.,
regurgitant jet area and its ratio with right atrial area), and
they proposed new criteria for estimating TR severity based
on vena contracta area: less than 0.5 cm2 for mild, 0.5–
0.75 cm2 for moderate, and greater than 0.75 cm2 for severe.
Recently, using 3D echocardiography-derived regurgitant
volume as a reference standard, Utsunomyia et al.60 identified
a cutoff value of 0.61 cm2 for vena contracta area by 3D TEE
to discriminate severe from moderate TR with sensitivity of
78% and specificity of 97% (area under the curve = 0.93,
P < .001). The recommended cutoff of 0.40 cm2 for 2D
echocardiography proximal isovelocity surface area and
effective regurgitant orifice area had lower sensitivity (58%)
and specificity (79%) than the 3D echocardiography vena
contracta area. Notably, the 3D echocardiography vena
contracta area had an independent and incremental value
to grade TR severity over clinical assessment and integrated
multiparametric 2D echocardiography/Doppler evaluation
recommended by guidelines.61 The cutoff value of the 3D
echocardiography vena contracta area to identify severe TR
was larger for the FTR subgroup than for the primary TR
subgroup (0.63 cm2 vs. 0.51 cm2, respectively).
PRIMARY TRICUSPID REGURGITATION
CARDIAC IMPLANTABLE ELECTRONIC DEVICE LEAD-
INDUCED TRICUSPID REGURGITATION
A sizable number of patients with a permanent pacemaker
or an implantable cardioverter-defibrillator (ICD) (ranging
from 7% to 45% in various studies22) may show significant
TR due to the interference of the leads of such devices with
TV function as the primary cause of valve incompetence.62
Proposed mechanisms involved in the occurrence of CIED-
induced TR can be classified as implantation related, pacing
related, and device mediated.22 Multiple leads, apical RV
pacing, bulky or stiff ICD leads, etc., seem to be associated
with higher likelihood of CIED-induced TR. The lead itself
may interfere with TV function by various mechanisms:
impingement upon a leaflet (Figure 11.6), adherence,
entrapment within the TV subvalvular apparatus, leaflet
perforation, or iatrogenic avulsion (during lead implantation
or extraction, respectively).63
The diagnosis of CIED lead-induced TR may be challenging
using conventional 2D echocardiography because of the
difficulties in identifying the spatial relationship between
the lead and the TV leaflet. 2D echocardiography enables
appreciation of the trajectory of the device lead in only
17% of cases.64 With transthoracic 3D echocardiography,
visualization of the device lead is more reliable and feasible
(74%–90%) than with 2D echocardiography.64,65 The en face
view of the TV obtained by 3D echocardiography allows
for precise identification of the route of the lead across the
right heart cavities, of its position at the TV level, and its
spatial relationship with the individual leaflets. Impinging
or adherent leads on the middle part of the leaflets on 3D
echocardiography en face views were associated with greater
degrees of TR, while leads located in commissural positions
or in the center of the valve were less likely to be associated
with significant TR. Thus, 3D echocardiography remains
the imaging modality of choice for assessment of CIED lead-
induced TR and has been proposed in the imaging protocol
of patients considered for lead removal.66
CONGENITAL TRICUSPID REGURGITATION
Among the congenital abnormalities of the TV, 3D
echocardiography plays a specific role in delineating the
anatomy and functional consequences of Ebstein anomaly.
Ebstein anomaly is a congenital defect of the TV in which
the origins of the septal or posterior leaflets, or both, are
displaced downward into the RV of more than 8 mm/m2,
resulting in the atrialization of the RV inflow. A redundant,
sail-like anterior leaflet with several fenestrations is
generally present. There is a wide spectrum of the severity of
TV involvement, and the outcome of patients with Ebstein
anomaly is mainly dependent on its severity.67 Although 2D
echocardiography can show the characteristic displacement
of the septal leaflet and the redundant and elongated
anterior leaflet, the complex anatomy of the disease and
the mechanisms of TV regurgitation are very difficult to
assess by conventional 2D echocardiography views. In adult
patients with Ebstein anomaly, it has been reported that 3D
echocardiography was particularly useful in delineating
the chordal attachment of the three leaflets of the TV.68,69
This was accomplished by multiple systematic cropping
and sectioning of the 3D echocardiography datasets,
enabling the visualization of the characteristic “bubble-
like” appearance of the leaflets, resulting from the bulging
of the nontethered leaflet areas. In addition, an en face view
of the TV is easily obtainable with 3D echocardiography in
order to measure the leaflet surface areas and to visualize
the regions of ineffective leaflet coaptation. The ability
to measure the surface and the free leaflet margin by 3D
echocardiography is particularly noteworthy in view of the
current repair techniques that involve the construction of
a monocuspid TV using the tissue of the large anterior
leaflet.67 Moreover, 3D echocardiography can be useful in
evaluating the size of the functional RV, and in estimating
the severity of TR by measuring the vena contracta area on
cross-sectional planes placed at the narrowest region of the
3D color Doppler jet.
CARCINOID HEART DISEASE
The TV is the most frequently affected valve in carcinoid
heart disease.70 The valvular involvement consists of leaflet
thickening with excessive fibrosis and markedly restricted
motion. The fibrotic leaflets move in a stiff “board-like”
fashion rather than the normal undulating motion,70 and their
restricted opening leads to the RV inflow obstruction. The TV
leaflets are usually retracted and held partially open during
both systole and diastole, hence resulting in a combined TR
and stenosis, the former being predominant (Figure 11.9).
3D echocardiography is particularly valuable in
assessing patients with carcinoid disease due to its ability
to visualize simultaneously all three TV leaflets from either
the atrial or the ventricular side, their reduced mobility
and stiffness, and the chordal attachments from unique
perspectives.71
TRICUSPID VALVE PROLAPSE
Until the advent of 3D echocardiography, TV prolapse
has remained a poorly defined entity. It is most commonly
associated with MV myxomatous degeneration in 20% up
to 48% of cases. However, isolated prolapse of the TV
leaflets without concomitant mitral disease has been
reported as well.74 Prolapse of one or more leaflets (more
Tricuspid Regurgitation  127
frequently anterior and septal), elongation of chordae,
or chordal rupture producing severe eccentric TR may
be identified (Figure 11.11). Myxomatous-related annular
dilatation contributes not only to the valve incompetence,
but also to progressive worsening of TR.
RHEUMATIC TRICUSPID REGURGITATION
In rheumatic heart valve disease, 2D echocardiography
images show thickening and shortening of the TV leaflets,
which may exhibit some doming in diastole, and result
in combined stenosis and TR. TV leaflet thickening
and restriction had been reported in about one-third
of patients with significant TR after MV surgery, but
the true incidence of organic TV involvement might
actually be higher due to the limitations of conventional
echocardiography to assess the TV morphology. Doppler
recordings of transtricuspid flow velocity allow the
calculation of mean gradient and of the valve area by
pressure half-time method, as described for the MV.
However, unlike what is routinely done for assessing
mitral stenosis severity, neither transthoracic nor
transesophageal 2D echocardiography can routinely
provide en face views of the TV stenotic orifice and of
the fused commissures. Using 3D echocardiography,
the stenotic orifice of the  TV can be clearly visualized
from the ventricular side and can be planimetered on
multiplanar reconstructed images75,76 (Figures 11.7 and
11.8).
TRAUMATIC TRICUSPID REGURGITATION
Traumatic TR is a rare cardiovascular complication that
may occur as a consequence of blunt chest trauma, with
disruption of chordal structures, or from internal (usually
iatrogenic) trauma from a pacemaker lead, a stiff guidewire,
a bioptome during RV endomyocardial biopsy, or during
radiofrequency ablation for treatment of arrhythmias
when devices can perforate TV leaflets or damage
subvalvular chordal apparatus. 3D echocardiography can
accurately delineate the anatomy of the TV and identify
the flail leaflet(s) and the involvement of the subvalvular
apparatus (ruptured chordae and/or papillary muscle),
and may help in the decision making and in planning
the surgical correction.72,73 Another cause of iatrogenic,
traumatic TR is represented by repeated endomyocardial
biopsies (Figure 11.11). TR is the most frequent valvular
abnormality that occurs after cardiac transplantation.
INFECTIVE ENDOCARDITIS OF THE TRICUSPID VALVE
Right-sided infective endocarditis (IE) is rare (5%–10%
of all cases of IE), and the majority of cases (90%) involve
the TV. The main echocardiographic features of TV IE
are the presence of vegetations, which are typically large
(>15–20 mm in length), highly mobile, and affect mainly
the anterior TV leaflet. The main complication of TV
IE is severe TR, and abscess formation was infrequent.
Vegetations or masses of the TV apparatus can be nicely
characterized as shape and size using 3D echocardiography.
3D echocardiographic color Doppler supports the diagnosis
with information on TR mechanism and severity. 3D
echocardiography is particularly useful in patients with
prosthetic devices and TV prostheses to assess the precise
location of the vegetations and their relationship with the
prosthetic structures.77 2D echocardiography has a good
sensitivity to detect pathologic masses and to assess their
mobility, due to its high temporal and spatial resolution.
However, 2D echocardiography limited views may miss

A B

C D

Figure 11.14  Multiplanar reconstruction of tricuspid vegetation from Figure 11.13 illustrating the use of 3D echocardiography to display
and measure the maximal dimensions of the vegetation, overcoming the limitations of 2D echocardiography for its sizing (plane position,
through-plane motion during cardiac cycle, etc.) .

128  3D Echocardiography
the diagnosis when the vegetations develop outside the
standard 2D views of the TV, and lead to uncertainties and
errors regarding their precise insertion and maximal size.
Vegetation size is an important predictor for embolic events
and for response to treatment.51 However, most vegetations
are irregularly shaped and highly mobile, making it difficult
to accurately image them in one 2D view or to select the
largest diameter (Figure 11.13). The selection of a diameter
that is not truly the largest may lead to the misinterpretation
of patient prognosis. 3D echocardiography images the
entire volume of the vegetation mass, allowing for accurate
measurements from multiple planes in order to identify the
true largest dimensions47 (Figure 11.14, ).
CONCLUSION
3D echocardiography complements the conventional 2D
and Doppler echocardiographic assessment of the TV with
detailed information on leaflet morphology and spatial
geometry, mechanism, and severity of TR, and has become
the preferred ultrasound imaging method for assessing
patients with TV pathology. An improved assessment of
valve anatomy and understanding of the pathophysiological
mechanisms underlying the TV regurgitation could
lead to the development of more effective surgical and
interventional techniques for TV repair.
REFERENCES
1. Nath J, Foster E, Heidenreich PA. Impact of tricuspid regurgitation on
long-term survival. J Am Coll Cardiol. 2004;43:405–9.
2. Lee JW, Song JM, Park JP, Kang DH, Song JK. Long-term prognosis of
isolated significant tricuspid regurgitation. Circ J. 2010;74:375–80.
3. Calafiore AM, Gallina S, Iaco AL et al. Mitral valve surgery for functional
mitral regurgitation: Should moderate-or-more tricuspid regurgitation be
treated? A propensity score analysis. Ann Thorac Surg. 2009;87:698–703.
4. Varadarajan P, Pai RG. Prognostic implications of tricuspid regurgitation
in patients with severe aortic regurgitation: Results from a cohort of 756
patients. Interact Cardiovasc Thorac Surg. 2012;14:580–4.
5. Neuhold S, Huelsmann M, Pernicka E et  al. Impact of tricuspid
regurgitation on survival in patients with chronic heart failure: Unexpected
findings of a long-term observational study. Eur Heart J. 2013;34:844–52.
6. Mascherbauer J, Kammerlander AA, Marzluf BA, Graf A, Kocher
A, Bonderman D. Prognostic impact of tricuspid regurgitation in
patients undergoing aortic valve surgery for aortic stenosis. PLOS ONE.
2015;10:e0136024.
7. Dahou A, Magne J, Clavel MA et al. Tricuspid regurgitation is associated
with increased risk of mortality in patients with low-flow low-gradient aortic
stenosis and reduced ejection fraction: Results of the multicenter TOPAS
Study (True or Pseudo-Severe Aortic Stenosis). JACC Cardiovasc Interv.
2015;8:588–96.
8. Henein MY, O’Sullivan CA, Li W et  al. Evidence for rheumatic valve
disease in patients with severe tricuspid regurgitation long after mitral
valve surgery: The role of 3D echo reconstruction. J Heart Valve Dis.
2003;12:566–72.
9. Di Mauro M, Bivona A, Iaco AL et al. Mitral valve surgery for functional
mitral regurgitation: Prognostic role of tricuspid regurgitation. Eur J
Cardiothorac Surg. 2009;35:635–9; discussion 639–40.
10. Ohno Y, Attizzani GF, Capodanno D et  al. Association of tricuspid
regurgitation with clinical and echocardiographic outcomes after
percutaneous mitral valve repair with the MitraClip System: 30-day and
12-month follow-up from the GRASP Registry. Eur Heart J Cardiovasc
Imaging. 2014;15:1246–55.
11. Lindman BR, Maniar HS, Jaber WA et al. Effect of tricuspid regurgitation
and the right heart on survival after transcatheter aortic valve replacement:
Insights from the placement of Aortic Transcatheter Valves II inoperable
cohort. Circ Cardiovasc Interv. 2015;8(4).
12. Badano LP, Muraru D, Enriquez-Sarano M. Assessment of functional
tricuspid regurgitation. Eur Heart J. 2013;34:1875–85.
13. Khalique OK, Cavalcante JL, Shah D et  al. Multimodality imaging
of the tricuspid valve and right heart anatomy. JACC Cardiovasc Imaging.
2019;12:516–31.
14. Baumgartner H, Falk V, Bax JJ et al. 2017 ESC/EACTS guidelines for
the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.
15. Nishimura RA, Otto CM, Bonow RO et al. 2017 AHA/ACC Focused
Update of the 2014 AHA/ACC guideline for the management of patients
with valvular heart disease: A report of the American College of Cardiology/
American Heart Association Task Force on Clinical Practice Guidelines. J
Am Coll Cardiol. 2017;70:252–89.
16. Muraru D, Hahn RT, Soliman OI, Faletra FF, B.asso C, Badano LP.
3-Dimensional echocardiography in imaging the tricuspid valve. JACC
Cardiovasc Imaging. 2019;12:500–15.
17. Sutton JP 3rd, Ho SY, Vogel M, Anderson RH. Is the morphologically
right atrioventricular valve tricuspid? J Heart Valve Dis. 1995;4:571–5.
18. Kawada N, Naganuma H, Muramatsu K, Ishibashi-Ueda H, Bando K,
Hashimoto K. Redefinition of tricuspid valve structures for successful ring
annuloplasty. J Thorac Cardiovasc Surg. 2018;155:1511–9.e1.
19. Holda MK, Zhingre Sanchez JD, Bateman MG, Iaizzo PA. Right
atrioventricular valve leaflet morphology redefined: Implications for
transcatheter repair procedures. JACC Cardiovasc Interv. 2019;12:169–78.
20. Addetia K, Yamat M, Mediratta A et al. Comprehensive two-dimensional
interrogation of the tricuspid valve using knowledge derived from three-
dimensional echocardiography. J Am Soc Echocardiogr. 2016;29:74–82.
21. Miglioranza MH, Mihaila S, Muraru D, Cucchini U, Iliceto S, Badano
LP. Dynamic changes in tricuspid annular diameter measurement in
relation to the echocardiographic view and timing during the cardiac
cycle. J Am Soc Echocardiogr. 2015;28:226–35.
22. Addetia K, Harb SC, Hahn RT, Kapadia S, Lang RM. Cardiac
implantable electronic device lead-induced tricuspid regurgitation. JACC
Cardiovasc Imaging. 2019;12:622–36.
23. Badano LP, Hahn R, Rodriguez-Zanella H, Araiza Garaygordobil D,
Ochoa-Jimenez RC, Muraru D. Morphological assessment of the tricuspid
apparatus and grading regurgitation severity in patients with functional
tricuspid regurgitation: Thinking outside the box. JACC Cardiovasc Imaging.
2019;12:652–64.
24. Muraru D, Surkova E, Badano LP. Revisit of functional tricuspid
regurgitation; Current trends in the diagnosis and management. Korean
Circ J. 2016;46:443–55.
25. Surkova E, Muraru D, Iliceto S, Badano LP. The use of multimodality
cardiovascular imaging to assess right ventricular size and function. Int J
Cardiol. 2016;214:54–69.
26. Lang RM, Badano LP, Tsang W et  al. EAE/ASE recommendations
for image acquisition and display using 3D echocardiography. Eur Heart J
Cardiovasc Imaging. 2012;13:1–46.
27. Addetia K, Muraru D, Veronesi F et al. 3-Dimensional echocardiographic
analysis of the tricuspid annulus provides new insights into tricuspid valve
geometry and dynamics. JACC Cardiovasc Imaging. 2019;12(3):401–12.
28. Taramasso M, Pozzoli A, Basso C et al. Compare and contrast tricuspid
and mitral valve anatomy: Interventional perspectives for transcatheter
tricuspid valve therapies. EuroIntervention. 2018;13:1889–98.
29. Huttin O, Voilliot D, Mandry D, Venner C, Juilliere Y, Selton-Suty C. All
you need to know about the tricuspid valve: Tricuspid valve imaging and
tricuspid regurgitation analysis. Arch Cardiovasc Dis. 2016;109:67–80.
30. Grande-Allen KJ, Barber JE, Klatka KM et al. Mitral valve stiffening in
end-stage heart failure: Evidence of an organic contribution to functional
mitral regurgitation. J Thorac Cardiovasc Surg. 2005;130:783–90.
31. Silbiger JJ. Mechanistic insights into atrial functional mitral
regurgitation: Far more complicated than just left atrial remodeling.
Echocardiography. 2019;36:164–9.
32. Dreyfus J, Durand-Viel G, Raffoul R et al. Comparison of 2-dimensional,
3-dimensional, and surgical measurements of the tricuspid annulus size:
Clinical implications. Circ Cardiovasc Imaging. 2015;8:e003241.
33. Fukuda S, Saracino G, Matsumura Y et al. Three-dimensional geometry
of the tricuspid annulus in healthy subjects and in patients with functional
tricuspid regurgitation: A real-time, 3-dimensional echocardiographic study.
Circulation. 2006;114:I492–8.
Tricuspid Regurgitation  129
34. Muraru D, Surkova E, Badano LP. Revisit of functional tricuspid
regurgitation: Current trends in the diagnosis and management. Korean
Circ J. 2016;46:443–55.
35. Tei C, Pilgrim JP, Shah PM, Ormiston JA, Wong M. The tricuspid valve
annulus: Study of size and motion in normal subjects and in patients with
tricuspid regurgitation. Circulation. 1982;66:665–71.
36. Messer S, Moseley E, Marinescu M, Freeman C, Goddard M, Nair S.
Histologic analysis of the right atrioventricular junction in the adult human
heart. J Heart Valve Dis. 2012;21:368–73.
37. Anderson RH, Ho SY, Becker AE. Anatomy of the human atrioventricular
junctions revisited. Anat Rec. 2000;260:81–91.
38. Tretter JT, Sarwark AE, Anderson RH, Spicer DE. Assessment of the
anatomical variation to be found in the normal tricuspid valve. Clin Anat
(New York, NY). 2016;29:399–407.
39. Xanthos T, Dalivigkas I, Ekmektzoglou KA. Anatomic variations of the
cardiac valves and papillary muscles of the right heart. Ital J Anat Embryol.
2011;116:111–26.
40. Hahn RT. State-of-the-art review of echocardiographic imaging in
the evaluation and treatment of functional tricuspid regurgitation. Circ
Cardiovasc Imaging. 2016;9(12).
41. Singh JP, Evans JC, Levy D et al. Prevalence and clinical determinants of
mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study).
Am J Cardiol. 1999;83 897–902.
42. Klein A, Burstow D, Tajik A et al. Age-related prevalence of valvular
regurgitation in normal subjects: A comprehensive color-flow examination
in 118 volunteers. J Am Soc Echocardiogr. 1990;3 54–63.
43. Sugeng L, Shernan SK, Salgo IS et  al. Live 3-dimensional
transesophageal echocardiography initial experience using the fully-
sampled matrix array probe. J Am Coll Cardiol. 2008;52:446–9.
44. Topilsky Y, Maltais S, Medina Inojosa J et  al. Burden of tricuspid
regurgitation in patients diagnosed in the community setting. JACC
Cardiovasc Imaging. 2019;12:433–42.
45. Dreyfus GD, Corbi PJ, Chan KM, Bahrami T. Secondary tricuspid
regurgitation or dilatation: Which should be the criteria for surgical
repair? Ann Thorac Surg. 2005;79:127–32.
46. Dreyfus GD, Martin RP, Chan KM, Dulguerov F, Alexandrescu C.
Functional tricuspid regurgitation: A need to revise our understanding. J
Am Coll Cardiol. 2015;65:2331–6.
47. Asch FP, Bieganski PM, Panza JA, Weissman NJ. Real-time 3-dimensional
echocardiography evaluation of intracardiac masses. Echocardiography.
2006;23:218–24.
48. Topilsky Y, Tribouilloy C, Michelena HI, Pislaru S, Mahoney DW,
Enriquez-Sarano M. Pathophysiology of tricuspid regurgitation.
Quantitative Doppler echocardiographic assessment of respiratory
dependence. Circulation. 2010;122:1505–13.
49. Najib MQ, Vinales KL, Vittala SS, Challa S, Lee HR, Chaliki HP.
Predictors for the development of severe tricuspid regurgitation with
anatomically normal valve in patients with atrial fibrillation. Echocardiography.
2012;29:140–6.
50. Utsunomiya H, Itabashi Y, Mihara H et  al. Functional tricuspid
regurgitation caused by chronic atrial fibrillation: A real-time 3-dimensional
transesophageal echocardiography study. Circ Cardiovasc Imaging. 2017;10(1).
51. Habib G, Badano L, Tribouilloy C et  al. Recommendations for the
practice of echocardiography in infective endocarditis. Eur J Echocardiogr.
2010;11:202–19.
52. Ton-Nu TT, Levine RA, Handschumacher MD et  al. Geometric
determinants of functional tricuspid regurgitation: Insights from
3-dimensional echocardiography. Circulation. 2006;114:143–9.
53. Matsunaga A, Duran CM. Progression of TR after repaired functional
ischemic mitral regurgitation. Circulation. 2005;112(Suppl):I453–7.
54. Colombo T, Russo C, Cilibert GR et  al. Tricuspid regurgitation
secondary to mitral valve disease: Tricuspid annulus function as guide to
tricuspid valve repair. Cardiovasc Surg. 2001;9:369–77.
55. Anwar AM, Geleijnse ML, Soliman OI et  al. Assessment of normal
tricuspid valve anatomy in adults by real-time three-dimensional
echocardiography. Int J Cardiovasc Imaging. 2007;23:717–24.
56. Sukmawan R, Watanabe N, Ogasawara Y et al. Geometric changes of
tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary
130  3D Echocardiography
hypertension quantified by novel system with transthoracic real-time
3-dimensional echocardiography. J Am Soc Echocardiogr. 2007;20:470–6.
57. Min SY, Song JM, Kim JH et  al. Geometric changes after tricuspid
annuloplasty and predictors of residual tricuspid regurgitation: A real-time
three-dimensional echocardiography study. Eur Heart J. 2010;31:2871–80.
58. Chen Y, Liu YX, Yu YJ et al. Prognostic value of tricuspid valve geometry
and leaflet coaptation status in patients undergoing tricuspid annuloplasty:
A three-dimensional echocardiography study. J Am Soc Echocardiogr.
2019;32(12):1516–25.
59. Velayudhan DE, Brown TM, Nanda NC et al. Quantification of tricuspid
regurgitation by live three-dimensional transthoracic echocardiographic
measurements of vena contracta area. Echocardiography. 2006;23:793–800.
60. Utsunomiya H, Harada Y, Susawa H et al. Comprehensive evaluation of
tricuspid regurgitation location and severity using vena contracta analysis:
A color Doppler three-dimensional transesophageal echocardiographic
study. J Am Soc Echocardiogr. 2019;32(12):1526–37.e2.
61. Zoghbi WA, Adams D, Bonow RO et  al. Recommendations for
noninvasive evaluation of native valvular regurgitation: A Report from the
American Society of Echocardiography developed in collaboration with
the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr.
2017;30:303–71.
62. Al-Mohaissen MA, Chan KL. Prevalence and mechanism of tricuspid
regurgitation following implantation of endocardial leads for pacemaker or
cardioverter-defibrillator. J Am Soc Echocardiogr. 2012;25:245–52.
63. Lin G, Nishimura RA, Connolly HM, Dearani JA, Sundt TM 3rd, Hayes
DL. Severe symptomatic tricuspid valve regurgitation due to permanent
pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol.
2005;45:1672–5.
64. Seo Y, Ishizu T, Nakajima H, Sekiguchi Y, Watanabe S, Aonuma K.
Clinical utility of 3-dimensional echocardiography in the evaluation of
tricuspid regurgitation caused by pacemaker leads. Circ J. 2008;72:1465–70.
65. Mediratta A, Addetia K, Yamat M et al. 3D echocardiographic location
of implantable device leads and mechanism of associated tricuspid
regurgitation. JACC Cardiovasc Imaging. 2014;7:337–47.
66. Chang JD, Manning WJ, Ebrille E, Zimetbaum PJ. Tricuspid valve
dysfunction following pacemaker or cardioverter-defibrillator implantation.
J Am Coll Cardiol. 2017;69:2331–41.
67. Attenhofer CH, Connolly HM, Dearani JA, Edwards WD, Danielson GK.
Ebstein’s anomaly. Circulation. 2007;115:277–85.
68. Patel V, Nanda NC, Rajdev S et al. Live/real time three-dimensional
transthoracic echocardiographic assessment of Ebstein’s anomaly.
Echocardiography. 2005;22:847–54.
69. Bharucha T, Anderson RH, Lim ZS, Vettukattil JJ. Multiplanar
review of three-dimensional echocardiography gives new insights into the
morphology of Ebstein’s malformation. Cardiol Young. 2010;20:49–53.
70. Bhattacharyya S, Toumpanakis C, Burke M, Taylor AM, Caplins
ME, Davar J. Features of carcinoid heart disease identified by 2- and
3-dimensional echocardiography and cardiac MRI. Circ Cardiovasc Imaging.
2010;3:103–11.
71. Muraru D, Tuveri MF, Marra MP, Badano LP, Iliceto S. Carcinoid tricuspid
valve disease: Incremental value of three-dimensional echocardiography.
Eur Heart J Cardiovasc Imaging. 2012;13:329.
72. Nishimura K, Okayama H, Inoue K et al. Visualization of traumatic
tricuspid insufficiency by three-dimensional echocardiography. J Cardiol.
2010;55:143–6.
73. Kamiya C, Ohara T, Nakatani S et al. Traumatic tricuspid regurgitation
caused by myocardial laceration: A three-dimensional echocardiographic
study. J Am Soc Echocardiogr. 2010;23:903.e1–e3.
74. Weinreich DJ, Burke JF, Bharati S, Lev M. Isolated prolapse of the
tricuspid valve. J Am Coll Cardiol. 1985;6:475–81.
75. Faletra F, La Marchesina U, Bragato R, De Chiara F. Three-dimensional
transthoracic echocardiography images of tricuspid stenosis. Heart.
2005;91:499.
76. Cai Q, Ahmad M. Three-dimensional echocardiography in valvular
heart diseases. Echocardiography. 2012;29:88–97.
77. Naqvi TZ, Rafie R, Ghalichi M. Real-time 3D TEE for the diagnosis of
right-sided endocarditis in patients with prosthetic devices. J Am Coll Cardiol
Imaging. 2011;3:325–7.
 12 Infective Endocarditis
INTRODUCTION
Echocardiography still plays a major role in the diagnosis,
treatment, and follow-up of patients with infective
endocarditis (IE). Echocardiography has the advantages
of being rapidly available, cost efficient, repeatable, and
with a good diag­nostic  yield. Echocardiography, in the
form of transthoracic echocardiography (TTE), is the first-
line imaging technique in suspected IE. Transesophageal
echocardiography (TEE) is recommended in all patients
with clinical suspicion of IE and a negative or nondiagnostic
TTE. For patients with prosthetic valves and intracardiac
devices, TEE should always be performed whenever IE is
suspected because of the lower sensibility of TTE in such
cases.1
The echocardiographic hallmarks of IE (major
criteria in the modified Duke algorithm for IE diagnosis)
are the following: presence of vegetations, abscesses,
pseudoaneur ysms, intracardiac f istulas, valv ular
perforations or valvular aneurysms, and/or a new partial
dehiscence of a prosthetic valve. 2 TTE and TEE especially
are the first-line imaging techniques to accurately identify
all of the abnormalities induced by an infectious process
involving the endocardium. Other imaging modalities
are to be used when TTE and TEE are of suboptimal
quality and thus noncontributory to the diagnosis of IE
and when the clinical suspicion remains high.
Unfortunately, echocardiography (even TEE) is not
100% sensitive, nor specific for the diagnosis of IE. For
native valve endocarditis, the diagnostic sensitivity and
specificity of TTE range between 50%–90% and 90%,
respectively, as compared to a sensitivity of 90%–100%
and specificity of greater than 90% for 2D TEE. 3 For
suspected prosthetic valve endocarditis (PVE), the
sensitivity of TTE and TEE is lower, at 40%–70% and 85%,
respectively. 3 Results can be false negative in cases with
very small vegetations (<2 mm), in nonvegetation forms
of IE, in endocarditis on prosthetic valves or intracardiac
devices, or whenever TEE is performed very early in the
disease’s course when vegetations are not yet present or
when they have already embolized. Hence, newer imaging
techniques showed their ability to improve diagnostic
accuracy in IE and are now part of the major imaging
criteria for IE in the European Society of Cardiology
guidelines on IE. 1 Cardiac computed tomography
(CCT), fluorine-18-fluorodeoxyglucose positron emission
tomography/computed tomography (18F-FDG-PET/CT),
and radiolabeled autologous white blood cell (WBC)
scintigraphy are the newer imaging techniques proven
valuable in the diagnosis and management of patients
with IE, especially in patients with PVE, patients with
intracardiac devices, and patients in whom IE remains
uncertain after the TEE examination.1,3
ROLE OF 3D ECHOCARDIOGRAPHY IN
INFECTIVE ENDOCARDITIS
Although the role of 3D echocardiography is not clearly
defined in the current guidelines on the diagnosis and
management of IE,1 acquiring and analyzing 3D images of
the valves and cardiac structures with 3D echocardiography
in patients with IE are clinically useful. 3D TTE is probably
less informative than 3D TEE because of its lower spatial
resolution and image quality. It has, however, a very
important role in the accurate assessment of left ventricular
(LV) systolic function in patients with severe valvular
regurgitation secondary to IE.
The superior diagnostic accuracy of 3D TEE is related to
improved spatial resolution (high-frequency transducers),
the close proximity of the esophagus to the cardiac
structures, and the lack of acoustic interference from the
ribs and lung that often hamper TTE image quality.
3D TEE has an excellent balance between spatial and
temporal resolution and can help in both the diagnosis and
the management of patients with IE, as discussed further.
A 3D TEE examination should be done only after a
complete 2D examination, and it should never replace it. It
should be kept in mind that if image quality is poor with
2D TEE, it will only be worse with 3D TEE. Because spatial
and temporal resolution are generally worse with 3D TEE
than with 2D TEE, 3D TEE will not be superior to 2D TEE in
identifying small-size vegetations. This is one of the reasons
that 3D TEE should be attempted only after a complete 2D
TEE examination.
The strength of 3D TEE is in its ability to accurately
identify the correct anatomical position of any vegetation,
abscess, pseudoaneurysms, intracardiac fistula, valvular
perforation, or valvular aneurysms, and to accurately
identify the localization of a new paravalvular leak on a
prosthetic heart valve.4 It is extremely helpful for a correct
sizing of bulky and very mobile vegetations (Figure 12.1, ).5
3D TEE can be very useful in identifying vegetations with
unusual localizations, such as at the level of the valve
commissures or in locations that are in an off-plane from
the usual standard views used with 2D TEE (Figures 12.2
and 12.3, ).
3D TEE AND CORRECT ANATOMICAL
LOCATION AND SIZING OF VEGETATIONS
An experienced 2D TEE sonographer is able to accurately
localize the insertion of a vegetation on the mitral, aortic,
or tricuspid valve after sequential scanning of the entire
valve tissue from multiple angles with 2D TEE (Figure 12.4,
Panels A–F, ). However, with 3D TEE this step
is clearly faster and more precise (Figure 12.4, Panel G, ),
Infective Endocarditis  131
 B
A

Figure 12.1  Patient with infective endocarditis of the mitral valve presenting a very mobile vegetation on the atrial side of the anterior
mitral valve leaflet (white arrow). (Panel A) The approximate measurement of the length of the vegetation done by the sonographer in 2D
indicating a length of 1 cm and a width of 0.7 cm. (Panel B) The acquired 3D volume focused on the vegetation and rendered from the same
perspective as the 2D image from Panel A. (Panel C) The correct measurement of the vegetation length done after correct alignment with
the vegetation long axis and showing a maximal length of 1.2 cm, hence increasing the accuracy of the measurement .

A B

Figure 12.2  Patient with infective endocarditis with a small vegetation (white arrow) located on the ventricular side of the aortic valve (Panel
B) that could be missed if only the classical long-axis view at 130° is imaged (Panel A); this vegetation is located more laterally underneath
the left coronary cusp (Panel C). The vegetation is seen with 2D echocardiography after a careful probe angulation toward the lateral side
(Panel B). However, with 3D TEE, the vegetation and its location are easily seen on the ventricular side of the aortic valve (Panel C, yellow
arrow). For a better visualization, see video .

132  3D Echocardiography
 A B

ALC ALC

Figure 12.3  Infective endocarditis on a native mitral valve showing a small rounded vegetation close to the anterolateral commissure (ALC) of
the mitral valve as seen from the en face view with 3D TEE. (Panel A) Mitral valve opened with the vegetation located on the atrial side of the
posterior mitral valve on P1 (yellow arrow). (Panel B) Mitral valve closed in systole showing the vegetation localization at P1, close to the ALC.
Such a vegetation could be missed if systematic acquisition of several image planes around the mitral valve are not performed with 2D TEE .

A B

C D

E F

Figure 12.4  Systematic evaluation with 2D TEE in a patient presenting with an infective endocarditis on the mitral valve. (Panel A) In this
midesophageal five-chamber view, P1 and A1 are visualized and no vegetation is seen. (Panel B) In this midesophageal four-chamber view,
P2 and A2 are visualized and no vegetation is seen. (Panel C) In this midesophageal intercommissural view, P3, A2, and A1 are seen, and
abscess of the mitral annulus at the level of P3 can be identified. (Panel D) In this midesophageal two-chamber view, A1, A2, and P3 are
visualized, and no vegetation is seen. (Panel E) In this midesophageal three-chamber view, A2 and P2 are visualized and a small vegetation
is seen (yellow arrow). (Panel F) In this midesophageal three-chamber view tilted medially toward the posteromedial commissure, A1 to A2
and P3 are visualized, and a more voluminous vegetation is seen attached to the atrial side of P3 (white arrow). Without this last view, the
P3 vegetation could have been missed .(Continued)

Infective Endocarditis  133

 G

Figure 12.4 (Continued)  Systematic evaluation with 2D TEE in a patient presenting with an infective endocarditis on the mitral valve.
(Panel G) The en face view of the mitral valve is shown, and the vegetation situated at the level of P3 (green arrow) is identified, letting us
understand that what was thought to be a small vegetation on P2 (Panel E, yellow arrow) was actually a prolongation of the big vegetation
on P3. On P2, there is no other vegetation present. Note that the associated abscess of the mitral annulus at the level of P3 is also seen with
3D in the intercommissural section (Panel G, upper left quadrant). The green arrow indicates the vegetation on the atrial side of the mitral
valve as seen with 3D en face view .

especially in cases in which valve anatomy is complex, such
as in endocarditis on Barlow disease, or in cases in which
cardiac axis is unusual and mental reconstruction of 3D
images from 2D images becomes much more difficult even
for experienced cardiologists.
3D TEE can give a very accurate assessment of the size of
a bulky and irregularly shaped vegetation.5 In such cases,
2D TEE is less accurate because of the high mobility of the
vegetation with in- and out-of-plane movement which makes
it very difficult to align perfectly with the longest axis of the
vegetation and measure its exact maximal length (Figure
12.1, and Figure 12.5, ). 3D TEE after correct cropping
of the 3D volume comprising the entire vegetation gives the
maximal diameter of the vegetation with higher accuracy
(Figure 12.1, Panel C, and Figure 12.5).6 Since the length
of the vegetation is a criterion for prophylactic surgery in
patients with IE to decrease the risk of embolization, accurate
assessment of vegetation’s size is necessary and helpful in
the management of these patients. It has to be mentioned
that the superiority of 3D TEE to improve patient’s outcome
with surgery based on 2D- or 3D-derived vegetation size is
not yet proven, as published data are yet scarce. Outcome
data available to date come from vegetation sizing with
2D TEE and not with 3D TEE. For small-size vegetations,
2D TEE performs better than 3D TEE because of the
higher spatial and temporal resolution (Figure 12.6, ).​

Figure 12.5  Flexi-Slice tool is used to align with the maximal length of the vegetation situated on the atrial side of P3 (same patient from
Figure 12.4). This enables the measurement of the maximal length of the vegetation which is found to be 2.2 cm. See also Video for a better
understanding of the measurement. The green arrow indicates the vegetation on the atrial side of the mitral valve as seen with 3D en face
view .

134  3D Echocardiography
 A B
Figure 12.6  Small vegetation situated on the atrial side of the posterior mitral leaflet at the level of P3 scallop easily seen with 2D TEE (Panel
A, arrow). Note that in the 3D zoom en face view of the mitral valve (Panel B), this small vegetation is nearly invisible and could be easily
missed if a complete 2D TEE with systematic assessment of all views of the mitral valve is not performed
The biplane/X-plane modality with color Doppler is very
valuable in routine clinical TEE to distinguish between a
true mass attached to the endocardial surface or an image
artifact.
3D TEE AND CORRECT LOCATION AND
DESCRIPTION OF PARAVALVULAR ABSCESSES
The diagnosis of a paravalvular abscess is usually done with
2D TEE because of the higher spatial resolution, but the
correct sizing and extension of a perivalvular abscess can
be done with 3D TEE. In patients with abscesses located on
the posterior side of a prosthetic valve in the aortic position,
the exact extension of the abscess in the longitudinal axis
behind the aortic wall can be assessed with 3D TEE after
cropping of the 3D volume acquired of the aortic root. With
sequential 2D scanning in the transverse plane, it would
be difficult to do such an estimation accurately, and in the
120° long-axis view of the aortic root, it is difficult to avoid
oblique scanning and overestimation of the actual height.
For patients with PVE and abscess located on the anterior
aspect of the aortic root and aortic annulus, visualization of
the abscess with 3D TEE, as with 2D TEE, can be hampered
by the acoustic shadowing related to the presence of the
prosthetic material. In this case. imaging is to be completed
with TTE in order to image the anterior aspect of the aortic
root and annulus and/or with CCT which offers excellent
spatial resolution and is a 3D imaging technique with
inherent advantages.
3D TEE AND CORRECT LOCALIZATION AND
SIZING OF PSEUDOANEURYSMS
Pseudoaneurysm formation relates to what is left after
the intracavitary discharge of a former abscess in a
patient presenting with IE (Figure  12.7). These are
very frequent in patients with PVE. Diagnosis is made
with 2D echocardiography (Figure 12.7, Panels D,
and E, ), but 3D TEE is especially useful in complete
morphological characterization of the pseudoaneurysm
and especially for follow-up of the evolution when surgery
is not an option (Figure 12.7, Panel F, ). For follow-up,
it is particularly important to assess whether there is or is
.
not a progressive enlargement of the pseudo-aneurysm.
This could be difficult to ascertain with precision by 2D
echocardiography because of the complex 3D shape that
the pseudo-aneurysm may have. Hence, 3D imaging in this
case is very helpful (Figure 12.7, Panel F, ). 3D TEE has
the advantage over contrast CCT for the follow-up because
it can be repeated as many times as necessary with no
patient irradiation but has lower spatial resolution than
the CCT.
3D TEE AND INTRACARDIAC FISTULAS
SECONDARY TO INFECTIVE ENDOCARDITIS
Diagnosis of an intracardiac fistula as a complication of IE
is usually done with 2D color Doppler echocardiography.
However, 3D color Doppler TEE can be excellent in
the description of the anatomical localization of the
intracardiac fistula with regard to the surrounding
anatomical structures, jet direction, and actual size of the
fistula (Figure 12.8,  ).
3D TEE AND VALVE PERFORATION
3D TEE gives excellent anatomical information in patients
with mitral valve perforation secondary to IE because  of
the en face view of the mitral valve (Figure 12.9, ).7 A large
perforation may be easily seen with 3D TEE (Figure 12.9,
), but a small one may be missed because of lower spatial
resolution of the 3D imaging and the use of an inadequate
gain setting (2D gain too high, Figure 12.10, ).
3D TEE may have a higher chance of detecting perforations
than 2D TEE through the en face view of the mitral valve7 in
cases in which the sonographer does not perform a systematic
2D and color flow Doppler assessment from multiple scan
views around the mitral valve and misses a perforation
located in an out-of-plane view. However, 3D TEE seems
a less-performing method than 2D TEE in identifying
perforations involving the aortic cusps, because of the lower
spatial resolution combined with the difficulty to adequately
visualize the three aortic cusps. One important issue is
that dropout artifacts related to parallel scanning of the
valve tissue or to calcifications are not to be misdiagnosed
as valvular perforations (Figure 12.11, ). These are very
Infective Endocarditis  135
 A B

D E

Figure 12.7  Patient with infective endocarditis after a Bentall procedure. (Panels A and B) Discrete thickening of the peri-aortic tissue
suggestive of an abscess (yellow arrow) as seen from the long-axis view (Panel A) and short-axis view (Panel B). (Panel C) The same images in
short- and long-axis views cropped from a 3D zoom volume of the aortic root. Patient with infective endocarditis after a Bentall procedure.
(Panels D and E) Formation of a pseudo-aneurysm a few months after the identification of the abscess (white arrow). (Panel D) Long-axis view
of the aortic root showing the pseudo-aneurysms: diffuse thickening of the peri-aortic space together with an echo-free space around the
aortic conduit. (Panel E) Short-axis image of the cavity of the pseudo-aneurysm which is situated on the posterior aspect of the aortic root.
(Panel F) Exact measurement of the length and width of the pseudo-aneurysm cavity from a 3D zoom volume dataset. This allows correct
alignment with the aortic conduit and avoids oblique cut planes in the transverse axis which may overestimate the cavity size. Such exact
measurements are very important for the follow-up in order to detect rapid enlargement of the cavity size .

136  3D Echocardiography
 A B

C D

Figure 12.8  Aorto-left atrial fistula as a complication of infectious endocarditis involving the aortic valve and aortic root. Patient underwent a
surgical aortic valve replacement with a mechanical prosthesis. (Panel A) 2D TEE at 45° short-axis view at the level of the aortic valve showing an
abnormal cavity situated on the posterior aspect of the aortic root and aortic prosthesis (white arrow). (Panel B) Color flow 2D TEE at 45° short-
axis view at the level of the aortic valve showing a systolic flow with origin at the level of this abnormal cavity and directed into the left atrium
(yellow arrow). (Panel C) 2D TEE at 120°–130° long-axis view showing an abnormal cavity situated on the posterior aspect of the aortic root and
aortic prosthesis (green arrow). (Panel D) Color flow 2D TEE at 120°–130° long-axis view showing a systolic flow with origin at the level of this
abnormal cavity and directed into the left atrium (thick yellow arrow). (Panel E) Same as in Panel D, but flow is depicted in diastole. With 2D TEE,
an aorto-left atrial fistula is suspected. (Panel F) 3D zoom of the aortic root and prosthesis, which shows the exact location of the origin of the
aorto-atrial fistula on the posterior side of the aortic sinus of Valsalva (thick white arrow) .(Continued)

Infective Endocarditis  137

 G

Figure 12.8 (Continued)  Aorto-left atrial fistula as a complication of infectious endocarditis involving the aortic valve and aortic root. Patient
underwent a surgical aortic valve replacement with a mechanical prosthesis. (Panel G) Color flow 3D TEE at 45° short-axis view at the level
of the aortic valve showing the flow origin at the level of the posterior sinus of Valsalva. (Panel H) Cropping of the 3D color flow volume
showing the exact origin and size of the aorto-left atrial fistula .

A B

AL PMC
AL PMC
ALC
ALC

PL
PL

Figure 12.9  3D zoom en face view of the mitral valve in systole (Panel A) and diastole (Panel B), as seen from the left atrium. The valve is
oriented in the anatomical position. A large perforation situated at the level of the P2 is easily seen (yellow arrow) during systole (Panel A)
but not in diastole (Panel B) . (AL, anterior leaflet; ALC, anterolateral commissure; PL, posterior leaflet; PMC, posteromedial commissure.)

138  3D Echocardiography
 A B

C D

Figure 12.10  (Panel A) Endocarditis of the mitral valve complicated by chordae rupture (white arrow), severe mitral regurgitation (green
arrow), and anterior leaflet perforation (yellow arrow). With color flow Doppler, the perforation of the anterior mitral leaflet is confirmed
by identifying the regurgitation jet through the anterior leaflet tissue (Panel A, yellow arrow) . However, if the valve is analyzed only with
3D zoom mode in the en face view (Panel B) , this small perforation of the anterior mitral leaflet can be missed. A higher 2D gain setting
will make this small perforation invisible (Panel C, yellow arrow) . However, once diagnosed with 2D and 2D color Doppler and with the
appropriate gain setting, this perforation can be identified with 3D (Panel D, yellow arrow). With 3D TEE, its exact position on the anterior
mitral leaflet is accurately indicated (Panel D, yellow arrow) .

Figure 12.11  Patient with infective endocarditis of the aortic valve. On the left-hand side of the panel, the aortic valve is seen in the long-
(upper panel) and short-axis views (lower panel). The white arrow points to a large vegetation situated on the ventricular side of the aortic
valve as seen from the long-axis view of the aortic valve. On the right-hand side is a 3D zoom volume at the level of the aortic valve, as
seen from the aortic root perspective. The aortic valve is displayed with the right coronary cusp at 6 o’clock. The left (yellow arrow) and
the noncoronary cusps (green arrow) seem to have two big perforations. However, these are not perforations but dropout artifacts related
to parallel scanning of the aortic cusps leading to dropout artifacts in the 3D volume. Use of 2D and 3D color flow is strongly advised to
distinguish between dropout artifacts and true cusp perforations.

Infective Endocarditis  139

common for the aortic valve. Valve perforations should always
be confirmed by 3D color Doppler.
3D TEE AND PARAVALVULAR LEAKS
SECONDARY TO PROSTHETIC VALVE
ENDOCARDITIS
Paravalvular leaks (PVLs) secondary to IE on a prosthetic
valve in mitral position are best described with 3D TEE.
With 3D color Doppler TEE, the exact location of the PVL
around the mitral annulus and the exact size and shape of
the regurgitant orifice are easily identified (Figure 12.12, ).
The presence and the extent of the valve dehiscence leading
to PVL should not be based solely on 3D TEE imaging, as
dropout artifacts may lead to overdiagnosis both in terms
of presence and the size of PVL ( ). It should be diagnosed
with 2D color Doppler and further assessed with 3D color
Doppler (Figure  12.12, ). For the PVLs on prosthesis
situated in the aortic position, diagnosis with 3D color
Doppler TEE is difficult for PVLs situated on the anterior
aspect of the prosthesis, due to acoustic shadowing that

A B

C D

E F

G H

Figure 12.12  Patient with paravalvular leak (PVL) on a biologic valve implanted in the mitral position after infective endocarditis of the
mitral annulus and mitral valve (Panels A to E). Systematic 2D color flow assessment of the mitral valve prosthesis indicates that two PVLs
are present, one anteriorly close to the aortic valve (Panels A and E) and the second medially (Panels B and C). However, the extent of these
PVLs is hard to ascertain from the 2D dataset. With 3D color flow Doppler of the mitral prosthesis, the exact location and extent of the PVLs
are easily assessed: one jet at 11 o’clock and a larger elliptic jet from 2 to 4 o’clock (Panel F) . A 3D zoom with focus on the medial side of
the mitral prosthesis is performed to show the exact morphology of the medial PVL (Panel G) . However, confirmation of the exact length
and width of the PVL is more accurate with 3D color Doppler which confirms that there is indeed a PVL (and not only a dropout artifact) and
with Flexi-Slice allows exact measurement of the width and the length of the PVL (Panel H) .

140  3D Echocardiography
hampers the identification of the regurgitant jet origin
around the annulus. However, such PVLs can be accurately
assessed in terms of anatomical localization and sizing when
situated on the posterior aspect of the prosthesis and when
adequately using 3D color Doppler TEE. Anteriorly situated
PVLs can be suspected if the regurgitant jet extension into
the left ventricular outflow tract can be visualized from the
3D color dataset.
CONCLUSION
3D TEE is a powerful tool in the diagnosis and management
of patients with IE. However, it should be used only as
a complement to a complete 2D evaluation and with
knowledge of the pitfalls that may be encountered to avoid
false-negative diagnosis or overdiagnosis. Importantly,
3D TEE is excellent for morphological description of
vegetations and local complications associated with
infective endocarditis and should be used systematically in
clinical practice.
REFERENCES
1. Habib G, Lancellotti P, Antunes MJ et al. 2015 ESC Guidelines for the
management of infective endocarditis. Eur Heart J. 2015;36(44).
2. Li JS, Sexton DJ, Mick N et  al. Proposed modifications to the Duke
criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;
30(4):633–8.
3. Cahill TJ, Baddour LM, Habib G et al. Challenges in infective endocarditis.
J Am Coll Cardiol. 2017;69(3):325–44.
4. Tanis W, Teske AJ, van Herwerden LA et  al. The additional value of
three-dimensional transesophageal echocardiography in complex aortic
prosthetic heart valve endocarditis. Echocardiography. 201532(1):114–25.
5. Utsunomiya H, Berdejo J, Kobayashi S, Mihara H, Itabashi Y, Shiota T.
Evaluation of vegetation size and its relationship with septic pulmonary
embolism in tricuspid valve infective endocarditis: A real time 3DTEE study.
Echocardiography. 2017;34(4):549–56.
6. Berdejo J, Shibayama K, Harada K et al. Evaluation of vegetation size
and its relationship with embolism in infective endocarditis: A real-time
3-dimensional transesophageal echocardiography study. Circ Cardiovasc
Imaging. 2014;​7(1):149–54.
7. Thompson KA, Shiota T, Tolstrup K, Gurudevan S V, Siegel RJ. Utility of
three-dimensional transesophageal echocardiography in the diagnosis of
valvular perforations. Am J Cardiol. 2011;107(1):100–2.
Infective Endocarditis  141
 13 Surgical Management
INTRODUCTION
Echocardiography is widely employed to evaluate surgical
procedures, especially in the operating room (OR). Before
the surgery, echocardiography is essential for determining
surgical indication in patients with valvular heart disease
and  congenital heart disease. Most information can
be obtained with conventional 2D echocardiography,
including TEE. Therefore, in terms of the specific role of 3D
echocardiography, its clinical value is rather limited. Most
valvular heart surgeries, such as aortic valve (AV) and mitral
valve (MV) replacement and/or repair, can be performed
without the aid of 3D echocardiographic imaging. However,
3D echocardiography, especially real-time 3D TEE, can
assist surgery in some specific areas as follows.
MITRAL VALVE SURGERY
For MV surgery, 3D echocardiography, especially real-
time 3D transesophageal echocardiography (TEE),
can demonstrate anatomical MV features better than
conventional 2D echocardiography.1 There are many cases
in which 3D TEE benefitted surgical outcomes.2 For instance,
in Figure 13.1, 2D TEE in the OR showed a large proximal
isovelocity surface area (PISA), justifying surgical repair of a
ruptured chorda (arrow, Figure 13.1A, ). But its connection
to the anterior leaflet was not visible with ease. Real-time
3D TEE could show the connection between the base and
the tail of the long flail and also another small flail of the
anterior leaflet in the medial side, which was not clearly
visualized by 2D TEE (Figure 13.1B, ). This additional 3D
TEE information in the OR allowed the surgeon to make the
appropriate choices with confidence. A chordal attachment
was added to the small medial side flail because of the 3D
TEE image, resulting in a fully successful outcome (Figure
13.1C, and D). A recent study showed the value of 3D TEE
for MV cleft. In this report, 3D TEE played an essential role
in the evaluation of single and multiple MV clefts, improving
morphological and functional assessments of the valve, with
potential implications for surgical planning.3
As compared to 3D TEE, 3D transthoracic
echocardiography (TTE) is not yet routinely (at least at the
Heart Institute in Los Angeles, California) clinically applied,
mainly due to its suboptimal image quality. However,
recently an interesting study on the use of 3D TTE before
MV surgery was reported.4 In this study, 149 consecutive
patients with severe degenerative mitral regurgitation (MR)
underwent complete 3D TTE before surgery and 2D TEE
(not 3D TEE) in the operating room. 3D TTE was feasible
in a relatively short time (8 ± 4 minutes), with good (49%)
and optimal (33%) imaging quality in the majority of cases.
3D TTE had significant better overall accuracy compared to
2D TEE (93% and 91%, p < .05, respectively). 2D TEE was
significantly more specific than 3D TTE in the identification
142  3D Echocardiography
of A3 prolapse (99% vs. 96%). The authors concluded that
3D TTE with or without color Doppler is a feasible and
useful method in the analysis of MV prolapse; it allows a
preoperative and noninvasive description of the pathology
as accurate as 2D TEE.4 Typically, though, real-time 3D TEE
is performed in the OR and outpatient settings in the Heart
Institute; thus, this study may not apply here. However, the
progress of 3D TTE may benefit MR patients before surgery
in the near future.
After MV surgery, it is mandatory to check for any residual
MR. If the residual MR seems significant, a second pump may
be necessary to correct the problem. TEE needs to indicate
the location of the origin of the residual MR. However,
2D TEE often cannot show precise information on the
location of residual MR although its approximate location is
suggested. Figure 13.2A ( ) shows a 37° location of the 2D
TEE probe, suggestive of a medial location of the residual
leak. However, until its exact location was shown by real-time
3D TEE (Figure 13.2B, ), the surgeon could not be confident
about where to explore. The surgeon was immediately able
to find a loosened stich there and fixed the leak. As seen in
this case, real-time 3D TEE can be essential for visualizing
the location of paravalvular leaks for a second pump run for
further repair. This process or the communication between
surgeons and echocardiologists or cardiac anesthesiologists
in the OR with the use of 3D TEE and clockwise description
(Figure 13.2B) will certainly reduce the anxiety of surgeons
and improve surgical outcomes.
AORTIC VALVE SURGERY
As for AV surgery, anatomical information, especially whether
the valve is trileaflet or bicuspid, is an important factor for the
choice of surgery vs. transcatheter aortic valve replacement
(TAVR). Among patients with severe aortic stenosis who were
at low surgical risk, the rate of the composite of death, stroke,
or rehospitalization at 1 year was significantly lower with TAVR
than with surgery.5 In this study on low-risk patients for TAVR,
the registry did not include bicuspid aortic valve (BAV) cases.
But data from the RESPOND registry demonstrated good
clinical and echocardiographic outcomes up to 1 year after
TAVR in BAV patients using the repositionable Lotus Valve.6
However, clear 3D AV images may still be important for the
determination of the type of procedure (Figure 13.3A). In
this particular patient, the aortic root and ascending aorta
were also dilated. Clear 3D imaging of the bicuspid valve in
Figure 13.3B is important for the decision of surgical repair
for the root and ascending aortic dilation because the cutoff
value of the size of the aortic root and/or ascending aorta root
is smaller for BAV than trileaflet aortic valves.7 Because aortic
valve with root surgery precludes TAVR, even in those with
trileaflet aortic valves, 3D echocardiography can characterize
different forms of aortic valve and root abnormalities, such
as root dilation with aortic valve prolapse, and attempt to
 AV
A B C

LA

D AV
AV

Figure 13.1  Severe mitral valve regurgitation due to severe flail and prolapse of the mitral anterior leaflet (A) . (B) 3D TEE before the repair
of the mitral valve . (C,D) Postoperative TEE color Doppler (C) and 3D (D, Left Panel in diastole and Right Panel in systole). (AV, aortic
valve; LA, left atrium; LV, left ventricle.)

B C

AO

LAA

Figure 13.2  (A) 2D TEE after mitral valve (MV) replacement in the operating room. A significant residual MV paravalvular regurgitation is
noted . (B) Left Panel is a 3D color Doppler TEE showing the location of the paravalvular leak after mitral valve regurgitation (arrow) . (C)
Right Panel is a schema of the clock-like expression of the MV (see the main text). (AO, aorta; LAA, left atrial appendage.)

Surgical Management  143

 A
Figure 13.3  (A) Bicuspid valve images of 3D TEE (Left Panel) and 2D TEE (Right Panel). Please note that 2D TEE does not definitively show
bicuspid aortic valve in this patient. (B) 3D TEE showing calcified bicuspid aortic valve (left in early systole and right in mid-late systole).
define echocardiographic predictors of successful valve-root
complex repair.8
TRICUSPID VALVE SURGERY
As for the tricuspid valve (TV), 3D imaging may be useful
for its surgical operation. Measurement of the TV annular
diameter is one of the most important parameters (4 cm
in the apical four-chamber view) for the indication of
surgical annuloplasty when left-side surgery will be done
at the same time. A recent paper reported feasibility of 3D
echocardiography in the OR setting. 3D measurements have
been found to be superior to 2D measurements and allow
for greater precision and accuracy that may guide better
intraoperative surgical decision-making.9 In a more recent
study, however, 3D TTE and 3D TEE had no difference in
the annular measurement. Thus, use of 3D TTE is suggested
over 3D TEE.10
The use of 3D TEE revealed that residual tricuspid
regurgitation after tricuspid annuloplasty was associated
with a shorter total leaflet length, larger tenting volume,
and higher TV morphological score (from a total score of
leaflet mobility, leaflet thickening, subvalvular thickening,
and calcification).11 With the help of 3D echocardiography
for determining TV annulus geometry, a 3D geometric ring,
the so-called MC ring, was conceived.12,13 These days, this 3D
TV ring is one of the most popular TV annuloplasty rings.
144  3D Echocardiography
SURGERY FOR CARDIAC MASS
3D TEE provides an acceptable morphological
characterization of intracardiac masses, correlating well
with surgical inspection.14,15 In patients with cardiac mass,
including thrombi, myxomas, and lymphomas, 3D TEE can
provide better therapeutic decision making compared with
2D TEE, especially on the choice of optimal surgical access
prior to removal of intracardiac masses.14,15
Another commonly seen cardiac mass is papillary
fibroelastoma. Figure 13.4A ( ) shows an example. 3D TEE
can show its shape, size, and motion. In this case, we could
not tell its nature until pathological evaluation was done
after its surgical removal. After surgery, no more mass is
seen above the tricuspid valve (Figure 13.4B, ).
However, do we really need 3D TEE for surgical removal
of a cardiac mass such as myxoma or papillo-fibroelastoma?
3D imaging may help surgeons in planning reconstruction
of the area before the operation. In this case, the location,
shape, motion, and lack of involvement with the tricuspid
valve gives the surgeon a more definite idea about what
would happen after its removal. This type of contribution
depends on the anatomical variation of the mass relative to
its neighborhood cardiac structure.14 Unless we have 3D TEE
images, we cannot tell how important their contribution
could be. In this sense, 3D imaging is valuable for surgery
of a cardiac mass.
 A
Figure 13.4  (A) A mass in the right atrium detected by 2D TEE . The size and shape appear to be changing during the cardiac cycle. (B) A
mass is clearly visualized by 3D TEE before surgical removal (Left Panel) . After surgery, no mass is seen at the same location (Right Panel) .
SURGERY FOR CONGENITAL HEART DISEASE
Regarding adult congenital disease in general, see Chapter
16. As for the surgical contribution of 3D echocardiography
in this field, routine use of 3D echocardiography was
reportedly feasible and valuable for some types of congenital
heart disease. Surgeons found the 3D images helpful for
providing a realistic and almost specimen-like preview
of the surgical anatomy that facilitates planning of the
surgical program.16,17 In a more recent report, 3D printing
or 3D printed models did not change the surgical decision
in most cases of complex congenital heart disease (21 of
40 cases, 52.5% cases). However, in 19 of the 40 selected
complex cases, 3D printed models helped redefine the
surgical approach.18 3D printing with and without 3D TEE
may benefit surgery for CHD because of the individual
complexities of the cardiac anatomy.
CONCLUSION
Surgical views of the mitral valve by 3D TEE are valuable
before operations for surgeons to determine what would
be the best choice for the patient. In other areas, such as
congenital heart disease, 3D printing for surgical planning
would be truly beneficial because of its individualized nature.
Future development of this field with 3D echocardiography
and other modalities such as computed tomography and
magnetic resonance imaging may change surgical planning
completely for each individual patient.
REFERENCES
1. Turton EW, Ender J. Role of 3D echocardiography in cardiac surgery:
Strengths and limitations. Curr Anesthesiol Rep. 2017;7(3):291–8.
2. Scohy TV, Ten Cate FJ, Lecomte PV et al. Usefulness of intraoperative
real-time 3D transesophageal echocardiography in cardiac surgery. J Card
Surg. 2008;23(6):784–6.
3. Moura-Ferreira S, Sampaio F, Ribeiro J, Fontes-Carvalho R. A rare
case series of mitral valve clefts diagnosed by 3D echocardiography
and mini-review of the literature. Echocardiography. 2019;36(6):
1203–7.
4. Gripari P, Mapelli M, Bellacosa I et  al. Transthoracic echocardio­
graphy in patients undergoing mitral valve repair: Comparison of
new transthoracic 3D techniques to 2D transoesophageal echo­
cardiography in the localization of mitral valve prolapse. Int J
Cardiovasc Imaging. 2018;34(7):1099–107.
5. Mack MJ, Leon MB, Thourani VH et  al. Transcatheter aortic-valve
replacement with a balloon-expandable valve in low-risk patients. N Engl J
Med. 2019;380(18):1695–1705.
6. Blackman DJ, Van Gils L, Bleiziffer S et al. Clinical outcomes of the Lotus
Valve in patients with bicuspid aortic valve stenosis: An analysis from the
RESPOND study. Catheter Cardiovasc Interv. 2019;93(6):1116–23.
7. 2010 ACCF/AHA/A ATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients with Thoracic
Aortic Disease Representative Members, Hiratzka LF, Creager MA,
Isselbacher EM et al. Surgery for aortic dilatation in patients with bicuspid
aortic valves: A statement of clarification from the American College of
Surgical Management  145
Cardiology/American Heart Association Task Force on Clinical Practice
Guidelines. J Thorac Cardiovasc Surg. 2016;151(4):959–66.
8. Hagendorff A, Evangelista A, Fehske W, Schafers HJ. Improvement
in the assessment of aortic valve and aortic aneurysm repair
by 3 -dimensional echocardiography. JACC  Cardiovasc Imaging.
2019;12(11,1):2225–44.
9. Bhatt HV, Spivack J, Patel PR et al. Correlation of 2-dimensional and
3-dimensional echocardiographic analysis to surgical measurements
of the tricuspid valve annular diameter. J  Cardiothorac Vasc Anesth. 2019;
33(1):137–45.
10. Volpato V, Lang RM, Yamat M et al. Echocardiographic assessment
of the tricuspid annulus: The effects of the third dimension and
measurement methodology. J Am Soc Echocardiogr. 2019;32(2):​238–47.
11. Utsunomiya H, Itabashi Y, Mihara H et  al. Usefulness of 3D
echocardiographic parameters of tricuspid valve morphology to predict
residual tricuspid regurgitation after tricuspid annuloplasty. Eur Heart J
Cardiovasc Imaging. 2017;18(7):809–17.
12. Fukuda S, Saracino G, Matsumura Y et al. Three-dimensional geometry
of the tricuspid annulus in healthy subjects and in patients with functional
tricuspid regurgitation: A real-time, 3-dimensional echocardiographic
study. Circulation. 2006;114(1 Suppl):I492–8.
146  3D Echocardiography
13. Fukuda S, Gillinov AM, McCarthy PM, Matsumura Y, Thomas JD,
Shiota T. Echocardiographic follow-up of tricuspid annuloplasty with
a new three-dimensional ring in patients with functional tricuspid
regurgitation. J Am Soc Echocardiogr. 2007;20(11):1236 –42.
14. Muller S, Feuchtner G, Bonatti J et  al. Value of transesophageal 3D
echocardiography as an adjunct to conventional 2D imaging in preoperative
evaluation of cardiac masses. Echocardiography. 2008;25(6):624–31.
15. Espinola-Zavaleta N, Lozoya-Del Rosal JJ, Colin-Lizalde L, Lupi-
Herrera E. Left atrial cardiac myxoma. Two unusual cases studied by 3D
echocardiography. BMJ Case Rep. 2014;2014.
16. Del Pasqua A, Sanders SP, de Zorzi A et al. Impact of three-dimensional
echocardiography in complex congenital heart defect cases: The surgical
view. Pediatr Cardiol. 2009;30(3):293–300.
17. Charakida M, Pushparajah K, Simpson J. 3D echocardiography in
congenital heart disease: A valuable tool for the surgeon. Future Cardiol.
2014;10(4):497–509.
18. Valverde I, Gomez-Ciriza G, Hussain T et al. Three-dimensional printed
models for surgical planning of complex congenital heart defects: An
international multicentre study. Eur J Cardiothorac Surg. 2017;52(6):1139–48.
14 Nonsurgical Transcatheter Treatment
INTRODUCTION
Catheter-based treatment of cardiac abnormalities,
including valvular heart disease and congenital heart
defects, has been increasingly accepted as an alternative
treatment choice. The use of echocardiography, including
TEE, for such catheter-based treatments is essential for
the success of the procedures. However, in general, 3D
echocardiography would add little for certain procedures
such as transcatheter aortic valve replacement (TAVR). As
for other cardiac procedures such as mitral valve (MV)
procedures, significant contributions are reported and
experienced. Discussed in this chapter are the present
perspectives on the role of 3D echocardiography for
transcatheter procedures in adult cardiology.
VALVULAR HEART DISEASE
TRANSCATHETER AORTIC VALVE REPLACEMENT
TAVR has been accepted as an alternative treatment
for inoperative or high-risk patients with severe aortic
stenosis.1 In intermediate-risk and even low-risk patients,
TAVR was reportedly at least similar to surgical aortic valve
replacement with respect to the primary end point of death
or disabling stroke.2,3
3D echocardiography can demonstrate an en face view
of a calcified stenotic aortic valve and a newly implanted
bioprosthetic valve as seen in Figure 14.1. However, clinically,
Figure 14.1  3D TEE images of the aortic valve before (Upper Panels, left in systole and right in diastole) and after transcatheter aortic valve
replacement (Lower Panels, left in systole and right in diastole).
it can play only limited roles for TAVR because conventional
2D echocardiography and computed tomography (CT) can
provide enough information for the procedure, including
determination of the severity of aortic valve stenosis and
regurgitation. Proper sizing of the aortic annulus before
TAVR using 3D methods, including CT and 3D TEE, is
important for the success of TAVR because the shape of
the aortic annulus is not circular.4 3D methods should
be used to evaluate the aortic annulus size because 2D
imaging techniques provide only a sagittal view, which may
underestimate it.4,5 3D TEE measurement of the aortic
annulus is useful to decide the proper size of the TAVR
valve.6 However, we and others recommend the use of CT
for this purpose rather than 3D TEE when CT is available.7,8
CLOSURE OF PARAVALVULAR AORTIC VALVE
REGURGITATION AFTER TRANSCATHETER AORTIC
VALVE REPLACEMENT
After TAVR, paravalvular aortic valve regurgitation (AR)
is considered to be an ominous prognostic factor when
its degree is greater than mild. Echocardiography is most
widely used for determining the severity of AR, but it has
not yet been established for determining the degree of
paravalvular leak after TAVR.9 Newer types of the TAVR
valves, such as the  SAPIEN 3, have been developed with
successful reduction of paravalvular AR and improved
outcomes.10 When more than moderate AR is found, a
plugging procedure can be performed immediately in
Nonsurgical Transcatheter Treatment  147
 A mitral valve regurgitation, device closure of paravalvular
B type has typically degenerative valve changes such as mitral
C
Figure 14.2  Device closure of a significant paravalvular leak after
transcatheter aortic valve replacement. (A) A significant leak before
the plugging . (B) A 3D TEE image showing a catheter at the site of
leakage . (C) Color Doppler simultaneous biplane 2D TEE images,
showing successful plugging .
the catheterization laboratory. 3D echocardiography has
increased the feasibility of percutaneous approaches for the
management of paravalvular regurgitation.11 Transcatheter
repair of paravalvular leak after TAVR with or without 3D
imaging can be safely and effectively accomplished, leading
to reduction in hospitalizations, improvement in symptoms,
and improvement in long-term survival rates.12 As seen in
Figure 14.2, real-time 3D TEE could show the location of
the catheter at the leaking site (Figure 14.2B), resulting in
the successful reduction of the post-TAVR paravalvular leak
(Figure  14.2A through 14.2 C, ). In this situation, as
seen in Figure 14.2A and C, simultaneous 2D TEE biplane
imaging as a part of 3D echocardiographic capabilities is
of great value and should be applied for the detection of
the leakage size and location with color Doppler in the
catheterization laboratory.
TRANSCATHETER PROCEDURES FOR MITRAL
VALVE DISEASE
Catheter procedures treating MV disease include balloon
valvuloplasty for MV stenosis, edge-to-edge clip repair for
148  3D Echocardiography
mitral regurgitation (MR) of the artificial valve, valve-in-
valve procedure, and native valve replacement. 3D TEE
is indispensable for these mitral valve procedures except
balloon valvuloplasty.
CLIP PROCEDURE FOR MITRAL REGURGITATION
For the clip procedure, patients are classified into two types
of MR: primary or organic and secondary or functional MR,
according to the EVEREST study.13 The primary or organic
valve prolapse and/or flail. Functional mitral regurgitation
(FMR) is caused by surrounding structures such as a dilated
left ventricle (LV) and also mitral annular dilation due to
chronic atrial fibrillation.14 Edge-to-edge clip repair was
accepted for surgically risky patients with moderately severe
to severe degenerative MR in October 2013 and for those
with moderately severe and severe FMR in March 2019 in
the United States.15,16 Because the inclusion criteria for
the clip procedure is MR degree greater than or equal to
moderate to severe (3 or 4/4), echocardiographic judgment
of the MR severity is critical. However, the degree of MR
is determined by conventional 2D echocardiography with
the combination of color Doppler - derived regurgitant jet
size, the size of the proximal isovelocity surface area, the
size of vena contracta, and also transmitral inflow velocity,
the density of the continuous-wave Doppler velocity signal
of MR, left atrial (LA) and LV sizes.17 In our recent study,
high-quality 3D TEE analysis of the vena contracta area
was a highly recommended alternative for estimating MR
severity.18 Addition or summation of separate vena contracta
areas created by the clip procedure may be useful for
judging any residual MR.
Anatomical assessment of the MV pathology is essential
for the selection of management options. 3D TEE provides
for better imaging and anatomical analysis of the MV, such
as prolapse location, flail gap, and width in this setting.19
Therefore, even before going into the procedure room when
the cause of MR is not clear by TTE, TEE with 3D capability
is highly recommended to evaluate the detailed anatomy of
the MV, especially as TEE findings of an unexpected nature
may change the management choice.
INTRAPROCEDURAL ECHOCARDIOGRAPHY
In the catheterization laboratory, TEE with real-time 3D
capability is essential to assist during the entire procedure,
including atrial septal puncture guidance, positioning of
the clip on the MV orifice, and grasping of both MV leaflets
(Figure 14.3A).20,21 Residual MR after the first clip is not
uncommon. Quick and precise imaging of the residual
MR (location and severity) with 3D TEE (Figure 14.3A and
B, ) is extremely important for the interventionist to
place the second and possibly third clips properly.22
After completion of the clip procedure, MV stenosis and
iatrogenic atrial septal defect (iASD) need to be checked
by TEE. We reported the value of real-time 3D TEE for
determining the unique shape, size, and location of the ASD
created by the septal puncture with the large catheter and its
sheath (24F) used for the clip procedure (Figure 14.4).23 In
 A

LV LV

LV

LV

Figure 14.3  (A) Edge-to-edge mitral valve clip repair. Upper panel shows 2D color TEE showing two simultaneous apical views with severe
functional mitral valve regurgitation (MR) before the clip procedure. Lower Panels (left in diastole and right in systole) show post-clip color
Doppler 3D TEE with medially mild residual MR (Right Panel, arrows). (B) 2D and 3D TEE color Doppler images showing residual MR at the
medial side of the clip .

LA

䌒A

Figure 14.4  2D and 3D TEE showing an iatrogenic atrial septal defect (ASD) (Left Panel, arrow) and 3D TEE (Right Panel, arrow). (LA, left
atrium; RA, right atrium)

Nonsurgical Transcatheter Treatment  149

Figure 14.5  3D TEE images before (Left Panel) , during (Middle Panel) , and after (Right Panel) transcatheter closure of paravalvular
leak of the mitral valve prosthesis .

a published paper, patients with iASD showed higher death
rates during the first 6 months.24 In our study, elevated LA
pressure after MV clip was associated with persistent iASD.25
The size of the ASD can be a factor for LA pressure after the
clip procedure. Once again, only 3D TEE can determine the
shape and size of the ASD created by the catheter (Figure
14.4). In addition, 3D TEE demonstrated improvement of MR
with an increase in leaflet coaptation and a greater reduction
of anteroposterior annular diameter in patients with atrial
FMR than in ventricular FMR. In other words, 3D TEE
identified differential effects of clipping on MV geometry
between patients with atrial and ventricular FMR.14,26
DEVICE CLOSURE OF PARAVALVULAR MITRAL
REGURGITATION
Paravalvular prosthetic MR is not uncommon and is
often asymptomatic. However, up to 5% of post-mitral
valve replacement (MVR) patients may have significant
paravalvular MR and thus need revision surgery because
of heart failure symptoms with hemolytic anemia. These
patients with paravalvular prosthetic MR often pose a high
risk for redo surgery. Therefore, catheter-based closure of
paravalvular MR has been introduced with the use of TEE
for such high-risk patients. Because it is often difficult to
accurately identify the location of prosthetic MR with 2D

LA
LA

AO
AO LV
LV

Pre-MVR Post-MVR

Figure 14.6  2D and 3D TEE images before (Left Panel) and after (Right Panel) transcatheter mitral valve replacement (MVR). (Upper Panels)
Color Doppler 2D TEE long-axis images showing severely calcified stenotic native mitral valve with proximal isovelocity surface area (Upper
Left Panel, arrow) and normal transmitral flow (Upper Right Panel, blue color) after the transcatheter MVR. (Lower Panels) Real-time 3D TEE
images of severely calcified stenotic mitral valve (Left) and the replaced valve (Right).

150  3D Echocardiography
Figure 14.7  3D TEE image of transcatheter replacement (Left Panel, arrows) and repair with a MitraClip (Right Panel, arrow) of the tricuspid
valve .

echocardiography, TEE with 3D color Doppler capacity
is chosen to assess the severity and location of prosthetic
MR.27–30 In our study, color Doppler 3D TEE showed the
exact location of the circumferential orifice of paravalvular
regurgitation around the artificial MV and thus was able to
effectively assist the transcatheter device closure procedure
(Figure 14.5, ).28 The location of the paravalvular leak
visualized by 3D color Doppler TEE is described using the
clock-like expression. (The aortic valve is 12 o’clock, and
the left atrial appendage [LAA] is 9 o’clock.) This way, the
interventionist and the echocardiography specialist and/
or cardiac anesthesiologist in the procedure room can

Figure 14.8  (A) 3D TEE showing the orifice and shape of the left atrial appendage (LAA). (B) 3D TEE images of a WATCHMAN device with
slight rotation of the en face view.

Nonsurgical Transcatheter Treatment  151

communicate with a common language. This is extremely
important for the success of the procedure.
VALVE-IN-VALVE PROCEDURE
For valvular prosthetic MR and post-MV repair with
a ring, a transcatheter valve-in-valve procedure or
valve-in-ring procedure is now performed under TEE
monitoring. Transcatheter transapical mitral valve-in-valve
implantation for dysfunctional biological mitral prosthesis
can be performed with minimal operative morbidity and
mortality and favorable midterm clinical and hemodynamic
outcomes. 31 3D TEE was used for transfemoral valve-in-
valve implantations using Edwards SAPIEN 3, which would
prevent or reduce paravalvular MR. 32
LA
AO
RA
Figure 14.9  (A) 2D (Left Panel) and 3D (Right Panel) TEE images showing the catheter through the patent foramen ovale (PFO) (arrow)
(B) 3D TEE images showing a PFO closure procedure . (C) Images of 3D TEE (Left Panel) and color Doppler 2D TEE (Right Panel) showing
a PFO closure device (arrow) without residual shunt .
152  3D Echocardiography
TRANSCATHETER MITRAL VALVE REPLACEMENT
FOR NATIVE MITRAL VALVE
Recently, transcatheter MV replacement for native MV with
severe annular calcification has been reported. This so-called
transcatheter MV implantation or replacement, TMVI or
TMVR, emerged as an option in patients at high risk for
surgery.33,34 In a recent publication, TMVI for native severely
calcified MV disease (82% mitral stenosis and 18% MR)
appeared technically feasible with acceptable initial acute and
midterm hemodynamic and clinical outcomes. For 8 out of
the 11 patients, TEE was used to guide the procedure during
clip closure.33,34 In our institution, it is clinically routine to use
intraprocedural TEE with 3D capability to evaluate the severity
of mitral stenosis and regurgitation before deployment and
LA
RA
.
also to determine the location of the catheter (Figure 14.6)
and the presence of residual paravalvular regurgitation, if
any. TEE with real-time 3D capability would be essential for
visualizing the location of the residual or recurrent valvular
and/or paravalvular leaks in such patients.
TRICUSPID VALVE PROCEDURES
It is not easy to obtain all three leaflets in a single 2D
plane. Therefore, 3D echocardiography, which can show
all three leaflets in one view, has strong advantages over
2D echocardiography in both the transthoracic and the
transesophageal approach. Utsunomiya et al. reported the
value of 3D echocardiography for assessing the surgical
result of tricuspid valve repairs.35 3D echocardiography can
show the leakage location with ease, although the short-
axis 2D echocardiographic views taken by experienced
echocardiography teams can also show it. With the 3D
echocardiography method, transcatheter tricuspid repair
has been reported with certain success (Figure 14.7, ).36
NON-VALVULAR HEART DISEASE
LAA has complicated anatomical features, with structural
characteristics that are not easily visualized with 2D
LA
RA
Figure 14.10  (A) Color Doppler 2D TEE showing left-to-right shunt (arrow) through a secundum atrial septal defect (ASD). (B) 3D TEE showing
a catheter through the ASD (Left Panel) and an en face view of the closure device (Right Panel). (LA, left atrium; RA, right atrium.)
echocardiography. With the help of 3D echocardiography as
seen in multiple cutting planes (Figure 14.8A), we can fully
understand its structure, such as its chicken wing shape.
Percutaneous LAA occlusion with a Watchman device can
prevent patients with atrial fibrillation from stroke (Figure
14.8B). Correct sizing of the ostium of LAA is important
in LAA occlusion procedures. However, the variability of
the ostium geometry often complicates the assessment of
the true ostium diameter. 3D TEE can facilitate this step
of the procedure. In fact, in 55 patients undergoing LAA
device closure, 3D TEE was reportedly feasible to use in
decisions regarding device size.37 3D printing of the LAA
using real-time 3D TEE data may also provide perfect and
rapid application in LAA occlusion to assist with physician
planning and decision making.38
PATENT FORAMEN OVALE/ATRIAL SEPTAL DEFECT/
VENTRICULAR SEPTAL DEFECT CLOSURE
Patent foramen ovale (PFO) is a relatively common
congenital condition that has been implicated
in cryptogenic stroke as a result of paradoxical
thromboembolism by right-to-left shunting. Many studies
have demonstrated that transcatheter PFO closure
significantly reduced the incidence of recurrent strokes
Nonsurgical Transcatheter Treatment  153
 A

LA

AO
LV

VSD
RV

LV LV
AO

RV
RV

VSD

Figure 14.11  (A) Color Doppler 2D TEE (Left, arrow) and 3D TEE (Right, arrow) images showing a membranous ventricular septal defect
(VSD) . (B) A color Doppler 3D TEE image showing shunt through the VSD . (C) 3D TEE images showing transcatheter closure device over
the VSD (arrows) . (AO, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.)

154  3D Echocardiography
in a small group of high-risk patients with PFO and atrial
septal aneurysm compared with antithrombotic drugs.
Intracardiac echocardiography (ICE) and 2D TEE have
become the elected techniques for guiding PFO closure.
However, real-time 3D TEE may be superior to 2D TEE
or ICE in the accurate assessment of the morphology
and efficacy of transcatheter closure devices because of
Figure 14.12  (A) Color Doppler 2D TEE showing post-infarction VSD. (B) 3D TEE images showing VSD (arrows). (C) Color Doppler 2D TEE
showing the closure device without significant residual shunt.
better spatial orientation. 39 As seen in Figure 14.9A ( ),
the catheter is clearly through the tunnel from the right
atrium to the left atrium. 2D TEE did not clearly show the
spacial relationship between the catheter and PFO tunnel.
The view of the closure device is impressive and shows it
clearly covering the PFO when imaged by 3D TEE (Figure
14.9B and C, ).
Nonsurgical Transcatheter Treatment  155
ATRIAL SEPTAL DEFECT CLOSURE
ASD closure is monitored by ICE and/or 2D TEE with 3D
capability. Clinically, ASD is visualized by 2D TEE with
color Doppler (Figure 14.10A). However, its size is more
accurately assessed by 3D TEE than by 2D TEE or ICE.40
3D TEE can be used to obtain an en face view of the ASD
and important surrounding structures, which provides
for analysis of not only the size but also its type, shape,
orientation, number, position, and rims in a single live
3D echocardiographic view. Also, 3D TEE is ideal for
monitoring the position and configuration of devices
and delivery hardware using live, real-time imaging
techniques.41 Following deployment of the ASD occlusion
device, it is essential to ensure that both septum primum
and secundum are between the occluder discs as seen in
Figure 14.10B. Catheter closure can be successful if close
attention is paid to the morphology of the defect and
incorporation of margins within the discs of the septal
occluder, which 3D TEE can demonstrate.42
VENTRICULAR SEPTAL DEFECT CLOSURE
Two types of ventricular septal defects (VSDs) exist, one
congenital and the other post-myocardial infarction. For
both types, 3D echocardiography is useful for transcatheter
closure. Congenital perimembranous VSDs have a close
anatomical relationship to the aorta, aortic valve, and
tricuspid valve, which may make percutaneous closure
difficult. 3D echocardiography can show variations in the
geometry of the perimembranous VSDs (Figure 14.11A
and B, ). In publications, the maximal diameter of
the septal defect by 3D echocardiography was on average
2 mm greater than the diameter by 2D echocardiography.
3D echocardiography enabled visualization of the close
relationship of the septal tricuspid leaflet, the aortic valve,
and the perimembranous VSD, showing the mechanism of
its closure and the associated aortic regurgitant lesions.
The profile of the prosthesis implanted percutaneously was
shown in the different 3D views (Figure 14.11C, ).43
VSD or ventricular septal rupture (VSR) after acute
myocardial infarction (AMI) are potentially lethal
mechanical complications of acute coronary syndromes.
Given high surgical mortality partly due to unsuccessful
repair, transcatheter closure has emerged as a potential
strategy in selected cases.44 We used 3D TEE in such a case
and found it clinically important to guide our interventionists
in multiple device deployments for successful outcomes
(Figure 14.12A through 14.12C).45
CONCLUSION
Transcatheter management of cardiac patients is gaining
widespread popularity. 3D echocardiography, especially
real-time 3D TEE, in the catheterization or hybrid
laboratory is indispensable for certain procedures such as
edge-to-edge closure of MR and closure of paravalvular
leaks. Future developments with other modalities, such as
fusion imaging with 3D echocardiography, would further
enhance the success of transcatheter procedures.
156  3D Echocardiography
REFERENCES
1. Smith CR, Leon MB, Mack MJ et al. Transcatheter vs. surgical aortic-valve
replacement in high-risk patients. N Engl J Med. 2011;364(23):2187–98.
2. Leon MB, Smith CR, Mack MJ et  al. Transcatheter or surgical
aortic-valve replacement in intermediate-risk patients. N Engl J Med.
2016;374(17):1609–20.
3. Mack MJ, Leon MB, Thourani VH et  al. Transcatheter aortic-valve
replacement with a balloon-expandable valve in low-risk patients. N Engl J
Med. 2019;380(18):1695–1705.
4. Saitoh T, Shiota M, Izumo M et  al. Comparison of left ventricular
outflow geometry and aortic valve area in patients with aortic stenosis
by 2-dimensional vs. 3-dimensional echocardiography. Am J Cardiol.
2012;109(11):1626–31.
5. Husser O, Rauch S, Endemann DH et al. Impact of three-dimensional
transesophageal echocardiography on prosthesis sizing for transcatheter
aortic valve implantation. Catheter Cardiovasc Interv. 2012;80(6):956–63.
6. Papachristidis A, Papitsas M, Roper D et  al. Three-dimensional
measurement of aortic annulus dimensions using area or circumference
for transcatheter aortic valve replacement valve sizing: Does it make a
difference? J Am Soc Echocardiogr. 2017;30(9):871–8.
7. Jilaihawi H, Doctor N, Kashif M et  al. Aortic annular sizing
for transcatheter aortic valve replacement using cross-sectional
3-dimensional transesophageal echocardiography. J Am Coll Cardiol.
2013;61(9):​9 08–16.
8. Khalique OK, Hamid NB, White JM et  al. Impact of
methodologic  differences in three-dimensional echocardiographic
measurements of the aortic annulus compared with computed tomographic
angiography before transcatheter aortic valve replacement. J Am Soc
Echocardiogr. 2017;30(4):414–21.
9. Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ. Assessment of
paravalvular regurgitation following TAVR: A proposal of unifying grading
scheme. JACC Cardiovasc Imaging. 2015;8(3):340–60.
10. Kodali S, Thourani VH, White J et al. Early clinical and echocardiographic
outcomes after SAPIEN 3 transcatheter aortic valve replacement in
inoperable, high-risk and intermediate-risk patients with aortic stenosis.
Eur Heart J. 2016;37(28):2252–62.
11. Kinno M, Raissi SR, Olson K A, Rigolin VH. Three-dimensional
echocardiography in the evaluation and management of paravalvular
regurgitation. Echocardiography. 2018;35(12):2056–70.
12. Dhoble A, Chakravarty T, Nakamura M et al. Outcome of paravalvular
leak repair after transcatheter aortic valve replacement with a balloon-
expandable prosthesis. Catheter Cardiovasc Interv. 2017;89(3):462–68.
13. Feldman T, Kar S, Rinaldi M et  al. Percutaneous mitral repair
with the MitraClip system: Safety and midterm durability in the initial
EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J
Am Coll Cardiol. 2009;54(8):686 –94.
14. Nagaura T, Hayashi A, Yoshida J et  al. Percutaneous edge-to-edge
repair for atrial functional mitral regurgitation: A real-time 3-dimensional
transesophageal echocardiography study. JACC Cardiovasc Imaging.
2019;12(9):1881–3.
15. Sorajja P, Mack M, Vemulapalli S et  al. Initial experience with
commercial transcatheter mitral valve repair in the United States. J Am Coll
Cardiol. 2016;67(10):1129–40.
16. Stone GW, Lindenfeld J, Abraham WT et al. Transcatheter mitral-valve
repair in patients with heart failure. N Engl J Med. 2018;379(24):2307–18.
17. American College of Cardiology, American Heart Association Task
Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists,
Bonow RO, Carabello BA, Chatterjee K et al. ACC/AHA 2006 guidelines
for the management of patients with valvular heart disease: A report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (writing Committee to Revise the 1998 guidelines
for the management of patients with valvular heart disease) developed
in collaboration with the Society of Cardiovascular Anesthesiologists
endorsed by the Society for Cardiovascular Angiography and Interventions
and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006;48(3):e1–148.
18. Berdejo J, Shiota M, Mihara H, Itabashi Y, Utsunomiya H, Shiota T. Vena
contracta analysis by color Doppler three-dimensional transesophageal
echocardiography shows geometrical differences between prolapse
and pseudoprolapse in eccentric mitral regurgitation. Echocardiography.
2017;34(5):683–9.
19. Izumo M, Shiota M, Kar S et  al. Comparison of real-time three-
dimensional transesophageal echocardiography to two-dimensional
transesophageal echocardiography for quantification of mitral valve
prolapse in patients with severe mitral regurgitation. Am J Cardiol.
2013;111(4):588–94.
20. Biner S, Perk G, Kar S et al. Utility of combined two-dimensional and
three-dimensional transesophageal imaging for catheter-based mitral valve
clip repair of mitral regurgitation. J Am Soc Echocardiogr. 2011;24(6):611–7.
21. Wunderlich NC, Siegel RJ. Peri-interventional echo assessment for the
MitraClip procedure. Eur Heart J Cardiovasc Imaging. 2013;14(10):935–49.
22. Altiok E, Paetsch I, Jahnke C et al. Percutaneous edge-to-edge mitral
valve repair: Assessment of immediate post-procedural treatment effect
using color 3-dimensional transesophageal echocardiography and cardiac
magnetic resonance imaging. J Am Coll Cardiol. 2011;58(11):e21.
23. Saitoh T, Izumo M, Furugen A et  al. Echocardiographic evaluation
of iatrogenic atrial septal defect after catheter-based mitral valve clip
insertion. Am J Cardiol. 2012;109(12):1787–91.
24. Schueler R, Ozturk C, Wedekind JA et al. Persistence of iatrogenic atrial
septal defect after interventional mitral valve repair with the MitraClip
system: A note of caution. JACC Cardiovasc Interv. 2015;8(3):450–9.
25. Ikenaga H, Hayashi A, Nagaura T et  al. Left atrial pressure
is  associated with iatrogenic atrial septal defect after mitral valve clip.
Heart. 2019;105(11):864–72.
26. Bushari LI, Reeder GS, Eleid MF et al. Percutaneous transcatheter edge-
to-edge MitraClip technique: A practical “step-by-step” 3-dimensional
transesophageal echocardiography guide. Mayo Clin Proc. 2019;94(1):89–102.
27. Anwar AM, Nosir YF, Alasnag M, Chamsi-Pasha H. Real time three-
dimensional transesophageal echocardiography: A novel approach for the
assessment of prosthetic heart valves. Echocardiography. 2014;31(2):188–96.
28. Biner S, Kar S, Siegel RJ, Rafique A, Shiota T. Value of color
Doppler three-dimensional transesophageal echocardiography in the
percutaneous closure of mitral prosthesis paravalvular leak. Am J Cardiol.
2010;105(7):984–9.
29. Johri AM, Yared K, Durst R et al. Three-dimensional echocardiography-
guided repair of severe paravalvular regurgitation in a bioprosthetic and
mechanical mitral valve. Eur J Echocardiogr. 2009;10(4):572–5.
30. Hamilton-Craig C, Boga T, Platts D, Walters DL, Burstow DJ, Scalia G.
The role of 3D transesophageal echocardiography during percutaneous
closure of paravalvular mitral regurgitation. JACC Cardiovasc Imaging.
2009;2(6):771–3.
31. Cheung A, Webb JG, Barbanti M et  al. 5-Year experience with
transcatheter transapical mitral valve-in-valve implantation for
bioprosthetic valve dysfunction. J Am Coll Cardiol. 2013;61(17):1759–66.
32. Nejjari M, Himbert D, Brochet E, Attias D. First-in-man full
percutaneous transfemoral valve-in-valve implantations using Edwards
SAPIEN 3 prostheses to treat a patient with degenerated mitral and aortic
bioprostheses. Interact Cardiovasc Thorac Surg. 2016;23(3):508–10.
33. Himbert D, Bouleti C, Iung B et al. Transcatheter valve replacement in
patients with severe mitral valve disease and annular calcification. J Am Coll
Cardiol. 2014;64(23):2557–8.
34. Puri R, Abdul-Jawad Altisent O, del Trigo M et al. Transcatheter mitral
valve implantation for inoperable severely calcified native mitral valve
disease: A systematic review. Catheter Cardiovasc Interv. 2016;87(3):540–8.
35. Utsunomiya H, Itabashi Y, Mihara H et  al. Usefulness of 3D
echocardiographic parameters of tricuspid valve morphology to predict
residual tricuspid regurgitation after tricuspid annuloplasty. Eur Heart J
Cardiovasc Imaging. 2017;18(7):809–17.
36. Avenatti E, Barker CM, Little SH. Tricuspid regurgitation repair with a
MitraClip device: The pivotal role of 3D transesophageal echocardiography.
Eur Heart J Cardiovasc Imaging. 2017;18(3):380.
37. Schmidt-Salzmann M, Meincke F, Kreidel F et  al. Improved
algorithm for ostium size assessment in Watchman left atrial appendage
occlusion using three-dimensional echocardiography. J Invasive Cardiol.
2017;29(7):232–8.
38. Liu P, Liu R, Zhang Y, Liu Y, Tang X, Cheng Y. The value of 3D printing
models of left atrial appendage using real-time 3D transesophageal
echocardiographic data in left atrial appendage occlusion: Applications
toward an era of truly personalized medicine. Cardiology. 2016;135(4):255–61.
39. Martin-Reyes R, Lopez-Fernandez T, Moreno-Yanguela M et al. Role
of real-time three-dimensional transoesophageal echocardiography for
guiding transcatheter patent foramen ovale closure. Eur J Echocardiogr.
2009;10(1):148–50.
40. Suematsu Y, Takamoto S, Kaneko Y et al. Beating atrial septal defect closure
monitored by epicardial real-time three-dimensional echocardiography
without cardiopulmonary bypass. Circulation. 2003;107(5):785–90.
41. Roberson DA, Cui V W. Three-dimensional transesophageal
echocardiography of atrial septal defect device closure. Curr Cardiol Rep.
2014;16(2):453.
42. Alobaidan M, Saleem A, Abdo H, Simpson J. Successful percutaneous
closure of spiral atrial septal defect. Echo Res Pract. 2015;2(1):K7–9.
43. Bassil R, Acar P, Abadir S et al. [New approach to perimembranous
ventricular septal defect by real-time 3D echocardiography]. Arch Mal Coeur
Vaiss. 2006;99(5):471–6.
44. Assenza GE, McElhinney DB, Valente AM et al. Transcatheter closure of
post-myocardial infarction ventricular septal rupture. Circ Cardiovasc Interv.
2013;6(1):59–67.
45. Kulkarni M, Conte AH, Huang A, Lubin L, Shiota T, Kar S. Coronary artery
disease, acute myocardial infarction, and a newly developing ventricular sep-
tal defect: Surgical repair or percutaneous closure? J Cardiothorac Vasc Anesth.
2011;25(6):1213–6.
Nonsurgical Transcatheter Treatment  157
 15 Artificial Valves
INTRODUCTION
Despite the important progress in repair techniques,
prosthetic valve replacement is frequently required for heart
valve disease treatment.1 Various prosthetic cardiac valves
(PCVs) have been developed to improve hemodynamics
and durability and to reduce the complication rate of
surgically implanted prostheses. 2,3 In recent years, new
percutaneously implantable artificial valves have been
introduced to the toolbox, changing the clinical scenario
for the PCV population. In addition to clinical evaluation,
transthoracic echocardiography (TTE), comprehensive
of 2D, spectral Doppler (SD), and Doppler color flow
mapping (CFM), is recognized as the first-line diagnostic
tool for the assessment of PCV function following surgical
or percutaneous valve implantation.4 Although it provides
useful morphological and hemodynamic information,
TTE may be challenging for artificial valve evaluation due
to acoustic shadowing, especially with mechanical mitral
prostheses. On clinical examination with suspicious TTE
findings, transesophageal echocardiography (TEE) is
frequently required for the ultimate assessment of artificial
valve function and abnormalities. Conventional 2D TEE
provides accurate imaging with high spatial and temporal
resolution into the selected cross-sectional view. However,
skillful manipulation in the esophagus and various degrees
of probe flexion or anteflexion are required to achieve a
quasi-complete examination of prosthetic valves. Since 2D TEE
provides single-plane images, the entire artificial valve and
the surrounding anatomical structures cannot be displayed
in a single en face view. Consequently, accurate prosthetic
valve evaluation depends greatly on the operator’s skill
to mentally reconstruct cardiac structures from multiple
2D TEE tomographic images. 5 With increasing spatial
and temporal resolution, 2D TEE supplemented with 3D
A B
Figure 15.1  3D TEE, en face atrial surgical view of mechanical mitral prosthesis. (A) Anatomical and (B) anti-anatomical occluder disk
orientation.
158  3D Echocardiography
TEE imaging has progressively emerged as an important
diagnostic tool for PCV evaluation. Providing complete
prosthetic valve imaging without cut-plan limitations
together with an attitudinal anatomical view of its spatial
relationship with adjacent structures, 3D TEE overcomes
the potential disadvantages of the 2D approach.6 Figure 15.1
shows a 3D image with a left atrial en face view rendering
of mechanical mitral prosthesis with anatomical (Figure
15.1A) and anti-anatomical (Figure 15.1B) occluder disk
orientation.
Recently, the availability of a freely movable light
transilluminator system (TrueVue) has enhanced 3D TEE
rendering with high-quality details and depth refinement,
providing accurate photorealistic imaging of the prosthetic
valve. Structural findings together with the occluder/leaflet
motion of artificial mechanical and biological valves may
be clearly imaged.7 Figure 15.2 ( ) shows 3D TEE atrial
and ventricular rendering of a normally functioning mitral
bioprosthesis using conventional 3D and photorealistic
TrueVue systems.
3D TEE imaging provides an accurate assessment of
the actual characteristics of the implanted prosthesis,
highlighting potential inconsistencies between in
vivo parameters and the manufacturer’s labeled valve
size. According to recent suggestions of the European
Association for Cardio-Thoracic Surgery (EACTS), the
Society of Thoracic Surgeons (STS), and the American
Association for Thoracic Surgery (AATS) Valve Labelling
Task Force,8 the sizing and labeling of PCV is an important
but still unresolved issue awaiting standardized definition.
The dimensional characteristics of biological PCV that
can be derived with 3D TEE include true “internal orifice
diameter” (ID), stent ID, planimetric orifice area (POA),
and external sewing ring diameter (ESRD). The ID is the
most relevant physical dimension that determines PCV
 A B

C D

A1 B1

C1 D1

Figure 15.2  3D TEE of normally functioning biological mitral prosthesis. (A) Atrial view, diastole ; (B) atrial view, systole; (C) ventricular
view, diastole ; (D) ventricular view, systole. A1, B1, C1, and D1 TrueVue imaging, respectively .

performance and is the most widely used parameter for
the selection of transcatheter valve-in-valve prosthesis
size.9 Some manufacturers report stent ID, which does
not account for the space between the leaflet tissue and
stent. In particular, significant inconsistencies occur more
frequently in porcine or pericardial biological prostheses
with leaflets sutured inside the stent (true ID < stent ID)
than in bioprostheses with leaflets sutured outside the stent
frame (true ID = stent ID). As hemodynamic performance
is not directly related to labeled valve size, the actual ID
and opening leaflet area measurement (POA) may improve
PCV hemodynamic characterization and performance
standardization beyond the manufacturer’s sizing and
labeling data (Figure 15.3A and B).

Artificial Valves  159

 A

Figure 15.3  (A) 3D TEE showing biological mitral prosthesis. Yellow dotted line: True “internal orifice diameter” (ID); Green dotted line: stent
ID; Red dotted line: external sewing ring diameter (ESRD); Yellow dotted circle: true internal planimetric orifice area (IPOA); Red dotted circle:
internal planimetric orifice area (POA). (B) Transesophageal 2D biological mitral valve view guided by 3D imaging. (1) True internal diameter
(red solid line); (2) External sewing ring diameter (ESRD) (red dotted line); (3) true internal planimetric orifice area (IPOA) (yellow circle).

A mechanical prosthesis may be clearly imaged with 3D TEE
in terms of orientation, occluder motion, and geometric
opening area, even though the anterior part of aortic PCV
visualization may be suboptimal, especially in patients
with a coexisting mechanical mitral prosthesis. Effective
orifice area (EOA) is the most important parameter for the
ultimate assessment of hemodynamics and malfunction
of biological and mechanical prostheses. The continuity
equation using TTE is the conventionally accepted method
to determine EOA: Effective prosthesis area = LVOT
area × LVOT TVI (stroke volume)/prosthesis TVI, where
LVOT (left ventricular outflow tract) area equals (LVOT
diameter/2)2 × 3.14, LVOT -TVI is the time velocity integral
of the LVOT velocity obtained with pulsed-wave Doppler,
and prosthesis TVI is the time velocity integral of prosthesis
outflow obtained with continuous Doppler.10 Continuity
equation reliability in EOA assessment is related to optimal
alignment of the ultrasound beam with prosthetic flow

160  3D Echocardiography
and accurate determination of stroke volume using LVOT
area calculated with squared diameter measurement from
the parasternal long-axis view.11 Elliptical shape, small
size, calcification, and aortic prosthetic sewing or stent
may affect the accurate assessment of LVOT area using a
single squared dimension and related EOA determination.
The common clinical consequence of unreliable LVOT
measurement leads to EOA underestimation, challenging
the hemodynamic and clinical relevance of the calculated
PCV performance index. 3D TEE assessment of the left
ventricular outflow area refines the determination of
the effective prosthetic area, avoiding potential errors in
the stroke calculation when a minor diameter alone with
conventional transthoracic approach is used. The addition
of 3D TEE CFM offers a complete visualization of diastolic
flow through the prosthesis, matching the bioprosthesis
opening leaflet area or double orifice of the mechanical
prosthesis, which is generated by occluder opening.
3D TEE IN MALFUNCTIONING SURGICALLY
IMPLANTED ARTIFICIAL VALVES
PROSTHETIC VALVE OBSTRUCTION
Prosthetic valve obstruction is generally caused by thrombus,
pannus, vegetations, or primary occluder/bioleaf let
Figure 15.4  TEE showing a biological mitral prosthesis. (A) 2D imaging showing apparently fixity of one leaflet
with 2D-derived imaging showing clear evidence of normal leaflet motion .
abnormalities. In addition to careful clinical examination,
TTE provides important parameters suggesting prosthetic
valve obstruction, including disk or bioleaflet motion
analysis (M-mode and 2D images), Doppler transprosthetic
gradient, prosthetic area deriving from continuity equation,
and subverted CFM imaging. 2D TEE supplemented by
3D imaging permits the recognition or refinement of the
prosthetic obstruction mechanism to choose an appropriate
therapeutic management.12
OCCLUDER/LEAFLET PRIMARY ABNORMALITIES:
TRICKS AND TIPS
Occluder or leaflet motion evaluation is key to establishing a
diagnosis of PCV obstruction. In patients with a mechanical
prosthesis, occluder malfunctioning may be intermittent,
requiring prolonged and careful observation during TEE
examination in a highly suspicious clinical context. Even
though it provides high-resolution imaging, 2D TEE may
sometimes underestimate maximum occluder/bioleaflet
motion depending on the alignment of the ultrasound beam
with the prosthetic valve opening plane. Offering complete
visualization of occluder/bioleaflet motion, 3D TEE
overcomes the potential limitations of the 2D approach.5,6,13
Figure 15.4 ( ) shows a patient with a surgically implanted
mitral bioprosthesis with apparent restricted motion of
. (B) TrueView imaging
Artificial Valves  161
one cusp at early perioperative 2D TEE. Subsequent 3D
TEE imaging clearly shows a normally functioning mitral
bioprosthesis with preserved leaflet motion and normal
planimetric area.
Figure 15.5 reports a case of apparent reduced disk
motion of a mechanical mitral prosthesis (ON-X25) due
to the malalignment of 2D cropped images with opening
disk plane. Additional 3D TEE images show complete leaflet
motion, averting misdiagnosis of prosthesis malfunction.
An accurate evaluation of transprosthetic flow with
Doppler CFM may be useful to support the diagnosis
of an obstructive condition. In particular, in patients
with bileaflet mechanical mitral valves, loss of one of
the prosthetic diastolic inflow jets is highly suggestive of
occluder malfunctioning or obstruction (Figure 15.6, ).
In patients with a biological prosthesis, 3D TEE provides
additional information on an obstruction mechanism
caused by structural valve deterioration (SVD). Using
appropriate gain adjustment, leaflet calcification can be
clearly depicted with 3D TEE. Optimized TrueVue analysis
may further refine valve calcification mapping. Leaflet
motion analysis with 3D-guided images provides accurate
measurement of the valve opening area, corroborating
the diagnosis and hemodynamic burden of prosthetic
obstruction. In addition to degenerative calcification, an
immunomediated reactivity may induce leaflet stiffness,
reducing the valve opening area.14 Figure 15.7 ( ) shows
an example of early leaflet hypomobility in a patient with
biological mitral prosthesis valve.
NONSTRUCTURAL OCCLUDER/BIOLEAFLET
ABNORMALITIES
Thrombus and pannus are the most common causes of
PCV obstruction related to nonstructural occluder/leaflet
abnormalities. Clinical phenotypes may vary depending
on the degree of occluder/leaflet malfunctioning and
embolic occurrence. Massive prosthetic valve obstruction
is associated with clinical and hemodynamic instability
requiring emergency surgical or thrombolytic treatment.14,15
Nonsignificant occluder/leaflet abnormalities may be
characterized by a subtle clinical course or progressive
congestive heart failure. TEE is crucial for ultimate
thrombus identification and its interference with
prosthetic function, providing useful information for
subsequent therapeutic management. However, TEE
may have some limitations, including suboptimal or
inadequate visualization of the ventricular side of a mitral
or tricuspid prosthesis, and the anterior side of an aortic
prosthetic valve, especially in patients with a coexisting
mechanical mitral prosthesis. Multiple views, together with
appropriate cropping planes using 3D-TEE, may overcome
the limitations of 2D imaging and may provide additional
information concerning thrombus characteristics
(dimension, insertion, echogenicity, mobile component)
that will guide therapeutic management. According to a
recently published meta-analysis,12 3D TEE shows a higher
sensitivity (81%) than TTE (20%) or 2D TEE (68%) in
detecting prostheses masses in patients suspected of PCV
obstruction. Supplemental analysis with TrueVue may
162  3D Echocardiography
further enhance the capability of 3D TEE imaging to depict
thrombus characteristics. Thrombosis is usually associated
with a spontaneous left intra-atrial smoking effect, which
may also limit or mask the 3D TEE atrial surgical view. A low-
gain setting is required to attenuate or abolish the smoking
effect with the disadvantage of conventional 3D TEE
imaging deterioration. The additional use of TrueVue with
appropriate transillumination provides high-quality mitral
valve prosthesis images despite a coexisting atrial smoking
effect. Appropriately addressing the transillumination
system, prosthesis imaging can be optimized to improve
3D TEE diagnostic capability in the presence of intra-atrial
smoking effect, maintaining the gain level that precludes
conventional 3D TEE imaging.
Thrombus and pannus differentiation is crucial to select
patients who might benefit from thrombolysis rather than
surgery.15–18
3D imaging with gain optimization and appropriate
transillumination analysis with TrueVue may improve
thrombus rendering, showing a soft echogenic mass
rather than the higher translucence of pannus, together
with localization on the upstream side of the prosthesis.
Figure 15.8 ( ) shows an example of a large mass with soft
echogenicity sided in the atrial face of a mechanical mitral
prosthesis, suggesting a diagnosis of thrombus.
Figure 15.9A through 15.9C shows a case of circumferential
pannus surrounding the prosthesis ring masking surgical
suture signs.
The identification of pannus in the aortic prosthesis
may be challenging due to suboptimal 2D imaging of
the anterior site, especially in patients with a coexisting
mechanical mitral prosthesis. Appropriate 3D rendering
provides a visualization of pannus commonly extended
to the left ventricular side of the aortic prosthesis
(Figure 15.10).
Pannus might also be an obstruction mechanism in
biological prostheses.19 Figure 15.11 reports a case of biological
prosthesis obstruction due to an intrastent pannus that was
visualized using an off-axis deep esophageal 2D TEE view
(“transcardia view”) permitting a complete cross section of the
prosthesis. Intrastent pannus findings were visualized with 3D
TEE, and the residual intrastent area was calculated using 2D
imaging guided by multiview analysis. The pannus findings
were confirmed during subsequent surgery performed
because of symptoms occurrence and severe pulmonary
artery hypertension (sPAP 90 mm Hg) during stress exercise
echocardiography.
Biological PCV obstruction may be due to cusp
hypomobility as a consequence of an infective or
immunoreactive process that can also occur during the
early phase following surgical implantation. Following
TTE measurement of a high transprosthetic gradient,
3D TEE, providing an accurate analysis of prosthesis
leaflet morphology and motion, may distinguish normal
functioning, high-flow conditions, or patient prosthesis
mismatch from obstructive PCV disease (Figure 15.12).
Early detection of presymptomatic leaflet disease
may identify a subset of patients who might benefit from
appropriate and effective strategies, including risk
 A1 A2

B1 B2

C1 C2

D1 D2

Figure 15.5  TEE showing a case of apparent reduced disk motion of a mechanical mitral prosthesis due to the malalignment of 2D cropped
images with opening disk plane. (A1,A2) 2D TEE, midesophageal view: reduced motion of prosthesis occluder, which appears normal at
subsequent 3D imaging; (B1,B2) systolic and diastolic conventional imaging; (C1,C2) systolic and diastolic TrueVue 3D imaging, respectively;
(D1,D2) preserved double inflow color flow mapping.

Artificial Valves  163

 A B C

Figure 15.6  3D TEE, midesophageal view of mechanical prosthetic mitral valve showing a loss of one diastolic inflow jet due to blocked
occluder. (A) 2D imaging; (B) color flow mapping ; (C) 3D imaging .

A B C

D E

Figure 15.7  TEE showing early hypomobility of medial leaflet in a patient with biological mitral prosthesis valve. (A) 2D TEE “transcardia
view”; (B,C) 3D TEE, conventional imaging ; (D,E) TrueVue 3D TEE imaging .

burden reduction of structural deterioration (i.e., arterial
hypertension, immunoreactivity) or the introduction of oral
anticoagulant treatment to induce regression or prevent
thrombosis progression.19–22
Figure 15.13 shows a workup model to evaluate an aortic
valve prosthesis.
PROSTHETIC VALVE REGURGITATION
Patients with surgically implanted PCV may develop
regurgitation that can occur outside the valve prosthesis, as
a consequence of leak around the sewing ring (paravalvular
regurgitation, PVR), or inside the valve prosthesis due
to occluder/bioleaflet malfunctioning (intraprosthetic
regurgitation, IPR). Echocardiography is the main tool used
to distinguish the site, identify the mechanism, quantify
regurgitation, and guide the appropriate therapeutic
strategy. 23,24 Multiple structural factors may subtend
PVR development, including tissue friability, annular
calcification, infection, suture rupture, and the recent use
of corticosteroid therapy. The clinical course of PVR may
be asymptomatic but can lead to heart failure, hemolytic
anemia or both. Heart failure is related to PVR severity and
associated left atrial compliance, whereas hemolytic anemia
may also occur in the presence of small PVR, especially in
an eccentric regurgitation.25 Although TTE and 2D TEE
provide important parameters, 3D TEE plays a dominant
role in the ultimate diagnosis and therapeutic management
of PVR patients. Using an en face anatomical view, 3D TEE can
map the leak site using a nomenclature based on prosthetic
sites overlapping the clock face26–30 (Figure 15.14):
• For the mitral prosthesis, the aortic valve is represented
by 12 o’clock, the midpoint of the posterior anulus is
represented by 6 o’clock, the left atrial appendage is at
9 o’clock and the interatrial septum at 3 o’clock.
• For the aortic prosthesis, we can use the mirror imaging
of the mitral prosthesis nomenclature.
Careful attention should be paid to avoid artifacts of
ultrasound imaging (i.e., dropout, stitching, acoustic
shadowing, and reverberation) during multibeat acquisitions

164  3D Echocardiography
 A B

C D

Figure 15.8  TEE showing a case of large intraprosthesis mechanical mitral valve thrombus. (A) 2D large intraprosthesis thrombus occluding
the lateral orifice . (B) TEE and color flow mapping, subverted intraprosthetic flow with a loss of one diastolic inflow jet. (C) 3D atrial view,
large thrombus surrounding the prosthetic annulus and occluding the medial orifice . (D) 3D cropped anteroseptal view .

in an attempt to obtain an accurate 3D CFM overlapping with
prosthetic valve morphology at high temporal and spatial
resolution. Although improved by the use of dedicated
software, multibeat 3D imaging acquisition in patients with
atrial fibrillation may be limited by R-R changes, which lead
to stitch artifact development. In addition, ultrasound gain
setting should be optimized to obtain a clear PCV image
without low-gain dropout (mimicking a leak) or a high-
gain setting, mimicking or masking a paraprosthetic leak,
respectively (Figure 15.15).

A B

Figure 15.9  3D TEE atrial view. (A) Circumferential prosthetic ring pannus, masking surgical sutures, overlapping the anatomical specimen
(B); (C) atrial view of normal prosthesis showing surgical sutures.

Artificial Valves  165

 A1 A2 A3

B1 B2 B3

C1 C2 C3

D1 D2 D3

Figure 15.10  Pannus at ventricular side of mechanical aortic prosthesis in a patient with a coexisting mechanical mitral prosthesis. (A1) TTE,
three-chamber apical view, showing an hyperechogenic structure in the left ventricular side of the aortic prosthesis with correlated large
convergency area at color flow mapping (CFM) (A2) and high gradient (A3), confirmed at TEE using transgastric long-axis view (B1: 2D; B2:
CFM; B3: Doppler gradient). (C1, C2, C3) 3D TEE, midesophageal cropped imaging focused on left ventricular outflow tract showing a pannus
into the ventricular side of the aortic prosthesis (C1: long axis; C2, C3: short axis), confirmed at surgery (D1, D2, D3).

166  3D Echocardiography
 A1 A2 A3

B1 B2 B3

C1 C2 C3

D1 D2 D3

Figure 15.11  A case of biological mitral prosthesis obstruction (A1: mean gradient 8 mm Hg), turbolent diastolic color flow mapping (A2)
with normal pulmonary arterial pressure (A3), increasing during exercise (B1-B2: mean gradient 20 mm Hg ), together with severe pulmonary
hypertension (B3: 90 mm Hg) due to an intrastent pannus, which was visualized using an off-axis deep esophageal 2D TEE view (“transcardia
view”) (C1-C2-C3) permitting a complete cross section of the prosthesis. Intrastent pannus findings were visualized with 3D TEE (D1), and
the residual intrastent area was calculated using 2D imaging guided by multiview analysis. The pannus findings were confirmed during
subsequent surgery (D2, D3).

Comparison of the atrial view with a focused ventricular
view of the prosthesis may help distinguish artifacts from
true leaks (Figure 15.16A and B).
The use of TrueVue may enhance the visualization
of paraprosthetic leakage using a high-gain setting that
may oversaturate conventional 3D TEE imaging. Another
important trick to avoid the gain-related trap in leak
identification is the coherence between the mapped leak
site and the overlapping 3D CFM regurgitant jet.
The quantification of PVR may be challenging,
especially in the presence of eccentric or multiple
regurgitant jets. Regurgitant jet measurement may be
inaccurate using a single 2D echocardiography plane
because the majority of patients have complex shaped
leaks. In addition to a clear identification of the jet site, 3D
CFM can improve the quantitative evaluation of PVR 30 with
accurate measurement of vena contracta (VC) parameters
(diameter and area) and the regurgitant convergence area
by cropping the 3D CFM signal using full-volume mode
at the downstream valve prosthesis site. In particular, in
patients with multiple regurgitant leaks, VC areas of the
different orifices can be planimetered and added together
to obtain accurate PVR assessment severity (Figure 15.17A
through 15.17C).

Artificial Valves  167

 A1 A2

Figure 15.12  3D TEE showing a normally functioning biological aortic prosthesis (A1) in a symptomatic patient with high gradient (50 mm
Hg) and reduced indexed area (0.5 cm2 /m2) at TTE, increasing during exercise together with severe pulmonary hypertension. TrueVue analysis
provides a clear visualization of a normal opening area (A2: ventricular side of systolic opening of aortic prosthetic valve).

TTE TTE TTE

Vmax <3 m/sec Vmax 3–4 m/sec Vmax >4 m/sec
Mgrad <20 mm Hg Mgrad 20–34 mm Hg Mgrad >35 mm Hg
EOA >0.85 cm2/m2 EOA ≤0.85 cm2/m2 EOA ≤0.65 cm2/m2

2D and 3D TEE
Normal valve
structure and motion
Calcificated leaflet
3D-stroke volume Mild calcification Thrombosis
3D-EOA Mild thrombosis Pannus
Reduced leaflet motion
>0.85 cm2/m2 ≤0.85 cm2/m2 Reduced opening area

Normal
prosthesis Patient prosthesis
High-flow state mismatch Cinically
Pre-clinical SVD or non-SVD
significant PCV

Figure 15.13  Echocardiographic workup for aortic prosthesis evaluation.

Using 3D TEE, we provide important information on

the site, shape, size, number, extension, and anfractuosities
of the leak subtending the PVR.24 Regurgitant anatomical
LM 6 orifice measurement may be inaccurate using a single 2D
3 RCA echocardiography plane because the majority of patients
LAA
RC
LC have complex, nonplanar, irregular, and asymmetrically
9
shaped orifices. Using 3D TEE imaging measurement of
9 NC
12 the anatomical regurgitant lesion, the maximal area can
be obtained. Due to masking or suboptimal imaging of the
anterior region, the additive value of 3D TEE is lower in
ventricular-arterial prosthetic valves (aortic and pulmonary
6 3
prostheses) than in atriaventricular prostheses (mitral and
tricuspid) (Table 15.1).
The characteristics of paraprosthetic leaks are essential
to plan and guide the percutaneous treatment strategy.31
Figure 15.18A through 15.18D shows different leak shapes
Figure 15.14  Nomenclature for paravalvular regurgitation using
suitable for percutaneous treatment using a single device or
clock face. (LAA, left atrial appendage; LC, left coronary sinus; LM, multiple devices, respectively.
left main coronary artery; NC, noncoronary sinus; RC, right coronary The development of intraprosthesis regurgitation may
sinus; RCA, right coronary artery.) subtend a nonstructural or structural occluder/bioleaflet

168  3D Echocardiography
 A1 A2

B1 B2

Figure 15.15  3D TEE showing gain dependence of paravalvular leak imaging. (A1) Masked leak by high gain setting; (A2) mimicked leak by
low gain setting; (B1) large paravalvular leak with coherent regurgitation site and extension (B2).

A B

Figure 15.16  3D TEE. A double paravalvular leak of mechanical mitral prosthesis (dotted green circles): (A) Atrial view; (B) ventricular view.

A B C

Figure 15.17  3D TEE showing an oval-shaped paravalvular leak of a mechanical mitral prosthesis (A, dotted circle) with a correlated
regurgitation (B, color flow mapping); (C) cropped imaging focused to measure the vena contracta area of the regurgitant jet.

Artificial Valves  169

 Table 15.1  Additive Value of Three-Dimensional Echocardiography in Artificial Valve Evaluation
ECO-TT 2D TEE 3D TEE
Attitudinal Imaging
Comprehensive view + + +++
Surrounding structures + + +++
Biological/Mechanical
Prostheses
Atrio-Ventricular Site
(Mitral, Tricuspid) ++ ++ +++
Obstruction + ++ +++
Regurgitation + +++ +++
Leaflet/occluder mobility + ++ +++
Structural deterioration + ++ +++
Nonstructural deterioration thrombosis ++ (ventricular side) ++ +++(atrial side)
Internal diameter and area ++ (ventricular side) ++ (atrial side) +++ (atrial side)
Paravalvular leak - + +++
Biological/Mechanical
Prostheses
Ventricular-Arterial Site
(Aorta, Pulmonary) +++ (anterior side) +++ (posterior side) ++/+++
Obstruction +++ (anterior side) +++ (posterior side) ++/+++
Regurgitation ++ +++ +++
Leaflet/occluder mobility + +++ +++
Structural deterioration + +++ +++
Nonstructural deterioration thrombosis + +++ +++
Internal diameter and area + +++ +++
Paravalvular leak + ++ +++
Mismatch ++ +++ +++
Patient/Prostheses
Endocarditis - +++ +++
Vegetation vs. Thrombus

malfunction. Structural deterioration is the most common

cause of intraprosthetic biological valve regurgitation due to
primary leaflet damage, including calcification, detachment,
phlogosis, or septal endocarditis. Nonstructural issues, such
as large thromboses or vegetations, may cause intraprosthetic
regurgitation due to interference with prosthetic occluder/
bioleaflet motion.32
A C
B D
Figure 15.18  3D TEE showing differently shaped paravalvular leaks
of mitral valve prosthesis. (A) Oval-shaped leak that can be closed
using one Amplatzer device (B); (C) crescent-shaped leak that can be
closed with multiple devices (D).
ENDOCARDITIS
Endocarditis occurs in 1%–6% of PCV patients (incidence
0.3%–1.2% per patient-year) without significant
differences between mechanical and biological prostheses.
Endocarditis is a frightening complication in PCV patients
with high in-hospital mortality (20%–40%). Even though
it may play a role in the diagnostic workup, TTE has
important limitations in the recognition of endocarditis
due to a masking ultrasound effect in the upstream
prosthetic site, especially in patients with mitral and
tricuspid prostheses. The use of TEE, supplemented
by 3D imaging reconstruction, is crucial to diagnose
endocarditis, providing additional information on
vegetation morphology and local complications, including
paraprosthetic leak, abscess, perforation, and intracardiac
fistula. 33–35 The sensitivity of TEE in detecting prosthetic
valve vegetation verified at surgery or autopsy is higher
than TTE (82% vs. 36%, respectively). Maximum size
greater than 10 mm together with a soft echogenicity of
vegetation may be refined using 3D imaging in order to
stratify the embolic risk and guide the selection of optimal
timing for surgical treatment. 36 Differentiation between
vegetation and thrombus may be challenging in some
clinical contexts. For example, at times, the detection of
a paraprosthetic mass together with ambiguous clinical
findings for endocarditis following dental procedures or
noncardiac surgery requires a differential diagnosis of
vegetation and thrombus, which may be a consequence

170  3D Echocardiography
of concomitant anticoagulant discontinuation. A careful
multiple-view analysis of the mass using 3D imaging
may depict infiltrative findings around the prosthetic
ring suggesting endocarditis. Targeted 2D with 3D
imaging provides differentiation between isoechogenic
(myocardium-like) and hyperechogenic vegetation,
suggesting active or scarring evolution phases, respectively.
Paravalvular abscess, intracardiac postendocarditis shunts,
and paravalvular leak may also exploit 3D imaging analysis.
3D TEE IN MALFUNCTIONING
TRANSCATHETER ARTIFICIAL VALVES
In recent years, transcatheter replacement of dysfunctional
native and biological valves has substantially changed the
clinical scenario of PCV patients, providing a therapeutic
option in patients who are at high surgical risk or are
inoperable. 37–39 In addition to patient selection and
procedural monitoring, echocardiography is essential
for the surveillance of implanted prostheses to identify
complications and establish appropriate treatment.40–42
TRANSCATHETER IMPLANTED AORTIC VALVE
Transcatheter aortic valve replacement (TAVR) is the
most widely used percutaneous procedure that aims to
achieve effective and durable treatment of aortic valve
stenosis. Like surgically implanted biological valves,
TAVR requires systematic echocardiographic evaluation
to detect hemodynamic and morphological signs of
structural or nonstructural valve deterioration.21,42–45 In
particular, the specific features of TAVR may promote valve
deterioration including leaflet injury (such as crimping,
loading, dilatation), abnormal flow pattern, nonuniform
deployment, and frame expansion degree. A meta-analysis
including 8914 patients (median follow-up: 1.6–5 years)
reports an incidence from 0 to 1.34 × 100 patient-years
(overall 28.08 × 10,000 patient-years).46 Most of the basic
principles used to assess surgically implanted bioprostheses
remain the same for TAVR patients. Systematic TTE
evaluation in TAVR patients should focus on transprosthesis
gradient and EOA, valve stent position, leaflet thickness and
mobility, para- or intrastent regurgitation, and interaction
A B
Figure 15.19  A patient with transcatheter valve implantation for deterioration of surgically implanted biological aortic prosthesis. (A) 2D
Doppler showing normal transprosthetic gradient; (B) 2D TEE showing a preserved leaflet motion and opening leaflet area with thrombus
surrounding the bioprosthesis; (C) 3D TEE analysis clearly demonstrated a valve-sparing thrombosis, outside the frame of the reimplanted
valve, surrounding the previously surgically implanted valve.
with adjacent native structures such as mitral valve or systolic
anterior motion (SAM)-related dynamic LV obstruction.
However, due to prosthetic acoustic artifacts, TTE sensitivity
in the analysis of leaflet structure and motion may be
limited. In particular, early leaflet abnormalities cannot be
detected before hemodynamic impairment appears. Some
recent studies report a significant incidence of subclinical
immobility or thrombosis using computed tomography
(CT) scan in the absence of hemodynamic signs of valve
obstruction.47,48 Although no systematic studies have been
made, the use of TEE supplemented by 3D images may
refine the identification of structural valve deterioration
(leaflet thickening, calcification, and hypomobility) or
nonstructural abnormalities such as thrombosis. Thrombosis
may be an unexpected event without hemodynamic signs of
valve obstruction.19,20 Figure 15.19A through 15.19C reports
an impressive case of thrombosis at 2-month CT follow-up
after valve-in-valve TAVR in the absence of significant
gradient or valve area reduction. A subsequent TEE showed
a preserved leaflet motion and opening leaflet area. 3D
analysis clearly demonstrated a valve-sparing thrombosis,
outside the frame of the reimplanted valve, surrounding the
previously surgically implanted valve.
Figure 15.20A through 15.20C ( ) reports an
example of the added value of 3D TEE with TrueVue in
detecting intrastent endocarditis vegetation, which was not
clearly apparent at 2D imaging and conventional 3D TEE.
Valve regurgitation following TAVR is a clinically
relevant issue that can be related to varying factors, such
as undersizing for the native annular shape, prosthesis
malpositioning in the annulus, and calcification. Para- or
intrastent site assessment and regurgitation severity may be
made using TTE- or TEE-CFM. Paravalvular regurgitation
mapping requires a careful check of the regurgitant sites,
which can be multiple, eccentric, and located on different
planes.49–51 Using 3D TEE, a comprehensive view of aortic
valve prostheses may be obtained, leading to optimal
jet localization and respective measurement of vena
contracta area, which can be added for quantification
of multiple-jet regurgitation. Although a very small jet
and blooming effect are potentially limiting factors, 3D
TEE is more accurate than 2D TTE or 2D TEE imaging
in the assessment of aortic regurgitation following TAVR
C
Artificial Valves  171
 A B C

Figure 15.20  TEE reports a patient with transcatheter aortic valve replacement endocarditis and large and mobile iso-echogenic vegetation
more evident at 3D TEE with true system (C) than 2D (A) and conventional 3D (B) examination .

in selected patients with inconclusive data or challenging
jet shape, requiring meticulous multiplane 2D views.
However, the use of TTE can be complementary when
TEE is suboptimal for the anterior site exploration of
prosthetic aortic valves.
TRANSCATHETER IMPLANTED MITRAL VALVE
Transcatheter mitral valve replacement (TMVR) has been
recently proposed to treat mitral regurgitation in native
or in degenerated surgically implanted bioprostheses. 52,53
Echocardiography with 2D and 3D TEE together with CT
imaging are essential tools in selecting the workup of patients
who can benefit from TMVR, providing information on
suitable valve anatomy, prosthetic sizing, and left ventricular
outflow obstruction risk. Intraprocedural 2D and 3D TEE
are mandatory to monitor transcatheter valve implantation,
guiding the appropriate device seating, orientation, and
valve covering and avoiding paravalvular regurgitation,
device detachment, or left ventricular outflow obstruction53
(Figure 15.21).
TRANSCATHETER IMPLANTED TRICUSPID VALVE
Transcatheter tricuspid valve replacement (TTVR) may
be applied to treat failed surgically implanted biological
prostheses or prosthetic ring annuloplasty. Like TMVR,
3D TEE plays an essential role in guiding the implantation
procedure and recognizing prosthesis complications,
such as regurgitation or obstruction as a consequence of
structural deterioration or thrombosis. Figure 15.22 ( )
reports a 3D TEE in a patient with Ebstein disease who
underwent TTVR following a failed surgically implanted
bioprosthesis.
TRANSCATHETER IMPLANTED PULMONARY VALVE
Transcatheter pulmonary valve replacement (TPVR) can
potentially treat native pulmonary valve or bioprosthetic

A B

Figure 15.21  TrueVue 3D TEE monitoring of transseptal bioprosthesis implantation in a patient with structural degeneration of surgically
implanted biological prosthesis. (A) Transseptal catheter device monitoring. (B) Ultimate deployment of bioprosthesis (valve in valve) with
residual small septal defect at site of transseptal puncture.

172  3D Echocardiography
 A B C

D E F

Figure 15.22  Transcatheter tricuspid valve-in-valve. (A) 3D TEE showing a stenotic biological tricuspid prosthesis with high gradient (B); (C)
transcatheter valve-in-valve implantation; (D) postimplantation 3D TEE with improvement of prosthetic valve area together with transvalvular
gradient (E) and normal opening without leaks (F) .

conduct degeneration. 54 Like TAVR, TTE is required to A

monitor valve regurgitation or transvalvular gradient as signs
of the structural or nonstructural prosthesis deterioration.
In patients with nonconclusive TTE findings, 2D and
3D TEE may improve echocardiographic accuracy in the
quantification of pulmonary valve regurgitation and leaflet
degeneration detection. In particular, severe pulmonary
regurgitation may be confined in the early phase of diastole
B
as a consequence of the increase of end-diastolic right
ventricular pressure, limiting the pulmonary regurgitant
jet gradient. To avoid the potential pitfall for pulmonary
regurgitation evaluation, TEE offers accurate imaging
of pulmonary regurgitation with a transgastric long-axis
view of the right ventricular outflow tract and pulmonary
valve, together with the diastolic reverse of regurgitant jet
in the branch pulmonary arteries. Although published
experiences are lacking, the use of 3D TEE may improve
Figure 15.23  3D TEE showing a structural deterioration of biological
pulmonary insufficiency quantification, providing accurate
pulmonary valve with reduced leaflet opening (A), confirmed with computed
measurement of vena contracta diameter and area, as well as
tomography scan short- and long-axis views (B) in a patient with carcinoid
reliable assessment of biventricular stroke volume to quantify syndrome and liver metastasis requiring careful surveillance for selection of
regurgitant pulmonary volume and fraction (Figure 15.23). optimal timing for re-valve implantation.

CONCLUSION
On clinical examination with suspicious TTE findings, TEE
is frequently required for the ultimate assessment of artificial
valve function and abnormalities. With increasing spatial and
temporal resolution, 3D TEE has progressively emerged as an
important diagnostic tool for prosthetic cardiac valves evalu-
ation. Providing complete prosthetic valve imaging without
cut-plan limitations together with an attitudinal anatomical
view of its spatial relationship with adjacent structures, 3D TEE
overcomes the potential disadvantages of the 2D approach.
Recently, the availability of a freely movable light transillumi-
nator system (TrueVue) has enhanced 3D TEE rendering with
high-quality details and depth refinement, providing accurate
photorealistic imaging of the prosthetic valve.

Artificial Valves  173


REFERENCES
1. Nishimura RA, Otto CM, Bonow RO et  al. AHA/ACC Guideline for
the management of patients with valvular heart disease. J Am Coll Cardiol.
2014;63:2438–88.
2. Dunning J, Gao H, Chambers J et  al. Aortic valve surgery: Marked
increases in volume and significant decreases in mechanical valve use—An
analysis of 41227 patients over 5 years from the Society for Cardiothoracic
Surgery in Great Britain and Ireland National database. J Thorac Cardiovasc
Surg. 2011;142:776–82.
3. Pibarot P, Dumesnil JG. Prosthetic heart valves: Selection of the optimal
prosthesis and long-term management. Circulation. 2009;119:1034–48.
4. Zoghbi WA, Chambers JB, Dumesnil JG et  al. Recommendations for
evaluation of prosthetic valves with echocardiography and Doppler
ultrasound. J Am Soc Echocardiogr. 2009;22:975–1014.
5. Lancellotti P, Pibarot P, Chambers J et  al. Recommendations for the
imaging assessment of prosthetic heart valves: A report from the European
Association of Cardiovascular Imaging endorsed by the Chinese Society of
Echocardiography, the Inter-American Society of Echocardiography, and
the Brazilian Department of Cardiovascular Imaging. Eur Heart J Cardiovasc
Imaging. 2016;17(6):589–90.
6. Anwar AM, Nosir YF, Alasnag M, Chamsi-Pasha H. Real-time three-
dimensional transesophageal echocardiography: A novel approach for the
assessment of prosthetic heart valves. Echocardiography. 2014;31(2):188–96.
7. Genovese D, Addetia K, Kebed K et  al. First clinical experience with
3-dimensional echocardiographic transillumination rendering. JACC
Cardiovasc Imaging. 2019;12(9):1868–71.
8. Durko AP, Head ST, Pibarot P et  al. Characteristics of surgical
prosthetic heart valves and problems around labeling: A document from
the European Association for Cardio-Thoracic Surgery (EACTS)—The
Society of Thoracic Surgeons (STS)—American Association for Thoracic
Surgery (AATS) Valve Labelling Task Force. J Thorac Cardiovasc Surg.
2019;158(4):1041–54.
9. Mackensen GB, Lee JC, Wang DD et al. Role of echocardiography in
transcatheter mitral valve replacement in native mitral valves and mitral
rings. J Am Soc Echocardiograph. 2018;31(4):475–90.
10. Garcia D, Pibarot P, Landry C et al. Estimation of aortic valve effective
orifice area by Doppler echocardiography: Effects of valve inflow shape and
flow rate. J Am Soc Echocardiogr. 2004;17:​756–65.
11. Bitar JN, Lechin ME, Salazar G, Zoghbi WA. Doppler echocardiographic
assessment with the continuity equation of St. Jude medical mechanical
prostheses in the mitral valve position. Am J Cardiol. 1995;76:287–93.
12. Kim JY, Suh YJ, Han K, Kim YJ, Choi BW. Diagnostic value of advanced
imaging modalities for the detection and differentiation of prosthetic valve
obstruction. A systematic review and meta-analysis. JACC Cardiovasc Imaging.
2019;12(11 Pt 1):2182–92.
13. Baldwin ACW, Tolis G Jr. Tissue valve degeneration and mechanical
valve failure. Curr Treat Options Cardiovasc Med. 2019;21(7):33. Review.
14. Egbe A, Pislaru SV, Ali MA et al. Early prosthetic valve dysfunction due
to bioprosthetic valve thrombosis. The role of echocardiography. JACC
Cardiovasc Imaging. 2018;11(7):951–8.
15. Özkan M, Gündüz S, Biteker M et  al. Comparison of different TEE
guided thrombolytic regimens for prosthetic valve thrombosis: The TROIA
trial. JACC Cardiovasc Imaging. 2013;6(2):206–16.
16. Barbetseas J, Nagueh SF, Pitsavos C et  al. Differentiating thrombus
from pannus formation in obstructed mechanical prosthetic valves: An
evaluation of clinical, transthoracic and transesophageal echocardiographic
parameters. J Am Coll Cardiol. 1998;32:1410–7.
17. Ozkan M, Gündüz GS, Yildiz M et al. Diagnosis of the prosthetic heart
valve pannus formation with real-time three-dimensional transoesophageal
echocardiography. Eur Heart J Cardiovasc Imaging. 2010;11:E17.
18. Tanis W, Habets J, van den Brink RB, Symersky P, Budde RP,
Chamuleau SA. Differentiation of thrombus from pannus as the cause
of acquired mechanical prosthetic heart valve obstruction by non-
invasive imaging: A review of the literature. Eur Heart J Cardiovasc Imaging.
2014;15:119–29.
19. Makkar RR, Fontana G, Jilaihawi H et al. Possible subclinical leaflet
thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015;373:2015–24.
20. Chakravarty T, Søndergaard L, Friedman J et  al. Subclinical leaflet
thrombosis in surgical and transcatheter bioprosthetic aortic valves: An
observational study. Lancet. 2017;389(10087):2383–92.
174  3D Echocardiography
21. Dvir D, Bourguignon T, Otto CM et  al. Standardized definition of
structural valve degeneration for surgical and transcatheter bioprosthetic
aortic valves. Circulation. 2018;137:388–99.
22. Puri R, Auffret V, Rodés-Cabau J. Bioprosthetic valve thrombosis. J Am
Coll Cardiol. 2017;69:2193–211.
23. Franco M, Almer C, de Agustìn JA et  al. Three-dimensional color
Doppler transesophageal echocardiography for mitral paravalvular leak
quantification and evaluation of percutaneous closure success. J Am Soc
Echocardiogr. 2014;27(11):1153–63.
24. Ruiz CE, Hahn RT, Berrebi A et  al. Clinical trial principles and
endpoint definitions for paravalvular leaks in surgical prosthesis: An
expert statement. J Am Coll Cardiol. 2017;69:2067–87.
25. Shapira Y, Vaturi M, Sagie A. Hemolysis associated with prosthetic heart
valves: A review. Cardiol Rev. 2009;17(3):121–4.
26. Horton KD, Whisenant B, Horton S. Percutaneous closure of a
mitral perivalvular leak using three dimensional real time and color flow
imaging. J Am Soc Echocardiogr. 2010;23(8):903.e5–7.
27. Quader N, Davidson CJ, Rigolin VH. Percutaneous closure of
perivalvular mitral regurgitation: How should the interventionalists
and the echocardiographers communicate? J Am Soc Echocardiogr.
2015;28(5):497–508.
28. Flaschkampf FA, Wouters PF, Edvardsen T et al. Recommendations
for transoesophageal echocardiography: EACVI update 2014. Eur Heart J
Cardiovasc Imaging. 2014;15:353–65.
29. Singh P, Manda J, Hsiung MC et al. Live/real time three-dimensional
transesophageal echocardiographic evaluation of mitral and aortic valve
prosthetic paravalvular regurgitation. Echocardiography. 2009;26:980–7.
30. Spoon DB, Malouf JF, Spoon JN et  al. Mitral paravalvular leak:
Description and assessment of a novel anatomical method of localization.
JACC Cardiovasc Imaging. 2013;6:1212–4.
31. Krishnaswamy A, Kapadia SR, Tuzcu EM. Percutaneous paravalvular
leak closure-imaging, techniques, and outcomes. Circ J. 2013;77:19–27.
32. Gursoy MO, Kalcik M, Yesin M et al. A global perspective on mechanical
prosthetic heart valve thrombosis: Diagnostic and therapeutic challenges.
Anatol J Cardiol. 2016;16:980–9.
33. Habib G, Erba PA, Iung B et al. Clinical presentation, aetiology and
outcome of infective endocarditis. Results of the ESC-EORP EURO-
ENDO (European infective endocarditis) registry: A prospective cohort
study. Eur Heart J. 2019;40(39).
34. Hansalia S, Biswas M, Dutta R et al. The value of live/real time three-
dimensional transesophageal echocardiography in the assessment of
valvular vegetations. Echocardiography. 2009;26:1264–73.
35. Habib G, Badano L, Tribouilloy C et  al. Recommendations for the
practice of echocardiography in infective endocarditis. Eur Heart J Cardiovasc
Imaging. 2010;11:202.e19.
36. Daniel WG, Mügge A, Martin RP. Improvement in the diagnosis
of abscesses associated with endocarditis by transesophageal
echocardiography. N Engl J Med. 1991;324(12):795–800.
37. Smith CR, Leon MB, Mack MJ et al.; PARTNER Trial Investigators.
Transcatheter versus surgical aortic-valve replacement in high-risk
patients. N Engl J Med. 2011;364:2187–98.
38. Leon MB, Smith CR, Mack M et  al.; PARTNER Trial Investigators.
Transcatheter aortic-valve implantation for aortic stenosis in patients who
cannot undergo surgery. N Engl J Med. 2010;363(17):1597–607.
39. Hahn RT. Transcathether valve replacement and valve repair review
of procedures and intraprocedural echocardiographic imaging. Circ Res.
2016;119:341–56.
40. Zamorano J, Gonçalves A, Lancellotti P et al. The use of imaging in new
transcatheter interventions: An EACVI review paper. Eur Heart J Cardiovasc
Imaging. 2016;17(8):835–5.
41. Altiok E, Koos R, Schrder J et  al. Comparison of two-dimensional
and three-dimensional imaging techniques for measurement of aortic
annulus diameters before transcatheter aortic valve implantation. Heart.
2011;97:1578–84.
42. Hahn RT, Little SH, Monaghan MJ et  al. Recommendations for
comprehensive intraprocedural echocardiographic imaging during
TAVR. JACC Cardiovasc Imaging. 2015;8:​261–87.
43. Asgar AW. Transcatheter aortic valve replacement and valve durability.
Closing in on the finish line? Circulation. 2018;138:2608–10.
44. Didier R, Eltchaninoff H, Donzeau-Gouge P et  al. Five-year
clinical outcome and valve durability after transcatheter aortic valve
replacement in high-risk patients: FR ANCE-2 registry. Circulation.
2018;138:2597–607.
45. Singh M, Sporn ZA, Schaff HV, Pellikka PA. ACC/AHA versus ESC
Guidelines on Prosthetic Heart Valve Management. JACC Guideline
Comparison. J Am Coll Cardiol. 2019;73:1707–18.
46. Foroutan F, Guyatt GH, Otto CM. Structural valve deterioration after
transcatheter aortic valve implantation. Heart. 2017;103:1899–905.
47. Córdoba-Soriano JG, Puri R, Amat-Santos I et  al. Valve thrombosis
following transcatheter aortic valve implantation: A systematic review. Rev
Esp Cardiol (Engl Ed). 2015;68:198–204.
48. Pache G, Schoechlin S, Blanke P et al. Early hypo-attenuated leaflet
thickening in balloon expandable transcatheter aortic heart valves. Eur
Heart J. 2016;37:2263–71.
49. Van Belle E, Juthier F, Susen S et al., for the FRANCE 2 Investigators.
Postprocedural aortic regurgitation in balloon-expandable and self-
expandable transcatheter aortic valve replacement procedures: Analysis of
predictors and impact on long-term mortality: Insights from the FRANCE2
Registry. Circulation. 2014;129:1415–27.
50. Jerez-Valero M, Urena M, Webb JG et  al. Clinical impact of aortic
regurgitation after transcatheter aortic valve replacement: Insights into the
degree and acuteness of presentation. JACC Cardiovasc Interv. 2014;7:1022–32.
51. Pibarot P, Hahn RT, Weissman NJ, Monaghan MJ. Assessment of
paravalvular regurgitation following TAVR: A proposal of unifying grading
scheme. J Am Coll Cardiol Imaging. 2015;8:340–60.
52. De Backer O, Piazza N, Banai S et al. Percutaneous transcatheter mitral
valve replacement: An overview of devices in preclinical and early clinical
evaluation. Circ Cardiovasc Interv. 2014;7:400–9.
53. Urena M, Himbert D, Brochet D et al. Transseptal transcatheter mitral
valve replacement using balloon-expandable transcatheter heart valves. A
step-by-step approach. JACC Cardiovasc Interv. 2017;10(19):1905–19.
54. Ahmed MI, Escañuela MG, Crosland WA, McMahon WS, Alli OO,
Nanda NC. Utility of live/real time three-dimensional transesophageal
echocardiography in the assessment and percutaneous intervention of
bioprosthetic pulmonary valve stenosis. Echocardiography. 2014;31:531–3.
Artificial Valves  175
 16 Adult Congenital Heart Disease

asymptomatic patients may be considered for repair based

INTRODUCTION on volumetric data. The shape of the RV offers challenges
Congenital heart disease (CHD) remains the most common in measuring its size and function in 2D imaging compared
congenital disorder in newborns and affects 0.4%–1% of the with the left ventricle (LV). 5 3D echocardiography has
population.1 The spectrum of defects is wide and ranges emerged to address these limitations.6 In CHD it has
from small and hemodynamically insignificant lesions to become important due to unique projections from the living
very complex conditions, such as functionally univentricular complex anatomy (such as en face views), true volumetric
hearts (UVHs) with a variety of associated lesions. quantification without geometric assumptions, and live
Without appropriate intervention, childhood mortality is dynamic geometric guidance during the interventional
high, and few patients with complex CHD reach adulthood. procedures. Understanding the exact size and shape of
Remarkable advancements in cardiovascular care and the defects and the cardiac anatomy allows planning for
interventional therapies have led to a substantial decline the appropriate therapeutic intervention, whether it is
in mortality from CHD over the past decades. At present, surgery or percutaneous closure. Thus, at this time, 3D
nearly 90% of children born with a cardiac lesion are echocardiography is an important complement to routine
expected to survive beyond the age of 18 years2; as a result, 2D echocardiography or Doppler echocardiography.
adults with CHD now outnumber children with CHD.3
In adults, CHD presents two major survival patterns:
unrepaired survivors to adult life and CHD patients who
3D IMAGING TECHNIQUES IN ADULT CHD
underwent palliative or corrective therapeutic intervention Real-time 3D echocardiography is a useful technique in
(surgery or percutaneous procedure) in childhood. As CHD.7,8
adults, they subsequently face residual defects, sequelae,
or complications from interventions that contribute to MODALITIES OF DATA ACQUISITION
cardiovascular morbidity and mortality, and they will need
2D SIMULTANEOUS MULTIPLANE MODE
lifelong follow-up.
Although not truly “3D,” most 3D matrix transducers
This continually growing population presents a particular
permit the simultaneous display of orthogonal planes so
diagnostic challenge for the cardiologist. Echocardiography
that two or three distinct cross-sectional planes can be
remains the gold standard in diagnosis and provides
viewed simultaneously. Applications include assessment
information on the basic cardiac anatomy, orientation
of atrial septal defect (ASD)9 size and rim length (Figure
and position of the heart, venous return, connection of
16.1), size and shape of ventricular septal defects (VSDs),
the atria and ventricles, and origin of the great arteries.
It also allows examination of the morphology of cardiac
chambers, analysis of heart valves and ventricular function,
and noninvasive hemodynamic evaluation. In this adult
population, transthoracic echocardiography (TTE) is more
challenging than in pediatric patients because of larger body
size and often multiple previous surgical scars. Although most
adults undergo TTE and when necessary, complementary
transesophageal echocardiography (TEE) and magnetic
resonance imaging (MRI)4 are performed. The use of
TEE is also increasing since it has been shown that it has
a major impact on planning and guiding cardiac surgical
and interventional procedures. For their interpretation, the
cardiologists require special expertise in all aspects of native
and postoperative CHD.
When dealing with complex anatomy, such as in CHD,
both 2D TTE and 2D TEE have significant limitations. As
2D echocardiography captures a 2D slice of the heart, it
forces readers to mentally re-create the cardiac anatomy
to envision 3D structures. Furthermore, assessment of Figure 16.1  TEE imaging in an adult with secundum atrial septal
ventricular volumes and function may also be complicated defect (ASD) with adequate superior and inferior rims. Orthogonal
by geometry, particularly in systemic and subpulmonary multiplane mode: Apical four- to five-chamber view with probe
right ventricle (RV) and UVHs. The presence of RV rotated toward right-sided structures, and longitudinal bicaval view.
dysfunction in CHD carries poor prognosis, and many (ASD, atrial septal defect; LA, left atrium; RA, right atrium.)

176  3D Echocardiography
 A B C

Figure 16.2  TEE imaging in adult with normal mitral valve. Orthogonal multiplane mode in different leaflets (anterior A and posterior P):
(A) P1-A1, (B) P2-A2, (C) P3-A3.

atrioventricular (AV) valve morphology (Figure 16.2A
through 16.2C) and regurgitation, outflow tracts, and
arterial valves.
REAL-TIME 3D FULL-VOLUME DATASET
Full-volume 3D dataset is a large 3D pyramidal volume
electrocardiogram (ECG)-gated acquisition. A 3D full-
volume dataset is used for volumetric acquisition, needed
for quantification of left ventricle and atrium (Figure 16.3),
right ventricle and atrium, and functional single ventricle
volumes and ejection fractions. In addition, biplane or
triplane guidance of full-volume acquisitions can be used
to avoid loss of ventricular walls, leading to optimal offline
analysis of ventricular volume. In addition, a full-volume 3D
dataset is useful in structural heart diseases and CHDs.
Following are some technical tips:
• Optimal 2D echocardiography images with appropriate
gain (avoid low gain to avoid loss of tissue) and
compression setting (clear blood-tissue border -
minimize noise).
• Optimal 3D echocardiographic images with appropriate
gain (increased with respect to 2D echocardiography)
and compression setting.
ZOOM
3D zoom is a magnification of the pyramidal volume of a
region. 3D zoom and 3D color Doppler are indispensable
for visualizing valves, especially the mitral valve (MV)
(surgical repair or interventional procedures), CHDs,
and structural procedures (Figure 16.4 - ASD, 3D zoom,
precatheter closure).
Following are some technical tips:

• Multibeat acquisition of seven beats (seven subvolumes), • Good ECG signal with clear R-wave, no vibration,
if it is possible. controlled heart rate, no breathing, if possible
• triggering) avoiding artifacts of vibration, arrhythmias,
Good ECG signal with clear R-wave (3D full-volume • Small sector (e.g., in MV, avoiding much of the left
atrium [LA] or LV cavities)
or breathing. To improve frame rate to maximize axial • Optimal 2D echocardiography images - Optimal gain to
and temporal resolution, it is necessary to minimize the avoid false defects (e.g., false mitral cleft or interatrial
sector (low deep, narrow angle, and high density). communication) and optimal compression
• Optimal 3D echocardiography images (e.g., in MV,
acquisition in TEE, midesophageal long-axis detecting
the best orthogonal plane)

Figure 16.3  TTE left atrial volumes and ejection fractions. Full- Figure 16.4  Atrial septal defect with 3D zoom, precatheter closure;
volume four-chamber (4C), two-chamber (2C), and short-axis views. it permits sizing atrial septal defect dimensions and the rims.

Adult Congenital Heart Disease  177

Figure 16.5  Panoramic functional single ventricle, right ventricular, and left ventricular, huge left atrium, ventricular septal defect, and
atrial septal defect. (ASD, atrial septal defect; LA, left atrium; LV, left ventricle; M, mitral valve; T, tricuspid valve; RA, right atrium; RV, right
ventricle.)

“LIVE” 3D
The fundamental characteristic of this modality is that it
displays in real time, permits rotation and optimization of
the 3D pyramidal volume image, and avoids artifacts between
adjacent subvolumes (movement, respiration, arrhythmia).
The main use of this modality is to guide interventional
procedures (particularly ASDs, VSDs, and the AV valves)
and follow-up for CHDs (Figure 16.5).

COLOR DOPPLER
3D echocardiography color Doppler can be added to any
of the modalities mentioned previously. The problem is the
reduction of temporal resolution that improves by using
ECG-gated multibeat acquisition. Some manufacturers may
permit the user to prioritize temporal resolution over spatial
resolution to maintain an acceptable frame rate (Figure
16.6, ).
Color Doppler also permits identification of shunts,
insufficiencies, leaks, and stenosis.
PRESENTATION OF 3D ECHOCARDIOGRAPHIC IMAGES
Individual tilt or rotation of valves in CHDs must be
corrected.
The 3D display modes for CHD include (1) volume
rendering, (2) surface rendering, and (3) multiplanar
reformatted (MPR) image display.
1. Volume-rendered datasets can be electronically segmented,
allowing the operator to “crop” the heart in multiple
sections to expose the cardiac structure of interest from
any desired angle. This is especially useful for CHD prior
to surgery or intervention (Figure 16.7A and B, ).
2. Surface rendering presents the surfaces of structures
or organs with a solid appearance and is mainly used to
visualize size, shape, and function of cardiac structures.
Analysis software for this mode includes semiautomated
and fully automated endocardial border detection for
quantification of LV (Figure 16.8) and RV function as
Figure 16.6  Panoramic functional single ventricle, tricuspid
regurgitation, mitral regurgitation, and ventricular septal defect
. (MR, mitral regurgitation; TR, tricuspid regurgitation; VSD,
ventricular septal defect.)
well as semiautomated mitral leaflet motion detection
for quantification of valve function, both of which may
be limited by the abnormal ventricular shape or valve
morphology found in CHD.
. Multiplanar reconstruction (MPR) allows the 3D
3
echocardiography dataset to be viewed on a quad
screen with the 3D dataset cut into three planes
(sagittal, coronal, and transverse) (Figure 16.9) that are
configurable by the user. These planes, not available by
2D echocardiography, can aid in understanding complex
anatomies and facilitate the sizing of many lesions, such
as ASDs and VSDs. Valve areas, effective orifice areas,
and vena contracta areas of regurgitant jets can all
be measured by manipulating cutting planes to avoid
foreshortening or oblique measurements.

178  3D Echocardiography
 A B

Figure 16.7  Crop in two clips. (A) Right coronary (RC) from left sinus . (B) Left main (LM) coronary artery with bifurcation on left anterior
descending and left circumflex artery from the left sinus .

Figure 16.8  Semiautomated endocardial border detection for quantification of left ventricule in patient with tetralogy of Fallot. Four-
chamber (4C), two-chamber (2C), three-chamber (3C), and short-axis views.

Figure 16.9  Common atrioventricular (AV) valve, single ventricle, and AV regurgitation color Doppler in three planes (sagittal, coronal, and
transverse).

Adult Congenital Heart Disease  179


CLINICAL APPLICATIONS OF 3D
ECHOCARDIOGRAPHY IN ADULT CHD
There are a number of cardiac lesions for which 3D
echocardiography has an incremental value.7 Although it is
heavily weighted toward valvar lesions and defects in both
the atrial and ventricular septum in unrepaired adults, there
is also an incremental value of 3D echocardiography for the
assessment of more complex defects in repaired adults, such
as conotruncal anomalies.
SPECIFIC LESIONS IN UNOPERATED ADULTS
ATRIAL SEPTAL DEFECTS
Normal Anatomy of the Atrial Septum
3D TEE allows a detailed anatomical observation of the
interatrial septum, including the remnants of the fetal
circulation: the fossa ovalis (FO) and the foramen ovale.10
More than 25% of normal adults present a patent foramen
ovale, which under some circumstances may have pathologic
relevance. Moreover, most of the structural interventions in
the left heart require transseptal crossing of the interatrial
septum through the FO. Therefore, an adequate knowledge
of the anatomical features of the interatrial septum, as well
as its normal and pathologic variants is definitely required.
Figure 16.10 shows an en face view of the atrial septum as
viewed from the RA (Figure 16.10A) and from the LA
(Figure 16.10B) aspects. The FO does not lie exactly in the
middle of the atrial septum but instead is displaced a little
inferoposteriorly. Inferior to the FO is the inferior vena
cava (IVC), and inferoanteriorly, the coronary sinus (CS).
The superior vena cava (SVC) enters from above along the
posterior aspect of the atrial septum. The tricuspid valve
(TV) lies anteriorly. The aortic valve and root lie centrally in
the heart, wedged between the two atria and resting on the
atrial septum. Thus, the anterosuperior border of the FO is
related to the aortic root. The muscular rim characterizes
the RA aspect, whereas the LA aspect is flat.
A B
Figure 16.10  3D TEE image, en face view of secundum atrial septal defect from the right atrium (A) and from the left atrium (B). (Ao, aorta;
IVC, inferior vena cava; CS, coronary sinus; MV, mitral valve; RUPV, right upper pulmonary vein; SVC, superior vena cava.)
180  3D Echocardiography
Atrial Septal Defect
Atrial septal defects (ASDs) are highly relevant to
echocardiographers and clinicians as one of the most
common congenital abnormalities, not uncommonly
diagnosed and treated during adulthood. ASD types
include the following (Figure 16.11A through 16.11D):
1. Ostium secundum ASD, in the region of the fossa
ovalis and its surroundings, which comprise 80% of all
ASDs
2. Ostium primum ASD, positioned inferiorly, part of the
spectrum of endocardial cushion defects (see partial AV
septal defect)
3. Superior sinus venosus defect (5%), near the orifice of
SVC and associated with anomalous pulmonary venous
connection
4. Inferior sinus venosus defect (<1%), near the IVC entry
5. Unroofed coronary sinus, extremely rare interatrial
communications (<1%), located posteroinferior to the
oval fossa and often associated with PLSVC; caused by
a defect in the embryonic left arteriovenous fold, which
forms a common wall between coronary sinus and LA
2D Echocardiography
Guidelines recommend diagnosing an ASD by the
demonstration of shunting across the interatrial septum, with
evaluation of the right heart and associated abnormalities.4
2D TTE often serves this need, providing the necessary
imaging information to establish the diagnosis of ASD
and make informed clinical decisions.11 Table 16.1 shows
the components of a comprehensive echocardiographic
evaluation.
The subcostal view is the preferred window because the
interatrial septum is approximately perpendicular to the
echocardiography signal (Figure 16.12). The apical four-
chamber view can also be especially useful in evaluation
of the right heart. However, the parallel orientation of the
atrial septum to the echocardiographic signal in this view
 A B

C D

Figure 16.11  2D TTE examination showing different types of atrial septal defects (ASDs). (A) Secundum type ASD, (B) superior sinus venosus
defect (arrow), (C) unroofed coronary sinus, and (D) primum type ASD. (CS, coronary sinus; IVC, inferior vena cava; LAVV, left atrioventricular
valve; RAVV, right atrioventricular valve; SVC, superior vena cava.)

venous connections. Finally, the TEE can more precisely assess

Table 16.1  Echocardiographic Evaluation of Atrial
Septal Defect
Atrial septal defect (ASD) type, number, size, and shape
Direction of the shunt flow
Associated abnormalities
• Mitral valve prolapse
• Anterior mitral valve leaflet cleft (ostium primum ASD)
• Partial anomalous pulmonary venous connection (superior sinus
venosus ASD)
Right atrial and ventricular volume overload
Quantification of pulmonary arterial pressure
Pulmonary-to-systemic flow ratio
may lead to artifactual dropout and can be misleading.
Complementary views may be obtained from the parasternal
short axis and other nonstandard views.
Color Doppler confirms the ASD diagnosis and shows
the directionality of shunt flow. Pulsed-wave Doppler
allows assessment of lower-velocity flows across the
interatrial septum and can be useful in estimation of
the pulmonary flow to systemic flow ratio. Continuous-
wave Doppler may be used to assess the gradient across
the interatrial septum in patients with LA hypertension
and restrictive ASDs, or obstruction to pulmonary venous
return.
A TEE provides higher-definition visualization of the
interatrial septum. TEE is also particularly helpful to rule out a
sinus venosus ASD in the setting of RV enlargement and volume
overload of unknown etiology (Figure 16.13A and 16.13B).
Furthermore, a TEE may help to detect anomalous pulmonary
the size of an ASD and guide procedural planning.
3D Echocardiography
3D echocardiography has three potential roles in ASD:
1. It provides an en face view of the defect to evaluate the actual
types, numbers, size, and shape (which is typically oval, not
round)12 and to determine the shortest tissue rims around
the defect (Figure 16.14), which is important for multiple
ASD device closures and procedural monitoring. Among
the four types of ASD (secundum, primum, sinus venosus,
and coronary sinus), percutaneous transcatheter device
closure is feasible only in the secundum type, excluding
large defects (>38 mm diameter) or insufficient (<5 mm)
septal rims; however, a deficient retroaortic rim (anterior
rim) is not a contraindication to device closure, requiring
careful consideration.13
2. It may provide a better evaluation of the anatomy and
function of the MV or AV valves, particularly in patients
with an ostium primum defect.
3. It can provide volumetric information for an enlarged
RV or geometric details of the dilated tricuspid annulus
from the en face view, which can be used for concomitant
tricuspid annuloplasty during ASD patch closure.14
The following are technical tips to be highlighted15:
• Echocardiographic view to obtain 3D dataset to assess the atrial
septum: Acquisition from the midesophageal basal long-
axis (or bicaval) view. It is the most useful to reconstruct
3D images of the ASDs. This view is acquired from the
midesophageal position, after electronically rotating

Adult Congenital Heart Disease  181

Figure 16.12  2D subcostal echocardiographic views of the atrial septum showing an atrial septal defect in the midseptum and color Doppler
with left-to-right shunt. (LA, left atrium; RA, right atrium.)

the probe by 90°. This dataset contains, from anterior
to posterior, RA free wall, RA cavity, interatrial septum
(IAS), and LA cavity. Removal of the RA free wall brings
in view IAS from the RA perspective.
• Optimal gain settings before and during the acquisition:
Keeping the gain setting in midrange, cropping the
first dataset immediately after its acquisition. If there
are echocardiographic dropouts, then the gain must be
further increased before acquiring subsequent datasets.
Similarly, if the anatomical boundaries are getting
blurred, then gain must be decreased before acquiring
the next dataset.
• Presentation modes: 2D biplane (or triplane) has the
advantages of including the display of simultaneous
additional echocardiographic views, with high-
frame rates and excellent temporal resolution.
Complementary simultaneously displayed orthogonal
plane imaging provides incremental information
compared with that from a single plane, and this
imaging modality is uniquely suited to transcatheter

A B

Figure 16.13  3D TEE views demonstrating superior sinus venosus atrial septal defect from the right atrium (A) and from the left atrium (B).
(RUPV, right upper pulmonary vein.)

182  3D Echocardiography

Figure 16.14  3D TEE image, en face view of secundum atrial septal
defect from the right atrium (Ao, aorta; ASA, atrial septal aneurysm;
CS, coronary sinus; FO, fossa ovalis; IVC, inferior vena cava; SVC,
superior vena cava.)
procedure guidance. Also, 3D imaging allows for
multiple acquisition modes, including zoomed and
volume rendering. Once 3D volumes are acquired,
postprocessing is performed to align the plane of
the atrial septum with multiple 3D plane slices. This
approach facilitates an assessment of the shape of
an ASD and allows for measurement of the en face
diameters in multiple orthogonal views, without
the potential for bias due to malalignment of the
ultrasound planes (Figure 16.15).
ATRIAL ABNORMALITIES
Cor Triatriatum Dexter
Disruption of the involution of the right venous valves
during cardiogenesis is believed to be responsible for a wide
variety of abnormalities: prominent eustachian valve, Chiari
Figure 16.15  Atrial septal defect shape and size assessed using 3D
TEE. It allows the maximal ASD dimensions and planimetered area to
be obtained by multiplane orthogonal views.
network (2%–15%) and, in the most extreme case, cor
triatriatum dexter (CTD), in which the right atrium (RA) is
completely divided into two compartments by a membrane
that restricts flow toward the RV. CTD has an estimated
incidence of around 0.025% of all CHDs and is frequently
associated with right-side defects caused by abnormal fetal
circulation: stenosis or atresia of the pulmonary valve (PV),
TV abnormalities, and ASD.16 One variant is incomplete
CTD, in which the valve remnant, without completely
dividing the RA, is prolonged with the anterior border of
the atrial septum, thus generating septal misalignment with
ASD. Clinical signs depend on the degree of obstruction.
Furthermore, the presence of such a defect increases the
difficulty and risk of complications during percutaneous
ASD closure. Surgical repair may be considered when the
continuity of the membrane is extensive (from the retroaortic
margin to the AV border) or rigid (echocardiographically
thick), or the defect is very large.17
CTD can be diagnosed by echocardiography and
magnetic resonance imaging. 3D TEE allowed the precise
description of this anomaly (Figure 16.16A through 16.16D).
After cropping the anterior wall of the RA, real-time 3D
images in zoom modality of the RA internal cavity showed
how the membrane divided the atrium into a posterior
inflow in which the vena cava (VC) drain and an anterior
outflow chamber.
Cor Triatriatum Sinister and Supravalvular Ring
Cor triatriatum sinister is a rare CHD in which a thick
fibromuscular or membrane divides the LA into a proximal
or superior chamber that drains the pulmonary venous
blood and a distal or inferior chamber that is in contact
with the AVvalve and contains the atrial appendage and
the true atrial septum. It represents 0.1% of all CHDs, and
80% have associated ASD.18 Clinical features mimic those
of mitral stenosis.
3D echocardiography is able to show the exact
morphology and accurately visualize the number and
size of fenestrations in the fibromuscular membrane; it
distinguishes three groups18,19:
1. It is defined by the absence of connection between the
two chambers - the accessory chamber might connect
with the RA or some of the pulmonary veins might drain
in anomalous fashion.
2. There are one or a few small openings in the intra-atrial
membrane.
3. The accessory chamber communicates widely with the
true atrium by a large single opening (Figure 16.17).
The area of the foramen can also be accurately measured
and the relations of the membrane to other cardiac
structures can be assessed especially to differentiate cor
triatriatum sinistrum from the supravalvular ring, the latter
being located below the LA appendage (Figure 16.18).
ATRIOVENTRICULAR VALVE ABNORMALITIES:
CONGENITAL MITRAL VALVE DISEASE
Congenital malformations of the MV are often complex and
affect multiple segments of the valve apparatus. They may
Adult Congenital Heart Disease  183
 A
Figure 16.16  TEE in cor triatriatum dexter. (A,B) Restrictive left-to-right shunt through a large patent foramen ovale and a membrane that
separates the atrium into two parts. (B) Real-time 3D images in zoom modality of the right atrial internal cavity showing how the membrane
divides the atrium into an inflow and an outflow chamber. (C,D) The membrane contains wide openings (arrows).
occur in isolation or in association with other CHDs. The
majority of MV malformations are not simply classified, and
descriptive terms with historical significance (parachute,
mitral, or arcade) often lack the specificity that cardiac
surgeons demand as part of preoperative echocardiographic
morphological assessment:
First, pathoanatomical mechanism (cleft, valves-chordal,
abnormal leaf lets: thickness, mobility, calcification,
dysplastic), and second, the severity of mitral regurgitation
or stenosis.
Additional important findings include LV and RV
ventricular size and volumes, LA and RA size, tricuspid
regurgitation (TR), and pulmonary hypertension.
Pathoanatomical Mechanism
Systematic evaluation of the congenitally malformed
MV using segmental echocardiographic analysis is
recommended to assist precise communication and optimal
surgical management.
1. Supravalvar region: Mitral ring in Shone syndrome
(Figures 16.18 and 16.19, ).
2. Annulus: The annulus of the MV leaflet may be normal,
dilated, hypoplastic, or in extreme cases atretic.
3. Leaflets and commissures: Carpentier classification
(1976, revised 1998) is a surgical classification system
to specifically facilitate the development of tailored
184  3D Echocardiography
B
techniques for congenital MV repair. It was based on
the “predominant lesion,” as it was also observed that
multisegment pathology was the most prevalent.
The Carpentier classification was based on leaflet motion:
normal (I), prolapsed (II), and restricted (III) normal (A) or
abnormal (B) papillary muscle. In addition, it considered the
predominant anatomical and hemodynamic effects (mitral
regurgitation or mitral stenosis).
This description of congenital MV defects was widely
accepted and utilized over the next three decades. In 2008,
Oppido and colleagues further refined the classification
system by adding another level to Carpentier’s classification,
the quality of leaflet tissue: normal or dysplastic. In their
surgical series, dysplastic leaflets were associated with less-
favorable and less-durable repairs. Leaflets may be deficient,
underdeveloped, or associated with accessory tissue.
Carpentier I: Normal leaflet
• MV cleft is better seen by 3D TEE imaging: A leaflet cleft
is usually of the anterior MV leaflet with chords often
attached to its free edges (Figure 16.20).
Clefts of the posterior MV leaflet are rare and are often
confused with normal (but pronounced) indentations
of the posterior leaflet. Only clefts that affect the leaflet
tissue between these indentations should be regarded as
true clefts (Figure 16.21A and B).

Figure 16.17  3D TEE showing a supravalvular ring (blue arrows)
located below the left atrial appendage communicating widely with
the outflow chamber and the regurgitant mitral valve. Simultaneous
2D orthogonal plane imaging by TEE provided more accurate
measurements of the area.
• Double-orifice MV (Figure 16.22) may occur if there is
duplication of the orifice with each suborifice supported
by its own chordal apparatus. Alternatively, a bridging
valvar tissue may divide the inlet. The commissures may
be underdeveloped or absent.
• Annular enlargement: Functional mitral regurgitation
could be from dilated cardiomyopathy (leaflet and
papillary tethering) or atrial functional mitral
regurgitation. Additional important findings include
cooptation depth and length.20
• Perforated leaflet.
• Annular calcification.
• Carpentier II: Prolapsed leaflet. Additional important
findings include flail width and gap.
• Degenerative MV disease is from Barlow disease (Figure
16.23).
• Fibroelastic deficiency with prolapse or flail leaflets.
Carpentier IIIa: Restricted leaflet during diastole and
systole; rheumatic disease
Carpentier IIIb: Restricted leaflet during systole; functional
mitral regurgitation could be from ischemia/infarct
1. Tendinous chords: Chords may be fused, matted, thickened,
and/or shortened and result in variable degrees of
restriction of leaflet motion. When chords elongate, they
can allow leaflet prolapse. In the absence of chords, the
papillary muscles may directly insert into the leaflets.
2. Papillary muscles: Papillary muscle arrangements may be
normal with two symmetrical muscles located two-thirds
of the way from the basal to the apical end of the LV wall.
Alternatively, that arrangement may be asymmetrical (with
one dominant papillary muscle), less commonly single, or
multiple (as has been described with hammock valves).
Severity of Mitral Regurgitation
The mitral regurgitation severity should be assessed by
qualitative and quantitative methods. Blood pressure must
be registered, along with color Doppler jet size, pulmonary
venous flow, E wave, proximal isovelocity surface area (PISA),
and vena contracta area, preferably by 3D TEE imaging.
Severity of Mitral Stenosis
The mitral valve area (MVA) can be assessed by planimetry
using either 2D or 3D imaging, the pressure half-time, the
continuity equation, and the PISA method.
The MVA should be planimetered in the parasternal
short-axis view, in mid-diastole, after processing the 3D
dataset, and preferably by 3D TEE imaging.
3D echocardiography provides better alignment of the
image plane at the mitral tips, rendering a more accurate
and reproducible planimetric measurement with excellent
interobserver and intraobserver agreement.
3D TEE remains the method of choice for the diagnosis of
mitral rings, showing a discrete circumferential membrane
attached to the atrial surface of the MV leaflets (known as
an intramitral ring) or above the MV annulus (known as a
supramitral ring) and characteristically positioned below
the LA appendage and foramen ovale, as opposed to the
anatomy of cor triatriatum.
TRICUSPID VALVE
The TV has a complex anatomy.21 It is the largest and most
apically positioned of the valves and has three leaflets: anterior,
posterior, and septal, with the anterior leaflet being the largest.
The septal leaflet is the most consistent, the others being more
variable, often with several scallops and multiple commissures.
The valve is inserted in the area of fibroadipose tissue that
isolates the atria from the RV (the AVjunction). Similar to
the MV, the annulus of the TV has a nonplanar saddle shape,
with high and low points. As the small septal leaflet is fairly
fixed to the underlying septum, dilatation is thought to occur
primarily in the septal-lateral dimensions. This dilatation
results in a more circular and planar-shaped annulus. The
papillary muscles give support to the commissures. The medial
muscle or cone muscle gives support to the anterior-septal
commissure. The anterior muscle offers the chordae tendineae
that support the free edge of the anterior leaflet; a small muscle
offers chordae to the posterior leaflet. Finally, multiple strings
insert the septal leaflet into the interventricular septum. This
complex anatomy makes it difficult to examine the valve by
Adult Congenital Heart Disease  185
Figure 16.18  Bidimensional and 3D TEE in cor triatriatum sinister. The relation of the membrane (arrows) to patent foramen ovale (PFO),
left upper pulmonary vein (LUPV), and left atrial appendage (LAA) are fairly demonstrated. (Ao, aorta; LA, left atrium; MV, mitral valve; RA,
right atrium; RV, right ventricle.)
using 2D echocardiography. Thus, the posterior leaflet can
practically never be studied, and in addition, tomographic
images and orthogonal planes of the subvalvular apparatus
are very limited. Currently, 3D echocardiography provides
anatomical images that allow in vivo accurate anatomical
analysis (Figure 16.24A through 16.24D, ).22
Guidelines for performing and displaying 3D TEE images
recommend a standard approach for displaying the en face
view of the TV. The image can be displayed as if viewing
the TV from either the RA or RV orientation. In both, it is
suggested that the septal leaflet be displayed at the 6 o’clock
(inferior) position. En face views may be especially helpful
in localizing leaflet disease, such as prolapse, perforation,
Figure 16.19  Mitral supravalvular stenosis in Shone syndrome
186  3D Echocardiography
or vegetations, as well as localizing the origin of regurgitant
jets or performing planimetry of the tricuspid orifice area
(Figure 16.25A and B).21,22
TR in CHD may result from structural alterations of
any or all of the components of the TV apparatus and may
be classified as primary, when it is caused by an intrinsic
abnormality of the valve apparatus, or as secondary, when
it is caused by subpulmonary or systemic RV dilatation (see
later section “Transposition of the great arteries”). The
spectrum of congenital abnormalities of TV is large, while
there is a group of patients with TV dysplasia or congenitally
abnormal TVs that are underrecognized, Ebstein anomaly
and TV anomalies associated with atrioventricular septal
defects (AVSDs) are the most commonly discussed.
Ebstein Anomaly
Ebstein anomaly is a rare congenital cause of isolated TR
that has an extremely variable natural history.23 It may
present at any age, with a variety of hemodynamic and
electrophysiologic sequelae. Patients with isolated minor
or moderate TV displacement may remain asymptomatic
until late adult life. It is characterized by the tethering of TV
leaflets (most commonly the septal and posterior leaflets) to
the walls of the RV and ventricular septum. The tethering
process of the septal leaflet to the ventricular septum results
in an apparent displacement of the leaflet attachment toward
the apex of the RV, which is a characteristic feature seen on
2D TTE. Atrial septal defects, mainly secundum type, are
present in over 80% of patients with Ebstein abnormality.
2D TTE is one of the most important tests in the
evaluation of Ebstein anomaly. The key echocardiographic
. findings include exaggerated apical displacement of the
Figure 16.20  Anterior mitral valve cleft and ostium primum septal defect, 2D and 3D echocardiographic surgical views. (AV, aortic valve;
LA, left atrial; LV, left ventricle; MV, mitral valve; RA, right atrial; RV, right ventricle.)

A B

Figure 16.21  (A) Posterior mitral valve cleft and (B) anterior and posterior mitral valve cleft 3D echocardiographic surgical view. (AV, aortic
valve; MV, mitral valve.)

Figure 16.22  Real-time 3D transthoracic image of double-orifice

mitral valve.

Figure 16.23  3D TEE zoom. Barlow disease. Multisegmentary prolapse.

tricuspid annulus ( ≥8 mm/m2) compared with the mitral
annulus in an apical four-chamber view and a dysplastic TV
with RV dysfunction24 (Figure 16.26). Table 16.2 summarizes
characteristics of Ebstein anomaly demonstrable by 2D
echocardiography.
Unfortunately, 2D TTE is limited in its visualization of
certain key morphological features in Ebstein anomaly,
including the tethered and nontethered parts of the leaflets,
and adequate visualization of the posterior tricuspid leaflet,
which provide significant information that can be helpful in
the evaluation of these patients for TV repair.
3D echocardiography has demonstrated to be valuable in
the identification of the distribution and extent of tethering
of individual TV leaflets.25,26 The system may scan a 60° × 60°

Adult Congenital Heart Disease  187

 A B

C D

Figure 16.24  Transthoracic examination of tricuspid valve from different views. None of these windows can image the three leaflets
simultaneously. (A) Apical view, (B) parasternal short-axis view, (C) right ventricular inflow view, (D) transthoracic 3D imaging of the normal
tricuspid valve (right ventricular view) . (A, anterior; Ao, aorta; LA, left atrium; LV, left ventricle; P, posterior; RA, right atrium; RV, right
ventricle; RVOT, right ventricular outflow tract; S, septal.)

3D pyramid of data. Two orthogonal reference plans are used
to localize cardiac structures in the volume. Navigation by
cropping and sectioning data allows 3D views of the TV to
be obtained. The aim of cropping the 3D dataset is to create
a view similar to the view to be seen by the surgeon. Also,
multiplane imaging of the TV allows precise localization of
regurgitant jets and simultaneously display of the short- and
long-axis views of the tricuspid leaflets.
3D TTE visualized the characteristic bubble-like
appearance that results from the protrusion of the
nontethered parts of all three TV leaflets, the anatomy of the
chordal attachments in the RV free wall, or their extension
into the RV outflow tract (Figure 16.27). Mechanisms of
regurgitation are easier to comprehend from 3D images
(Figure 16.28, ). Finally, the benefits of 3D in the setting
of Ebstein anomaly are not limited to assessment of the
TV. This can also demonstrate the abnormal rotation of
the axis of the TV (Figure 16.29A, ). A more complete
assessment of the functional RV, including volumes, and of
the atrialized portion of the ventricle is important, as these
thinned portions of myocardium are poorly muscled and
prone to aneurysmal changes (Figure 16.29B).
ATRIOVENTRICULAR SEPTAL DEFECTS
An AVSD is a complex malformation that can be accurately
evaluated by echocardiography. It covers a spectrum
of congenital heart malformations characterized by a
common AV junction coexisting with deficient AV septation.
Complete AVSDs are identified by the presence of a large
AVSD (primum ASD and inlet VSD) with a single AV valve
located inside a single annulus containing five leaflets
(Figure 16.30A). Partial AVSDs have varying sizes of the
AVSD and a partitioned AV orifice.
The clinical presentation and survival pattern into
adulthood relate to the specific morphology of the defect
and the presence of associated lesions. Unrepaired
survivors to adult life are patients with ostium primum
ASD with or without both restrictive VSD and AV valve
regurgitation and patients with complete AVSD that
have moderate RV outflow tract obstruction or develop
pulmonary vascular disease (Eisenmenger syndrome). In
surviving patients following surgery, the most common
lesions that led to reintervention are left AV valve (LAVV)
regurgitation, subaortic stenosis, and residual shunts.27
There are features that are common to all hearts with
unrepaired AVSD, irrespective of the presence of atrial or
ventricular septal defects:
1. Absence of the AV muscular septum and loss of normal
offsetting of AV valves (Figure 16.30A)
2. LV inlet/outlet disproportion (Figure 16.30B)
3. Abnormal position of the LV papillary muscles

188  3D Echocardiography
 A
Figure 16.25  3D TEE image of the tricuspid valve. (A) Right atrial view in systole and right atrial view in diastole, showing the regurgitant
orifice (thick arrow). (B) Simultaneous orthogonal planes allow the tricuspid annulus area to be traced and the diameters to be accurately
measured.
4. Abnormal configuration of the AV valves
5. Trifoliate appearance (cleft) of the LAVV (Figure 16.30C)
3D Echocardiography
Compared with traditional 2D echocardiography, 3D TEE
provides a more comprehensive assessment of the defect in
Figure 16.26  Transthoracic apical four-chamber view in a patient
with Ebstein anomaly showing apical displacement of the septal
leaflet and severe tricuspid regurgitation.
unoperated survivors, including size, valvular structures,
as well as surrounding cardiac anatomy (Figure 16.31A and
B, ).28 In patients with complete ASVD, 3D TTE with its en
face view and its ability to adjust viewing at differing angles
offers a precise depiction of the superior bridging leaflet to
more confidently differentiate ASVD into modified Rastelli
types. Furthermore, in patients with partial AVSD, 3D imaging
provides a precise evaluation of the length, width, extent, and
size of the cleft (actually a partially open commissure) within
the LAVV, which 2D TTE is not as successful at doing. Also, 3D
TTE offers the assessment of AV valve regurgitation severity
Table 16.2  2D Echocardiographic Features in Ebstein
Anomaly
Apical displacement of the septal tricuspid valve leaflet (≥8 mm/m2)
Dysplasia and restrictive tricuspid leaflet motion
Abnormal chordal attachments to myocardium
Exaggerated motion of the anterior leaflet and abnormal attachments to
the free edge
Size of the tricuspid valve annulus
Severity of tricuspid regurgitation
Aneurysmal dilatation of RV outflow tract
Atrialization of RV inflow tract
Permanent foramen ovale or secundum atrial septal defect
Adult Congenital Heart Disease  189
Figure 16.27  Ebstein anomaly. Anomalous chordal attachments of septal and anterior leaflets to the right ventricular septum and free
wall. Rotation of the functional tricuspid orifice in Ebstein anomaly. Rotational shift of the functional tricuspid orifice away from the
atrioventricular junction to the plane that divides the trabecular and outlet zones of the ventricle.

utilizing color Doppler (Figure 16.32) and clearly showed the
classic elongated and narrowed left ventricular outflow tract
(LVOT) associated with ASVDs. Tunnel obstruction may be
seen in cases where there are discrete accessory chordae that
arise from the superior bridging leaflet and traverse the LVOT.
Table 16.3 displays long-term structural complications
following surgical repair in AVSD.
LAVV regurgitation is a common cause of reintervention
after repair of AVSD. Real-time 3D TTE is more effective
compared with 2D TTE in evaluating the LAVV in patients
who previously had AVSD repair by providing an en face
view of the valve (Figure 16.33). This visualization offered
useful information regarding the morphology of the valve,
its function, and increases in LAVV diameter after surgery
contributing to LAVV regurgitation.
VENTRICULAR SEPTAL DEFECTS
VSDs are the most common CHD defects. An isolated
VSD diagnosed in adults is relatively common with four
anatomical types: infundibular VSD (supracristal or sub­
arterial type), membranous VSD (the most common type;
about 80% of VSDs are this type), inlet defects (AV canal
type), and muscular defects.
2D TTE and 2D TEE can be used to make the diagnosis
of VSD, but the measurements are often inaccurate. As
VSDs are frequently oval rather than circular in shape, the
measured area of the defect on 2D oblique slices is often
an underestimation of the true area. 3D echocardiography
has a potential diagnostic role for two reasons. 29 First,
it can provide an en face VSD on the RV septal surface to
assess the actual shape and size of the defect, which can be

Figure 16.28  Real-time 3D echocardiography allows precise description of the regurgitant orifice and mechanisms of regurgitation (reduced
functional surface) in Ebstein anomaly .

190  3D Echocardiography
 A A

B B

C
Figure 16.29  Real-time 3D echocardiography shows (A) cases where
rotation/displacement of the functional valvular orifice was extreme,
if the plane was chosen which cuts the tricuspid valve (thin arrows)
through its long axis, the mitral valve (thick arrow) was seen in short
axis in the same plane . (B) Cross-sectional views at midventricular
level, showing atrialized (arrows) and functional right ventricle
together with the hinge points of anterior and septal leaflets, could
also be imaged by 3D echocardiography.

underestimated in routine 2D tomographic views. The size
of the VSD can be better understood by 3D TTE compared
with 2D TTE because of the improved visualization of
the major and minor axes of the defect. 3D TEE also
provides information on the relationship to surrounding
structures. The appropriate anatomy of the VSD location
Figure 16.30  Real-time 3D transesophageal echocardiographic
image perspective of the atrioventricular septal defect. There is a
common atrioventricular (AV) junction (A), and the aorta is located
anteriorly in an unwedged position (B). The left AV valve shows a
trifoliate appearance (C). (Ao, aorta; IAS, interatrial septum; IVS,
interventricular septum; LA, left atrium.)

A B

Figure 16.31  (A) 2D TEE image of atrioventricular septal defect (AVSD). (B) Real-time 3D TEE image of the atrioventricular junction in a
patient with AVSD. View from atrial perspective. The cleft (arrow) is just the line of apposition between the superior (S) and posterior
(P) bridging leaflets. The posterior bridging leaflet prolapses into the left atrium . (Ao, aorta; LA, left atrium; LV, left ventricle; RA, right
atrium; RV, right ventricle.)

Adult Congenital Heart Disease  191

 LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION
Subaortic Stenosis
Subaortic stenosis describes a group of congenital heart
lesions that result in obstruction of blood flow just under
the aortic valve in the LVOT. It is relatively rare, accounting
for around 6.5% of all CHD and can occur in isolation or
in association with other structural heart defects. Currently
it is considered a defect of postnatal development whose
prevalence is increasing in adults due to the greater number
of repaired CHDs that develop into evolutive subaortic
stenosis. In contrast to infants and children below 18 years,
adults show a slow rate of LVOT obstruction progression.
Aortic regurgitation (AR) is a common but usually mild and
nonprogressive consequence.31
Fixed subaortic stenosis can occur secondary to a discrete
shelf-like membrane, or a diffuse tunnel-type lesion.
Obstruction can also be due to accessory or anomalous
Figure 16.32  3D color Doppler imaging allows accurate
quantification of atrioventricular valve regurgitation.

Table 16.3  Long-Term Structural Complications

Following Surgical Repair in Atrioventricular Septal
Defect
Left atrioventricular valve regurgitation
Left ventricular outflow tract obstruction
Left atrioventricular valve stenosis
Right atrioventricular valve regurgitation/stenosis
Residual interatrial or interventricular shunt
Aortic regurgitation

from the tricuspid and aortic valves with an adequate rim

of tissue is important in transcatheter device closure30 Figure 16.34  Real-time 3D TEE showing the relationship of the
(Figure 16.34, ). Second, 3D volumetric assessment of the ventricular septal defect with the tricuspid and aortic valves . (*)
LV depicts the consequence of volume overload from the Ventricular septal defect. (AML, anterior mitral leaflet; Ao, aorta; LV,
hemodynamically significant VSD shunt. left ventricle; PV, pulmonary valve; TV, tricuspid valve.)

Figure 16.33  Left atrioventricular valve (LAVV) failure after atrioventricular septal defect repair. Standard TEE examination (Right) with color
Doppler (Middle) to assess LAVV regurgitation. (Left) An en face view of the LAVV by 3D TEE that demonstrates the sites of regurgitation.
(*) The residual cleft. (Thin arrow) A residual buttonhole at the base of the repaired leaflet.

192  3D Echocardiography

Table 16.4  2D Echocardiographic Findings for
Subaortic Stenosis
Morphology, type, and extent of the stenosis from the parasternal long
axis and apical five-chamber
Severity of the stenosis using continuous-wave Doppler and pulsed-wave
Doppler
Aortic valve stenosis and severity and mechanism of regurgitation
Aortic measurements in the parasternal long-axis view
Hypertrophy and function of the left ventricle
Figure 16.35  Real-time 3D echocardiography provides visualization
of the subaortic membrane and allows the stenosis area to be
assessed. (Ao, aorta; LA, left atrium; RV, right ventricle.)
MV tissue and diverticula or papillary muscle.31 Table 16.4
displays the usefulness of 2D echocardiography for subaortic
stenosis.
The 3D TTE offers visualization of the aortic valve and
subaortic membrane from different perspectives giving a
real-life depiction of the true cardiac anatomy and offering
insight as to the size and severity of stenosis.32 Viewing the
membrane en face from the LVOT (Figure 16.35), the orifice
area may also be measured. It is also important that the
echocardiographer fully assesses the aortic valve structurally
and functionally prior to surgery. TEE is often very helpful
in studying the relationship between the subaortic stenosis
and the aortic valve.
A B
Figure 16.36  Morphological variants of the aortic valve by 3D echocardiography. (A) “True” bicuspid valve with no raphe
valve with raphe . (C) Quadricuspid valve .
CONGENITAL AORTIC VALVE DISEASE
Congenital abnormalities of the aortic valve include the
bicuspid valve (true and with raphe) and rarely the uni- or
quadricuspid valve (Figure 16.36A through 16.36C, ).
Precise description of aortic valve morphology (bicuspid vs.
tricuspid) is important also to guide patient management.
Different cusp fusion associated with different evolution:
• Right and noncoronary cusps: More rapid progression of
aortic stenosis/regurgitation
• Right and left cusps: Higher incidence of aortic wall
degeneration and aortic coarctation
The 3D aortic valve rendering in motion allows
discrimination between a TV and a bicuspid valve with a
raphe that mimics a commissure, the latter showing a fish-
mouth opening. By 2D echocardiography, false-positive
diagnosis of bicuspid aortic valve may arise from incomplete
demonstration of all three-valve closure lines due to
inadequate aortic valve cross sections.33
3D TTE and 3D TEE for assessing aortic valve morphology
have been validated against surgical findings. The best view
is the en face view of the aortic valve from the aorta to define
leaflet margins and commissures.
The following are some tips:
• Optimal 2D imaging quality
• Electrocardiogram-gated
Parasternal view (better resolution) or apical view
• time, or real-time zoomed 3D (“stitched” volumes), real-
images
• resolution to be achieved (e.g., upforto higher
The smaller aortic valve size allows temporal
60 volumes per
second with narrow-angle, six-beat acquisition) in
comparison with MV imaging
• Slightly higher time gain/compression setting
• Breath-hold in expiration will minimize artifacts
Using 2D echocardiography, a parallel alignment
of the tomographic plane to the aortic valve orifice
is sometimes impossible to obtain in short-axis views,
especially in the setting of an enlarged ascending aorta. By
3D echocardiography, the proper alignment to the aortic
annulus has no restrictions (Figure 16.37A and B).
For regurgitant eccentric jets and cusp integrity, color 3D
data can be added as adjunct to 3D morphology and should
C
. (B) Bicuspid
Adult Congenital Heart Disease  193
 A B

Figure 16.37  (A) Enlarged ascending aorta. (B) 3D alignment permits identification of bicuspid valve in orthogonal plane. (AV, aortic valve;
LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.)

be integrated with color Doppler information provided by • Leaflet edge systole and diastole
2D echocardiography. • and right of the leaflet hinge-to-ostium distance left
Quantitation

Aortic Stenosis • Sinus volume and sinus width

In CHDs in which Doppler methods have known limitations
(subaortic stenosis or increased LVOT gradients, eccentric
• Aortic leaflet length (in the midsystolic frame)

jets, significant AR, small aorta, LV dysfunction, etc.), aortic
valve planimetry becomes critical for diagnosis.
Accurate LVOT size and geometry are critical34,35 for the
quantitation continuity equation of aortic stenosis severity,
for correct annulus sizing during TAVI, for calculating
stroke volume and shunt Qp/Qs, and for guiding the muscle
reduction therapies in septal hypertrophic cardiomyopathy.
Quantification of aortic valve area using 3D
echocardiography is more accurate than aortic valve
planimetry by 2D echo or continuity equation by Doppler
echocardiography.36
Volumetric 3D echocardiography and 3D-guided biplane
imaging may optimize the positioning of the cut plane at the
level of leaflet edges and, therefore, improve the accuracy
and reproducibility of aortic valve orifice planimetry. This
is critically important for the identification of the minimal
orifice area, particularly in congenital aortic stenosis with a
doming valve. Accuracy achieved with 3D TEE planimetry
was superior to 2D TEE, which significantly overestimated
the aortic valve area.
Effective height, which represents the height difference
between the central free margins and the aortic insertion
lines, can be easily determined by 2D echocardiography
and allows for identification of prolapse in the native cusps
and assessment of prolapse correction after valve repair.
Nonetheless, it allows only two of three aortic valve coaptation
planes to be seen. This may lead to a misunderstanding of
the underlying pathophysiological mechanism for AR and,
hence, to unsuccessful repair. In contrast, 3D TEE with
multiple plane reconstruction allows for visualization of all
three coaptation planes between the aortic valve cusps, and it
represents an invaluable tool in the assessment of aortic valve
geometry. It is highly recommended before aortic valve repair
to accurately study the complex cusps’ anatomy and their
geometric interrelation with the aortic root (Figure 16.38).37
The exact size and shape of the vena contracta are
important parameters in the quantitation of regurgitant
lesions. Calculations from 2D echocardiography are based
on the geometric assumption that the vena contracta area
is either circular or elliptical (Figure 16.39).

Aortic Regurgitation
Aortic valve repair is an excellent alternative to replacement
for aortic insufficiency.
3D echocardiography was more sensitive than 2D TEE in
detecting morphological abnormalities of the aortic valve
documented intraoperatively.
The preoperative data from 3D echocardiography are
valuable to predict optimal graft size and determine the
need for leaflet remodeling in patients with AR selected
for valve-sparing root surgery. These data include the
following:
• Leaflet deficiency, prolapse/perforation, commissural
fusion
• Root model and coaptation height Figure 16.38  Aortic root morphology assessment by high-resolution
• Intercommissural distance and leaflet height 3D TEE imaging.

194  3D Echocardiography

Figure 16.39  3D TEE and vena contracta in aortic regurgitation.
Figure 16.40  3D TEE and bicuspid aortic valve with aortic
endocarditis with pseudoaneurysm.
Aortic Valve Endocarditis
In the assessment of aortic valve endocarditis, 3D
echocardiography is capable of defining the size and shape of
vegetations, and complications (abscess, pseudoaneurysm)
(Figure 16.40).
SINUS OF VALSALVA ANEURYSMS
Sinus of Valsalva aneurysm (SVA) is a rare anomaly that arises
mostly from the right coronary (RCS) and noncoronary
Figure 16.41  TEE showing short-axis view at the aortic valve and the aneurysm (arrow) protruding into the right atrium. Color Doppler
echocardiography shows turbulent flow across the defect.
sinuses (NCS) and rarely from the left coronary sinus (LCS)
or multiple sinuses. When SVA ruptures, it is more apt to enter
the RV, followed by the RA, causing left-to-right shunting
and hemodynamic symptoms. Although surgical repair
is the traditional therapeutic option for a ruptured SVA,
transcatheter closure has recently been recognized to be a
safe alternative treatment. Previously, 2D echocardiography
was used to visualize the rupture. However, the detailed
delineation of sinus aneurysm anatomy provided by 3D
echocardiography has contributed to successful transcatheter
closure of the defect (Figure 16.41).38
REPAIRED ADULTS WITH CHD
TRANSPOSITION OF THE GREAT ARTERIES
In this anomaly, the aorta arises from the morphological RV,
and the pulmonary artery (PA) arises from the morphological
LV (i.e., there is ventriculoarterial discordance).39
Complete transposition of the great arteries (also known
as D-TGA) is one of the most common cyanotic defects
seen in newborns. Many patients with D-TGA have survived
into adulthood with an atrial switch procedure (Mustard
or Senning operation) performed in infancy, which leaves
the morphological RV supporting the systemic circulation.
Unfortunately, the atrial switch surgeries are associated with
several complications later in life including baffle leaks,
obstructions, and TV insufficiency. Now, the standard of
care includes surgery to switch the arterial structures.
Congenitally corrected TGA (ccTGA), also called L-TGA,
includes not only ventriculoarterial discordance but also AV
discordance and therefore also has a morphological RV and
a usually abnormal TV in the systemic circulation. Although
some patients with ccTGA (especially those with other
associated anomalies, for example, VSD, Ebstein anomaly)
are corrected in childhood, most ccTGA patients (especially
those with isolated ccTGA) do not require surgical repair in
childhood and are natural survivors into adulthood and are
diagnosed when they develop heart failure or TR.
For both populations, systemic RV failure is an important
long-term concern, leading to severe late complications.
In clinical practice, echocardiography is still used for the
assessment of RV function, as it is noninvasive, widely available,
Adult Congenital Heart Disease  195
Figure 16.42  Baffle leak in a patient with transposition of the great arteries after atrial switch repair. Standard 2D TEE (Left) and real-time
3D TEE display baffle leak orifice (arrow). (PVA, pulmonary venous atrium; SRV, systemic right ventricle; SVA, systemic venous atrium; TV,
tricuspid valve.)

relatively inexpensive, and has no adverse side effects (see abnormalities are nearly universal.43 Common chronic
section, “Right Ventricle in Adult Congenital Heart Disease”). postoperative complications in adulthood are pulmonary
regurgitation (PR), RV enlargement and dysfunction,
Atrial Switch and Baffle Complications and TR. Surgical relief of RVOT obstruction also results
3D TTE is useful for patients who previously underwent atrial in scar tissue and a noncontracting RVOT free wall,
switch procedures to assess for long-term complications
including baffle leaks (Figure 16.42) and obstruction, which
2D TTE can miss.40 Importantly, the measurements obtained
from 3D TTE have been consistent with data obtained
intraoperatively, confirming its accurate description. This
information gives cardiologists a more confident sense of
the size, shape, and morphology of the defect and can assist
in appropriate presurgical preparation and eventual repair.
Intra-atrial baffle obstructions occur in as many as 40% of
patients undergoing the Mustard procedure, making its
identification crucial. Diagnosis of the presence and severity
of intra-atrial baffle obstruction by 3D TEE is able to be
made by offering an en face short-axis view, which 2D TTE is
unable to capture (Figure 16.43).41

Systemic Tricuspid Valve

Compared with 2D TTE, 3D TTE was better at visualizing
valvular structures and evaluating their function,
specifically the TV, which is commonly involved in patients
with TGA. 3D TTE provides an en face view of the TV from
different aspects to identify all three leaflets in a detailed
manner, including the posterior leaflet, which 2D TTE is
often unable to visualize well.42 3D TTE can quantify the
areas of systolic non-coaptation of the leaflets (Figure
16.44A through 16.44C), evaluate specific defects in the
valvular leaflets, and assess for the presence of prolapse of
leaflet parts. Unlike 2D TTE, 3D TTE is able to monitor
progression of the defect by visualizing and sizing the vena
contracta and quantifying the severity of regurgitation.

REPAIRED TETRALOGY OF FALLOT

Tetralogy of Fallot (TOF) is one of the most common
cyanotic CHDs consisting of VSD, overriding of the aorta,
right ventricular outflow tract (RVOT) obstruction and
RV hypertrophy. Although surgical repair during the first
year of life has led to marked improvement in survival
into adulthood, residual hemodynamic and anatomical
Figure 16.43  Intra-atrial baffle obstruction in a patient with
transposition of the great arteries after atrial switch repair. Standard
TTE examination (Top Right) with color Doppler (Top Left) displays
pulmonary venous baffle stenosis. Orthogonal planes (Bottom Image)
allow accurate tracing of the stenosis area. (LV, subpulmonary left
ventricle; PPVV, pulmonary veins; PVA, pulmonary venous atrium;
SRV, systemic right ventricle.)

196  3D Echocardiography

A for precise evaluation of the size and shape of residual VSDs,
B
C
Figure 16.44  3D imaging of the systemic tricuspid valve: (A) Right
atrial view in systole, (B) right atrial view in diastole, and (C) right
ventricular view. It shows annular dilatation and tethering as a
mechanism of regurgitation.
which can progress to become an aneurysm. Branch
PA stenosis, residual ASD or VSD, aortic dilatation, AR,
and LV dysfunction are other structural and functional
abnormalities encountered in adults with repaired TOF.
Longitudinal follow-up with multimodality imaging has
been recommended for adults with repaired TOF.44 Routine
2D and Doppler echocardiography allow qualitative and
quantitative assessment of the RA and RV, RVOT, PA, TV and
PV, and atrial and ventricular septa. Assessment of the left
heart and proximal aorta is integral to the echocardiographic
assessment, and Doppler examination is particularly
important in this population for noninvasive hemodynamic
assessment of parameters, such as RV and PA pressures.
3D TTE can be particularly useful in this setting as it allows
particularly when the VSD is associated with other congenital
lesions, such as pulmonary stenosis or regurgitation.45
Moreover, for serial follow-up, 3D volume-rendered optimal
2D planes are preferred over 2D images for comparisons (see
section, “Right ventricle in adult congenital heart disease”),
since 3D echocardiography can further contain the entire
RV (including the RVOT) and evaluate the true volumetric
changes without simplifying geometric assumptions.46
Finally, several studies have highlighted the interest in 3D
echocardiography to describe PV and PA.
Pulmonary Valve and Right Ventricular Outflow Tract
The assessment of PV morphology is challenging using 2D
echocardiography. Thus, a short-axis view of the PV is not
generally obtained by either 2D TTE or TEE. The advantage
of 3D echocardiography is that an en face view of the PV can
be obtained with 3D zoom mode in almost all patients. This
allows visualization of all three leaflets simultaneously47,48
(Figure 16.45). Furthermore, 3D echocardiography is
accurate for pulmonary annulus sizing and provides new
information about the asymmetrical geometry of the
dilated PA.47 The vertical diameter of the PA has been found
to be longer than the horizontal diameter, which indicates
that the PA is not perfectly round but rather slightly oval
in patients with repaired TOF (Figure 16.45). Finally,
postoperative PR is common in patients with repaired TOF.
3D TTE has also been found to be more quantitative in the
assessment of PR severity by vena contracta area than 2D
TTE based on the additional views it offers.49 Thus, new
criteria have been proposed for assessing the severity of PR
using 3D TTE, which can help identify patients at high risk
who will require close follow-up.
VENTRICULAR FUNCTION IN CONGENITAL
HEART DISEASE
LEFT VENTRICLE IN CHD
Volumes and Function
LV volumes and EF guide therapy and follow-up. Measurement
of ventricular volumes and EF by 3D echocardiography is
more highly repeatable than by 2D echocardiography. 2D
echocardiography has important limitations in CHD because,
in contrast to 3D echocardiography, it makes assumptions of
LV shape. In CHD, the LV geometry is distorted by multiple
causes (RV volume and/or pressure overloaded).
3D echocardiography compares favorably to MRI but has
a bias to producing lower LV end-diastolic volume (EDV)
and end-systolic volume (ESV) compared with MRI in
patients with CHD in a meta-analysis of 3055 subjects from
95 studies. The repeatability of 3D echocardiography for
estimation of LV volume is good and supports its role for
serial follow-up, although the values are not interchangeable
with those obtained by MRI in the CHD population. Software
developed for the normal LV or RV should not be applied to
Adult Congenital Heart Disease  197
Figure 16.45  (Top) 3D TEE of pulmonary bioprosthesis in a patient with tetralogy of Fallot and pulmonary artery aneurysm at diastole (Right)
and systole (Left). (Bottom) En face view of the pulmonary annulus and pulmonary prosthetic valve seen from the perspective of the right
ventricular outflow tract.
patients with congenitally abnormal ventricles without being
validated.7
Disk summation is validated in children below 18 years
and adults with single ventricle and other CHD, with
excellent correlation in EDV (r = 0.96–0.98) and LV mass
(0.84–0.93) and in EF (r = 0.64–0.75), and excellent inter-
and intrareproducibility.
Semiautomated border detection is possible in children
and adults with CHD, with fair correlation in EDV (r = 0.95–
0.99) and ESV (r = 0.91–0.97) and great correlation in EF
(r = 0.69 in children below 18 years, and −0.88 in adults)
and excellent inter- and intrareproducibility.
The semiautomated summation of the disc method with
the operator manual correction is the least constrained
by geometry and should be included with postprocessing
software, particularly for ventricles of abnormal morphology.
The 3D echocardiography dataset is obtained from an
apical four-chamber view or subcostal four-chamber view
to include the entire LV volume, which is usually feasible
except when the LV is severely dilated. Current software
tracks the endocardium of the LV throughout the cardiac
cycle and therefore depends on acoustic windows and
adequate image quality.
The “triplane” view of the LV permits visualization of
the apical four-chamber, two-chamber, and three-chamber
views as well as the volume defined by the endocardial
border of the three reference planes.
The segmental view of the LV obtained by 3D
echocardiography can be used to assess LV volume, ejection
fraction, and synchrony based on tracking of the endocardial
border of the ventricle. A standard segmentation of the
ventricle is used to color-encode the basal, mid, and apical
segments. Most software algorithms assume a central axis
from the MV to the LV apex so that this type of analysis
198  3D Echocardiography
has not been validated for ventricles of more complex shape
(Figure 16.46, ).
3D Echocardiographic Assessment of Left Ventricular
Intraventricular Dyssynchrony
A drawback of 3D echocardiography is that it has lower
temporal resolution than 2D echocardiography and of
course M-mode.
Ventricular dyssynchrony is expressed as the standard
deviation of the time taken for segments to reach their
minimum systolic volume, indexed to the cardiac cycle
length (systolic dyssynchrony index, SDI). Current software
packages define abnormal wall motion with respect to the
central LV axis, which has limitations for some CHD patients
with a LV of unusual shape.7
The clinical application for 3D echocardiography
assessment of LV intraventricular dyssynchrony must be
avoided until more evidence is found in CHD.
Left Ventricular Mass in CHD
The clinical application of 3D echocardiography for LV
mass calculation in patients with CHD is not yet established.
3D echocardiographic values correlate well with MRI, with
excellent inter- and intrareproducibility, but the limits of
agreement remain wide.7
3D Speckle Tracking of the Left Ventricle in CHD
The clinical application of 3D speckle tracking in patients
with CHD is not yet established, because more data are
needed. 3D echocardiography has theoretical advantages
compared to 2D techniques for the assessment of myocardial
deformation. 2D speckle techniques can only follow unique
kernels through the cardiac cycle if these remain within
plane. In contrast, 3D techniques can potentially allow
measurement of twist and torsion.7
Figure 16.46  Segmental view of left ventricular 3D echocardiography in a patient with tetralogy of Fallot
RIGHT VENTRICLE IN ADULT CHD
RV dysfunction is not uncommon in adults with CHD. In
CHD, unlike acquired heart disease, the RV is not always
the subpulmonary ventricle: it may support the systemic
circulation as it does in patients with transposition
complexes. The result is chronic RV pressure overload. In
contrast, PR - a frequent problem after surgical repair of
the TOF - imposes a volume overload on the RV. Over time,
both conditions may lead to RV dysfunction and often this
becomes a major clinical concern.
3D Assessment of Right Ventricular Volumes and Function
Quantitative assessment of RV using 2D echocardiography
is challenging due to its complex geometry and highly
trabeculated endocardial borders. Visualizing both the
inflow and outflow in the same echocardiographic view
remains a major limitation. Furthermore, RV diameters by
2D echocardiography vary importantly with minor tilting
of the transducer, leading to under- or overestimation of
RV size. 50 3D echocardiography might overcome these
limitations by allowing the acquisition of the entire RV
(inflow, outflow, and apical part) in the same pyramidal
dataset that could be later analyzed to measure RV volumes
and EF without geometrical approximations. 51 More
recently, RV strain analysis from acquired 3D datasets has
been developed. It provides new parameters of RV global
and regional function, which integrate deformation in the
longitudinal and circumferential dimensions.52
Volume Loaded Right Ventricle
To determine the optimal timing for PV replacement,
several RV parameters have been proposed. Currently,
MRI is the reference standard for RV quantification
and the timing of PVR in repaired TOF with PR based
.
on preoperative MRI parameters. 53 Owing to the high
accessibility in patients with prior coils or devices, 3D
echocardiography-derived RV volume could be an
alternative for the RV evaluation after TOF repair. In
a single-center study with 25 patients with severe PR
secondary to either pulmonary valvotomy or TOF repair,
3D echocardiography RV volume was comparable to
MRI. 54 However, in adults with repaired TOF, despite a
good correlation between real-time 3D echocardiography
and MRI for RV EF, there was a large underestimation of
RV volumes, especially in severely dilated subpulmonary
RV, with great difficulties in encompassing the entire RV in
the pyramidal sector size.46 Further studies from multiple
centers are required to evaluate 3D echocardiography-
derived RV volume indices for timing the PVR in repaired
TOF.
Pressure Loaded Right Ventricle
Related to chronic pressure overload, severe ventricular
dilatation and hypertrophy are observed in all patients
with RV in subaortic position, as an adaptive process. The
systemic RV is characterized by important remodeling,
with spherical reconfiguration close to the LV shape, if
we exclude the RVOT. 55 Furthermore, Pettersen et  al.
have shown that the systemic RV contraction pattern
could be shifted toward the LV contraction pattern, with
predominant circumferential shortening and a relative
decrease in longitudinal shortening.56
LONGITUDINAL FUNCTION VARIABLES
Although they are valid in subpulmonary position, it remains
uncertain whether altered markers of longitudinal function
simply reflect the chronic response of the RV in subaortic
position to its loading conditions. Longitudinal variables
commonly used for RV systolic function assessment 50,51
Adult Congenital Heart Disease  199
are tricuspid annular plane systolic excursion (TAPSE)
in the lateral apical four-chamber view and M-mode; S′
tissue Doppler imaging (TDI) of the tricuspid ring in the
lateral apical four-chamber window; and TDI-derived strain
imaging or 2D strain imaging in the apical four-chamber
view. Isovolumic myocardial acceleration (IVA) is also a
TDI-based index of contractile function, which has been
applied to RV function assessment because it was shown
experimentally not only to measure contractile function
accurately, but also to be relatively independent of acute
changes in ventricular preload and afterload.51,56 Recently, a
cut-off to determine the lower limit of normal longitudinal
function of the systemic RV has been proposed, and it has
to be emphasized that it differs from that usually used for
subpulmonary RV. A RV global longitudinal strain (with
a cut-off of −10%) has been found to have the strongest
association with clinical events in TGA patients after atrial
switch, and a cut-off value of −13.3% provided 72% sensitivity
and 63% specificity in identifying transposition patients with
adverse clinical outcome.57,58 Therefore, there is no doubt
that severe impairment of longitudinal 2D strain is a marker
of global RV function impairment, and could be used as a
prognostic factor in serial quantitative assessment.
GLOBAL FUNCTION VARIABLES
Conventional global echocardiographic variables, such
as fractional area change, have also been applied to the
semiquantitative systolic RV function assessment with
acceptable results. With this, the circumferential and radial
contraction pattern of the RV free wall is incorporated into
the analysis of ventricular function, but the contribution of
RVOT to global RV function is ignored. A dedicated study
has yet to investigate the feasibility and reproducibility of
3D echocardiography-derived volumes and function for
systemic RV assessment. However, 2D echocardiography with
Figure 16.47  En face 3D zoom acquisition from right atrial perspective TEE images of an ostium secundum atrial septal defect (ASD)
demonstrating an ASD en face from the midesophageal bicaval view. ASD: Secundum, round, single, in foramen oval localization, without
atrial septal aneurysm with enough rims for catheter closure . (LA, left atrium; RA, right atrium.)
200  3D Echocardiography
3D knowledge-based reconstruction (2D echocardiography-
KBR) has already been validated against MRI in adolescents
and young adults with repaired D-TGA. 59 This imaging
tool is based on a piecewise smooth subdivision surface
reconstruction technology that creates a “knowledge base”
for the RV using image data acquired from a combinations
of views. Further studies are required to determine limits of
normal function and to evaluate 2D echocardiography-KBR
for predicting clinical outcomes.
GUIDANCE CATHETER INTERVENTION IN
ADULT CONGENITAL HEART DISEASE
ATRIAL SEPTAL DEFECT
Echocardiography in patients undergoing transcatheter
closure is critically important for appropriate patient
selection, real-time procedure guidance, assessment of
device efficacy and complications, and long-term follow-up.
TEE provides real-time, highly detailed imaging of the IAS,
surrounding structures (Figure 16.47, ), catheters (Figure
16.48, ), and closure device during transcatheter closure
(Figure 16.49, ).
3D TEE en face display can also aid in the recognition and
quantification of rim deficiencies, because the extent of the
deficiency relative to the surrounding structures such as the
aorta can be easily demonstrated and quantified (Figures
16.47 and 16.48). When the IAS is viewed from the LA (left),
the atrial septum should be oriented with the right upper
pulmonary vein at the 1 o’clock position. When displayed
as viewed from the RA (right), the SVC should be located at
the 11 o’clock position.
2D biplane (or triplane) imaging, a feature of currently
commercially available 3D imaging systems, is a unique
modality that takes advantage of 3D technology. The

Figure 16.48  3D zoom TEE images of an ostium secundum atrial
septal defect (ASD) and catheter from the right atrial perspective
demonstrating an ASD en face from the midesophageal bicaval
view  .
advantages of biplane imaging include the display of
simultaneous additional echocardiographic views, with
high frame rates and excellent temporal resolution with
color Doppler capability. Complimentary simultaneously
displayed orthogonal plane imaging provides incremental
information compared with that from a single plane, and
this imaging modality is uniquely suited to transcatheter
procedure guidance. Numerous reports of the advantages
of 3D TEE in guiding catheter interventions have been
published and include the use of biplane imaging. Figure
16.49 illustrates the use of biplane imaging during
percutaneous transcatheter closure of ASD during
deployment of the device.
3D TEE can be used for guidance during percutaneous
transcatheter closure and has been described to improve
the visualization ASD.
Figure 16.49  Orthogonal biplane imaging performed after
percutaneous transcatheter closure. Basal short-axis view and bicaval
view. The aortic rim device interaction with the aorta can be assessed
(arrow) . (AV, aortic valve; IVC, inferior vena cava, LA, left atrium;
RA, right atrium; SVC, superior vena cava.)
3D TEE can describe ASD60:
• Type: Patent foramen ovale (PFO), primum ASD,
secundum ASD, or other atrial communication (sinus
venosus defect, unroofed coronary sinus, anomalous
pulmonary vein drainage). Only ostium secundum
(and specific patients with PFO) can be closed
percutaneously.
• Doppler flow: Presence of left to right, right to left, or
bidirectional flow.
• Number: Single and multiple. A fenestrated septal
defect with multiple defects proximal to one another
may be closed with a single device. Multiple devices can
be used to close fenestrations that may not be close
enough to be covered by a single device.
• Size: Quantitative analysis of ASD using 3D
echocardiography should include the maximum
length, width, and area measured at atrial end diastole.
The ASD dimensions should also be measured at
atrial end systole to determine the change in the
dimensions during the cardiac cycle (dynamic ASD).
The ASD dimensions are measured in en face views
from either the RA or LA perspective using dedicated
quantitative software. The parameters calculated can
include the percentage of change in ASD length,
width, and area from atrial end diastole to atrial end
systole. Atrial end diastole is defined as the frame
with the largest ASD dimension and atrial end systole
as the frame with the smallest ASD dimension. The
number of defects in the atrial septum should be
quantified if multiple.
• Shape: Oval, round, or triangular or, at times, shaped
somewhat like an egg or a pear or slightly irregular.
• Location: High secundum ASD, sinus venosus defect SVC
or IVC type.
• Atrial septal aneurysm: Presence of atrial septal aneurysm.
• Tissue rims: Aortic or anterior, posterior, superior,
inferior, right upper pulmonary vein, and AV septal.
The distance between the defect and the aorta can
be easily measured, just as can the area of the defect
and length of rim deficiency when present (necessary
>4–5 mm except aortic or anterior ring).
• Surrounding structures: Aortic valve.
• Associated findings: Eustachian valve or Chiari network.
• Dynamic nature of ASD: Measurement of area and
maximum/minimal diameters in end systole and end
diastole.
• Stop-flow diameter of ASD: When balloon sizing is used for
percutaneous transcatheter closure.
3D echocardiography is better than 2D echocardiography
in multiple defects and multiple devices.
Because the IAS is a complex, dynamic, and 3D anatomical
structure, limitations exist in its evaluation using any single
form of 2D echocardiography. The interatrial septum does
not exist in a true flat plane that can be easily aligned or
interrogated using 2D imaging. Furthermore, 3D imaging
offers the potential to clearly and comprehensively define
the dynamic morphology of the defect, which has been
shown to change during the cardiac cycle.
Adult Congenital Heart Disease  201
 Complications of device closure that can be identified
include device embolization or migration, residual shunts,
aortic erosion, and pericardial effusion.
VENTRICULAR SEPTAL DEFECT
3D TEE has the potential to assist in interventional closure
of VSDs by rendering the depth of the field and allowing
visualization of the ventricular septum in any desired
orientation. 3D echocardiography permits simultaneous
viewing of two orthogonal planes and permits measurement
of the true maximum length and breadth of the defect. Also
like in ASD, 3D TEE permits projection of an en face view
of the VSD from which accurate sizing can be performed
irrespective of the shape or location of the defect and
independent of predefined angles. VSDs may often have
unusual or irregular shapes, and the 3D technique has the
ability to display such morphology and assist in the selection
of the appropriate occlusion device. Assessment of adjacent
structures and “rims” of the VSD is a major strength of
3D echocardiography compared to 2D echocardiography,
because all rims around the defect can be visualized in a
single sonographic projection and viewed from either the
LV or RV. The size of a given rim is not constant around
the defect, which needs to be accounted for during device
placement. In practice, the rim of the defect below the
aortic valve and proximity to the TV are crucial to avoid
compromising the aortic valve function or causing damage
to the TV. Adequacy of the size of rims will depend on defect
size and the type of device to be deployed. The precise
orientation of the occlusion device guidance of catheters
can be accurately monitored, and there is less need for
multiple changes in the rotational angle of the TEE probe
compared to 2D techniques.61
3D TEE can describe VSD in detail as follows:
• Type: Perimembranous, subarterial, inlet, and
muscular. Currently, devices are available for closure
of perimembranous and muscular VSD. Use of
perimembranous VSD has been limited due to the
complication of complete heart block or development
of significant regurgitation of the tricuspid or aortic
valves.
• Doppler flow: Presence of left to right, right to left, or
bidirectional flow.
• Number: Single and multiple. In patients with multiple
VSD, device closure can be used in conjunction with
surgical repair.
• Size: Quantitative analysis of VSD end diastole to decide
the device.
• Shape: Oval, round, triangular, irregular.
• Location: Subtypes of muscular VSD: anterior,
midmuscular, posterior or inlet muscular, apical
anterior or posterior.
• Ventricular septal aneurysm: Presence of ventricular septal
aneurysm.
• Tissue rims.
• Surrounding structures: Aortic valve and TV.
• Associated findings.
• Stop-flow diameter of VSD (when balloon sizing is used for
percutaneous transcatheter closure).
202  3D Echocardiography
The device is usually placed with TEE guidance via either
percutaneous or periventricular approach. Complications
of device closure that can be identified include device
embolization or migration, residual shunts, valve
regurgitation, and pericardial effusion.
TRANSEPTAL PUNCTURE
Needle or radiofrequency atrial septal perforation is used
for many purposes. It can be used to access the LA for
hemodynamic measurements or structural interventions.
On occasion, the creation of an interatrial communication
through the intact septum is needed to relieve elevated LA
pressure or to support cardiac output in the setting of severe
pulmonary hypertension. TEE is not always necessary but
can be very useful to ensure a safe transseptal puncture
(Figures 16.50 through 16.52, ).
A bicaval or short-axis view is usually optimal for
demonstrating the position of the dilator and the needle
in fossa ovalis. Real-time pressure tracing or injection of
contrast through the hollow needle helps to confirm that
the needle is in the LA rather than the aorta.
MITRACLIP
This minimally invasive catheter-based approach has
become a major breakthrough in the treatment of patients
with symptomatic severe mitral regurgitation and high
surgical risk.
MV clefts are better seen by 3D TEE imaging. Congenital
or more commonly acquired MV clefts can often be
associated with asymmetric leaflet tethering in patients with
secondary MR due to dilated/ischemic cardiomyopathy.
Although more challenging, isolated case reports have been
published demonstrating success in experienced centers.62
Therefore, caution is needed before tackling such pathology,
which may not be easily approachable. Center expertise is
required to optimize reduction of mitral regurgitation after
one or multiple MitraClip devices are implanted.
Degenerative MV disease is from either Barlow disease or
fibroelastic deficiency with prolapse or flail leaflets (Figure
16.53, ). Flail mitral leaflets should be evaluated for the
degree of mobility and the maximal flail gap distance
measured to determine if successful grasping will be possible
(ideally flail width <15 mm and flail gap <10 mm). Functional
mitral regurgitation could be either from ischemia/infarct or
from a dilated cardiomyopathy with subsequent leaflet and
papillary muscle tethering displacing the leaflet coaptation
below the annular level. Adequate leaflet grasping and
procedural success have been traditionally associated with
a coaptation depth less than 11 mm and coaptation length
of greater than 2 mm. In addition, ideal candidates for the
MitraClip procedure would also have central MV pathology
between the A2/P2 scallops, MVA 4.0 cm or greater, normal
leaflet thickness and mobility, no/minimal leaflet calcification,
posterior leaflet mobile length 1.0 mm or greater, or classic
isolated MV prolapse. Since there are the few chordae in the
middle portions of the A2 and P2 scallops, this is the ideal
location for grasping the leaflets and to avoid complications
of entangling chordae or even tearing these structures as
the MitraClip is brought into the LV. The valve area should
 A A B B

C C D D

Figure 16.50  The use of biplane imaging during percutaneous transseptal puncture before stent implantation in pulmonary vein stenosis
in a patient with dextrocardia and congenitally corrected transposition of the great arteries, hypertrophic cardiomyopathy of systemic right
ventricle, defibrillator and atrial fibrillation ablation . (AV, aortic valve; LA, left atrial; LV, left ventricle; MV, mitral valve; RA, right atrial;
RV, right ventricle; SVC, superior vena cava; TV, tricuspid valve.)

be planimetered in the parasternal short-axis 2D view, or
preferably by postprocessing with multiplanar reformatting
of a dedicated 3D dataset. MVA can decrease by 50% with the
first clip and further by 30%–40% with the second clip. A MVA
less than 4.0 cm is considered a relative contraindication to
the procedure, as the MitraClip will likely result in potentially
significant stenosis. Mitral gradients should also be established
as a baseline; however, overestimation of stenosis can occur
with severe mitral regurgitation from associated increased
transmitral flow. The individual scallops and chordae should
be evaluated to determine where the MitraClip would need to
be placed. Presence of leaflet and/or annular calcification will
require detailed assessment to ascertain whether the MitraClip
will be able to adequately and successfully grasp. Quantitation
of mitral regurgitation severity should be performed using a
2D or 3D PISA method or preferably 3D vena contracta area.
2D PISA in secondary MR may underestimate EROA due to
the crescentic shape of the MR regurgitant oriffice.63
Guidance of MitraClip implantation:
• Transseptal puncture
• Introduction of delivery sheath and clip delivery system

Figure 16.51  The same patient with congenitally corrected transposition of the great arteries .

Adult Congenital Heart Disease  203

 points for thickness, 6 for mobility, 10 for calcification,
and 9 for subvalvular apparatus involvement. The total
RT3DE score was calculated and defined as mild (<8),
moderate (8–13), or severe (≥14). MV morphology was
assessed using Wilkins’s score and compared with the new
RT3DE score.63
In CHD, 3D TEE permits evaluation of the area of mitral
stenosis and detects the results of mitral valvuloplasty.

PARAVALVULAR LEAKS IN PROSTHETIC VALVES

Paravalvular leaks (PVLs) after surgical valve implantation
have a multifactorial etiology but are mainly related to
specific anatomical characteristics of the valvular ring.
Mitral leaks are three times more common than aortic
leaks, and the incidence increases after reoperation.
Different percutaneous techniques with several devices
have been explored for leak closure, but we are still lacking
Figure 16.52  3D reconstruction and fusion. 3D TEE and cardiac devices specifically designed to treat this pathology more
tomography before stent implantation in pulmonary vein stenosis effectively. Percutaneous closure of mitral paravalvular
after atrial fibrillation ablation. leaks has been demonstrated to be a safe and effective
alternative to open surgical repair in selected patients
• MitraClip positioning above the MV with mitral paravalvular regurgitation. Successful PVL
• Grasping the MitraClip
Entering the into the LV closure depends on accurate localization of the site of
• Releasing and deploying additional MitraClips
mitral leaflets
• Removing the delivery system across the atrial septum
•
MITRAL STENOSIS
Anwar et al. introduced a score based on real-time 3D TTE
(RT-TT3DE) for the assessment of patients with mitral stenosis
before valvuloplasty. This score includes the evaluation of
both mitral leaflets and the subvalvular apparatus. The new
RT-TT3DE score is feasible and highly reproducible with good
interobserver and intraobserver agreement in the assessment
of MV morphology in patients with MS. RT-TT3DE is better able
to detect calcification and commissural splitting. Predictors
of optimal percutaneous ballon mitral valvuloplasty (PBMV)
results by the 3D scoring system are leaflet mobility and the
involvement of the subvalvular apparatus. The incidence and
severity of postprocedural MR are associated with a high
RT-TT3DE calcification score.
A new RT3DE score was constructed by dividing each Figure 16.54  3D TEE. Surgical view. Aorta in anterior and left
MV leaflet into three scallops and was composed of 31 atrial appendage in lateral view. Two MitraClips combined with
points (indicating increasing abnormality), including 6 percutaneous closure of the left atrial appendage.

Figure 16.53  Severe mitral regurgitation. A2 prolapse. 2D and 3D TEE . (A, aortic; A2, anterior 2; LA, left atrial; LV, left ventricle; P2,
posterior.)

204  3D Echocardiography
 A B C

D E F

Figure 16.55  (A) Severe regurgitation of paravalvular leak at 7 o’clock. (B) Catheter (arrow) procedure. (C) First device implantation (arrow).
(D) Second device implantation (arrows). (E) 3D result without interference with valve leaflets. (F) 3D color Doppler with excellent result.

regurgitation and efficient communication between the
echocardiographer and interventionalist. The use of 3D
TEE during intervention can assist the operator in crossing
the defect, thus reducing the risk of intervention failure. It
can prevent complications such as interference with valve
leaflets, it can assist in device size selection, and it can
help when more than one device is needed to close the
defect. 3D TEE locates the defect precisely, gives accurate
measurements and shape, guides the deployment, and
assesses the result. 3D TEE is fundamental to define the
localization (Figure 16.54). In surgical view (the aortic
valve is anterior, the LA appendage is anterolateral, and
the atrial septum is medial), the locations are defined as
on a clock face. Figure 16.55A through 16.55F illustrates
the procedure of implantation of two devices for a severe
paravalvular leak.

C
A B

E F
D

G H

Figure 16.56  (A) Huge pseudoaneurysm (arrow). (B) Color Doppler from left outflow tract to pseudoaneurysm. (C) Biplane vision of the
origin of the shunt (arrow). (D) Systodiastolic flow in M-mode. (E) Biplane vision during the procedure of closure of the origin of the shunt
(arrow). (F) Color during the procedure (arrow). (G) Three years later without residual shunt. (H) The thrombosed pseudoaneurysm 3 years
later (arrow).

Adult Congenital Heart Disease  205

OTHER PROCEDURES
3D TEE can be used for guiding intervention in other
CHDs, such as closure of baffle leaks in patients with
D-TGA after atrial switch and closure of coronary or
extracardiac fistulae. It also helps to characterize and
perform percutaneous interventions in rare complications
when surgery is contraindicated. Figure 16.56A through
16.56H illustrates the closure of a pseudoaneurysm in a
patient with a history of endocarditis in a bicuspid aortic
valve 10 years before.
CONCLUSION
Echocardiographic examination remains the first-line
tool that allows comprehensive evaluation of cardiac
anatomy and function in adult survivors with CHD. Among
echocardiographic modalities, 3D echocardiography
provides better delineation of spatial relationships in
complex cardiac geometries, more accurate volumetric
information without geometric assumptions, and clear and
dynamic 3D views of the anatomy of the cardiac defects.
Preprocedural en face examination of atrial septum or valve
malformations allows better decisions to be made in terms
of device closure or surgical repair. In summary, for optimal
adult CHD care, 3D echocardiography is an important
complement to routine 2D echocardiography.
REFERENCES
1. Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am
Coll Cardiol. 2002;39:1890–900.
2. Moons P, Boviin L, Budts W, Belmans A, Gewllig M. Temporal trends in
survival to adulthood among patients born with congenital heart disease
from 1970 to 1992 in Belgium. Circulation. 2010;122:2264–72.
3. Marelli AJ, Ionescu-Ittu R, Mackie AS et  al. Lifetime prevalence of
congenital heart disease in the general population from 2000 to 2010.
Circulation. 2014;130:749–56.
4. Di Salvo G, Miller O, Babu Narayan S et al.; 2016–2018 EACVI Scientific
Documents Committee. Imaging the adult with congenital heart disease: A
multimodality imaging approach-position paper from the EACVI. Eur Heart
J Cardiovasc Imaging. 2018;19(10):1077–98.
5. Crean AM, Maredia N, Ballard G et al. 3D Echo systemically underestimates
right ventricular volumes compared to cardiovascular magnetic resonance
in adult congenital heart disease patients with moderate or severe RV
dilatation. J Cardiovasc Magn Reson. 2011;13:78–86.
6. Vettukattil JJ. Three-dimensional echocardiography in congenital heart
disease. Heart. 2012;98:79–88.
7. Simpson J, Lopez L, Acar P et al. Three-dimensional echocardiography
in congenital heart disease: An expert consensus document from
the European Association of Cardiovascular Imaging and the
American Society of Echocardiography. Eur Heart J Cardiovasc Imaging.
2016;17:1071–97.
8. Nanda NC, Kisslo J, Lang R et  al. Examination protocol for three-
dimensional echocardiography. Echocardiography. 2004;21:763–8.
9. McGhie JS, van den Bosch AE, Haarman MG et  al. Characterization
of atrial septal defect by simultaneous multiplane two-dimensional
echocardiography. Eur Heart J Cardiovasc Imaging. 2014;15(10):1145–51.
10. Pushparajah K, Miller OI, Simpson JM. 3D Echocardiography of the atrial
septum: Anatomical features and landmarks for the echocardiographer.
JACC Cardiovasc Imaging. 2010;3:981–4.
11. Stout KK, Daniels CJ, Aboulhosn JA et al. 2018 AHA/ACC Guideline
for the Management of Adults With Congenital Heart Disease: A
Report of the American College of Cardiology/American Heart
Association Task  Force  on Clinical Practice Guidelines. Circulation.
2019;139(14):e698–800.
206  3D Echocardiography
12. Mehmood F, Vengala S, Nanda NC et  al. Usefulness of live three-
dimensional transthoracic echocardiography in the characterization of
atrial septal defects in adults. Echocardiography. 2004;21:707–13.
13. Tobis J, Shenoda M. Percutaneous treatment of patent foramen ovale
and atrial septal defects. J Am Coll Cardiol. 2012;60:1722–32.
14. Kong D, Cheng L, Dong L et al. Three-dimensional echocardiography
in the evaluation of right ventricular global and regional systolic function
in patients with atrial septal defect before and after percutaneous closure.
Echocardiography. 2016;33:596–605.
15. Faletra FF, Nucifora G, Ho SY. Imaging the atrial septum using real-
time three-dimensional transesophageal echocardiography: Technical tips,
normal anatomy, and its role in transseptal puncture. J Am Soc Echocardiogr.
2011;24(6):593–9.
16. García-López JC, Sánchez-Pérez I, Cazzaniga M, Pérez de León J,
González-Diéguez CC. Una forma rara de cardiopatía cianosante por
obstrucción supravalvular tricuspídea en el lactante. Revista Española de
Cardiología. 2005;58:1470–2.
17. Sánchez-Brotons JA, López-Pardo FJ, Rodríguez-Puras MJ, López-
Haldón JE. Cor triatriatum dexter in the adult. Revista Española de
Cardiología. 2010;63:885.
18. Willens HJ, Ferrer PL, Tamer DF et al. Cor triatriatum sinister in an
adult: Management guided by real time three-dimensional transesophageal
echocardiography and stress echocardiography. Echocardiography.
2010;27:E132–6.
19. Patel V, Nanda NC, Arellano I et al. Cor triatriatum sinister: Assessment
by life/real time three-dimensional transthoracic echocardiography.
Echocardiography. 2006;23:801–2.
20. Katz et al. Echocardiographic evaluation and guidance for MitraClip
procedure. Cardiovasc Diagn Ther. 2017;7:616–32.
21. Luxford J, Bassin L, D’Ambra M. Echocardiography of the tricuspid
valve. Ann Cardiothorac Surg. 2017;6(3):223–39.
22. Anwar AM, Geleijnse ML, Soliman OI et al. Assessment of normal tricuspid
valve anatomy in adults by real-time three-dimensional echocardiography. Int
J Cardiovasc Imaging. 2007;23:717–24.
23. Paranon S, Acar P. Ebstein’s anomaly of the tricuspid valve: From fetus
to adult: Congenital heart disease. Heart. 2008;94:237–43.
24. Attenhofer Jost CH, Connolly HM, Dearani JA, Edwards WD, Danielson
GK. Ebstein’s anomaly. Circulation. 2007;115:277–85.
25. Ahmed S, Nanda NC, Nekkanti R et  al. Transesophageal three-
dimensional echocardiographic demonstration of Ebstein’s anomaly.
Echocardiography. 2003;20:305–6.
26. Patel V, Nanda NC, Rajdev S et al. Live/real time three-dimensional
transthoracic echocardiographic assessment of Ebstein’s anomaly.
Echocardiography. 2005;22:847–54.
27. Shinebourne EA, Ho SY. Atrioventricular septal defect: Complete and
partial (ostium primum atrial septal defect). In: Gatzoulis MA, Webb GD,
Daubney PEF, eds. Diagnosis and Management of Adult Congenital Heart Disease.
Edinburgh, UK: Churchill Livingstone; 2003, pp. 179–87.
28. Faletra FF, Nucifora G, Ho SY. Real-time 3-dimensional transesophageal
echocardiography of the atrioventricular septal defect. Circ Cardiovasc
Imaging. 2011;4:e7–9.
29. Mehmood F, Miller AP, Nanda NC et al. Usefulness of live/real time
three dimensional transthoracic echocardiography in the characterization
of ventricular septal defects in adults. Echocardiography. 2006;23:421–7.
30. Acar P, Abadir S, Aggoun Y. Transcatheter closure of perimembranous
ventricular septal defects with Amplatzer occluder assessed by real-time
three-dimensional echocardiography. Eur J Echocardiogr. 2007;8:110–5.
31. Oliver JM, González A, Gallego P, Sánchez-Recalde A, Benito F,
Mesa JM. Discrete subaortic stenosis in adults: Increased prevalence and
slow rate of progression of the obstruction and aortic regurgitation. J
Am Coll Cardiol.  2001;38(3):835–42.
32. Bandarupalli N, Faulkner M, Nanda NC et  al. Erroneous diagnosis
of significant obstruction by Doppler in a patient with discrete subaortic
membrane: Correct diagnosis by 3D-transthoracic echocardiography.
Echocardiography. 2008;25:1004–6.
33. Muraru D, Badano LP, Vannan M, Iliceto S. Assessment of aortic valve
complex by three-dimensional echocardiography: A framework for its
effective application in clinical practice. Eur Heart J Cardiovasc Imaging.
2012;13:541–55.
34. Otani K, Takeuchi M, Kaku K et al. Assessment of the aortic root using
real-time 3D transesophageal echocardiography. Circ J. 2010;74:2649–57.
35. Ng AC, Delgado V, van der Kley F et  al. Comparison of aortic root
dimensions and geometries before and after transcatheter aortic valve
implantation by 2- and 3-dimensional transesophageal echocardiography
and multislice computed tomography. Circ Cardiovasc Imaging.
2010;3(1):94–102.
36. Gutiérrez-Chico JL, Zamorano JL, Prieto-Moriche E et al. Real-time
three-dimensional echocardiography in aortic stenosis: A novel, simple,
and reliable method to improve accuracy in area calculation. Eur Heart J.
2008;29:1296–306.
37. . Nijs J, Gelsomino S, Kietselaer BB et  al. 3D-echo in preoperative
assessment of aortic cusps effective height. World J Cardiol. 2014;6(7):689–91.
38. Vatankulu MA, Tasal A, Erdogan E, Sonmez O, Goktekin O. The role
of three-dimensional echocardiography in diagnosis and management of
ruptured sinus of Valsalva aneurysm. Echocardiography. 2013;30(8):E260–2.
39. Warnes CA. Transposition of the great arteries. Circulation.
2006;114:2699–709.
40. Skinner J, Hornung T, Rumball E. Transposition of the great arteries:
From fetus to adult. Heart. 2008;94:1227–35.
41. Ahmed S, Nekkanti R, Nanda NC et  al. Three-dimensional
transesophageal echocardiographic demonstration of intra-atrial baffle
obstruction. Echocardiography. 2003;20:683–6.
42. Abadir S, Léobon B, Acar P. Assessment of tricuspid regurgitation
mechanism by three-dimensional echocardiography in an adult patient
with congenitally corrected transposition of the great arteries. Arch
Cardiovasc Dis. 2009;102:459–60.
43. Apitz C, Webb GD, Redington AN. Tetralogy of Fallot. Lancet.
2009;374(9699):1462–71.
44. Valente AM, Cook S, Festa P et al. Multimodality imaging guidelines
for patients with repaired tetralogy of fallot: A report from the American
Society of Echocardiography: Developed in collaboration with the Society
for Cardiovascular Magnetic Resonance and the Society for Pediatric
Radiology. J Am Soc Echocardiogr. 2014;27:111–41.
45. Chen FL, Hsiung MC, Nanda N et  al. Real time three-dimensional
echocardiography in assessing ventricular septal defects: An
echocardiographic-surgical correlative study. Echocardiography.
2006;23:562–8.
46. Selly JB, Iriart X, Roubertie F et  al. Multivariable assessment of the
right ventricle by echocardiography in patients with repaired tetralogy of
Fallot undergoing pulmonary valve replacement: A comparative study with
magnetic resonance imaging. Arch Cardiovasc Dis. 2015;108:5–15.
47. Hadeed K, Hascoët S, Amadieu R et  al. 3D transthoracic
echocardiography to assess pulmonary valve morphology and annulus size
in patients with tetralogy of Fallot. Arch Cardiovasc Dis. 2016;109:87–95.
48. Anwar AM, Soliman O, van den Bosch AEet al. Assessment of pulmonary
valve and right ventricular outflow tract with real-time three-dimensional
echocardiography. Int J Cardiovasc Imaging. 2007;23:167–75.
49. Pothineni KR, Wells BJ, Hsiung MC et  al. Live/real time three-
dimensional transthoracic echocardiographic assessment of pulmonary
regurgitation. Echocardiography. 2008;25:911–7.
50. Rudski LG, Lai WW, Afilalo J et al. Guidelines for the echocardiographic
assessment of the right heart in adults: A report from the American
Society of Echocardiography endorsed by the European Association
of Echocardiography, a registered branch of the European Society of
Cardiology, and the Canadian Society of Echo­c ardiography. J Am Soc
Echocardiogr. 2010;23:685–713.
51. DiLorenzo MP, SM, Mercer-Rosa L. How best to assess right ventricular
function by echocardiography. Cardiol Young. 2015;25(8):1473–81.
52. Atsumi A, Seo Y, Ishizu T et al. Right ventricular deformation analyses
using a three-dimensional speckle-tracking echocardiographic system
specialized for the right ventricle. J Am Soc Echocardiogr. 2016;29:402–11.e2.
53. Oosterhof T, van Straten A, Vliegen HW et  al. Preoperative
thresholds for pulmonary valve replacement in patients with corrected
tetralogy of Fallot using cardiovascular magnetic resonance. Circulation.
2007;116:545–51.
54. Grewal J, Majdalany D, Syed I, Pellikka P, Warnes CA. Three-dimensional
echocardiographic assessment of right ventricular volume and function in
adult patients with congenital heart disease: Comparison with magnetic
resonance imaging. J Am Soc Echocardiogr. 2010;23:127–33.
55. Iriart X, Roubertie F, Jalal Z, Thambo JB. Quantification of systemic
right ventricle by echocardiography. Arch Cardiovasc Dis. 2016;109:120–7.
56. Pettersen E, Helle-Valle T, Edvardsen T et al. Contraction pattern of the
systemic right ventricle shift from longitudinal to circumferential shortening
and absent global ventricular torsion. J Am Coll Cardiol. 2007;49:2450–6.
57. Kalogeropoulos P, Deka A, Border W et al. Right ventricular function
with standard and speckle-tracking echocardiography and clinical events
in adults with D-transposition of the great arteries post atrial switch. J Am
Soc Echocardiogr. 2012;25:304–12.
58. Diller GP, Radojevic J, Kempny A et  al. Systemic right ventricular
longitudinal strain is reduced in adults with transposition of the great
arteries, relates to subpulmonary ventricular function, and predicts adverse
clinical outcome. Am Heart J. 2012;163:859–66.
59. Kutty S, Li L, Polak A, Gribben P, Danford DA. Echocardiographic
knowledge-based reconstruction for quantification of the systemic right
ventricle in young adults with repaired D-transposition of great arteries. Am
J Cardiol. 2012;109:881–8.
60. Silvestry FE, Cohen MS, Armsby LB et  al. Guidelines for the
echocardiographic assessment of atrial septal defect and patent foramen
ovale: From the American Society of Echocardiography and Society
for Cardiac Angiography and Interventions. J Am Soc Echocardiogr.
2015;28(8):910–58.
61. Charakida M, Qureshi S, Simpson JM. 3D echocardiography for
planning and guidance of interventional closure of VSD. JACC Cardiovasc
Imaging. 2013;6(1):120–3.
62. Freixa X, Hayami D, Basmadjian A et  al. MitraClip repair of a
“trileaflet” regurgitant mitral valve. EuroIntervention. 2015;11:355.
63. Anwar AM, Attia WM, Nosir YF et  al. Validation of a new score for
the assessment of mitral stenosis using real-time three-dimensional
echocardiography. J Am Soc Echocardiogr. 2010;23:13–22.
Adult Congenital Heart Disease  207
 17
INTRODUCTION
Aortic pathology is usually evaluated by multimodality
imaging including multidetector computed tomography
(CT), cardiac magnetic resonance, echocardiography,
and aortography. However, echocardiography, especially
transesophageal echocardiography (TEE), is a standard
method of choice due to its lower cost, wide availability, and
real-time assessment of the existing pathologies.
AORTIC ATHEROMA
Aortic atheroma is a clinical manifestation of systemic
atherosclerosis. According to the size (<4 mm or
≥4 mm) and character (mobile thrombus and/or
ulceration), the plaque can be grouped as simple plaque
and complex plaque; the latter has a potential risk of
systemic embolization.1 There are two distinct causes of
embolization. Thromboemboli are usually large; thus,
they occlude medium to large portions of the artery,
resulting in stroke, renal infarction, and peripheral
embolization. In contrast, cholesterol emboli are small
but persistent and are associated with blue toe syndrome
or progressive impairment of renal function. While
transthoracic echocardiography (TTE) has a limited
ability to detect and evaluate aortic atheroma, especially
in the descending thoracic aorta, TEE provides a superb
view of aortic atheroma for the entire part of the thoracic
aorta except for a short segment from the distal part of
the ascending aorta to the proximal aortic arch because
of interposition of the trachea precluding visualization
of this part. Withdrawing the probe from the deep
gastric position toward the upper esophagus, systematic
evaluation of the aortic plaque in the descending
thoracic aorta is possible in almost all patients using
A B
Figure 17.1  A case with complex plaque: (A) 2D long-axis image, (B) 2D short-axis image, (C) 3D en face view of the corresponding images.
Note that 3D image provides one-look recognition of the extent of complex plaque. Video also reveals a small thrombus attached on the
complex plaque .
208  3D Echocardiography
Aorta
2D TEE. However, a 3D transesophageal image provides
complementary information, such as one-look recognition
of the extent and severity of aortic plaques and en face view
of the plaque (Figures 17.1, and 17.2, ). It is also useful
to detect subtle abnormalities. 2
AORTIC DISSECTION
Aortic dissection is a major cause of acute aortic syndrome,
and due to its catastrophic nature, prompt and accurate
diagnosis is mandatory for the subsequent timely surgical
or percutaneous transcatheter interventions. With recent
advancements in transducer technology, the sensitivity
of TTE for the detection of type A aortic dissection has
improved to reach approximately 85%. 3 – 6 TTE is also
useful (1) to rule out other potential causes of acute chest
pain, such as acute myocardial infarction and pulmonary
embolism, and (2) to evaluate complications related to
type A aortic dissection, including aortic regurgitation
(AR), coronary artery involvement, and pericardial
effusion. However, TTE has a limited capability to
diagnose type B aortic dissection. In addition, negative
results of TTE do not always preclude the existence
of type A aortic dissection; thus, it requires further
imaging examinations. TEE has a superior sensitivity for
diagnosing both type A and type B aortic dissections. The
first step in diagnosing aortic dissection using TEE is to
identify the presence of a dissection flap and to define
the extent of the aortic dissection. Identification of false
and true lumen with a simultaneous searching entry tear
is a second important step. Last, assessment of coexisting
abnormalities in type A aortic dissection, such as AR
and coronary artery involvement, provides information
regarding optimal surgical planning of the aortic valve in
individual patients.7
C
 A

Figure 17.2  TEE images of mobile plaques extracted from 3D datasets in different locations (A) and (B) . The left three images represent
cropped 2D images from 3D datasets, and the right image shows a cropped 3D image. The 3D image provides more information on the
character of the mobile plaque compared with each 2D cutting plane.

The hallmark of the true lumen is characterized by
systolic expansion and diastolic shrinkage of the lumen
size that can be easily evaluated by real-time TEE. The
size of the true lumen is usually smaller than that of the
false lumen. Since flow velocity in the false lumen is often
very low, the condition is associated with smoke-like echo
and thrombus formation (Figure 17.3a, ). The detection
of an entry tear in type B aortic dissection, which is
usually located just below the left subclavian artery, is
possible using 2D TEE (Figure 17.3b). However, accurate

(a)
A B

C D
C

Figure 17.3  (a) A case of type B aortic dissection: 2D TEE short- and long-axis views (A) and (B) and corresponding views with color Doppler
echocardiography (C) and (D). A large thrombus and low-velocity swirling color Doppler flow with smoke-like echo are observed in the false
lumen. (E) and video represent a full-volume 3D dataset obtained from the same site .(Continued)

Aorta 209
 (b)

A B C

(c)

A B

C D

Figure 17.3 (Continued)  (b) 2D TEE images of entry tear. (Panels A and B) Oblique short- and long-axis views of the entry tear. (Panel C) Color
Doppler demonstration of the entry tear. (c) Corresponding 3D TEE images of the entry tear in the same patient from two cropped 2D color
images from 3D datasets (A) and (B), third view (C) which is perpendicular to the two views was obtained from which the entry tear area was
measured (D) . In this particular case, entry tear size was 0.44 cm2. Video shows cropped 2D color images.

estimation of entry tear size is not possible because 2D
TEE does not provide an en face view of the entry tear.
3D TEE has the potential to evaluate the accurate size of
the entry tear using 2D cut plane extracted from 3D TEE
datasets (Figure 17.3c, ). The prevalence of AR in type
A aortic dissection is around 50%. Table 17.1 summarizes
potential mechanisms of AR that can be evaluated by
2D TTE (Figure 17.4a, ). 8,9 3D TEE provides additional
information on the mechanisms of AR because it contains
a third dimension (Figure 17.4b, and c, ). Although a
study reported that the use of 3D TEE reduced the number
of cases of indeterminate coronary artery involvement as
detected by use of 2D TEE and multidetector CT,10 it is
not always easy to determine coronary artery involvement,
especially in patients who had no obvious regional wall
motion abnormalities.
Table 17.1  Potential Mechanisms of Aortic
Regurgitation in Type A Aortic Dissection
• Aortic valve tethering due to enlarged aortic root, especially
sinotubular junction
• Aortic leaflet prolapse due to dissection of disrupted normal leaflet
attachment
• Dissection flap prolapse across the aortic valve caused by aortic
regurgitation through either the hole of the prolapsed flap or the
incomplete attachment between native leaflet and dissection flap
• Coexisting abnormalities such as bicuspid aortic valve

210  3D Echocardiography
 (a)

A B

(b)
A B C

Figure 17.4  (a) Transthoracic 2D images at systole (A) and diastole (B) in a patient with type A aortic dissection. A dissection flap is seen
(yellow arrows). During diastole, part of the dissection flap protrudes into the left ventricular outflow tract (white arrows) with severe aortic
regurgitation. Video shows flow movements of the dissection flap between the left ventricular outflow tract and the ascending aorta .
(b) 2D TEE images extracted from 3D datasets at systole (A), at early diastole (B), and at late diastole (C). (Upper and Middle Panels) Two
orthogonal long-axis views and (Lower Panels) short-axis views of the aortic valve. Note the dissection flap invades the aortic valve during
diastole. Video shows 2D extracted views and 3D view using the same 3D dataset. A part of the flap enters the orifice of the left main coronary
artery (left upper video ).(Continued)

Aorta 211
 (c)

A B C

Figure 17.4 (Continued)  (c) Color 2D TEE images extracted from 3D datasets. Aortic regurgitation emanates between aortic leaflet and
protruding dissection flap, which is a mechanism of the aortic regurgitation in this particular patient. Video shows 3D color regurgitation
flow .

(a)

A C

B D

(b)

A B C D

Figure 17.5  (a) A case of penetrating aortic ulcer. (A) A short-axis color Doppler image at the site of penetration. (B) Continuous-wave
Doppler flow velocity at the corresponding site. (C) A short-axis color Doppler image at the site of another penetration. (D) Continuous-wave
Doppler flow velocity at the corresponding site. (b) 3D echocardiography assessment of penetrating ulcer using 3D color dataset. Using 3D
color dataset, an en face view of the penetrating ulcer was obtained, from which the color-coded area was measured with an area of 0.02 cm2.
(Continued)

212  3D Echocardiography
 (c)

A B

C D

Figure 17.5 (Continued)  (c) 3D TEE assessment of a penetrating ulcer using 3D black-and-white dataset. (A) 2D TEE image extracted from 3D
dataset showing the corresponding view of panel C in (a). (B) A perpendicular 2D long-axis view of panel A showing a small hole penetrating
the thickened aortic wall. (C) En face view of penetrating ulcer. (D) Area measurement. Area was 0.04 cm2. Video shows corresponding real-
time images .

of 2D cropped views (Figure 17.5cA through C, ) and

PENETRATING AORTIC ULCER
A penetrating aortic ulcer is another cause of acute aortic
syndrome, which is characterized by ulceration of an aortic
atherosclerotic plaque penetrating the media of the aortic
wall.3,6 A penetrating aortic ulcer has a risk to progress to
aortic dissection, pseudoaneurysm, and aortic rupture.
This is a complication of an advanced stage of complex
atherosclerosis and is preferentially developed at the middle
and distal part of the descending thoracic aorta. Although
the best imaging modality to diagnose a penetrating aortic
ulcer is contrast-enhanced multidetector CT that reveals
a localized aortic wall ulceration and its penetration into
the aortic wall, TEE with Doppler echocardiography also
detects penetrating ulcer and real-time flow dynamics
between the true lumen and the aortic wall (Figure 17.5a).
The accurate size of the penetrating ulcer can be assessed
by color Doppler 3D TEE (Figure 17.5b). In addition, the
orifice of the penetrating ulcer is confirmed with the use
visualized from the 3D TEE dataset (Figure 17.5cD).
INTRAMURAL HEMATOMA
Intramural hematoma is another cause of acute aortic
syndrome and is characterized by a hematoma in the
media of the aortic wall without a dissection flap and
false lumen. 3,6 The imaging hallmark of an intramural
hematoma is a localized and crescent-shaped aortic wall
thickening greater than 5 mm. As with a penetrating aortic
ulcer, an intramural hematoma has a risk of subsequent
aortic dissection and true or pseudo-aortic aneurysm. 5
Multidetector CT with and without contrast enhancement
and cardiac magnetic resonance are the best imaging
modalities to diagnose intramural hematoma. TEE is also
valuable for the diagnosis, especially when CT and magnetic
resonance imaging are not available or are of low quality.
However, 3D TEE may not add much in this scenario unless

Aorta 213
there is coexistence of other complicated aortic and aortic
valve abnormalities.
CONCLUSION
For the assessment of aortic pathologies, the clear clinical
advantage of 3D echocardiography over 2D echocardiography
has not yet been determined. Further studies should be required
to validate the routine adoption of 3D echocardiography in
patients with aortic disease.
REFERENCES
1. Saric M, Armour AC, Arnaout MS et  al. Guidelines for the use of
echocardiography in the evaluation of a cardiac source of embolism. J Am
Soc Echocardiogr. 2016;29:1–42.
2. Haruki N, Takeuchi M, Kaku K et al. Prevalence and clinical implication
of complex atherosclerotic plaque in the descending thoracic aorta of
Japanese patients assessed by transesophageal echocardiography. Circ J.
2010;74:2627–32.
3. Erbel R, Aboyans V, Boileau C et  al. 2014 ESC Guidelines on the
diagnosis and treatment of aortic diseases: Document covering acute
and  chronic aortic diseases of the thoracic and abdominal aorta of
the adult. The Task Force for the Diagnosis and Treatment of Aortic
Diseases of the European Society of Cardiology (ESC). Eur Heart J.
2014;35:2873–926.
214  3D Echocardiography
4. Evangelista A, Aguilar R, Cuellar H et al. Usefulness of real-time three-
dimensional transoesophageal echocardiography in the assessment of
chronic aortic dissection. Eur J Echocardiogr. 2011;12:272–7.
5. Evangelista A, Flachskampf FA, Erbel R et al. Echocardiography in aortic
diseases: EAE recommendations for clinical practice. Eur J Echocardiogr.
2010;11:645–58.
6. Goldstein SA, Evangelista A, Abbara S et  al. Multimodality imaging
of diseases of the thoracic aorta in adults: From the American Society
of Echocardiography and the European Association of Cardiovascular
Imaging: Endorsed by the Society of Cardiovascular Computed Tomography
and Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr.
2015;28:119–82.
7. Czerny M, Schmidli J, Adler S et al. Editor’s Choice—Current Options
and Recommendations for the Treatment of Thoracic Aortic Pathologies
Involving the Aortic Arch: An Expert Consensus Document of the European
Association for Cardio-Thoracic Surgery (EACTS) and the European
Society for Vascular Surgery (ESVS). Eur J Vasc Surg. 2019;57:165–98.
8. Movsowitz HD, Levine R A, Hilgenberg AD, Isselbacher EM.
Transesophageal echocardiographic description of the mechanisms of
aortic regurgitation in acute type A aortic dissection: Implications for aortic
valve repair. J Am Coll Cardiol. 2000;36:884–90.
9. Patel PA, Bavaria JE, Ghadimi K et  al. Aortic regurgitation in acute
type-A aortic dissection: A clinical classification for the perioperative
echocardiographer in the era of the functional aortic annulus. J Cardiothorac
Vasc Anesth. 2018;32:586–97.
10. Sasaki S, Watanabe H, Shibayama K et  al. Three-dimensional
transesophageal echocardiographic evaluation of coronary involvement
in patients with acute type A aortic dissection. J  Am Soc Echocardiogr.
2013;26:837–45.
18A Speckle Tracking
INTRODUCTION
Echocardiography is an evolving modality whose recent
improvements facilitate the assessment of 3D motion and
deformation, from routine evaluation to research on finer
aspects of the cardiac function.
First, image sequences contain local interference
patterns (the speckles), which are consistent with the tissue
mechanics across a few consecutive frames, and therefore
can be tracked to estimate motion and deformation.1 With
3D imaging, such patterns are accessible everywhere and
provide higher consistency in the tracking, contrary to 2D
imaging where speckles may jump out of the plane due to
the 3D nature of cardiac motion. Besides, 3D assessment no
longer requires approximating the 3D cardiac mechanics
from 2D projections.
Then, its temporal resolution is relatively high for the
assessment of cardiac mechanics: around 40–60 frames/s in
2D, and 20–50 frames/s in 3D. Such a resolution is necessary
for the assessment of fast events, and more generally for the
accuracy of measurements involving temporal derivatives
(velocity and strain rate, from displacement and strain,
respectively). A high enough temporal resolution guarantees
the consistency of speckle patterns across frames, and
therefore the accuracy of the estimated motion and
deformation, with substantial inaccuracies observed below
20 frames/s.2
Currently, the use of 3D no longer stands as a limitation3
and is accompanied by promising perspectives to improve
the temporal resolution to very high frame rates4 and the
automation of postprocessing tasks such as segmentation.5
The main challenges for the quantification of cardiac
mechanics from 3D echocardiography exist on the
technical side in stabilizing the quality of images and the
postprocessing techniques, and from the user perspective
in properly apprehending 3D during the acquisition and
the data interpretation.
This chapter therefore proposes an overview of the
quantification of cardiac motion and deformation through
3D echocardiography, with special attention on cardiac
mechanics to properly interpret and use this technique.
This review complements other published reviews on motion
and deformation estimation in echocardiography 6–9 and
specifically insights on 3D,2,10,11 and the chapters in previous
editions of this book.12,13
MYOCARDIAL MOTION AND DEFORMATION
Cardiac mechanics are by definition in 3D. Simplifying the
ventricles to 3D semi-ellipsoids is already of great help for
approximating global parameters from 2D such as volumes,
and understanding basic mechanisms of the cardiac
chambers.9 Looking more in detail at the cardiac structure,
cardiac motion and deformation are governed by the 3D
arrangement of the myofibers within the wall, with an angle
of inclination that varies gradually between the epicardial,
midmyocardial, and endocardial layers.14
Three orthogonal directions are therefore locally defined
over the ventricular meshes to better characterize the main
components of cardiac mechanics in healthy and diseased
cases: radial (from the endocardium to the epicardium),
longitudinal (from the base to the apex), and circumferential
(along the circumference). Deformation of a local piece
of myocardial tissue is a combination of longitudinal and
circumferential shortening, radial thickening, and shearing
(Figure 18A.1). The proportion of each component is mainly
determined by the wall properties, such as tissue contractility,
but also its composition, elasticity, incompressibility, etc. In
particular, incompressibility directly relates the components
along the three local directions, where longitudinal
and circumferential shortenings are coupled with radial
thickening to preserve tissue volume.
Given these simple considerations, a good imaging technique
and its associated postprocessing should be able to recover
these components of wall motion and deformation, encoded
by displacement and strain, respectively. Displacement is a 3D
vector that corresponds to a difference in position between
a given instant and the onset of the cycle. Strain encodes a
difference in the elongation of a small piece of tissue also
compared with the cycle onset. Figure 18A.2 illustrates this
concept in one dimension (straight line) and three dimensions
(surface or volume elements). It roughly corresponds to the
spatial derivative of the displacement vector, which for 3D
volumes is a 3D tensor (3 × 3 matrix). We often only quantify
its diagonal coefficients, which correspond to the radial,
circumferential, and longitudinal strain accessible in most
commercial software. Positive and negative strain correspond
to stretching and shortening, respectively. The extradiagonal
coefficients encode shearing and may also have a substantial
contribution to the 3D tissue deformation (Figure 18A.3), as
in the presence of rotation or twisting15 between the basal
and apical levels (also denoted by torsion after normalization
by the ventricular height16). The segmental/local changes
should be considered, independently of global measurements
(Figure 18A.4): global contraction may be the same between
two cases, despite reduced or exaggerated contraction locally,
related to, e.g., differences in the tissue viability.
Area strain was proposed to overcome inaccuracies in
estimating the radial component of deformation,17 already
marked for the left ventricle and unavoidable for the thin
wall of the right ventricle. It represents the deformation
of surface elements and is often calculated as the product
of longitudinal and circumferential strain components,
which should correspond to the inverse of the radial strain
component if the volume of local elements is preserved under
deformation.
Speckle Tracking  215
 A B C D

Longitudinal
shortening

Shearin
Longitudinal

g
l
dia ng
ial Ra keni Circumferential
d c
Ra Circumferential
th
i
shortening

Figure 18A.1  The three anatomical directions of myocardial motion and deformation. (A–C) Progressive zoom on a portion of the myocardium
with the radial, circumferential, and longitudinal directions overlaid. (D) Expected changes for this portion during systole, for a healthy
myocardium.

A B

Figure 18A.2  The values quantified in strain in 1D (A) and 3D (B–C). In case of surface meshes, as in current 3D right ventricular applications,
the concept of area strain extends the 1D definition to local area changes. In case of volume meshes, strain is a 3 × 3 matrix with diagonal
coefficients that correspond to forces orthogonal to the elemental surface, while nondiagonal coefficients relate to forces parallel to the
elemental surface (shearing).

Finally, changes in motion and deformation at a given
instant can be complemented by the estimation of velocity
and strain rate, which correspond to the temporal derivatives
of displacement and strain, respectively (Figure 18A.5).
HOW TO MEASURE MOTION AND
DEFORMATION
BASIC PRINCIPLES OF TRACKING
Speckle tracking consists of following local image patches
containing some speckles between consecutive frames. The
algorithm first locates a given patch in the next frame using
block matching or local image similarity comparisons.
The displacement of this patch between two consecutive
frames corresponds to an approximation of myocardial
motion between these instants (Figure 18A.6). Then,
motion is estimated along the whole sequence by chaining
the displacements obtained for each pair of consecutive
frames.
In practice, tracking is performed for speckles within the
myocardium (estimation of wall motion and deformation),
and more recently within the cavity after specific image
postprocessing (estimation of intracavity flow).18 The
technique therefore requires segmenting the cardiac wall
at given instants (for 3D, generally end diastole and end
systole). This segmentation defines the region of interest
for tracking and provides a first estimation of global motion
to further constrain the tracking of speckles and the
estimation of local deformation.
Although little information exists on the algorithms
used in commercial software, most are based on published
approaches.19–21 Nonetheless, substantial efforts are required
to validate this technique and to train clinical operators.
ALTERNATIVE APPROACHES
Image registration also allows displacement to be estimated
by comparing pairs of frames along the sequence. Contrary
to speckle tracking, this technique matches the full
echocardiographic images and not only the matching of
blocks defined locally. It can therefore operate on pairs of
consecutive frames (which then requires chaining pairwise
transformations to estimate the displacement from the

216  3D Echocardiography
 A Pure shear
E xx E xy
4 4

2 2
0.5
0 0
E xx E xy
Strain 2D: E = 0 0 5 10 15 0 5 10 15
E yx E xx E yx E yy
4 4
-0.5
2 2

Initial position 0 0

4 0 5 10 15 0 5 10 15

2
B Stretching
0 E xx E xy
0 5 10 15 4 4

2 2

0 0
0 5 10 15 0 5 10 15
E yx E yy
4 4

2 2

0 0
0 5 10 15 0 5 10 15

Figure 18A.3  Local variations in all the strain components (infinitesimal strain definition) for a 2D material that undergoes pure shear (A)
or a more complex deformation with both shearing and stretching along the horizontal axis (B).

L L

75% · L 75% · L

75% 75% 75% 50% 75% 100%

Figure 18A.4  Importance of the quantification of global and local deformation: Two walls shortening equally overall (75% of their initial
length), but with a very different local behavior due to different tissue viability.

Longitudinal displacement (mm) Longitudinal velocity (mm/s) Longitudinal strain (%) Longitudinal strain rate (%/s)
15 0
Basal septum
Midseptum 50
1
Apical septum
10 -0.05
0 0.5

5 -0.1
0
−50

-0.15 −0.5
0
−100
−1
Q1
MVC
AVO

AVC
MVO

Q2

Q1
MVC
AVO

AVC
MVO

Q2

Q1
MVC
AVO

AVC
MVO

Q2

Q1
MVC
AVO

AVC
MVO

Q2

Figure 18A.5  Longitudinal displacement, velocity, strain, and strain rate for a healthy volunteer at different levels of the septum, obtained
by 2D speckle tracking. Vertical bars indicate specific events of the cardiac cycle: Onset of QRS (Q1 and Q2), and mitral/aortic opening/closure
(MVO/MVC and AVO/AVC).

Speckle Tracking  217

onset of the cycle), or directly match a given frame to the
one at end diastole. A transformation model (locally affine,
spline, etc.) defines the amount of freedom in the estimated
matching, and therefore the complexity of the estimated
deformation. This technique is widely used in the academic
community as visible in recent validation initiatives.22–24 As
it operates on full images and not only speckles, it is not
specific to echocardiography and may be applied to any
imaging modality.
Additional knowledge can be incorporated to the
tracking. Shape models can guide the tracking and provide
physiologically plausible segmentations along the sequences.
Such models are generally obtained from a population of
healthy and diseased subjects using statistical learning
techniques. Although not explicitly reported in scientific
publications, some vendors mention that such models are
used in their tracking software in 2D25 and 3D.26 Biomechanical
constraints can be used in the transformation model, such as
temporal consistency,27 or incompressibility.28
Tissue Doppler differs from the previous methods. It does
not aim at matching image contents but analyzes phase
shifts of the returning echoes from which local motion and
deformation can be calculated along the beam direction.
It therefore has a much higher temporal resolution
compared to speckle tracking (around 200 frames/s).
However, it requires aligning the beam parallel/orthogonal
to the wall, for the recovery of longitudinal (apical view)
or radial (parasternal view) velocities. Manual tracking
of the observation points is offered in some software to
prevent inadequate measurements from the originally fixed
observation point.
STANDARDIZATION AND VALIDATION
The tracking algorithms involve several processing steps and
assumptions that should be standardized. Joint initiatives
including the European Association of Cardiovascular
Imaging, the American Society of Echocardiography, and
academic and industrial actors are currently focusing on
this issue for segmentation29 and tracking.30
Differences between manufacturers exist in the
definition of the myocardial segments, the intrinsic
definition of strain, which myocardial layer to process,
the postprocessing applied (e.g., spatial and temporal
smoothing), etc. In particular, the computation of
radial strain differs between vendors: some prefer its
estimation from area strain (the product of longitudinal
and circumferential components, upon elemental volume
conservation assumptions) rather than its direct estimation
from 3D images, for which the low spatial resolution across
the wall thickness is an issue.
Several validation studies recently reported on the
performance of academic and commercial software on
standardized datasets, including realistic simulated images
for which ground truth motion is known. 22–24,31,32 They
revealed substantial differences in the output measurements.
As a result, the estimation of global longitudinal parameters
is often emphasized to go beyond ejection fraction,33 while
looking at the circumferential and radial components, and
more local pattern changes are still limited to research.
218  3D Echocardiography
RECOMMENDATIONS FOR THE USE OF 3D
SPECKLE TRACKING
Speckle tracking is intensity based and therefore requires
good image quality and optimal acquisition. Poor or
exaggerated contrast in the walls, acoustic shadowing or
reverberations, and out-of-window or dropout artifacts are
some of the main imaging factors that can lower the tracking
accuracy. Random noise, lower wall visibility, and fuzzier
endocardial/epicardial delineations may be additional
limitations for 3D tracking. The lateral/anterior wall and
apical regions are particularly challenging to image in 3D
(e.g., field of view in dilated hearts, or limited possibilities
for optimizing the image quality in the clinical workflow).
Besides, the spatiotemporal resolution of 3D images is
still low compared with 2D images, with consequences on
the tracking accuracy: low spatial resolution affects the
quality of the speckle patterns and their resolution, and low
temporal resolution can distort measurements of fast events
(e.g., during isovolumic contraction/relaxation or at high
heart rates) and even normal patterns.2
In practice, analyzing an entire dataset can take a
nonnegligible amount of time, around 10 minutes for
3D depending on how practical the software interface is.
Understanding the postprocessing chain is therefore key to
reaching more reliable measurements and being critical on
the output values.
The user is often asked to correct end-diastolic and
end-systolic contours, which serve to initialize the
tracking of endocardial and epicardial contours along
the sequence. The software often allows correction of the
contours propagated along the entire sequence, before
the local tracking of speckles: we highly recommend the
user carefully check and correct the contours over the
entire cycle and navigate across the 3D images. After
the tracking of speckles, namely once the motion and
deformation output is available, the user may also enable/
disable several corrections that can substantially affect the
output. Spatial and temporal smoothing is often applied
to reduce noise in the estimated curves, which may hide
local spatial and temporal abnormalities depending on
the studied disease. We generally recommend turning
down this option when available. Finally, drift artifacts
may arise from the accumulation of errors along the cycle.
The transformation estimated between consecutive frames
is only an approximation of the true displacement: this
error is probably negligible between consecutive frames,
but accumulating the transformations along the cycle to
obtain displacements from end diastole may substantially
amplify these small errors. Most 2D commercial software
propose a drift correction, which assumes that cardiac
motion is cyclic and therefore constrains displacement
and strain at the end of the cycle to match their values at
the onset of the cycle (Figure 18A.6). In 3D, this option
may not be directly accessible to the user but still can be
implemented on homemade software from the exported
outputs (Figures 18A.7 through 18A.10). Note that this
correction does not concern myocardial velocity and strain
rate, which correspond to instantaneous parameters and
are not affected by the accumulation of errors.
 A B C

Longitudinal displacement (mm)

15

10

5
v( t )N

ti t i+1 t i+2 t i+3 ... 0

tN

Q1
MVC
AVO

AVC
MVO

Q2
v( t)1
t0
v( t )0 n t without drift correction
me
lace with drift correction
Disp

Figure 18A.6  Conservation of speckles over consecutive frames, allowing tracking along the cycle (A). The link between displacement and
instantaneous velocities (B). The accumulation of small errors along the sequence may require compensating for drifting (C).

strain curves. 4D deformation analysis shows a similar global

PRACTICAL EXAMPLES longitudinal function, with uniform and synchronous
HEALTHY CONTROL segmental deformation.
Deformation analysis was conducted for an active, healthy,
HEALTHY ATHLETE
30-year-old male, with no significant medical history or
A healthy, 42-year-old male athlete, training long-distance
cardiac disease (Figure 18A.7, ). The echocardiographic
running 6 days a week for the last 6 years was considered in
“window” is optimal. The left ventricle is of normal
deformation analysis (Figure 18A.8, ). The left ventricle
dimensions, and the ejection fraction is preserved (60%).
is representative of early stage changes that are seen in
2D speckle-tracking deformation shows that the global
athletes participating in endurance training associated
longitudinal function is in the normal range. The segmental
with repetitive chronic volume overload. Over time, these
deformation values are uniform, as well as the timings of
alterations result in eccentric left ventricular hypertrophy

Longitudinal strain Circumferential strain Area strain Radial strain

% % % %
0 0
0 80
-10 60
-10
-10 -20 40
-20
-30 20

-20 -30 0
-40
Frame
5 10 15 number 5 10 15 5 10 15 5 10 15
17 AHA segments
Average (global strain)

% % % %
-25 0 25 -30 0 30 -40 0 40 -60 0 60

Figure 18A.7  4D deformation analysis for a healthy subject. Longitudinal, circumferential, area, and radial strain traces and end-systolic
patterns, after drift correction. 3D echocardiographic sequence provided as video .

Speckle Tracking  219

 Longitudinal strain Circumferential strain
% %
0 0
0
-10
-10
-20
Frame
-20
10 20 30 40 number 10 20 30 40
17 AHA segments
Average (global strain)
% %
-25 0 25 -30 0 30
Figure 18A.8  4D deformation analysis for a healthy athlete. Display similar to Figure 18A.7
with increased wall thickness and overall mass, coupled with
comparably increased end-diastolic volumes and associated
increase in stroke volume so that EF and global deformation
at rest will be at the lower side. 2D speckle-tracking
deformation shows that global longitudinal function
is slightly decreased, which is in line with the enlarged
athlete’s heart and not related to intrinsic dysfunction. The
segmental deformation values are uniform. 4D deformation
analysis shows a similar global longitudinal function, with
uniform segmental deformation.
HYPERTENSION
A 57-year-old male patient with long-standing arterial
hypertension on antihypertensive therapy and with preserved
left ventricular ejection fraction (60%) was examined (Figure
18A.9, ). The left ventricle shows signs of a generalized
myocardial wall thickening indicative of hypertensive heart
disease; however, left ventricular mass is still in the normal
range. 2D speckle-tracking analysis shows that global
longitudinal function is normal. Segmental deformation
reveals a characteristic pattern of impaired basal septal
deformation. In the setting of increased blood pressure, due
to the increased local radius of curvature, the basal septal
segment is the first to show systolic dysfunction, quantifiable
by changes in deformation - decrease in longitudinal strain.
4D deformation analysis shows a slightly higher global
longitudinal function; nevertheless, the characteristic pattern
of basal septal impairment is still notable.
HYPERTROPHIC CARDIOMYOPATHY
A 42-year-old male patient with diagnosed hypertrophic
cardiomyopathy (HCM) and preserved ejection fraction
220  3D Echocardiography
Area strain Radial strain
% %
40
30
-10
20
-20
10
0
-30
-10
10 20 30 40 10 20 30 40
% %
-40 0 40 -60 0 60
.
(52%) was examined (Figure 18A.10, ). Localized
myocardial wall thickening can be recognized in the
anterior and inferior septum, as well as in the inferior
wall, resulting in elevated indexed left ventricular mass.
The maximal thickness is seen at the inferior part of
the septum measuring 22 mm. 2D speckle-tracking
deformation analysis demonstrates characteristic findings
in HCM - significant heterogeneity in regional myocardial
deformation is paired with the noticeable heterogeneity in
wall thickness. The greatest reduction in longitudinal strain
is seen in the interventricular septum. Areas of abnormal
deformation are surrounded by normal deformation in the
same ventricular region, a finding conceivably related to
the heterogeneous distribution of myocardial disarray. As
compared to findings of basal septal impairment in arterial
hypertension, the impairment seen in HCM is considerably
more pronounced. Global longitudinal strain is only slightly
reduced. 4D deformation analysis demonstrates a similar
heterogenic pattern of myocardial deformation.
CONCLUSION
Speckle tracking is an essential tool for the assessment
of cardiac mechanics, in particular through 3D motion
and deformation. The technique is at the crossroad
of developments on imaging (3D and high frame rate
sequences), automation of the processing (segmentation
and tracking), and validation/standardization initiatives.
Substantial improvements are therefore expected in the
near future. Nonetheless, using such tools will still require
caution in light of the technology used, appropriate training
upon acquisition, the use of processing software, and the
 Longitudinal strain Circumferential strain Area strain Radial strain
% % % %
0 10 80
10
0
0 60
-10
-10
-10 40
-20
-20
-20 20
-30
-30 -40 0
-30
Frame
-40 -50 -20
5 10 number 5 10 15 5 10 15 5 10 15
17 AHA segments
Average (global strain)

% % % %
-25 0 25 -30 0 30 -40 0 40 -60 0 60

Figure 18A.9  4D deformation analysis for a hypertensive patient. Display similar to Figure 18A.7 .

Longitudinal strain Circumferential strain Area strain Radial strain

% % % %
0 100
0 0
80
-10
-10 -10 60
-20
40
-20 -20 -30
20
-40 0
-30 -30
Frame
-50 -20
5 10 15 number 5 10 15 5 10 15 5 10 15
17 AHA segments
Average (global strain)

% % % %
-25 0 25 -30 0 30 -40 0 40 -60 0 60

Figure 18A.10  4D deformation analysis for a patient with hypertrophic cardiomyopathy. Display similar to Figure 18A.7 .

Speckle Tracking  221

interpretation of the results in light of the pathophysiology
of the observed subjects.
REFERENCES
1. Garcia D, Lantelme P, Saloux E. Introduction to speckle tracking in
cardiac ultrasound imaging. In: Loizou CP, Pattichis CS, D’hooge J, eds.
Handbook of Speckle Filtering and Tracking in Cardiovascular Ultrasound Imaging
and Video. London, UK: Institution of Engineering and Technology; 2018.
2. Amzulescu MS, De Craene M, Langet H et al. Myocardial strain imaging:
Review of general principles, validation, and sources of discrepancies. Eur
Heart J Cardiovasc Imaging. 2019;20:605–19.
3. Lang RM, Addetia K, Narang A et  al. Three-dimensional
echocardiography: Latest developments and future directions. JACC
Cardiovasc Imaging. 2018;11:1854–78.
4. Cikes M, Tong L, Sutherland GR et  al. Ultrafast cardiac ultrasound
imaging: Technical principles, applications, and clinical benefits. JACC
Cardiovasc Imaging. 2014;7:812–23.
5. Leclerc S, Smistad E, Pedrosa J et al. Deep learning for segmentation
using an open large-scale dataset in 2D echocardiography. IEEE Trans Med
Imaging. 2019;38:2198–210.
6. Bijnens BH, Cikes M, Claus P et al. Velocity and deformation imaging
for the assessment of myocardial dysfunction. Eur J Echocardiogr.
2009;10:216–26.
7. Cikes M, Sutherland GR, Anderson LJ et al. The role of echocardiographic
deformation imaging in hypertrophic myopathies. Nat Rev Cardiol.
2010;7:384–96.
8. Mor-Avi V, Lang RM, Badano LP et  al. Current and evolving
echocardiographic techniques for the quantitative evaluation of cardiac
mechanics. J Am Soc Echocardiogr. 2011;24:277–313.
9. Bijnens B, Cikes M, Butakoff C et al. Myocardial motion and deformation:
What does it tell us and how does it relate to function? Fetal Diagn Ther.
2012;32:5–16.
10. Cheung YF. The role of 3D wall motion tracking in heart failure. Nat
Rev Cardiol. 2012;9:644–57.
11. Jasaityte R, Heyde B, D’hooge J. Current state of three-dimensional
myocardial strain estimation using echocardiography. J Am Soc Echocardiogr.
2013;26:15–28.
12. Stoylen A. Strain echocardiography. In: Shiota T, ed. 3D Echocardiography.
London, UK: Informa Healthcare; 2007, pp. 141–51.
13. Duchateau N, Bijnens BH, D’hooge J et al. Three-dimensional assessment
of cardiac motion and deformation. In: Shiota T, ed. 3D Echocardiography,
2nd ed. Boca Raton, FL: CRC Press; 2013, pp. 201–13.
14. Vendelin M, Bovendeerd PH, Engelbrecht J et al. Optimizing ventricular
fibers: Uniform strain or stress, but not ATP consumption, leads to high
efficiency. Am J Physiol. 2002;283:​H1072–81.
15. Ashraf M, Zhou Z, Nguyen T et al. Apex to base left ventricular twist
mechanics computed from high frame rate two-dimensional and three-
dimensional echocardiography: A comparison study. J Am Soc Echocardiogr.
2012;25:121–28.
16. Henson RE, Song SK, Pastorek JS et al. Left ventricular torsion is equal
in mice and humans. Am J Physiol Heart Circ Physiol. 2000;278:H1117–23.
222  3D Echocardiography
17. Seo Y, Ishizu T, Enomoto Y et al. Endocardial surface area tracking for
assessment of regional LV wall deformation with 3D speckle tracking
imaging. JACC Cardiovasc Imaging. 2011;4:358–65.
18. Assi KC, Gay E, Chnafa C et al. Intraventricular vector flow mapping—A
Doppler-based regularized problem with automatic model selection. Phys
Med Biol. 2017;62:7131–47.
19. Adam D, Landesberg A, Konyukhov E et al. On changing coordinate
systems for longitudinal tensor-based morphometry. Proceedings IEEE
Computers in Cardiology. 2004, pp. 337–40.
20. Behar V, Adam D, Lysyansky P et al. The combined effect of non-linear
filtration and window size on the accuracy of tissue displacement estimation
using detected echo signals. Ultrasound. 2004;41:743–53.
21. Leitman M, Lysyansky P, Sidenko S et al. Two-dimensional strain—A
novel software for real-time quantitative echocardiographic assessment of
myocardial function. J Am Soc Echocardiogr. 2004;17:1021–9.
22. Tobon-Gomez C, De Craene M, McLeod K et  al. Benchmarking
framework for myocardial tracking and deformation algorithms: An open
access database. Med Image Anal. 2013;17:632–48.
23. De Craene M, Marchesseau S, Heyde B et al. 3D strain assessment in
ultrasound (Straus): A synthetic comparison of five tracking methodologies.
IEEE Trans Med Imaging. 2013;32:1632–46.
24. Alessandrini M, Heyde B, Queiros S et al. Detailed evaluation of five 3D
speckle tracking algorithms using synthetic echocardiographic recordings.
IEEE Trans Med Imaging. 2016;35:1915–26.
25. Knight DS, Schwaiger JP, Krupickova S, Davar J, Muthurangu V, Coghlan
JG. Accuracy and test-retest reproducibility of two-dimensional knowledge-
based volumetric reconstruction of the right ventricle in pulmonary
hypertension. J Am Soc Echocardiogr. 2015;28:989–98.
26. Schreckenberg M, inventor; Tomtec Imaging Systems GmbH, assignee.
Adaptation of a 3D-surface model to boundaries of an anatomical structure
in a 3D-image data set. United States Patent US9280816B2, 2013.
27. De Craene M, Piella G, Camara O et al. Temporal diffeomorphic free-
form deformation: Application to motion and strain estimation from 3D
echocardiography. Med Image Anal. 2012;16:427–50.
28. Mansi T, Pennec X, Sermesant M et al. iLogDemons: A demons-based
registration algorithm for tracking incompressible elastic biological tissues.
Int J Comput Vis. 2011;92:92–111.
29. Papachristidis A, Galli E, Geleijnse ML et al. Standardized delineation
of endocardial boundaries in three-dimensional left ventricular
echocardiograms. J Am Soc Echocardiogr. 2017;30:1059–69.
30. Voigt JU, Pedrizzetti G, Lysyansky P et al. Definitions for a common
standard for 2D speckle tracking echocardiography: Consensus document
of the EACVI/ASE/Industry Task Force to standardize deformation
imaging. Eur Heart J Cardiovasc Imaging. 2015;16:1–11.
31. D’hooge J, Barbosa D, Gao H et al. Two-dimensional speckle tracking
echocardiography: Standardization efforts based on synthetic ultrasound
data. Eur Heart J Cardiovasc Imaging. 2016;17:693–701.
32. Alessandrini M, Chakraborty B, Heyde B et al. Realistic vendor-specific
synthetic ultrasound data for quality assurance of 2-D speckle tracking
echocardiography: Simulation pipeline and open access database. IEEE
Trans Ultrason Ferroelectr Freq Control. 2018;65:411–22.
33. Cikes M, Solomon SD. Beyond ejection fraction: An integrative approach
for assessment of cardiac structure and function in heart failure. Eur Heart
J. 2016;37:1642–50.
18B Tissue Tracking
INTRODUCTION
Myocardial tissue tracking based on a 3D dataset has
been anticipated because the heart moves in a 3D space.
Regional myocardial deformation was first assessed on
the basis of tissue velocity with tissue Doppler imaging.1
However, wall deformation can be accurately estimated
only at regions parallel to the ultrasound beam owing
to the use of the Doppler effect. Next, 2D speckle
tracking echocardiography (STE), which is based on
tracking of speckle patterns created by interference of
ultrasound beams in the myocardium, became available.
This methodology is based on a B-mode image, so it is
conceptually angle independent of the ultrasound beam.
In the setting of 2D echocardiography, the heart moves
through the 2D plane of interest, and in fact, different
myocardium appears in the 2D image frame by frame. This
is called the “through-plane or out-of-plane phenomenon.”
Figure 18B.1 illustrates the effect of 3D motion on the
cross-sectional image plane image for the left ventricle
(LV). 2 LV translation and rotation might be perceived
as being due to ventricular contraction on the 2D image
and, therefore, might lead to either underestimation or
overestimation of the segmental deformation. Especially,
longitudinal shortening makes the LV base move toward
the apex by approximately 10 mm during systole in a
healthy subject (Figure 18B.2, ). In addition, for the
right ventricle (RV), 2D assessment has drawbacks of the
intrinsic complexity in its anatomical and deformation
pattern (Figure 18B.3, ). As a result, this may cause no
negligible effects on the accuracy of tissue tracking in
2D images. In contrast, 3D full-volume LV and RV data
overcome the limitation of plane-dependency of the 2D
image. 3 Recently, all four cardiac chambers - LV, RV, left
atrium (LA), and right atrium (RA) - have become the
target of 3D tissue tracking.
The challenging work of developing 3D tissue tracking
was first undertaken by Toshiba Medical Systems.4 As of
2019, several 3D tissue-tracking systems were available as
academic or commercial on-board or offline software in
ultrasound systems.5,6
3D tracking promises to track myocardium irrespective
of its direction of motion as long as the myocardium
remains within the scan volume data. 3D tissue-tracking
technology is now opening the next stage in the noninvasive
quantification of myocardial wall deformation.
PRINCIPLES OF 3D TISSUE TRACKING
WALL MOTION TRACKING TECHNOLOGY
3D wall motion tracking (3D WMT) has been developed for
the purpose of 3D wall motion analysis. This application
uses pattern-matching processing 7 to detect motion in
dynamic ultrasound images, and this is generally referred
to as speckle tracking. 3D WMT therefore enables 3D STE.
First, the basic principles of speckle tracking technology
are discussed, using 2D WMT as an example. In speckle
tracking, a template image is set centered on the reference
point for the detection of motion as the start frame. The
application estimates the position to which the local
domain in the template image has moved in the next frame
by searching for the area with the most similar speckle
pattern near the reference point in the next frame (moving
point) (Figure 18B.5 upper panel). This processing is called
pattern matching. As a result, information concerning motion
as a movement vector (the position vector of the moving
point to the position vector of the reference point) at the
reference point is acquired. By performing such pattern
matching over the entire myocardial region of interest,
information concerning myocardial motion between two
frames can be obtained. The myocardial region of interest
in the start frame is then moved to the most likely position
in the next frame based on the motion information for
the myocardium. This processing is called tracking. In the
next frame, the motion information for the myocardial
region of interest at the tracked position is detected by
pattern matching, and tracking is performed. This process
is repeated for all subsequent pairs of successive frames for
the entire cardiac cycle. As a result, the positions of local
tissues as they move over time can be tracked throughout
the cardiac cycle.
Speckle tracking does not make use of Doppler
information and is therefore not affected by the angle
between the direction of tissue motion and the direction
of the ultrasound beam, which is an advantage over tissue
Doppler imaging.
DEVELOPMENT OF 3D WALL MOTION TRACKING
FROM 2D WALL MOTION TRACKING
Cardiac structures and motion are in three dimensions, and
thus 3D motion should be evaluated for strain analysis in
WMT. A 3D cube of image data rather than a single plane
of 2D image data is used as the template image in 3D WMT
(Figure 18B.5, lower panel). The 3D volume that is most
similar to this cubic template is searched for in the next
3D image frame. Then, the 3D motion information (3D
movement vector) of the corresponding part is searched
for (Figure 18B.4).8 This pattern matching using 3D images
is performed for the volume corresponding to the entire
myocardium, and tracking processing using 3D movement
vectors is repeated for the entire cardiac cycle. As a result,
3D wall motion analysis of the entire heart is achieved.
The basic principle of 3D tracking is simply an extension
of the 2D speckle tracking technique to three dimensions.
However, since 3D pattern matching involves much more
intensive data processing, improvements in processing
Tissue Tracking  223
 A speed are required. In fact, the degree of data processing
is increased from the second to the third power. To meet
this requirement, the efficiency of a pattern-matching
technology known as the sum of squared differences (SSD)
has been increased for 3D WMT.8
B

FEATURES OF 3D WALL MOTION TRACKING

Strain is a measure of deformation representing shortening
or expansion of an object and is defined as follows:
C Strain = (Lt  −  L0)/L0, where L0 is initial length and Lt is
length at time t. Unlike velocity or displacement, strain is
unaffected by the motion of the entire heart and therefore
is more suitable for regional wall motion analysis. 3D STE
D is achieved by applying the information concerning wall
motion obtained by 3D tracking to strain analysis. In 3D
WMT, it is possible to compute many wall motion parameters
at one time for the entire LV from a single 3D image dataset.
E In particular, radial, longitudinal, and circumferential
strain, which are the three orthogonal strain values that are
important for assessing LV structure, can be determined
simultaneously for the entire LV myocardium (Figure
18B.6). Based on the 3D STE, three unique functions, area
strain, activation imaging, and quad-chamber tracking,
have been developed.

Figure 18B.1  Effects of rotation and translation about each of the
three primary axes and longitudinal shortening in the recording of
a 2D short-axis view (Middle Panels), apical view (Right Panels), and
3D full-volume image (Left Panels) of the left ventricle. (A) Rotation
about the horizontal minor axis, (B) rotation about the long axis,
(C) rotation about the ventricular minor axis, (D) translation, and (E)
longitudinal shortening. Based on the 2D image, translation, rotation,
and longitudinal shortening might be perceived as being due to
ventricular contraction and might lead to either underestimation or
overestimation of segmental function.
AREA STRAIN
The area change ratio, which is called “area strain” by some
authors, can be calculated in 3D WMT (Figure 18B.7).
The area change ratio is physiologically synonymous with
the radial strain if the myocardial volume is conserved
throughout the cardiac cycle. Area change ratio is more
robust than the radial strain because the former does not
depend on the epicardial tissue tracking which is often the
suboptimal quality of the image.9

Figure 18B.2  Plastic bag image showing displacement of left ventricle by 3D speckle tracking. The basal segment of the left ventricle moves
toward the apex over 10 mm. Its dynamic movement may result in through-plane phenomenon in 2D echocardiography .

224  3D Echocardiography
 N-th frame (N + 1)-th frame

2D

2D template of a
tracking point (red
2D scanning area
pixel)

3D

Figure 18B.3  Plastic bag image showing displacement of right 3D template of a

ventricle by 3D speckle tracking. The lateral part of the tricuspid
annular plane is seen toward the apex. Its dynamic movement may
affect the angle dependency in M-mode assessment of the tricuspid
annular systolic excursion .
tracking point (red 3D scanning area
voxel)
Figure 18B.4  Schematic image of both 2D (Upper Panels) and 3D
(Lower Panels) tissue tracking algorithms. Red pixel/voxel is the
2D/3D template of a tracking point. To determine the position of the
pixel/voxel of interest, the most similar pixel/voxel is searched for in
the surrounding regions in the next frame.

Figure 18B.5  Example image of 2D (Upper Panels) and 3D (Lower Panels) speckle tracking echocardiography (STE). The square area of interest
in the first frame is searched in the next frame by pattern matching in 2D STE, and the cubic template of interest in the first frame is searched
in the next frame by pattern matching in 3D STE.

Tissue Tracking  225

Figure 18B.6  Radial, longitudinal, and circumferential strain in 3D tracking. Radial strain (left) is synonymous with wall thickening, longitudinal
strain (middle) measures shortening in the basal-lateral long-axis direction, and circumferential strain (right) measures shortening in the
short-axis direction.

Figure 18B.7  Area change ratio. Area change ratio, which is a unique parameter of 3D tracking, is the endocardial area change from the
red square in frame 1 to the yellow square in the next frame n.

Conventionally, 2D images have been used for torsion
analysis, but it is difficult to measure the distances between
multiple short-axis images, and there are theoretical
restrictions that make it impossible to use the image data
of the same cardiac cycle. However, in 3D WMT, such
restrictions do not apply, and ideal torsion values can be
calculated simultaneously to determine the rotation of
each short-axis plane and the distance between the planes.
It is also possible to determine a new parameter known as
regional torsion, which represents the spatial distribution
of torsion values (Figure 18B.8).
ACTIVATION IMAGING AS THE ISOCHRONE
CONTRACTION MAPPING
The mechanical contraction timing of the myocardium is
correlated with the electrical activation time measured by
electrophysiological mapping and can be measured using
activation imaging on 3D WMT.10 With activation imaging,
the time that has elapsed before the value of regional
strain obtained by 3D WMT reaches a specified threshold
with respect to the peak value, which is mapped in colors.
This process is schematically shown in Figure 18B.9 ( ).
The propagation of ventricular contraction is represented
visually by displaying the changes in the distribution of
strain at the leading edge of contraction.
Quad-chamber tracking (QCT) has been newly devel-
oped as a function to simultaneously display two or more
3D WMT analysis results. It is also possible to align the status
before and after treatment side by side if they are in the
same heart chamber, and to automatically anatomically align
and display the analysis results of different heart chambers
(Figure 18B.10, ). QCT can assess not only individual ven-
tricular function but also the interdependence among four
chambers in the same heartbeat. The results of the volume
measurements, left and right ventricular stroke volume, can

226  3D Echocardiography
Figure 18B.8  Rotation, twist, and torsion to base in 3D tracking. Rotation (left) is the regional rotational displacement angle on the short-
axis plane measured in degrees. Twist (middle) is the angle difference of the rotation between the referential mitral annulus and the regional
short-axis plane measured in degrees. Torsion to base (right), which is the original parameter of 3D tracking, is the twist gradient with respect
to the basal plane of the left ventricle and is measured in degrees/centimeter.
be compared directly, and it may improve the accuracy of
the measurement.
COMPARISON OF 2D vs. 3D STRAIN
Table 18B.1 summarizes the comparison among the 2D
and 3D speckle tracking echocardiography, 5 based on
the previously mentioned differences. Among the various
options for 3D STE software, two vendor-specific onboard
software programs were selected in Table 18B.1.
VERIFICATION OF 3D STRAIN
3D WMT as previously described has been realized in the
Canon Aplio i900 ultrasound system, and the verification
results for artificial data based on a numerical model have
Figure 18B.9  Schematic drawing of activation imaging (AI) mapping.
To visualize the timing of deformation with AI mapping, the time at
which a local wall motion index reaches a threshold with respect
to the peak value is displayed in different colors. The threshold is
25% of the maximum area change ratio value in each region was
recommended, according to the previously determined protocol by
comparison with the endocardial contact mapping data .
been reported.8 The error ratio of all strain measurements
was based on the global average across all 16 wall segments.
In almost all cases, good results were obtained, and the
error ratio was less than 5%. In addition to the numerical
model verification, in vivo verification has been reported
in an experimental animal model using sonomicrometry
implantation for LV11 and RV,12 because sonomicrometry
is the only method available to assess 3D myocardial
deformation, and no other noninvasive imaging method
can verify the accuracy of 3D echocardiography tracking.
In each of 10 anesthetized sheep, sonomicrometry crystals
were implanted on the endocardium at the basal, mid, and
apical free walls. 3D STE datasets were obtained from the
open chest apical approach at a frame rate of approximately
30 frames/s. Segmental longitudinal, circumferential strain,
and area change ratio measurements by 3D echocardiography
were compared with those by sonomicrometry at baseline
and during pharmacological and mechanical stress tests
(dobutamine and propranolol infusion and coronary artery
occlusion or pulmonary artery banding). Good correlations
were observed between strain measurements by 3D STE
and those by sonomicrometry in both LV and RV. Among
the correlations between 3D STE and sonomicrometry, the
components of circumferential and longitudinal strain and
area change ratio showed good accuracy for the estimation of
regional deformation. Among three strain components, only
the area change ratio showed significant differences during
the ischemic stress studies in LV,9 and pulmonary banding
stress in RV.12 Accordingly, both experimental studies for left
and right ventricles suggest the area change ratios are reliable
and robust parameters quantifying ventricular regional
deformation in a noninvasive fashion.
VOLUME VERIFICATION WITH
CARDIAC MAGNETIC RESONANCE
For LV volume calculation, 3D STE offers superior accuracy and
reproducibility over that of 2D echocardiography in the setting
of magnetic resonance imaging (MRI) as the gold standard
Tissue Tracking  227
Figure 18B.10  Quad-chamber tracking by 3D STE as a function to simultaneously display 3D WMT analysis results of four chambers. The
volume change of each ventricle is also available in a time-volume curve (upper right) and table (lower right column) .

for analysis.13 For RV volume measurement verification, the

comparison with cardiac magnetic resonance imaging has CLINICAL APPLICATIONS OF 3D TISSUE
been reported in the RV.14 Similar to the results of previous 3D TRACKING
echocardiography–derived RV volume validation,15 3D STE–
Recently, a growing amount of clinical research using 3D
derived RV volume and ejection fraction (EF) showed modest
tissue tracking has been published.3,5,16 Especially, the area
but significant underestimation in RV EF of 2% and RV end-
change ratio (area strain) correlates well with visual wall
diastolic volume of 10 mL. In addition, the regional RV wall
motion assessment by experts in assessing regional wall
contributes global RV function differently; specifically, inlet
motion abnormality.17
area strain and outflow circumferential strain showed close
correlation with RV EF.

Table 18B.1  Comparison of 2D vs. 3D Speckle Tracking Analysis by Canon and GE Specific Software
3D Strain

Characteristics 2D Strain Canon, Wall Motion Tracking GE, Echopac

Acquisition Multiple views for entire LV analysis One apical 3D full volume One apical 3D full volume
Reliance on good image quality Yes + Yes ++ Yes ++
Number of heartbeats for analysis 1 beat 1–6 beats 1–6 beats
Temporal resolution 40–80 frames/s Up to 40 volumes/s 34–50 volume/s
Out-of-plane motion of speckles Yes No No
Cardiac chamber for applicable LV, RV free wall, and others LV, RV, and others LV
Parameters
  Global longitudinal strain Nonsimultaneous segmental peak on Simultaneous segmental values Simultaneous segmental values
different cardiac cycle
  Radial strain Measured Measured Calculated from area strain by the
law of volume conservation
  Area strain or area change ratio No Yes Yes
  Torsion (twist angle/apical length) No Yes Yes
  Isochrone mapping of No (Yes, by Canon Aplio-i) Yes (Activation Imaging) No
contraction
Drift compensationa Yes Yes No
a All segmental strain curves are forced by the software to return to baseline at end diastole.

228  3D Echocardiography
 A B
C
Figure 18B.11  Histological photograph of a rat heart in short-axis
(A), long-axis (B), and coronal sections from the subendocardium
to subepicardium. Myofibral orientation gradually changes in a
clockwise direction from 80° in the subendocardium to horizontal
in the midwall and to –80° in the subepicardial left ventricular layer.
REFERENCE VALUE FROM HEALTHY
SUBJECTS
Recently, four studies have been published for 3D TSE–
derived normal values. According to these, the area strain
calculations of the LV are −42.0%18 or −38.8%19 by Artida,
Toshiba system, and −33% or −32% by E9 GE systems.20
The discrepancy between the two vendors may be due to
the different algorithms, which should be overcome in the
future, as the 2D STE–derived strain.
HEART FAILURE AND CARDIOMYOPATHY
The major advantage of 3D tissue tracking is its ability
to obtain multiple wall deformation parameters in one
LV image in a less time-consuming manner than other
methods.21 Based on the LV architecture, each deformation
index reflects the abnormality of different myocardial
layers.22 3D tissue tracking can also differentiate normal
from abnormal myocardial segments just as well as cardiac
MRI can. 23 As shown in a cross-sectional histological
specimen (Figure 18B.11), the myofiber arrangement of the
LV is not uniform. In the subendocardium, the myofibers
are longitudinally oriented. The angle of the myofibers
toward the horizontal axis (Figure 18B.11) continuously
decreased to mid-wall from 90 degree to 0 degree, and
decreases in subepicardial from 0 degree to – 90 degree.
As summarized in Table 18B.2, longitudinal contraction
is predominantly governed by the subendocardial layer.
However, transmural involvement of the myocardial injury
leads to a reduction in LV circumferential and torsional
deformation and results in a decreased EF. 24 Therefore,
the combination of multiple deformation indices provides
pathophysiologic insight into the mechanics of LV
dysfunction.25 The spacial distribution of LV deformation
in a bull’s eye map given by 3D STE gives us additional
information to utilize in the differential diagnosis of
myocardial disease, i.e. apical spearing of longitudinal
strain in cardiac amyloidosis (Figure 18B.12, ).
CARDIAC DYSSYNCHRONY IMAGING
Among clinical applications of 3D STE, dyssynchrony
assessment is one of the most promising fields of
interest. 26 –28 LV activation mapping in patients with left
bundle branch block is shown in Figure 18B.13 ( ). The
images show mean temporal changes of circumferential
strain from early systole (left panel) to end systole (right
panel). First, the yellow area, which corresponds to
regional contraction, is shown at the apical septal area.
Then, the yellow area propagates to the basal lateral
wall turning at the apex. This propagation pattern is a

Table 18B.2  Myocardial Deformation and Layer-Specific Myocardial

Damage in Heart Failure
Diffuse Subendocardial Diffuse/Large Transmural

Lesion

Clinical syndrome Heart failure with preserved EF Heart failure with reduced EF
Amyloidosis
Dilated cardiomyopathy
Underlying heart disease Chemotherapy-induced cardiomyopathy
Transmural infarction
Hypertensive heart
Longitudinal strain ↓↓ ↓↓
Circumferential strain → ↓↓
Radial strain →/↓ ↓↓
Torsion →/↑ ↓↓
EF →/↓ ↓↓
EF, ejection fraction.

Tissue Tracking  229

 A C E

B D F

Figure 18B.12  Longitudinal strain (LS) apical sparing in amyloid light-chain (AL) cardiac amyloidosis. (A) The multi planer reconstruction
(MPR) image of 3D echocardiography ; (B) the 3D speckle tracking results superimposed on the MPR image ; (C) 2D image of the four-
chamber view ; (D) polar map of longitudinal strain, in which the red color indicates the preserved LS in mid and apical left ventricular (LV)
views, and blue indicates the severely impaired LS in basal LV; (E) the plastic bag with both epicardial and endocardial wire ; (F) the plastic
bag with color coding of LS .

Early systole End systole

Sep Lat

–10.00 –10.00 –10.00 –10.00

[%] [%] [%] [%]

DCM with LBBB, time sequence of circumferential strain distribution

Figure 18B.13  Left ventricular dyssynchrony images by 3D speckle tracking echocardiography in a patient with idiopathic dilated
cardiomyopathy and left bundle branch block . (Lat, lateral wall; Sep, septal wall.)

230  3D Echocardiography
typical dyssynchrony in a patient with left bundle branch
block. In addition, the pattern is similar to the images
of propagation of electrical activation provided by
voltage mapping systems. 29 The promising 3D STE strain
distribution pattern predicting cardiac resynchronization
therapy (CRT) response is the U-shaped mechanical
propagation, 27 which may reflect the electrical block-line
within the LV. 29 In addition, the optimal pacing site can
be clearly demonstrated in individual patients using 3D
tissue tracking.
Recently, CRT for systemic RV or univentricle has been
limited to congenital heart disease clinics. 30 Successful
CRT in a patient with an arterial switch operation for
transposition of great arteries was visualized with 3D
echocardiography activation imaging (Figure 18B.14, ).
The activation imaging clearly showed the latest site of
contraction, so the epicardial lead for the systemic ventricle
was positioned there. The symptom of heart failure
improved with RV reverse remodeling. Another example is
shown in Figure 18B.15 ( ).
Another example of the clinical utility for activation
imaging in WPW syndrome31 is shown in Figure 18B.16
( ). The earliest contraction site corresponds well with
the accessory pathway ablation site. It indicates accurate
estimation of the electrical propagation by 3D STE
activation imaging.

A B

Figure 18B.14  Electrocardiogram (ECG) and images before (left) and after (right) cardiac resynchronization therapy (CRT) in patient with
the atrial switch operation for transposition of the great arteries. (A) ECG before CRT (left) showed a wide QRS (160 ms) with complete right
bundle branch block. ECG after CRT (right) showed decreased QRS duration. (B) Cine mode magnetic resonance imaging showed that the
systemic right ventricle (RV) showed apparent dyssynchrony before CRT . (C) Color-coded 3D mechanical activation mapping of the systemic
RV. The earliest sites of mechanical activation are denoted by an orange to red color, and the latest sites are denoted with purple. Before
CRT (left), the latest activation site was at the basal lateral wall. The activation map after CRT (right) showed a uniform activation pattern
with biventricular pacing (white arrows indicate pacing sites) .

Tissue Tracking  231

 A D E

Figure 18B.15  Right (RV) and left ventricular (LV) activation imaging before and after cardiac resynchronization therapy (CRT) in patients
with repaired tetralogy of Fallot with right ventricular outflow tract (RVOT) epicardial pacing. (A) Activation imaging color map, on which blue
indicates early and red indicates delayed shortening ; (B) RV and LV plastic bag wire image ; (C) plastic bag image with activation mapping
indicating the RVOT free wall is the earliest contraction, and it propagates to the LV through the interventricular septum ; (D) before and
(E) after CRT, 2D images of fourchamber view, biventricular activating maps, and area strain-time curves in each LV and RV segment . The
dyssynchronous motion of both ventricles remarkably improved and resulted in synchronous motion.

As with 2D speckle tracking, vendor-specific algorithms

LIMITATION OF CURRENT 3D SPECKLE
TRACKING ECHOCARDIOGRAPHY
Among the factors affecting strain measurements, the lower
frame rate of 3D STI is the most problematic in obtaining
accurate strain data; this lower frame rate may cause large
differences in speckle patterns between sequential frames.
The algorithm makes it possible to set a frame rate for each
image of approximately 40 Hz, which is recommended as
the minimum frame rate to limit frame-by-frame changes
in the speckle pattern.32
produce significant discrepancies in strain values.
Standardization will be required in the future for general
clinical utilization.
CONCLUSION
3D tissue tracking is a powerful potential tool for evaluating
myocardial wall deformation in a comprehensive manner
and might provide new insight into various clinical problems
beyond that provided by conventional echocardiographic
indices.

232  3D Echocardiography
Figure 18B.16  Multimodality assessment before and after LV lateral accessory pathway (ACP) ablation in Wolff-Parkinson-White syndrome.
Intracardiac electric activation mapping before (A) and after (B) ACP ablation. 3D echo activation imaging of LV before (C) and after
(D)  , time-area strain curves before (E) and after (F) ablation. 12 leads electrocardiogram before (G) and after ablation (H). The LAO
fluoroscopic view during the successful ablation with the schema of the mitral annulus clock orientation (I).

REFERENCES
1. Edvardsen T, Gerber BL, Garot J, Bluemke DA, Lima JA, Smiseth OA.
Quantitative assessment of intrinsic regional myocardial deformation
by Doppler strain rate echocardiography in humans: Validation against
three-dimensional tagged magnetic resonance imaging. Circulation.
2002;106:50–6.
2. Mann DL, Gillam LD, Weyman AE. Cross-sectional echocardiographic
assessment of regional left ventricular performance and myocardial
perfusion. Prog Cardiovasc Dis. 1986;29:1–52.
3. Seo Y, Ishizu T, Atsumi A, Kawamura R, Aonuma K. Three-dimensional
speckle tracking echocardiography. Circ J. 2014;78:1290–301.
4. Kawagishi T. Speckle tracking for assessment of cardiac motion and
dyssynchrony. Echocardiography. 2008;25:1167–71.
5. Muraru D, Niero A, Rodriguez-Zanella H, Cherata D, Badano L. Three-
dimensional speckle-tracking echocardiography: Benefits and limitations
of integrating myocardial mechanics with three-dimensional imaging.
Cardiovasc Diagn Ther. 2018;8:101–117.
6. Satriano A, Pournazari P, Hirani N et  al. Characterization of right
ventricular deformation in pulmonary arterial hypertension using three-
dimensional principal strain analysis. J Am Soc Echocardiogr. 2019;32:385–93.
7. Bohs LN, Friemel BH, McDermott BA, Trahey GE. A real time system for
quantifying and displaying two-dimensional velocities using ultrasound.
Ultrasound Med Biol. 1993;19:751–61.
8. Takeguchi T, Nishiura M, Abe Y, Ohuchi H, Kawagishi T. Practical
considerations for a method of rapid cardiac function analysis based on
three-dimensional speckle tracking in a three-dimensional diagnostic
ultrasound system. J Med Ultrason. 2010;37:41–49.
9. Seo Y, Ishizu T, Enomoto Y, Sugimori H, Aonuma K. Endocardial
surface area tracking for assessment of regional LV wall deformation with
3D speckle tracking imaging. JACC Cardiovasc Imaging. 2011;4:358–65.
10. Seo Y, Yamasaki H, Kawamura R et al. Left ventricular activation imaging
by 3-dimensional speckle-tracking echocardiography. Comparison with
electrical activation mapping. Circ J. 2013;77:2481–9.
11. Seo Y, Ishizu T, Enomoto Y et al. Validation of 3-dimensional speckle
tracking imaging to quantify regional myocardial deformation. Circ
Cardiovasc Imaging. 2009;2:451–9.
12. Atsumi A, Seo Y, Ishizu T et al. Right ventricular deformation analyses
using a three-dimensional speckle-tracking echocardiographic system
specialized for the right ventricle. J Am Soc Echocardiogr. 2016;29:402–411.e2.
13. Nesser HJ, Mor-Avi V, Gorissen W et al. Quantification of left ventricular
volumes using three-dimensional echocardiographic speckle tracking:
Comparison with MRI. Eur Heart J. 2009;30:1565–73.

Tissue Tracking  233

14. Ishizu T, Seo Y, Atsumi A et al. Global and regional right ventricular
function assessed by novel three-dimensional speckle-tracking
echocardiography. J Am Soc Echocardiogr. 2017;30:1203–13.
15. Shimada YJ, Shiota M, Siegel RJ, Shiota T. Accuracy of right ventricular
volumes and function determined by three-dimensional echocardiography
in comparison with magnetic resonance imaging: A meta-analysis study. J
Am Soc Echocardiogr. 2010;23:943–53.
16. Urbano-Moral JA, Patel AR, Maron MS, Arias-Godinez JA, Pandian NG.
Three-dimensional speckle-tracking echocardiography: Methodological
aspects and clinical potential. Echocardiography. 2012;29:997–1010.
17. Kleijn SA, Aly MF, Terwee CB, van Rossum AC, Kamp O. Three-
dimensional speckle tracking echocardiography for automatic assessment
of global and regional left ventricular function based on area strain. J Am
Soc Echocardiogr. 2011;24:314–21.
18. Kleijn SA, Pandian NG, Thomas JD et  al. Normal reference values
of left ventricular strain using three-dimensional speckle tracking
echocardiography: Results from a multicentre study. Eur Heart J Cardiovasc
Imaging. 2015;16:410–6.
19. Perez de Isla L, Millan M, Lennie V et al. Area strain: Normal values
for a new parameter in healthy people. Revista Española de Cardiología.
2011;64:1194–7.
20. Muraru D, Cucchini U, Mihaila S et  al. Left ventricular myocardial
strain by three-dimensional speckle-tracking echocardiography in
healthy subjects: Reference values and analysis of their physiologic
and technical determinants. J Am Soc Echocardiogr. 2014;27:
858–71.e1.
21. Perez de Isla L, Balcones DV, Fernandez-Golfin C et  al. Three-
dimensional-wall motion tracking: A new and faster tool for myocardial
strain assessment: Comparison with two-dimensional-wall motion tracking.
J Am Soc Echocardiogr. 2009;22:325–30.
22. Sengupta PP, Korinek J, Belohlavek M et al. Left ventricular structure
and function: Basic science for cardiac imaging. J Am Coll Cardiol.
2006;48:1988–2001.
23. Maffessanti F, Nesser HJ, Weinert L et al. Quantitative evaluation of
regional left ventricular function using three-dimensional speckle tracking
echocardiography in patients with and without heart disease. Am J Cardiol.
2009;104:1755–62.
234  3D Echocardiography
24. Geyer H, Caracciolo G, Abe H et al. Assessment of myocardial mechanics
using speckle tracking echocardiography: Fundamentals and clinical
applications. J Am Soc Echocardiogr. 2010;23:351–69, quiz 453–5.
25. Sengupta PP, Kramer CM, Narula J, Dilsizian V. The potential of
clinical phenotyping of heart failure with imaging biomarkers for guiding
therapies: A focused update. JACC Cardiovasc Imaging. 2017;10:1056–71.
26. Tanaka H, Matsumoto K, Hiraishi M et  al. Multidirectional left
ventricular performance detected with three-dimensional speckle-tracking
strain in patients with chronic right ventricular pacing and preserved
ejection fraction. Eur Heart J Cardiovasc Imaging. 2012;13:849–56.
27. Seo Y, Ishizu T, Kawamura R et  al. Three-dimensional propagation
imaging of left ventricular activation by speckle-tracking echocardiography
to predict responses to cardiac resynchronization therapy. J Am Soc
Echocardiogr. 2015;28:606–14.
28. Seo Y, Ishizu T, Sakamaki F, Yamamoto M, Aonuma K. Left bundle
branch block and echocardiography in the era of CRT. J Echocardiogr.
2015;13:6–14.
29. Auricchio A, Fantoni C, Regoli F et  al. Characterization of left
ventricular activation in patients with heart failure and left bundle-branch
block. Circulation. 2004;109:1133–9.
30. Khairy P, Van Hare GF, Balaji S et al. PACES/HRS expert consensus
statement on the recognition and management of arrhythmias in adult
congenital heart disease: Developed in partnership between the Pediatric
and Congenital Electrophysiology Society (PACES) and the Heart Rhythm
Society (HRS). Endorsed by the governing bodies of PACES, HRS, the
American College of Cardiology (ACC), the American Heart Association
(AHA), the European Heart Rhythm Association (EHRA), the Canadian
Heart Rhythm Society (CHRS), and the International Society for Adult
Congenital Heart Disease (ISACHD). Can J Cardiol. 2014;30:e1–e63.
31. Ishizu T, Seo Y, Igarashi M et al. Noninvasive localization of accessory
pathways in Wolff-Parkinson-White syndrome by three-dimensional
speckle tracking echocardiography. Circ Cardiovasc Imaging. 2016;9(6).
32. Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J3rd .
Novel speckle-tracking radial strain from routine black-and-white
echocardiographic images to quantify dyssynchrony and predict response
to cardiac resynchronization therapy. Circulation. 2006;113:960–8.
 19
INTRODUCTION
Transthoracic echocardiography (TTE) is usually the first
diagnostic technique that detects a cardiac mass. It also
allows for serial imaging along the follow-up without the
need for radiation, iodine, or gadolinium contrast agents.
Among the disadvantages are the inherent limitations of the
technique such as the window dependence, the limitations
in the tissue characterization, and the limited visualization
of extracardiac or paracardiac structures.
In the study of cardiac masses, transesophageal
echocardiography (TEE) has a higher sensitivity and
specificity than TTE1 and provides for a more detailed
description of size, morphology, attachment site, extension,
and hemodynamic effects of the mass, and it aids in the
intraoperative management of cardiac tumors. 2D TEE
offers planar images that must be mentally integrated. When
we incorporate 3D TEE, we obtain optimal visualization in
a more anatomical and real way. The most used modality
in this context is real-time 3D; also useful are the X-plane
mode (capacity to section the mass and display it from two
simultaneous angles) and the cropping of the mass.
When a cardiac mass is detected, a detailed description
is necessary to provide a correct differential diagnosis.2–5
• Location of the mass: Intracavitary, intramyocardial, or
pericardial. The intracavitary localization (in one
or several cardiac chambers) facilitates the diagnosis
because the paracardiac or pericardial masses are
more difficult to detect, especially if they are of small
size, being better evaluated by cardiac computed
tomography (CCT) or cardiac magnetic resonance
(CMR) imaging. The most frequent intramyocardial
(single or multifocal) location of tumors is the lateral
wall of the left ventricle and the interventricular septum.
The visceral pericardium is the most common location
of cardiac metastases. Some cardiac tumors have a
certain preference to be located in specific anatomical
locations (Table 19.1).
• Size and morphology: Large masses may cause valve or
intracavitary obstruction (Figure 19.1). The size of an
intracardiac mass (vegetation, tumor, or thrombus)
is also an important predictor for embolic events.
Maximum diameter measurements from 2D may lead
to underestimation comparing to the 3D technique.6
In the case of endocarditis, the size of the vegetation
Table 19.1  Preferential Location of Cardiac Tumors
Left Atrium Right Atrium Ventricles Any Chamber
Myxomas Angiosarcoma Fibroma Lipoma
Leiomyosarcoma Lymphoma Rhabdomyoma Hemangioma
Osteosarcoma Rhabdomyosarcoma
Cardiac Masses
influences the risk of embolism and therefore an earlier
surgical approach. The shape and size of vegetations can
be more accurately evaluated by 3D echocardiography
than conventional 2D echocardiography.13
• Mobility: The mobility and friability of a mass give an
idea of the risk of embolism being a potential cause of
systemic or pulmonary embolism.
• Relationship of mass with other cardiac structures: The
affectation of several structures leads to suspect
malignancy, and it is fundamental in the possibility
of exeresis and in the surgical planning. 3D
echocardiography improves the study of the spatial
relationship of the mass (Figure 19.2).
• Zone and mode of adhesion: The zone of adhesion is
sometimes key to diagnosis. For example, a mass
with a pedicle implantation zone in the oval fossa
characteristically corresponds to an atrial myxoma
(Figure 19.3), while tumors associated with the lateral
auricular wall or interatrial septum but with a wide
implantation base are more likely to be malignant
(Figure 19.2).
• Tissue characterization: Echocardiography in general has
limitations in tissue characterization: thrombi have a
homogeneous structure, while heterogeneous areas can
be found in tumors (Figure 19.4). The echocardiographic
contrast study provides information on the vascularization
of the mass. As thrombi are avascular, they do not
enhance at all, whereas contrast-enhanced masses usually
correspond to malignant tumors.
• Hemodynamic repercussion: Large or mobile masses may
lead to interference in the opening or closing of the
valve on the left (Figure 19.2) or right side (Figure
19.5) of the heart. Large pleuropericardial cysts (Figure
19.6) and primary or metastatic pericardial tumors
associated with pericardial effusion may produce
cardiac tamponade.
A correct differential diagnosis will direct the treatment.
Initially, several possibilities must be considered:
• Tumor mass in different locations (valvular, intracavitary,
myocardial, or pericardial); primary tumor (benign or
malignant) or metastatic tumor
• Intracavitary thrombus
• Endocarditis masses
• Anatomical structures with pathology with appearance
of mass
• Normal anatomical structures with mass effect
In the differential diagnosis of the cardiac masses, the
following should be considered:
• The characteristics and clinical context of the patient
such as age, the presence of atrial fibrillation, or a
known neoplastic or infectious process. For example, a
mobile mass attached to a valve in an infectious context
Cardiac Masses  235
 Pericardial
effusion

Mass
LV
in RV
Mass
in RV

LV
RA
LA

Mass in
RV

Lung metastases

Figure 19.1  Echocardiographic and cardiac computed tomographic images of total occupation of the right ventricle by endocavitary
metastases from endometrial carcinoma with compression of the left ventricle.

P e dicle
Myx oma
IAS

MV

B
Figure 19.3  A mass with pedicle implantation in the oval fossa
characteristically is an atrial myxoma (3D TEE).

supports the diagnosis of vegetation, while without

• Certain echocardiographic characteristics allow us to
Figure 19.2  (A) 2D TEE: Left atrial mass related to the interauricular
septum. (B) X-plane technique shows extension toward the mitral
valve indicates malignancy and rules out the possibility that it is a
myxoma, being in fact an undifferentiated sarcoma.
infectious data it would support other diagnoses such
as thrombus, fibroelastoma, or Lambl excrescence.
differentiate a benign cardiac tumor from a malignant
tumor. The following suggest malignancy (Table 19.2):
mass size greater than 5 cm, appearance on the right
side of the heart, ventricular location, infiltration of
myocardium or pericardium with pericardial effusion,
especially if it is hemopericardium, or the presence of
pleural effusion.

236  3D Echocardiography
 A

PC

LV
RV

B Figure 19.6  Pleuropericardial cysts may produce cardiac tamponade.

(LV, left ventricle; RV, right ventricle.)

Table 19.2  Echocardiographic Differences of Benign

and Malignant Cardiac Tumors
Benign Tumors Malignant Tumors

Location Left chambers > Right chambers > Left

Right chambers; chambers; intramural,
intracavitary pericardial
Size <5 cm, single lesion >5 cm, multiple lesions
Morphology Regular, defined Irregular contours
contours
Extension to Near No Yes
Structures
Figure 19.4  3D TEE cropping. (A) Discrete heterogenicity (different
Calcification Small foci in myxoma, Big foci in osteosarcoma
echolucency) of left atrial myxoma. (B) Anechoic areas in malignant
fibroma, or teratoma
tumor .
Contrast No or mild Yes
Enhancement
Pericardial Effusion No Possible

CARDIAC TUMORS
Cardiac tumors may be primary (benign or malignant) or
metastatic (by definition, malignant) (Table 19.3). Primary
tumors are rare with an incidence of less than 0.1% in
autopsy series.

BENIGN PRIMARY TUMORS

Figure 19.5  Obstructive myxoma in the right ventricle including the
tricuspid septal leaflet that is practically indistinguishable. The myxoma
was resected and a tricuspid biological prosthesis was implanted; the
histological study confirmed the diagnosis of myxoma.
• Other echocardiographic findings. For example, a
left ventricular mass associated with apical aneurysms
or other regional wall motion abnormalities is highly
suggestive of mural thrombi.
In adults, benign primary tumors account for 75% of primary
heart tumors, with myxoma and papillary fibroelastoma
being the most common. Other tumors such as fibroma
(usually intramyocardial) and teratoma, usually pericardial,
are rare. Lipomas can occur in any location and are also
rare. In children, the rhabdomyoma is the most frequent
tumor in ages less than 1 year, is associated with tuberous
sclerosis, and is usually multiple but is very rare in adults.
MYXOMA
Myxoma is the most common benign tumor, most frequently
(80%) located in the left atrium, attached to the area of the
oval fossa through a thin pedicle. 3D TEE allows the precise
location of the attachments of the myxoma to be identified
(Figure 19.3). Less frequently, it is located in the right atrium,

Cardiac Masses  237

Table 19.3  Differential Diagnosis between
Vegetation and Other Valvular Lesions
Vegetation Pseudotumor/Tumor

Mobility Oscillating and Fixed and dependent on

independent of valvular valve movement P a pilla r y
movement Non Fibr oe la stoma
c o r on a r y
Echogenicity Isoechogenic with Echogenicity other than c us p
myocardium myocardium
Location Auricular side in Both sides Le ft
atrioventricular valves c o r on a r y
c us p
and ventricular side in
sigmoid valves
Shape Lobulated or amorphous Filament with narrow
attachment
Associated Pseudoaneurysms, Absence of associated
Anomalies turbulent flow, or valvular regurgitation or
regurgitation turbulent flows

Figure 19.7  Papillary fibroelastoma in aortic valve (aortic side) .

and rarely it is located in ventricles or valves (Figure 19.5).

LIPOMAS AND LIPOMATOUS HYPERTROPHY
They are heterogeneous and mobile masses that can reach
OF THE ATRIAL SEPTUM
great size, friable with peripheral and sessile areas of greater
Lipomas are encapsulated, echogenic, nonpandiculated
mobility, which explains their embolic risk. The heterogeneity
and homogeneous fatty tumors that are preferably located
of the mass with areas of necrosis or hemorrhage (echolucents)
in the left ventricular endocardium. If they are pericardial,
or calcification (more frequent in right atrial myxomas) can
they can compress the coronary arteries or associate
be revealed with 2D or 3D echocardiography by cropping
pericardial effusion and if they are intramyocardial they
(Figure 19.3).
can produce arrhythmias. Unlike myxomas, they have no
Patients may be asymptomatic or debut with embolic
areas of calcification, necrosis, or hemorrhage. They are
or obstructive phenomena (dyspnea, dizziness/syncope)
usually solitary but may be multiple in patients with tuberous
because the tumor tends to grow inside the atrium and
sclerosis.
may prolapse in the left ventricle during the diastole. It
More frequent is the lipomatous hypertrophy of the
may also be accompanied by a general syndrome with fever
interauricular septum which is defined as a fat deposit of
and weight loss. Familial myxomas constitute less than 10%
more than 8 mm thick and is associated with advanced age
of all myxomas.5 The Carney complex is a syndrome with
and obesity. The fat infiltration respects the fossa ovalis, so
autosomal dominant inheritance that includes cardiac and
that the interauricular septum acquires an aspect of “weight,”
noncardiac myxomas (at earlier age and more recurrent),
displayed more anatomically in 3D echocardiography
schwannomas, and other endocrine tumors with anomalies
(Figure 19.9).
in skin pigmentation.
FIBROMAS
PAPILLARY FIBROELASTOMA Fibromas are uncommon benign tumors that are most often
This is the second most frequent benign tumor. The seen in children (second most common benign pediatric
papillary fibroelastoma is more frequently located in the cardiac tumor) but are rare in adults. On echocardiography,
left valve, especially in the aortic valve (it can appear in
both sides) and in the mitral valve (more frequent in its
auricular side). They are small masses of 2–10 mm, mobile
and attached by a pedicle to the valvular endocardium,
usually unique, and 3D TEE shows its anemone appearance
(Figure 19.7, ).
Surgical excision is recommended in asymptomatic
La mbl
patients with low surgical risk in fibroelastomas in left e x c r e s c e nc e

valves with a diameter of 1 cm or greater. If they are small,

it is difficult to distinguish them from Lambl excrescences,
which are masses of connective tissue, avascular, located
in the valve closing line and more filiform in appearance
(Figure 19.8, ). 3D TEE adds important information in
the assessment of a cardiac mass for better definition of
the mass, attachment location, and mobility, which could Figure 19.8  Lambl excrescence in closed mitral valve (anterior
provide guidance for surgical excision. leaflet) .

238  3D Echocardiography
Figure 19.9  Lipomatous hypertrophy of the interauricular septum (black arrow) respects the fossa ovalis (white arrow).
they appear as distinct, highly echogenic, and well-
demarcated masses that often extend into the cavity of
the ventricle. The most common locations are the left
ventricular free wall, anterior free wall, or ventricular
septum. Extension into the cavity is not infrequent, which
can lead to obstruction and heart failure symptoms but is
not associated with systemic embolization. Otherwise, the
myocardial location can lead to arrhythmias and sudden
death, so resection is usually recommended even in
asymptomatic cases.
RHABDOMYOMA
Rhabdomyomas are the most common primary cardiac
tumor in children, typically appearing before the first year.
The majority are associated with tuberous sclerosis and tend
to be multiple. The rhabdomyomas are usually seen on the
ventricular walls (left ventricle or ventricular septum) or
on the atrioventricular valves. Echocardiography reveals
multiple small, lobulated, homogeneous, hyperechoic,
pedunculated, or intramural tumors.
MALIGNANT TUMORS
PRIMARY MALIGNANT TUMORS
Primary cardiac malignancies are less frequent than benign
tumors and represent 20% of primary cardiac tumors, the
most frequent being sarcomas. The clinical presentation can
vary and depends on the location of the tumor. Precordial
pain usually indicates a malignant rather than a benign
process.
Sarcoma
Angiosarcoma is the most frequent sarcoma. It is usually
located in the right atrium and is very invasive in nature
with infiltration of the heart wall and pericardium, with
pericardial effusion and cardiac tamponade. It has a lobed
and heterogeneous aspect. It can involve the right ventricular
entrance tract and may affect the atrioventricular groove. It
may cause dysfunction of the tricuspid valve.
Other types of sarcoma (undifferentiated,
rhabdomyosarcoma, leiomyosarcoma, fibrosarcoma,
and osteosarcoma) are more common in the left atrium.
Echocardiographically, the different types of sarcomas are
indistinguishable. Only osteosarcomas can be distinguished
by calcifications.
Sometimes sarcoma is presumed to be benign myxoma,
and the suspicion of sarcoma is only made at the time
of surgery due to its invasive nature. However, unlike
myxomas, sarcomas are not related to the oval fossa via
a pedicle. They are visualized as a mobile, broad-based,
nonhomogeneous mass with hypoechoic/anechoic
areas by necrosis and hemorrhage zones, which can be
detected by 2D echocardiography or cropping in the 3D
echocardiographic study (Figure 19.4). They tend to be
large, to occupy the cavity, and to have multiple tumor
Cardiac Masses  239
 AO
I mpla nt
(a nte r ior w a ll LA)
LAA
S a r c oma
(la te r a l w a ll LA)
Figure 19.10  Left atrial leiomyosarcoma, 3D TEE allows the display
of multiple tumor implants. (AO, aorta; LA, left atrium; LAA, left
atrial appendage.)
implants (Figure 19.10). Due to their great size and
mobility, they can produce hemodynamic compromise
such as dyspnea or syncope as a consequence of the
obstruction of the tracts of entry or exit of the chambers
affected, visualized in an anatomical way by using 3D
echocardiography (Figure  19.11, ). Surgery often has a
palliative intent to remove the obstruction produced by the
tumor. The prognosis is poor with a 1-year survival of less
than 25%, with the best prognosis corresponding to cases
of treatment with complete resection and chemotherapy.7
Mesothelioma
Although mesothelioma is more frequently a pleural tumor
that has been associated with asbestos exposure, it can
spread to the pericardium or appear exclusively in the
pericardium producing pericardial constriction. These
tumors, if suspected by echocardiography, require thoracic
CT or resonance imaging for study (Figure 19.12). The
prognosis associated with pericardial mesothelioma is poor,
LAA
Figure 19.11  Left atrial sarcoma causing obstruction in the mitral
valve (black arrow: Sarcoma). (LAA, left atrial appendage.)
240  3D Echocardiography
Figure 19.12  Computed tomography in patient with pericardial
constriction echocardiographic data with findings of pleuropericardial
mesothelioma.
although pericardial surgery with radiotherapy may be a
palliative treatment.
METASTATIC CARDIAC TUMORS
Metastatic tumors are about 30 times more common than
primary tumors of the heart. In autopsy series, 1.5%–20%
of patients who die of cancer present cardiac metastases.8
Lung cancer, breast cancer, and hematological tumors
are the tumors that most frequently metastasize to the
heart. Melanoma has a propensity to metastasize in the
heart, usually in advanced stages. Most cardiac metastatic
tumors remain clinically silent and are often diagnosed
postmortem.
The most frequent is metastatic pericardial involvement
(70%), followed by epicardial and myocardial involvement
(Figure 19.13), with endocardial/intracavitary involvement
being less frequent (5%) (Figure 19.1). Significant or
recurrent pericardial effusion with or without tamponade
is the most frequent echocardiographic finding, and its
appearance should be considered as a manifestation of
metastatic cardiac involvement. The pericardial effusion
may contain cancer cells, clots, and fibrin in its interior
adhered to the leaves of the pericardium. The pericardial
involvement can produce cardiac tamponade, and the high
echogenicity of hemorrhagic pericardial effusion suggests
malignancy ( ).
Intramyocardial metastases can be detected by
echocardiography, and the use of echocardiographic
contrast enhances the mass, which is indicative of
vascularization and generally of malignancy. CMR or CCT
allows better visualization of cardiac metastatic involvement
(Figure 19.13).
Metastases can reach the heart through several
mechanisms: by hematogenous or lymphatic dissemination
of cancer cells, by intravascular extension, or by direct
infiltration by contiguity (mediastinal tumors). The
lymphatic route is the most common in lung, breast, and
esophageal cancers, and being the hematogenous route, it
is the usual route in melanoma, lymphomas, and leukemias.

A benign tumors such as leiomyomatosis or pelvic or uterine
B higher echogenicity than the adjacent myocardium, and
Figure 19.13 Intramyocardial metastases. (A) Contrast
echocardiography enhances the metastases in the lateral wall of the
left ventricle (black arrows). (B) Cardiac magnetic resonance imaging
shows this metastases and also in the apex of the right ventricle (red
arrows).
Figure 19.14  Lung carcinoma metastases with intravascular extension through left superior pulmonary vein (X-plane).
Vascular extension via the inferior cava is more frequent
in renal tumors (hypernephroma) and among some
angiomyxomas, in which resection is curative.9 Vascular
extension to the left atrium of a pulmonary tumor is possible
through the pulmonary veins (Figure  19.14). Although
melanoma can be detected as a symptomatic intracavitary
mass, it most often metastasizes silently, invading the
pericardial surface.
THROMBUS
The thrombi have a homogeneous appearance and smooth
contours and move synchronously with the adjacent heart
wall during the heart cycle. A thrombus usually has a
an increase in echogenicity is expected as organization
of the thrombus occurs. Recent thrombi may have more
ehcolucent areas (Figure 19.15A) requiring differential
diagnosis with tumors. In case of poor visualization, the study
with echocardiographic contrast helps in its detection and
delimitation in any cardiac cavity; it is difficult to capture the
thrombus even with echocardiographic contrast because it is
not vascularized (Figure 19.15B).
Echocardiographic detection of ventricular thrombi is
generally performed by TTE (TTE has greater than 90%
sensitivity and greater than 85% specificity for detection
of left ventricular thrombi), while the best evaluation of
atrial thrombi is generally performed by TEE. 3D (3D)
echocardiography has been demonstrated to be potentially
superior to the 2D technique.10 Ventricular thrombi are
usually contiguous with the zones of noncontracting
myocardium and may be laminar or protruding.
Cardiac Masses  241
 A

B Figure 19.16  Thrombus (black arrow) in left atrial appendage (red

arrow). Marshall ligament (blue arrow).

3D TEE allows a frontal visualization (en face) to define the

variable anatomy of the LAA orifice (Figure 19.21) and
also the thrombus orientation with respect to the cardiac
structures, providing an anatomical and real image and
also a better characterization of size, morphology, and
mobility.

Figure 19.15  (A) Recent thrombi may have more ehcolucent areas
(red arrows). (B) Characteristic lack of capture of the thrombus in A
echocardiographic contrast study.

Regarding the left atrial thrombi, in 90% of cases the

thrombus is in the left atrial appendage (LAA). The presence
of an enlarged chamber, atrial fibrillation, a stenotic mitral
valve, and low cardiac output state favor the blood stasis
and the thrombus formation. A low appendage blood flow
emptying velocity is associated with the presence of LLA
thrombus. LAA is sometimes seen in TTE (parasternal
short axis through the cardiac base and the apical two- or
four-chamber view), and the detection of thrombus in atrial
appendage by TTE is possible but the reported sensitivity of
this technique is low11 ( ). B
TEE is useful in the case of thrombus associated
with cardiac structures better visualized by TEE, such
as atria and of course the LAA (Figure 19.16), mitral
valve or prosthesis ( ), interauricular septum (Figure
19.17), coronary sinus (Figure 19.18), and aorta except
midascending aorta (Figure 19.19).
Regarding the left atrial appendage, it is interesting to
study not only the presence of thrombus or spontaneous
contrast, but also its morphology (multilobed, chicken
wing, or windsock morphology), since the morphology
in chicken wing presents less risk embolism.12 3D TEE Figure 19.17  Thrombus (black arrow) in transit through a permeable
with the X plane technique helps to easily assess the foramen ovale, diagnosed in a patient with paradoxical stroke and
morphology of the LAA (Figure 19.20) and to distinguish pulmonary thromboembolism. (A) From right atrial side (red arrow:
small thrombi from normal pectineal muscles. Real-time fossa ovalis). (B) From left atrial side.

242  3D Echocardiography

Figure 19.18  Coronary sinus thrombosis with thrombus inside (white
arrow) and in the right atrium (black arrow). Tricuspid valve (red arrow).
Figure 19.19  Thrombosis (black arrow) in descending aorta as
complication of protruding atherosclerotic plaques (red arrows).
MASSES IN ENDOCARDITIS: VEGETATIONS,
ABSCESSES, AND PSEUDOANEURYSMS
Echocardiography has a fundamental role before, during,
and after treatment - in medical treatment, and even more
importantly if the treatment is surgical. It is necessary to
assess complications such as the presence of abscesses,
pseudoaneurysms, fistulas, perforation, or valvular
rupture as it allows for greater precision in the anatomical
description of the lesions and their morphology, size, and
relationship with neighboring structures.
The assessment of patients with infection includes,
in many cases, CCT, CMR, and even positron emission
tomography (PET).9
VEGETATIONS
3D echocardiography allows a more comprehensive
visualization of the vegetation as an oscillating mass (or
A
Figure 19.20  3D TEE X-plane technique helps to assess the morphology
of the left atrial appendage. (A) Windsock. (B) Multilobulated. (C)
Chicken wing.
not), and its precise attachment site to the generally valvular
endocardium or to prosthetic intracardiac material.10 In usual
clinical practice, the clinical context helps us in the differential
diagnosis of different entities. Echocardiography is essential in
two aspects: differential diagnosis with other lesions and size
and mobility of vegetation. There are some characteristics that
help us in the differential diagnosis between vegetation and
other valvular lesions (fibroelastoma, flail leaflet or chordal
rupture, thrombus, Lambl excrescences, strands) (Table 19.3).
Lambl excrescences or strands represent a particularly
difficult differential diagnosis in patients with fever in whom
the diagnosis of endocarditis is to be confirmed. They are
small filaments of connective tissue that are located on the
valve surfaces, most frequently in the aortic valve at the
level of its ventricular surface and in the mitral valve at the
level of its auricular portion. They have also been described
in prosthetic valves although this is rarer. Most cases are
asymptomatic, and this is an incidental finding that does
not require treatment, but cases of stroke associated with
this entity have been described (Figure 19.8).
Cardiac Masses  243
Figure 19.21  Real-time 3D TEE and multiplanar reconstruction allow a frontal visualization (en face) to define the variable anatomy of the
left atrial appendage orifice.

Embolism is frequent in infective endocarditis (IE), PERIANNULAR EXTENSION

complicating 20%–50% of cases of IE, falling to 6%–21%
after initiation of antibiotic therapy. Surgery to prevent
embolism is indicated in patients with persisting vegetations
greater than 10 mm after one or more clinical or silent
embolic events despite appropriate antibiotic treatment.
Surgery may be considered in patients with very large
(>30 mm; class IIa level of evidence B) or large (>15 mm;
class IIb; level of evidence B) isolated vegetations on the
aortic or mitral valve, although this decision is more difficult
and must be very carefully individualized according to the
probability of conservative surgery.14
This is more frequent in cases of aortic prosthesis. Abscesses
usually involve the mitroaortic intervalvular fibrous body
and appear as a periannular echo-dense area. When they
are small, they are difficult to diagnose as they are difficult
to distinguish echocardiographically from a thickening
of the aortic wall. When they are large, they can become
true masses that do not correspond to a tumor but to an
endocarditis with a large vegetation with  periannular
extension, with images of abscess and fistula (Figure 19.22).
Echocardiographically, pseudoaneurysms are visualized
as a pulsating cavity free of perivalvular echoes with color

Figure 19.22  Large mass in left atrium corresponding to a vegetation (red arrow). See also a fistula between aortic root (blue arrow) and
left atrium (white arrow).

244  3D Echocardiography
flow inside. The differential diagnosis with other cardiac
masses such as tumors or thrombus is very simple.
ANATOMICAL STRUCTURES WITH
MASS EFFECT PATHOLOGY
PERICARDIAL STRUCTURES
Although the diagnosis of pericardial effusion is often
simple using TTE, echocardiography has an important
limitation for the complete visualization of the pericardium
compared to other techniques. Localized effusions or
pericardial cysts are frequently accidental findings of
CCT or CMR requested for another reason, as they are
techniques that offer a greater field of anatomical vision.
Pericardial cysts are benign lesions, usually diagnosed by
chance as they are often asymptomatic although they may
cause dyspnea, chest pain, or cough (Figure 19.6). They
are more frequent on the right side, especially in the right
cardiophrenic angle. They may lead to cardiac tamponade
if the pericardium is ruptured or resolve spontaneously
probably by drainage in the pleural space. Its treatment
depends on the size, symptoms, or doubt of malignancy.
They are treated by percutaneous drainage or surgical
resection by thoracotomy, which is a low-risk surgery.
VALVULAR STRUCTURES: LIQUEFACTIVE OR CASEOUS
NECROSIS OF THE MITRAL ANNULUS
The liquefactive necrosis of the mitral annulus is a benign
entity with degenerative etiology and is a variant of mitral
annular calcification. This consists of a chronic degenerative
process more frequent in advanced ages, women, patients
with hypertension, and patients with chronic renal
insufficiency or alterations of the calcium metabolism.
Echocardiographically, a nodular image of smooth contours
with calcified edges is visualized, presenting greater
echogenicity and with an echolucent area inside, located
in the posterior region of the mitral annulus. Its location
circumscribed to the posterior annulus helps to differentiate
Figure 19.23  Liquefactive necrosis of the mitral annulus.
it from cardiac tumors and mitral valve abscesses. It usually
begins in the basal area of the posterior mitral valve and can
extend to the entire mitral annulus15 (Figure 19.23).
VASCULAR STRUCTURES
CORONARY ANEURYSM
A coronary aneurysm is when the diameter of the artery is
1.5 times larger than the caliber of the adjacent segments.
The most frequent etiology of coronary aneurysms in
adulthood and in the West is atherosclerosis, and Kawasaki
disease is another of the etiologies that must be ruled out
in the presence of these aneurysms. By means of 3D TEE,
we can visualize the origins of both coronary arteries and
are able to obtain diagnostic images of coronary aneurysms.
Miyashita confirmed that real-time 3D echocardiography
is superior to 2D echocardiography for coronary artery
visualization, particularly for extensive visualization of the
coronary arteries.16
CORONARY SINUS
The coronary sinus is where the coronary venous cardiac
system drains. The coronary sinus is where the coronary
venous cardiac system drains. The coronary sinus runs
adjacent to the circumflex artery at the level of the left
atrioventricular furrow and drains into the right atrium
(RA) at the posterior level, where the Thebesian valve
is located (Figure 19.24). If it is dilated, it is visualized
echocardiographically as an echolucent vascular structure
that protrudes in the posterior or posterolateral face of the
left atrium. Among the most frequent causes of dilation is
the persistence of the left superior vena cava that drains into
it. The injection of agitated serum from the left arm fills
the coronary sinus and is sufficient to make the diagnosis
of this entity and exclude that it is another type of mass.
Real-time 3D TEE is superior to 2D echocardiography in
evaluating the anatomy of the coronary sinus in different
pathological situations as well us in guiding intracardiac
procedures.17
Cardiac Masses  245
Figure 19.24  Coronary sinus flow draining in right atrium (3D).
Figure 19.25  Mass in the left atrium associated with atrial septum corresponding to a vascular malformation (X-plane and en face views,
color 3D).
OTHER STRUCTURES
Abnormal vascular structures such as congenital Valsalva
sinus aneurysms, ventricular pseudoaneurysms, and other
vascular malformations (Figure 19.25) sometimes simulate
a mass effect and force a more comprehensive anatomical
study. In the majority of cases, it is necessary to complete the
diagnosis by conducting cardiac CCT or CMR to determine
the extent of the vascular malformations.
NORMAL ANATOMICAL STRUCTURES
WITH MASS EFFECT
Abnormal masses must be distinguished from normal
cardiac structures that may mimic a mass (Table 19.4).1
The recognition of these normal variants depends on
the physician’s experience. Among them, due to their
246  3D Echocardiography
greater prevalence, the following stand out: the ligament
of Marshall, the crista terminalis, and the Chiari network.
The ligament of Marshall is the fibrous structure that
separates the LAA from the left upper pulmonary vein.
Usually the proximal part is thin and the distal tip can be
wider and protrude inside the atrium, which can resemble
a tumor or a thrombus, so it was also called Coumadin
ridge because it can be confused with a thrombus or as a
Q-tip sign for the bulbous morphology of its end. It is a
structure of great importance for electrophysiologists and
hemodynamists due to its importance as an anatomical
reference in the ablation of atrial fibrillation and in the
closure of the LAA, since a prominent ligament can cause
instability of the ablation catheter, and it can be confused
with a thrombus in the LAA, causing misdiagnosis. Once
the morphology of this structure is known with 3D TEE, the
correct diagnosis is immediate (Figure 19.26).
 The crista terminalis is a fibromuscular structure that
Table 19.4  Normal Anatomical Structures with Mass extends from the superior to the inferior vena cava separating
Effect the smooth posterior wall of the right atrium from the
Right trabeculae anterior wall. If this structure is very marked, it
Right Atrium Left Atrium Ventricle Left Ventricle can simulate a mass in the posterior wall of the right atrium,
Chiari network Calcified mitral Moderator False chords simulating thrombus or myxoma. The 2D and 3D TEE
Eustachian annulus band Papillary allows us to see its relationship with neighboring structures,
valve Coronary sinus Muscle muscles its echogenicity similar to the atrial endocardium and the
Crista terminalis Marshall ligament bundles/ Left ventricle absence of infiltrative data, allowing a differential diagnosis
Catheters/ between left trabeculations trabeculations
to be made quite easily.
pacemaker upper pulmonary Catheters and
leads vein and left atrial pacemaker The Eustachian valve and the Chiari network are
Lipomatous appendage leads embryonic remnants. The first one is located at the mouth
hypertrophy of Lipomatous of the inferior cava, and if it is prominent it can simulate a
interatrial hypertrophy of thrombus. The Chiari network extends to the interauricular
septum interatrial septum
septum with a mobile and fenestrated morphology. It can
Pectinate Transverse sinus
muscles Pectinate muscles be seen in approximately 2% of the population and is an
Fatty material Suture line incidental finding in echocardiography or postmortem
(surrounding following studies. Echocardiographic diagnosis is made by the
the tricuspid transplant presence of a hyperechogenic, hypermobile structure
annulus)
adjacent to the mouth of the inferior vena cava. Sometimes
it has a less fenestrated and less mobile morphology. The

LUP

LAA

Figure 19.26  Ligament of Marshall (blue arrow) in 2D and 3D views. (LAA, left atrial appendage; LUPV, left upper pulmonary vein.)

Figure 19.27  Fatty material surrounding tricuspid annulus simulates a pathological mass (X-plane and 3D views).

Cardiac Masses  247

Chiari network has been found to facilitate paradoxical
embolism in cases of permeable foramen ovale and may
interfere with the catheters during structural intervention.
These two structures should not be confused with thrombus,
vegetations, or tumors. Roldán and colleagues confirmed18
that 3D TEE had better anatomical and functional
correlation with matched embryonic remnant specimens of
the right sinus valve (i.e., crista terminalis, Eustachian valve,
Thebesian valve, and cor triatriatum dexter) than with the
corresponding 2D images alone.
Sometimes fat surrounding the tricuspid annulus can
simulate a pathological mass (Figure 19.27). The moderator
band is a prominent muscle trabeculation only present in
the right ventricle. It is visualized near the apex as a thick
echodense band from the interventricular septum to the base
of the anterior papillary muscle. It is most visible when the right
ventricle is dilated, acquiring a more unfolded morphology. It
should not be confused with an apical thrombus.
CONCLUSION
3D TEE allows a real vision of the cardiac masses, by
better defining their characteristics and their intracavitary
or valvular obstruction. It may become the best
echocardiographic approach in the preoperative diagnosis
and in the planning of the surgical intervention.
REFERENCES
1. Ragland MM, Tak T. The role of echocardiography in diagnosing space-
occupying lesions of the heart. Clin Med Res. 2006;4(1):22–32.
2. Badano LP, Muraru D, Iliceto S. 2013. Echocardiography of cardiac
masses: From two to three-dimensional imaging. In: Basso C, Valente M,
Thiene G, eds. Cardiac Tumor Pathology. Current Clinical Pathology, 20–30.
Totowa, NJ: Humana Press.
3. Zaragoza-Macias E, Chen MA, Gill EA. Real time three-dimensional
echocardiography evaluation of intracardiac masses. Echocardiography.
2012;29:207–19.
4. Plana JC. Added value of real-time three-dimensional echocardiography
in assessing cardiac. Echo Res Pract. 2016;3(4):​R65–77.
248  3D Echocardiography
5. Mankad R, Herrmann J. Cardiac tumors: Echo assessment. Curr Cardiol
Rep. 2009;11(3):205–9.
6. Asch FM, Bieganski SP, Panza JA, Weissman NJ. Real-time 3-dimensional
echocardiography evaluation of intracardiac masses. Echocardiography.
2006;23(3):218–24.
7. Oliveira GH, Al-Kindi SG, Hoimes C, Park SJ. Characteristics and
survival of malignant cardiac tumors: A 40-year analysis of >500 patients.
Circulation. 2015;132(25):2395–402.
8. Al Mamgani A, Baartman L, Baaujens M et al. Cardiac metastases. J Clin
Onclol. 2008;13(4):369–72.
9. Rilo I, Subinas A, Velasco S, Laraudogoitia E. Aggressive angiomyxoma
of the pelvis with cardiac involvement. Rev Esp Cardiol. 2006;59(11):1202–3.
10. Puskas F, Cleveland JC Jr, Singh R et al. Detection of left ventricular apical
thrombus with three-dimensional transesophageal echocardiography.
Semin Cardiothorac Vasc Anesth. 2011;15(3):102–4.
11. Manning WJ, Weintraub RM, Waksmonski CA et  al. Accuracy of
transesophageal echocardiography for identifying left atrial thrombi. A
prospective, intraoperative study. Ann Intern Med. 1995;123:817–22.
12. Di Biase L, Santangeli P, Anselmino M et  al. Does the left atrial
appendage morphology correlate with the risk of stroke in patients with
atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol.
2012;60(6):531–8.
13. Berdejo J, Shibayama K, Harada K et  al. Evaluation of vegetation
size and its relationship with embolism in infective endocarditis: A real-
time 3-dimensional transesophageal echocardiography study. Cardiovasc
Imaging. 2014;7:149–54.
14. Habib G, Lancellotti P, Antunes MJ et  al. ESC Scientific Document
Group. 2015 ESC Guidelines for the management of infective endocarditis:
The Task Force for the Management of Infective Endocarditis of the
European Society of Cardiology (ESC). Endorsed by: European Association
for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear
Medicine (EANM). Eur Heart J. 2015;36(44):3075–128.
15. Deluca G, Correale M, Leva R et al. The incidence and clinical course
of caseous calcification of the mitral annulus. J Am Soc Echocardiogr.
2008;21:828–33.
16. Miyashita M, Karasawa K, Taniguchi K et al. Usefulness of real-time
3-dimensional echocardiography for the evaluation of coronary artery
morphology in patients with Kawasaki disease. J Am Soc Echocardiogr.
2007;20:931.
17. Mahmoud HM, Al-Ghamdi MA, Ghabashi AE. Real time three-
dimensional transesophageal echocardiography guided coronary sinus
cannulation during mitral annuloplasty device therapy for a patient with
chronic severe mitral regurgitation. Echocardiography. 2015;32(1):181–3.
18. Roldán F-J, Vargas-Barrón J, Espinola-Zavaleta N et  al. Three-
dimensional echocardiography of the right atrial embryonic remnants. Am
J Cardiol. 2002;89(1):99–101.
 20 Atrial Fibrillation
INTRODUCTION
Atrial fibrillation (AF) is one of the most common
arrhythmias in the general population affecting more than
30 million adults worldwide, and this number is estimated to
rise steeply as a consequence of the aging population.1 AF
is a major cause of stroke, heart failure, and mortality and
requires effective risk stratification. Preventing the hazardous
consequences of AF is one of the main goals of medical
therapy. In addition, effective restoration and maintenance of
sinus rhythm are the main goals of catheter-based or surgical
ablation techniques. Furthermore, transcatheter closure of
the left atrial appendage (LAA), the main source of emboli,
has been shown to have similar outcomes as anticoagulation
therapy in large, randomized studies.2,3 Noninvasive imaging
techniques have contributed to the understanding of the
arrhythmogenic substrate that leads to AF and are pivotal
in the selection of patients who will benefit from ablation
techniques and transcatheter closure of the LAA. 2D and
3D echocardiography have provided important insights into
the risk stratification and management of patients with AF
through early identification of LA structural and electrical
remodeling and are important in monitoring the LAA
transcatheter closure techniques. This chapter reviews the
evidence on the use of 3D echocardiography in the risk
stratification and management of patients with AF.
ECHOCARDIOGRAPHY FOR RISK
STRATIFICATION IN ATRIAL FIBRILLATION
STROKE
Recent studies have indicated that 20%–30% of patients with
ischemic stroke were diagnosed with AF prior to, during, or
after the index event.4 Risk prediction occurs conventionally
by calculating CHADS2 and CHADS2-VASC scores, based
on clinical risk factors. Additionally, echocardiographic-
derived measurements can complement these clinical risk
scores. The presence of spontaneous echocardiographic
contrast is a widely recognized sign of low blood flow velocity,
leading to increased thromboembolic risk. In patients with
nonvalvular AF, the vast majority of thrombi originate from
the LAA. The anatomy and function of the LAA are best
assessed with transesophageal echocardiography (TEE). On
2D TEE, the LAA should be visualized at 0°–30°, 60°–90°,
and 110°–120° to fully appreciate the morphology of the
LAA and differentiate pectinate muscles from thrombus
(Figure 20.1). The use of echocardiographic contrast may
help to differentiate thrombus from pectinate muscles and
reduces the number of uncertain results from 17.8% to 5.6%
(Figure 20.2, ).4 In patients with chronic AF and low blood
flow velocities, the presence of dense sludge or spontaneous
echocardiographic contrast is frequent and is associated with
an increased risk of thromboembolism (Figure 20.3, ). 5
Using pulsed-wave Doppler, the velocity of the blood flow
and function of the LAA can be assessed (Figure 20.4).5,6
In sinus rhythm, the LAA flow pattern reflects the LAA
contraction, LAA filling, late systolic reflections, and early
diastolic LAA outflow, whereas in AF, the LAA flow pattern
is characterized by sawtooth signals of variable amplitude.
Systolic velocities less than 20 cm/s have been associated
with spontaneous echocardiographic contrast and risk of
stroke.5
3D TEE permits the acquisition of the entire volume of
the LAA and visualization of the dimensions of the ostium,
presence of different lobes, and spatial relationship with
other structures (pulmonary veins, mitral valve, circumflex
coronary artery, and coronary sinus and pulmonary
artery). Using a biplane view, the dimensions of the LAA
can be assessed in orthogonal planes and may simplify the
assessment of the LAA using 2D echocardiography (Figure
20.5). Nevertheless, it should be used with caution since
this visualization mode may miss thrombi if the LAA is not
scrolled entirely. Using 3D volume acquisition, the anatomy
and dimensions of the LAA can be assessed similarly to
computed tomography, allowing the use of multiplanar
reformation planes to obtain the cross-sectional area and
perimeter of the LAA ostium and body (of importance in
LAA closure techniques) (Figure 20.6, ). The feasibility
of assessing the most common LAA morphologies with
3D TEE has been confirmed in previous research.7 This
requires optimal 3D visualization in several consecutive
cardiac cycles during image acquisition and offline
reconstruction with dedicated software. The cauliflower
LAA morphology (discussed in detail later this chapter)
has been associated with increased stroke risk. However,
this remains controversial due to the high interobserver
variability in LAA morphology identification.7
LAA end-diastolic volume derived from 3D TEE has
been correlated with stroke risk. Chen et  al. 8 evaluated
444 patients with nonvalvular AF with 3D TEE before
radiofrequency ablation. By using offline analysis with
commercially available software, multiplanar reconstruction
slice-plane mode enabled calculation of end-systolic and
end-diastolic LAA volumes with subsequent calculation of
the LAA ejection fraction (EF) (Figure 20.7). In multivariate
analysis, an end-diastolic LAA volume greater than 8.6 mL
independently predicted thromboembolic events (odd
ratio 1.556%, 95% confidence interval 1.176–2.057). 8 In
addition, the feasibility of LAA flow velocity measurements
with 3D TEE has been demonstrated in patients in sinus
rhythm and AF and has additional value for identification
of thromboembolic risk.9 The LAA flow velocity has been
shown to have a high correlation with the LAA EF obtained
with 3D echocardiography.10 However, measurement of the
LAA EF is more difficult to perform and limited by image
Atrial Fibrillation  249
 A B C

LA
LA
LSPV
Ao LAA
LAA PM
LAA

LV

Figure 20.1  Assessment of left atrial appendage dimensions with 2D TEE. Panels A, B, and C show the left atrial appendage (LAA) at different
midesophageal views: 35°, 80°, and 124°. This corresponds to a cauliflower-shaped LAA since there are several lobes divided by pectinate
muscles (PM) as seen in the 124° view. The spatial relationships are shown: aortic valve (Ao), left atrium (LA), left ventricle (LV), and left
superior pulmonary vein (LSPV).

A B

LA LA
?

LV
LV

Figure 20.2  Use of echocardiographic contrast to evaluate the presence of left atrial thrombus. (Panel A) The differential diagnosis between
thrombus or sludge remains difficult (arrow). After demonstration of intravenous echocardiographic contrast, the left atrial appendage is
fully replenished, and the pectinate muscle is shown (Panel B, arrow) . (LA, left atrium; LV, left ventricle.)

A B
C D

LSPV
LAA

Figure 20.3  Visualization of spontaneous echocardiographic contrast on 3D TEE. (Panels A and B) The orthogonal views of the left atrial
appendage (LAA). The arrows indicate the presence of dense sludge or spontaneous echocardiographic contrast. From the orthogonal views
(Panels C and D), the full volume of the LAA can be obtained, and the sludge is visualized as blurry echoes coming out of the LAA ostium
(Panel D, arrow) . (LSPV, left superior pulmonary vein.)

quality. LAA flow velocity assessment is usually obtained
with 2D TEE. Dentamaro et  al.9 have demonstrated that
the addition of real-time 3D TEE provides optimal accuracy
in the assessment of LAA flow velocity and can be of
particular value when there is any doubt of LAA thrombi
being present.
3D TEE is superior to 2D TTE and comparable to 2D TEE
for the assessment of the intracardiac thrombi. With the use
of biplane imaging and crop function, 3D TEE can better
differentiate a thrombus from other structures, which is of
utmost importance for stroke risk prediction.11 In 45 consecutive
patients with definite or suspected intracardiac thrombi,

250  3D Echocardiography
 A B C

Figure 20.4  Assessment of the left atrial appendage function with pulsed-wave Doppler. (Panel A) Schematic pulsed-wave Doppler recording
of the left atrial appendage (LAA) flow velocities across the cardiac cycle (ECG). (Panel B) The pulsed-wave Doppler recording of a patient
in sinus rhythm. Note that the numbers correspond to the wave reflections during LAA contraction, LAA filling, late systolic reflections, and
early diastolic LAA outflow as in the schematic representation of panel A. During atrial fibrillation, the pulsed-wave Doppler pattern of the
LAA flow resembles the saw tooth (Panel C). (Reproduced with permission from Delgado V et al. J Am Coll Cardiol. 2017;70[25]:3157–72.)

A B

Figure 20.5  Assessment of the left atrial appendage dimensions with 3D TEE using biplane views. From the midesophageal 125° view of
the left atrial appendage (Panel A), the axis of interest is set (dotted line with blue arrowhead), and the orthogonal plane view is shown in
Panel B. The dimensions of the left atrial appendage ostium are shown in both views (at the level of the circumflex coronary artery, Cx). For
specific closure devices, the dimension 1 cm below the ostium plane (Panel A, dotted double arrowhead) and the length of the landing zone
(Panel B, dotted arrow) should be measured.

Anwar et al. compared the evaluation of intracardiac thrombi
between transthoracic real-time 3D echocardiography and 2D
TTE.11 The LAA could be adequately visualized in 78% of
patients with real-time 3D echocardiography compared to 33%
by 2D TTE. Transthoracic real-time 3D echocardiography was
able to detect more additional thrombi in the LAA and showed
poor agreement with 2D TTE for LAA thrombi detection
(Kappa: 0.21) but excellent agreement with 2D TEE (Kappa:
0.90).11
Finally, LA A and LA mechanics (LA A emptying
fraction, LA longitudinal strain) evaluated with speckle
tracking strain analysis or velocity vector imaging have
been registered to determine LAA thrombus regardless
of CHADS2 and CHADS2-VASC score.12,13 In particular,
LA reservoir strain derived from 2D speckle tracking
echocardiography is associated with an increased stroke
risk. A reduced LA reservoir strain represents reduced LA
compliance, most likely due to increased LA fibrosis. In a
large contemporary study including 1361 patients with AF,
100 patients developed stroke during follow-up.14 When
corrected for CHADS2-VASC score, age, and anticoagulant
use, each 10% absolute reduction in LA reservoir strain
resulted in a 27% higher risk of stroke (95% confidence
interval 0.55–0.95, p = .020).14 Although very promising,
validation of this technique in clinical practice and in
particular the advent of 3D echocardiography is warranted

Atrial Fibrillation  251

 A B
LSPV

LAA

C D

Figure 20.6  Measurement of the left atrial appendage dimensions from 3D full-volume data obtained with 3D TEE. Using commercially
available postprocessing software, the 3D full-volume data (Panel A) can be postprocessed, and the multiplanar reformation planes can be
aligned to obtain the cross-sectional area of the left atrial appendage ostium (Panel D). The area, perimeter, and maximum and minimum
diameters can be measured (Panel D) . (LAA, left atrial appendage; LSPV, left superior pulmonary vein.)

before it can be routinely applied in risk stratification of
patients with AF.
HEART FAILURE
AF and heart failure compose a vicious cycle in which
one condition maintains, or even aggravates, the other.
AF and heart failure share common pathophysiological
factors such as age, hypertension and obesity. On the
one hand, AF precipitates heart failure by (1) irregular
and fast ventricular rhythm, (2) loss of effective atrial
contractility, (3) LA dilation and dysfunction, (4) LV and
LA fibrosis, and (5) annular remodeling of the mitral and
tricuspid valves leading to regurgitation.15 Furthermore,
heart failure predisposes to AF through elevated LV filling
pressures and diastolic dysfunction, leading to increased
atrial pressure and subsequent atrial remodeling. Both
heart failure with reduced ejection fraction (HFrEF)
as well as heart failure with preserved ejection fraction
(HFpEF) commonly coexist with AF. Cardiac imaging with
echocardiography remains the imaging technique of first
choice to evaluate patients with heart failure and AF.
Evaluation of conventional LV parameters for systolic and
diastolic function using 3D echocardiography is extensively
described in Chapter 2. In addition, tissue Doppler imaging,
contrast echocardiography, and strain analysis contribute to
the evaluation of LV and LA hemodynamics and mechanics
(see Chapters 2, 5, 18A and 18B).
LV global longitudinal strain by speckle tracking
echocardiography assesses the active deformation of the
myocardium and has proven to be suitable for detection of
subtle LV dysfunction. In patients with AF and preserved LV
EF (LV EF >50%), subtle LV dysfunction could be identified
with 2D speckle tracking echocardiography. This was
demonstrated in patients with drug-refractory AF undergoing
catheter ablation but also in patients with persistent AF.16,17
The feasibility and reproducibility of 3D speckle tracking
echocardiography analysis of LV strain have been previously
demonstrated, and normal values have been reported.16
However large intervendor differences cause major limitations
to the implication of 3D speckle tracking echocardiography
in clinical practice.16 Moreover, 3D global longitudinal strain
has been associated with mortality in a mixed population of
patients requiring clinical echocardiography, with a better
predictive value than 2D global longitudinal strain and LV
EF18 (see Chapters 2, 18A and 18B).
Mitral regurgitation is also a common denominator in
heart failure and AF. Whereas primary (organic) mitral
regurgitation refers to structurally abnormal mitral
leaflets or subvalvular apparatus, AF is conventionally
associated with secondary (functional) mitral regurgitation
where leaflet malcoaptation is caused by (mainly) left
ventricular remodeling. Recently a third mechanism of
mitral regurgitation has been proposed in patients with
isolated AF without LV remodeling: atrial functional mitral
regurgitation.19 In this hypothesis, mitral regurgitation
originates solely by mitral annular dilatation caused by
atrial remodeling. However, this theory is still highly
debated.19 3D TEE can provide a major contribution to the
assessment of mitral regurgitation, since this technique
enables measurement of leaflet area, length, and thickness,

252  3D Echocardiography
Figure 20.7  Assessment of left atrial appendage volumes and ejection fraction with 3D TEE. From the 3D full-volume data, using
postprocessing software to measure the left ventricular systolic function (EchoPac GE Healthcare, Norway), the contours of the left atrial
appendage can be defined, and the time-volume curve can be obtained as well as the ejection fraction.

and annular parameters such as annulus area (see Chapters
7A and 7B). This approach was used by Kagiyama et al.20 in
their study including 28 patients with AF and significant
mitral regurgitation without LV dysfunction, 56 AF patients
without mitral regurgitation, and 16 normal controls.20 They
reported a significantly smaller total leaflet area to mitral
annulus area ratio in patients with AF and mitral regurgitation
compared to the other groups (1.29 ± 0.10 vs. 1.65 ± 0.24
vs. 1.70 ± 0.29, respectively; p < .001). Additionally, each
percent decrease in this ratio was independently associated
with significant mitral regurgitation. These results suggest
not only annular dilation in patients with atrial functional
mitral regurgitation but also leaflet remodeling. The advent
of 3D echocardiography proves to have a crucial role in
characterization of the mitral regurgitation mechanism, as
discussed in detail in Chapters 7A and 7B of this book.
ECHOCARDIOGRAPHY IN THE MANAGEMENT
OF ATRIAL FIBRILLATION
Treatment of AF aims at keeping sinus rhythm as long
as possible to prevent risk of thromboembolism, heart
failure, further atrial dilation, and mitral regurgitation.
Pharmacological or electrical cardioversion are usually
the first-choice therapies to convert and maintain sinus
rhythm. However, at long-term follow-up, recurrences are
frequent, and more aggressive therapies such as catheter
ablation are needed. If rhythm control is not successful,
heart rate control is a valid option, and the evidence has not
consistently shown that this strategy is inferior to rhythm
control in terms of hard endpoints.1 When rate control is
pursued, effective control of heart rate to prevent heart
failure development and prevention of thromboembolism
are key. Some patients may develop bleeding complications
or may have recurrences of thromboembolisms because
of ineffective anticoagulation therapy. In those situations,
transcatheter closure of the LAA has become a safe and
feasible alternative to prevent thromboembolic events.21
In this section, the role of 3D echocardiography to guide
electrical cardioversion, catheter ablation, and transcatheter
closure of the LAA are discussed.
ELECTRICAL CARDIOVERSION
In patients with AF lasting longer than 48 hours, electrical
cardioversion can be performed safely after demonstrating
that the LAA does not have any thrombus on TEE. The
presence of thrombus in patients referred for electrical
cardioversion has been reported to be as high as 14%, with

Atrial Fibrillation  253

Figure 20.8  Assessment of left atrial phasic function with 3D TTE prior to catheter ablation of atrial fibrillation. From 3D full-volume
acquisition of the left atrium, the multiplanar reformation planes are aligned to obtain the long axis of the left atrium. Using postprocessing
software to analyze left ventricular systolic function, the left atrium can be manually traced, and the 3D cast volume can be obtained as well
as the time-volume curve. The maximum and minimum volumes can be calculated as well as the left atrial ejection fraction .

88% of them located inside the LAA.22 In patients treated
with novel oral anticoagulants or warfarin, the frequency
of intracardiac thrombus was 4.4% and 2.9%, respectively.23
Early cardioversion guided by TEE is safe and is associated
with fewer bleeding complications and a higher success rate
than a strategy based on prolonged anticoagulation. The
success of the electrical cardioversion can also be evaluated
with the use of TEE. An LAA velocity measured on pulsed-
wave Doppler greater than 40 cm/s was independently
associated with maintenance of sinus rhythm 1 year after
cardioversion.
RADIOFREQUENCY CATHETER ABLATION
Pulmonary vein isolation is the main catheter ablation
technique. Additional ablation lines can be performed
on the posterior wall of the left atrium, mitral annulus,
and appendage in order to increase the success rate of the
procedure. Selection of patients who may benefit from these
therapeutic techniques remains challenging, and various
parameters have been proposed to predict the success of
catheter ablation. Left atrial dimensions, function, and
fibrosis have been associated with the recurrence of AF
after ablation. 2D echocardiographic techniques have
provided the most evidence on the correlates of recurrence
of AF after ablation. Larger maximum and minimum left
atrial volumes and poorer reservoir function and EF of the
left atrium measured with 3D TTE have been associated
with higher risk of recurrence of AF after ablation (Figure
20.8, ).24 In addition, late-gadolinium contrast-enhanced
cardiovascular magnetic resonance permits visualization
of replacement fibrosis of the LA wall. The DECA AF
study showed that the extent of replacement fibrosis in
the LA was associated with higher rates of recurrences of
AF after catheter ablation. 25 Using 3D speckle tracking
echocardiography, Watanabe et al. 26 showed that the LA
dyssynchrony, measured as the standard deviation of time
to peak longitudinal strain of 18 LA segments relative to
the RR interval, and reservoir function correlated with
the voltage of the electrograms obtained by endocardial
mapping. Patients with low-voltage electrograms
(reflecting more LA fibrosis) had more pronounced LA
dyssynchrony and worse LA reservoir function. Whether
these parameters predict the success of catheter ablation
techniques needs to be demonstrated.
Computed tomography is the mainstay imaging
technique to plan the procedure, since the 3D data of the
left atrium, pulmonary veins, and LAA provided by this
technique are frequently merged with navigation systems

254  3D Echocardiography
 A B

C D

Figure 20.9  Ablation of the right superior pulmonary vein guided with 3D TEE. (Panels A and C) The fluoroscopic views. (Panels B and D) The
respective 3D TEE views during the ablation of the right superior pulmonary vein. (Abl, ablatio catheter; Map, mapping catheter.) (Reproduced
with permission from Faletra FF et al. JACC Cardiovasc Imaging. 2012;5[4]:456–62.)

that allow the integration of electrical maps and guidance
of the procedure. From a transfemoral vein approach, the
catheters are placed in the left atrium through a transseptal
puncture. Fluoroscopy or intracardiac echocardiography
are used to guide the transseptal puncture. TEE is usually
performed before the procedure to rule out the presence
of LAA thrombus and is seldom used during the procedure.
However, some centers may use it when the procedure is
performed under general anesthesia and the patient is
intubated. 3D TEE provides excellent visualization of the
manipulation of the catheters and the anatomy of the
interatrial septum, LAA, and pulmonary veins (Figure
20.9).27 In the past, the use of intracardiac echocardiography
and electroanatomical mapping allowed the creation of 3D
reconstructions of the LA (CartoSound) (Figure 20.10). The
advent of 3D intracardiac echocardiographic probes may
help to simplify the procedure. However, no data exist on
the feasibility of this technique to guide catheter ablation
of AF.
TRANSCATHETER LEFT ATRIAL APPENDAGE CLOSURE
In patients with AF and contraindications for long-term
oral anticoagulation who have high risk of stroke, the use
of transcatheter LAA closure devices may be considered
(class IIb indication, level of evidence B in current European
Society of Cardiology guidelines).1 The strongest evidence
on the efficacy of this therapeutic alternative stems from the
studies using the WATCHMAN and the Amplatzer Amulet
devices (Figure 20.11). The WATCHMAN device (Boston
Scientific, Natick, Massachusetts) is a parachute-shaped
self-expanding nitinol frame covered by a polyethylene
terephthalate fabric membrane that faces the body of the
left atrium.21 The Amplatzer Amulet LAA occluder (Abbott-
Structural Heart Solutions, Minneapolis, Minnesota) is a self-
expandable nitinol mesh with a distal lobe and a proximal
disk connected by a short central waist. The distal lobe also has
hooks around its circumference that anchor the device into
the LAA. During patient selection, preprocedural imaging
needs to evaluate the dimensions and spatial relationships of
the LAA and rule out the presence of LAA thrombus. TEE
(preferably 3D) and computed tomography are the imaging
techniques of first choice to evaluate those questions. Table
20.1 summarizes the LAA morphological requirements for
each device. The use of 3D TEE is complementary to 2D
TEE in order to appreciate the morphology of the LAA
and accurate sizing of the diameters of the LAA ostium
and landing zone. By aligning the multiplanar reformation
planes along the body of the LAA and across the ostium of
the LAA, those measurements can be performed to select the
most appropriate size of the closure device (Figure 20.12).

Atrial Fibrillation  255

 A C
E

B D
F

Figure 20.10  Use of intracardiac echocardiography and CARTOSound to reconstruct the left atrium during catheter ablation of atrial
fibrillation. The contours of the left atrium are traced on the views of the left atrium obtained with the intracardiac echocardiography (Panels
A–D), and by using the CARTOSound system, the 3D cast of the left atrium is reconstructed (Panels E and F).

A B

Figure 20.11  Transcatheter left atrial appendage closure devices. (Panel A) The WATCHMAN device and the respective 3D TEE view once
deployed. See the typical 8-appearance of the nitinol mesh. (Panel B) The Amplatzer Amulet device and the respective 3D TEE view once
deployed. ([A] Reproduced with permission from Wunderlich et al.)

Table 20.1  Anatomical Requirements for Left Atrial Appendage Closure Devices
Amplatzer Amulet LAA Occluder WATCHMAN

Ostium Diameter The diameter should be smaller than the disc –

Landing Zone Diameter
Required Landing Zone Diameters
Choice of the Device Size
Required Depth of Main Anchoring Lobe
General Morphological Exclusion Criteria
Cx, circumflex coronary artery; LAA, left atrial appendage.
size of the selected device
10 mm distally from the ostial plane into the Measured from the inferior part of the LAA ostium at
lobe the level of the Cx to a point 1–2 cm distally to the
tip of the rim to the left superior pulmonary vein
11–31 mm 17–31 mm
1.5–3.4 mm larger than the largest measured 2–4 mm larger than the largest measured diameter
diameter
>12 mm ≥19 mm for the smallest device
– Presence of thrombus/cardiac tumor

256  3D Echocardiography
 A B

Cx
18 mm

Cx
14 mm

C D

16 mm

Figure 20.12  Measurement of the left atrial appendage dimensions to size the Amplatzer Amulet occluder device. From the 3D full volume
of the left atrial appendage, the multiplanar reformation planes are displayed and oriented through the ostial plane (crossing the circumflex
coronary artery, Cx) and the landing zone. In this patient, the ostial diameters are 18 × 16 mm, and the landing zone is 14 mm. (A) En face
view of the left atrial appendage ostium on 3D volume rendering; (B,C) orthogonal long-axis views of the left atrial appendage; (D) double
oblique cross sectional view of the left atrial appendage ostium.

The procedure is guided by fluoroscopy and TEE (although
the experience using intracardiac echocardiography is
growing). Key procedural steps are the transseptal puncture,
device delivery and positioning, and confirmation of adequate
sealing. In addition, monitoring of potential complications
should be performed. 3D TEE facilitates the procedural
guidance. From a 3D full-volume en face view of the interatrial
septum, the most appropriate location of the transseptal
puncture can be defined (posterior and inferior, Figure 20.13).
The use of the biplane views can help to monitor the transseptal
puncture as well (Figure 20.13). After successful transseptal
puncture, the guidewire can be secured in the LAA, and the
introductory catheter can be advanced with the device. The
deployment of the device is best monitored with biplane views,
and after deployment the 3D full-volume acquisition permits
accurate visualization of the LAA sealing. The occluder

A
C D

Superior SVC
Ao

Anterior Posterior
B Ao CS
Catheter TV
MV

Inferior

Figure 20.13  Guidance of the transseptal puncture for transcatheter left atrial appendage closure. (Panels A and B) The biplane views of
the interatrial septum with the bicaval view as the reference plane. The 3D full volume of the interatrial septum is shown in Panel C as seen
from the left atrial view. The aortic valve (Ao) marks the anterior area, whereas the mitral valve (MV) indicates inferior. The sweet spot for
the transseptal puncture in this intervention is in the inferoposterior quadrant. (Panel D) The right atrial view of the interatrial septum. The
coronary sinus (CS), superior vena cava inferior (SVC), and tricuspid valve (TV) can be observed.

Atrial Fibrillation  257

 A B
Figure 20.14  Assessment of deployment of the Amplatzer Amulet closure device. (Panel A) Example of a device well deployed, with the body
of the distal lobe well compressed by the left atrial appendage walls. (Panel B) In contrast, the example of a patient with an important gap
between the device and the left atrial appendage wall (yellow arrow) .
should be adequately compressed by the LAA walls to avoid
subsequent complications such as device embolization (Figure
20.14). The use of color Doppler permits the evaluation of
para-device leaks that have not been consistently associated
with recurrence of thromboembolic events at follow-up, but
if they are large (>5 mm), continuation of anticoagulation is
recommended.3 In addition, the spatial relationship of the
closure device and the circumflex coronary artery, mitral
valve, and pulmonary veins needs to be evaluated to avoid
potential complications (impingement of the circumflex
coronary artery, mitral valve dysfunction, and pulmonary vein
stenosis). Before release of the device, the tug test is performed
by providing gentle traction of the catheter to demonstrate
that the device has a stable position ( ).
During the follow-up, TTE may be sufficient to monitor the
stable position of the closure device. However, TEE provides
better image quality to assess erosion of the surrounding
tissue, thrombus formation, and peridevice gaps.
CONCLUSION
Echocardiography is the imaging technique of first choice
to evaluate patients with AF; it gives information on the
anatomical and functional substrate and permits risk
stratification of the patients. TEE is key to assess the LAA
dimensions and function and to rule out the presence of
thrombus, and its role during transcatheter closure of the
LAA is undisputable. 3D echocardiography is key in the
assessment of LA volumes and function, and the addition
of speckle tracking techniques helps to better understand
the contractile status of the LA myocardium.
REFERENCES
1. Kirchhof P, Benussi S, Kotecha D et  al. 2016 ESC guidelines for the
management of atrial fibrillation developed in collaboration with EACTS.
Eur Heart J. 2016;37(38):2893–962.
2. Holmes DR, Jr., Kar S, Price MJ et al. Prospective randomized evaluation
of the Watchman Left Atrial Appendage Closure device in patients with
atrial fibrillation versus long-term warfarin therapy: The PREVAIL trial. J
Am Coll Cardiol. 2014;64(1):1–12.
258  3D Echocardiography
3. Holmes DR, Reddy V Y, Turi ZG et  al. Percutaneous closure of the
left atrial appendage versus warfarin therapy for prevention of stroke in
patients with atrial fibrillation: A randomised non-inferiority trial. Lancet.
2009;374(9689):534–42.
4. Jung PH, Mueller M, Schuhmann C et  al. Contrast enhanced
transesophageal echocardiography in patients with atrial fibrillation
referred to electrical cardioversion improves atrial thrombus detection
and may reduce associated thromboembolic events. Cardiovasc
Ultrasound. 2013;11(1):1.
5. Fatkin D, Kelly RP, Feneley MP. Relations between left atrial appendage
blood flow velocity, spontaneous echocardiographic contrast and
thromboembolic risk in vivo. J Am Coll Cardiol. 1994;23(4):961–9.
6. Delgado V, Di Biase L, Leung M et al. Structure and function of the
left atrium and left atrial appendage: AF and stroke implications. J Am Coll
Cardiol. 2017;70(25):3157–72.
7. Bai W, Chen Z, Tang H, Wang H, Cheng W, Rao L. Assessment of the
left atrial appendage structure and morphology: Comparison of real-time
three-dimensional transesophageal echocardiography and computed
tomography. Int J Cardiovasc Imaging. 2017;33(5):623–33.
8. Chen Z, Bai W, Li C et al. Left atrial appendage parameters assessed
by real-time three-dimensional transesophageal echocardiography predict
thromboembolic risk in patients with nonvalvular atrial fibrillation. J
Ultrasound Med. 2017;36(6):1119–28.
9. Dentamaro I, Vestito D, Michelotto E et  al. Evaluation of left atrial
appendage function and thrombi in patients with atrial fibrillation: From
transthoracic to real time 3D transesophageal echocardiography. Int J
Cardiovasc Imaging. 2017;33(4):491–8.
10. Valocik G, Kamp O, Mihciokur M et al. Assessment of the left atrial
appendage mechanical function by three-dimensional echocardiography.
Eur J Echocardiogr. 2002;3(3):207–13.
11. Anwar AM, Nosir YF, Ajam A, Chamsi-Pasha H. Central role of real-
time three-dimensional echocardiography in the assessment of intracardiac
thrombi. Int J Cardiovasc Imaging. 2010;26(5):519–26.
12. Ono K, Iwama M, Kawasaki M et al. Motion of left atrial appendage as a
determinant of thrombus formation in patients with a low CHADS2 score
receiving warfarin for persistent nonvalvular atrial fibrillation. Cardiovasc
Ultrasound. 2012;10:50.
13. Valocik G, Kamp O, Mihciokur M et al. Assessment of the left atrial
appendage mechanical function by three-dimensional echocardiography.
Eur J Echocardiogr. 2002;3(3):207–13.
14. Leung M, van Rosendael PJ, Abou R et al. Left atrial function to identify
patients with atrial fibrillation at high risk of stroke: New insights from a
large registry. Eur Heart J. 2018;39(16):1416–25.
15. Carlisle MA, Fudim M, DeVore AD, Piccini JP. Heart failure and atrial
fibrillation, like fire and fury. JACC Heart Fail. 2019;7(6):447–56.
16. Bernard A, Addetia K, Dulgheru R et  al. 3D echocardiographic
reference ranges for normal left ventricular volumes and strain:
Results from the EACVI NORRE study. Eur Heart J Cardiovasc Imaging.
2017;18(4):475–83.
17. Tops LF, Den Uijl DW, Delgado V et al. Long-term improvement in left
ventricular strain after successful catheter ablation for atrial fibrillation
in patients with preserved left ventricular systolic function. Circ Arrhythm
Electrophysiol. 2009;2(3):249–57.
18. Medvedofsky D, Maffessanti F, Weinert L et  al. 2D and 3D
echocardiography-derived indices of left ventricular function and shape:
Relationship with mortality. JACC Cardiovasc Imaging. 2018;11(11):1569–79.
19. Silbiger JJ. Does left atrial enlargement contribute to mitral leaflet
tethering in patients with functional mitral regurgitation? Proposed role
of atriogenic leaflet tethering. Echocardiography. 2014;31(10):1310–1.
20. Kagiyama N, Hayashida A, Toki M et al. Insufficient leaflet remodeling
in patients with atrial fibrillation: Association with the severity of mitral
regurgitation. Circ Cardiovasc Imaging. 2017;10(3).
21. Price MJ. Safety and efficacy of transcatheter left atrial appendage
closure for stroke prevention in patients with atrial fibrillation. Prog
Cardiovasc Dis. 2018;60(4–5):542–9.
22. Klein AL, Grimm RA, Murray RD et  al. Use of transesophageal
echocardiography to guide cardioversion in patients with atrial fibrillation.
N Engl J Med. 2001;344(19):1411–20.
23. Frenkel D, D’Amato SA, Al-Kazaz M et  al. Prevalence of left atrial
thrombus detection by transesophageal echocardiography: A comparison
of continuous non-vitamin K antagonist oral anticoagulant versus warfarin
therapy in patients undergoing catheter ablation for atrial fibrillation. JACC
Clin Electrophysiol. 2016;2(3):295–303.
24. Montserrat S, Sitges M, Calvo N et al. Effect of repeated radiofrequency
catheter ablation on left atrial function for the treatment of atrial
fibrillation. Am J Cardiol. 2011;108(12):1741–6.
25. Marrouche NF, Wilber D, Hindricks G et al. Association of atrial tissue
fibrosis identified by delayed enhancement MRI and atrial fibrillation
catheter ablation: The DECAAF study. JAMA. 2014;311(5):498–506.
26. Watanabe Y, Nakano Y, Hidaka T et  al. Mechanical and substrate
abnormalities of the left atrium assessed by 3-dimensional speckle-tracking
echocardiography and electroanatomic mapping system in patients with
paroxysmal atrial fibrillation. Heart Rhythm. 2015;12(3):490–7.
27. Faletra FF, Nucifora G, Regoli F, Ho SY, Moccetti T, Auricchio A. Anatomy
of pulmonary veins by real-time 3D TEE: Implications for catheter-based
pulmonary vein ablation. JACC Cardiovasc Imaging. 2012;5(4):456–62.
Atrial Fibrillation  259
 21 3D Printing
INTRODUCTION
3D printing is a fast-growing technique used to transform
digital objects into physical models. It was first introduced in
1986, and since then it has extended from the aeronautical
industry to medicine with promising clinical applications.
The purpose of this chapter is to provide an overview of the
use of echocardiography for 3D rapid prototyping. The basic
principles for printing models from 3D echocardiography
acquisition, postprocessing of the medical images, and rapid
prototyping techniques are explained. The applications
of 3D printing technology for medical education, device
innovation, and surgical and interventional planning are
discussed. Finally, we evaluate the current limitations of the
technology and its future directions.
It is out of the scope of this chapter to review 3D printing
applications solely based on other imaging technologies
such as magnetic resonance imaging (MRI) and computed
tomography (CT) which can be found in other recent
publications.1–4
3D PRINTING WORKFLOW: FROM 3D
ECHOCARDIOGRAPHY TO REALITY
3D printing requires a sequential process: 3D
echocardiography acquisition, imaging postprocessing, and
printing. A small error in one of the steps will be translated
to the successive phases, resulting in inaccuracies and
printed models that have nothing to do with the patient’s
anatomy.
3D ECHOCARDIOGRAPHY ACQUISITION
3D printing has been traditionally based on cross-sectional
imaging such as MRI and CT, as they can precisely
evaluate intracardiac and extracardiac anatomy. 3D
echocardiography has several advantages compared to
these techniques, as it may better assess valvular anatomy
and atrial and ventricular septal defects.5 This is why most of
the current works aim to use multimodality hybrid imaging,
combining cross-sectional imaging (MRI and CT) with 3D
echocardiography.6
Adequate imaging acquisition is the most critical step
in 3D printing. Poor image quality may result in grainy
and noisy images, which may result in a 3D model with
false holes and no correspondence with the real patient’s
anatomy. Errors in the other steps of 3D printing such as
in imaging processing or printing may be easier to solve,
but if image quality is poor, there will be very little room
for improvement. Inaccuracies in the imaging segmentation
or collapse in the 3D printing process can be solved using
computer software or repeating the printing by essaying
different printing parameters.
260  3D Echocardiography
The tips for an outstanding acquisition have already been
discussed in Chapter 1.
For 3D printing, 3D echocardiography spatial resolution is
often weighed in favor compared to temporal resolution. As
discussed later, if imaging fusion between echocardiography
and MRI or CT is anticipated, acquiring a larger 3D
echocardiographic volume may help for better alignment
and registration between the two imaging modalities.
Once images have been acquired, the next step is
exporting the information from the echocardiography
machine to the computer. Like any other imaging
modalities, such as MRI and CT, echocardiographic
images are also stored in DICOM format (Digital Imaging
and Communications in Medicine), the standard for the
communication and management of medical imaging
information. The key for integration is that DICOM groups
information into datasets or tags; therefore, it should enable
universal integration of medical images between scanners,
servers, hospitals, and visualization software no matter the
manufacturer. Unfortunately, in echocardiography, this is
not always the case, and there are two main limitations:
software restrictions and the absence of interoperability
among vendors. The former limits the accessibility of the
information stored within echocardiographic datasets.7
The latter is the lack of a standardized format for 3D
ultrasound data storage among vendors. Many essential
parameters are stored in vendor-specific “private tags.” 7
For example, when exporting a 3D file in a Philips QLab
workstation, critical information for the 3D reconstruction,
such as the spacing between slices (pixel Z height), instead
of being stored in the standardized tag “Slice Thickness”
is stored in a private data tag. The 3D ultrasound DICOM
file is therefore only correctly parsed by the same vendor
software, as it knows in which hidden tags the information
to reconstruct a 3D image can be found. Any attempt to
parse it with other software will result in unsuccessful or
inaccurate reconstruction.
Although the international community is attempting
to exert pressure on vendors to standardize DICOM
3D ultrasound imaging data, it may require time. In an
attempt to solve this problem in the meantime, Hosny et al.
recently published an open-source workflow method for
unlocking vendor-specific tags and generating 3D models
from routine echocardiographic datasets.7 The process
requires exporting the 4D echocardiography dataset to a
DICOM format file. The time frame of interest is chosen,
and using their custom software, it is exported into a
NRRD file (n-dimensional Nearly Raw Raster Data format).
This file can be imported into open-source software 3D
Slicer (https://www.slicer.org)8 for computer-aided design.
The authors claimed that time for data processing was
less than 5 minutes. Sometimes, the thickness derived
from 3D ultrasound may result in unrealistically thick
valves, particularly in pediatric datasets, which may
require arbitrary smoothness based on surgical input and
pathology review.9
POSTPROCESSING SOFTWARE
The next step is segmentation (Figure 21.1A), which is the
delineation of the cardiovascular structures of interest
and exclusion of irrelevant noncardiac structures. Image
segmentation is frequently laborious and user dependent
due to its reliance on expertise in structural heart disease,
congenital heart disease, and image processing.
There are three main kinds of segmentation: automatic,
semiautomatic, and manual. Although some software claims
to have 100% automatic segmentation, a combination of
automatic and manual segmentation is usually required and
encouraged to achieve accurate segmentation, but at the cost
of increased time. Manual and semiautomatic usually include
brightness thresholding and region growing. Image intensity-
based thresholding is the most reported methodology.10 The
dynamic motion of the leaflets and subvalvular apparatus
often complicates the segmentation process because current
3D echocardiography rarely provides sufficiently good image
data for these structures in one single frame acquisition.11
Identifying and choosing the right cardiac phase is critical
for segmenting valve anatomy. Diastolic phase is often
associated with leaflet dropout, whereas in systole individual
leaflet identification may be challenging. Understanding
the clinical application of the 3D model is the key to decide
which cardiac phase should be selected. For example, if a
3D model is intended for interventional closure of an atrial
septal defect, the diastolic phase may be preferred in order to
print the largest diameter of the communication and choose
A B
C D
Figure 21.1  3D printing workflow. (A) 3D echocardiography
segmentation. (B) Imaging postprocessing (computer-aided design).
(C) 3D printing. (D) Final aortic valve 3D printed model.
the adequate device. On the other hand, paravalvular leaks
are often better defined in the systolic phase.12
Available software for segmentation includes commercial
packages (Materialise, Leuven, Belgium) and freeware
alternatives (ITK snap, MITK snap, and 3D slicer).10 A
careful review of the imaging segmentation methodologies
and software has been previously published by Byrne et al.10
Before printing, the segmented geometry needs to be
modified using computer-aided design software. Due to poor
image contrast or inaccurate segmentation algorithm, there
can be holes or communication between adjacent structures
that should be manually corrected. Echocardiography
imaging often results in irregular surfaces due to its inherent
image quality, which should be smoothed and re-meshed
to increase the density of polygons. The segmentation is
exported as STL file (standard tessellation language), and
defects are modified in order to have a faithful copy of the
anatomy.
PRINTING TECHNIQUE
There are several categories of 3D printing: stereolithography,
selective laser sintering, Polyjet, and fused deposition
modeling. Each technology has its own benefits and
disadvantages. For example, stereolithography and Polyjet
are the most accurate and precise technology, the latter being
at the expense of high cost. Fused deposition modeling is
one of the cheapest technologies. 3D printing of valves can
be done with all of these technologies, particularly recently
as new flexible materials are commercially available. If the
3D models are intended to be used as phantoms imaged
using ultrasound, this must be considered when choosing
the printing material. Printing material has a significant
effect not only in mechanical properties, but also in acoustic
impedance.
For echocardiography 3D printing, “hollow” models
are often preferred over “blood pool” models. Blood pool
models are solid models, representing the blood pool, and
provide excellent visualization of the extracardiac vascular
structures and cardiac chambers (Figure 21.2A). However,
as they are solid, there is no view of the intracardiac
anatomy. In hollow models, the blood pool is removed to
allow inspection of the intracardiac cavities and valves in
detail (Figure 21.2B). Myocardium and vessel walls are
created and printed to allow extracardiac inspection as well.
The walls can be printed intact to allow surgical dissection
simulation or with predetermined cut-plane to allow easier
inspection.
Silicone cast models may reproduce better the specific
tissue-like mechanical properties of the valves and create
a more realistic user experience. This requires negative
mold fabrication for later silicone cast filling. The step-by-
step process for mitral valve printing is comprehensively
explained in other publications (Figure 21.3).13
3D PRINTING ACCURACY
Accuracy in medical 3D printing is of paramount
importance. Accuracy may be defined by three metrics:
agreement with diagnostic intraoperative findings,
measurement agreement, and mimicking the tissue
3D Printing  261
 A B

Figure 21.2  Solid and hollow 3D printed models. (A) Solid blood pool model. (B) Hollow model representing the right atrium and tricuspid
valve leaflets. (AL: Anterior leaflet, PL: Posterior leaflet, SL: Septal leaflet). (Adapted from Anwar S et al. JACC Basic Transl Sci. 2018; 3[2]:294–
312; Harb SC et al. JACC Cardiovasc Imaging. 2018;11:1531–4. With permission.)

mechanical properties. The  diagnostic quality assurance
process has been mainly based on feedback from surgeons
based on intraoperative room findings. Average accuracy
ranges from 4 out of 54,14 and 9.3 out of 1015 according to
different published reports. The geometrical accuracy of 3D
printed models compared with source 3D echocardiography
images has also been demonstrated. Olivieri et al. reported
that no significant differences were found between
conventional 2D echocardiographic measurements and 3D
model measurements, with a mean absolute error of only
0.4  ±  0.9 mm.16
According to the mechanical properties, Yoo et al. used
3D printed models for hands-on surgical training involving
50 surgeons and trainees.17 They concluded that 3D print
materials were not completely satisfactory, and the mechanical
properties including consistency, elasticity, and tensile
strength were different than those of the human myocardium
and pericardium. Surgeons found that flexible materials such
as TangoPlus were more difficult to sew and were easily torn
or cut through as compared with real tissue.17 As stated earlier,
silicone appears to be a better material that provides more
realistic physical properties close to human tissue.13,17 Chordae
tendinae are also very important structures that need to be
present in the 3D models for surgical simulations, and some
attempts have been made to try to manually incorporate
chordae-mimicking strings into the valve, but unfortunately
the printing technology is not yet available.
CLINICAL APPLICATIONS
The variety of techniques that can be used for surgical and
catheter-based interventions is growing exponentially. The
rate of success is a combination of an operator’s skills, the
learning curve, and experience, the latter directly related to
the center’s interventional volume. 3D printed models may
help in several of these aspects, such as better understanding
the anatomy, boosting the learning curve by simulation
training, and offering a full spectrum of anatomical
variability that is not always warranted in small centers.

A D

C E

Figure 21.3  Overview of the process of negative mold fabrication, from which silicone mitral valve replications can be cast. (A) Processed and
refined mitral valve mesh. (B) Designated template to fit the simulator’s enclosure. (C) Template with incorporated mitral valve. (D) Three-part
negative mold, fabricated from the positive mold in (C). (E) Silicone cast of a patient. (Adapted from Daemen JHT et al. Eur J Cardio-Thoracic
Surg. 2019;55:543–51. With permission.)

262  3D Echocardiography
 3D printed models have been used for precatheterization
and surgical simulation, mainly in individual cases. It is
widely claimed in those publications that preinterventional
planning may potentially reduce the operating time; in turn,
this may lead to fewer complications, shorter postoperative
stays, and lower health-care costs.4 Although it has been
demonstrated in other surgical subspecialties such as
craniofacial, the evidence in cardiovascular applications is
still limited to a few publications,15 and larger validation
studies are required.
MITRAL VALVE
An in-depth understanding of the complex mitral valve
anatomy and pathology is mandatory to decide the best
option for repair, either transcatheter mitral valve techniques
or surgical repair. Daemen et  al. presented a step-by-step
guide workflow for modeling and 3D printing the spectrum
of mitral valve disease.13 Six rigid plastic and four silicone-
cast mitral valve models were created from patient-specific
3D TEE acquisitions. The process of physical modeling was
reproducible and assisted in decision making, procedural
planning, and teaching.
The preoperative valve repair in complex cases of mitral
valve prolapse, annular dilatation, and posterior leaflet
restriction was simulated in a dedicated minimally invasive
mitral valve surgery simulator.19 Intraoperative in vivo
validation of the silicone mitral valve replication comparing
the in vitro simulation is also shown in an elegant and
comprehensive way.13
A B
Ginty et al. also explored the feasibility of creating patient-
specific dynamic deformable mitral valve models for surgical
and percutaneous repair.11 The authors incorporated chordae-
mimicking strings into the valve. Nylon strings were arranged
on the leaflets to simulate functioning and pathologic
chordae according to the modified-Duran classification.
They used a pulse duplicator20 to compare the ten models
to the procedure patient data. The models then were
placed in the heart phantom machine for assessment using
transesophageal echocardiographic (TEE) imaging with
Doppler to demonstrate the feasibility of this approach. Maybe
the most important contribution of this paper is highlighting
the importance of dynamic 3D printed models whether for
procedure planning, validation studies, or clinical training.
TRICUSPID VALVE
Percutaneous procedures for tricuspid valve repair are
an attractive alternative, particularly in those cases with
a high risk of surgical repair. Current clinical experience
with transcatheter therapies is still preliminary, limited to
a small number of cases. Moreover, numerous tricuspid
transcatheter devices have been developed which require
a learning curve. Due to the innovative nature of these
procedures and the high variability of the individual patient
anatomy, procedural planning using 3D printed models
may become an effective approach. Multimodality imaging
fusion combining CT and echocardiography may overcome
the limitations of suboptimal visualization of the tricuspid
valve anatomy (Figure  21.4).6 3D echocardiography data
C

D E F

Figure 21.4  Multimodality imaging fusion combining computed tomography and 3D echocardiography. Computed tomography (CT)
suboptimal timing of contrast for delineation with left-sided rather than right-sided opacification (A,B), resulting in better delineation of
mitral valve leaflets (MVL) compared with the tricuspid valve leaflets. (D) 3D TTE demonstrated the tricuspid valve leaflets well. (E) 3D color
Doppler analysis showing severe tricuspid regurgitation. Data from both CT and 3D echocardiography were combined. The CT was used for
modeling the right-sided structures (C) and the tricuspid valve leaflets were modeled based on the 3D echocardiography (F). (Adapted from
Harb SC et al. JACC Cardiovasc Imaging. 2018;11:1531–4. With permission.)

3D Printing  263
can be used to better refine the tricuspid valve leaflets in
order to produce a 3D printed model helpful for procedural
simulation.
CONGENITAL HEART DISEASE
Surgical and interventional planning in complex congenital
heart disease (CHD) is challenging due to the high variability
between individuals, small cardiac structures in children,
and the broad spectrum of conditions.15 A thorough
understanding of the complex spatial relationships between
anatomical and defective structures may avoid unexpected
findings and therefore may reduce operative time and
mortality. The impact of 3D models on surgical decision
change in patients with complex CHD has already been
demonstrated15; however, most of the studies are based on
MRI and CT images. Olivieri et al. explored the feasibility of
creating 3D printed models based on 3D echocardiographic
data in nine patients with structural heart disease before
intracardiac repair16 (Figure  21.5). Eight patients had
ventricular septal defect, and one had three perivalvular
leaks around a prosthetic aortic valve.
3D echocardiography has also been used for 3D
printing of pediatric atrioventricular valves. Mastering
the technical skills required to perform successful valve
repair in pediatrics is challenging due to the very small and
growing structures and the limited opportunity for practice.
Therefore, there is a need for valve model–based simulation
training in pediatrics and congenital heart disease. Scanlan
et al. created 3D printed models of atrioventricular valves
entirely dependent on 3D echocardiography datasets 9
(Figure 21.6). They included a range of children with
normal and congenital heart disease including hypoplastic
left heart syndrome and atrioventricular septal defects.
ATRIAL SEPTAL DEFECTS
Indication of percutaneous closure of an atrial septal defect
(ASD) requires evaluation of the location and size of the
defect and aims to determine if the risk of embolization
exceeds the morbidity of surgical closure. 3D printed models
A B
Figure 21.5  3D printing of intracardiac defects from 3D echocardiographic images. Comparison between the digital and printed 3D models.
(IVS, interventricular septum; LV, left ventricle; MB, moderator band; RV, right ventricle; TV, tricuspid valve; VSD, ventricular septal defect.)
(Adapted from Olivieri LJ et al. J Am Soc Echocardiogr. 2015;28:392–7. With permission.)
264  3D Echocardiography
can be a helpful decision-making tool, both for training in
younger fellows and for planning intervention in complex
cases. The feasibility of creating patient-specific ASD 3D
printed models from 3D echocardiography data was first
demonstrated by Bennett et al. (Figure 21.7).21
LEFT ATRIAL APPENDAGE OCCLUSION
Percutaneous approaches to left atrial appendage
occlusion have been shown to be effective in patients
with thromboembolic risk. Optimal sizing of the left
atrial appendage occlusion device is a crucial factor
for implantation success. Procedural planning and
device sizing are typically guided by echocardiography
and fluoroscopy. Fan et  al. evaluated the utility of 3D
echocardiography datasets to assist in evaluating the left
atrial appendage anatomy and testing the occluder device,
enabling more accurate sizing, particularly in complex
anatomy (Figure  21.8). 22 They included 107 consecutive
patients undergoing left atrial appendage occlusion using
the WATCHMAN device (Boston Scientific, Marlborough,
Massachusetts). They compared two groups: imaging-
guided group and 3D models–guided group. The imaging
alone guided group (72) was based on 3D TEE and
fluoroscopy. The 3D printing cohort (32 patients) device
selection was prospectively guided by 3D models in adjunct
to conventional clinical images (3D transesophageal and
fluoroscopy). Compared with the conventional imaging
alone cohort, the 3D model-guided patients achieved
higher implantation success and shorter procedural
times (p < .05) without complications. They had a 100%
implantation success in the 3D model–guided group, with
an average of 1.1 devices used per procedure.
LIMITATIONS AND FUTURE DIRECTIONS
There are several obstacles that prevent the incorporation
of echocardiography-based 3D printed models into routine
clinical practice. One of the main limitations is the lack of
Figure 21.6  3D echocardiogram-derived pediatric atrioventricular valves. Examples of tricuspid, complete atrioventricular canal and mitral
valve segmentation, atrial surface extraction, 3D rendering of thickened atrial surface, and molded and 3D printed valve models. (Adapted
from Scanlan AB et al. Pediatr Cardiol. 2018;39:538–47. With permission.)

intervendor compatibility for standardized DICOM format

exportation of the echocardiography data. Although A B
some attempts have been made to unlock vendor-specific
tags and establish an open-source workflow, industry
should cooperate in developing a DICOM standard for 3D
ultrasound imaging data.
In general, image quality has the largest effect on model
accuracy. Issues such as signal dropout, partial volume
effects, and inadequate field of view affect anatomical
accuracy. This means that an accurate model requires
meticulous echocardiography image acquisition. Improved
automatic multimodality imaging fusion will definitively
allow the creation of whole heart models including leaflets
and subvalvular apparatus.
Another limitation is the current software segmentation Figure 21.7  Ultrasound-derived 3D printing of atrial septal defect.
available in the market. The clinician, though having a (A) 3D reconstruction of atrial septum with visible atrial septal defect.
wealth of anatomical knowledge, is less familiar with image (B) HeartPrint flex 3D printed model. (Adapted from Samuel BP et al.
processing software than the medical physicist, and vice J Digit Imaging. 2015;28:459–61. With permission.)

3D Printing  265
 A B C

D E F

G H I

J K L M

Figure 21.8  Device sizing guided by echocardiography-based 3D printing. (A–F) From 3D TEE image to 3D physical model. (A,D) Segmentation
of left atrial appendage (LAA) (shaded area) on 3D TEE data. The major and minor ostial diameters and depth of the LAA are measured. (B,E)
Digital object created. (C,F) 3D printed physical model made of tissue-mimicking material. (A–C) Long-axis views and (D–F) short-axis views
demonstrating oval shape of the ostium. Arrows denote pulmonary vein ridge; stars denote appendicular trabeculations. (G–I) Device sizing
in 3D model. (G) Device compression and (H) protrusion in 3D model measured using a digital caliper. Note the device-related deformation
of the 3D-printed models, with the oval ostium becoming rounded after the deployment of a round WATCHMAN device. (I) Tug test for
stability. (J) Device compression and protrusion measured in clinical procedure. (K) 3D TEE en face view of final device position. (L) Color
Doppler assessment showing no peridevice leak. (M) In another case, color Doppler assessment revealed residual leak with a jet width of
3.4 mm. (Reproduced from Fan Y et al. J Am Soc Echocardiogr. 2019;32[6]:708–19.e1. With permission.)

versa. Additionally, the hours that can be spent completing
a complex segmentation are often incompatible with the
workload of clinical staff. Until these problems are solved, 3D
printing will remain limited to a select number of research
facilities that have the expertise and resources necessary to
perform complex image segmentation.
Even though pulsatile models are not always necessary,
atrioventricular valve pathologies are better understood in a
dynamic environment. Replicating a realistic hemodynamic
environment, mimicking patient-specific valvular tissue
properties and subchordae apparatus, is a substantial
challenge for current 3D printing technologies.

266  3D Echocardiography
 Although the range of material properties available
from commercial 3D companies is limited, technology is
constantly advancing, and a wider range of materials which
adequately mimic the dynamic mitral valve tissue will be
available soon. New materials will also be more affordable
and available for cheaper technologies such as FDM.
In the near future, the clinician will interact with realistic
3D replicas of the anatomy using different technologies
and not only physical 3D models. As explained in this
chapter, the main workload to create a 3D printed model is
based on image acquisition, segmentation, and computer-
aided design. Once the surface geometry (stl) is finished,
sending the file to the printer to have a 3D printed replica
is only one of several alternatives to interact, exploit,
and understand complex anatomies. Other alternatives
that are gradually emerging in the clinical scenario are
virtual, augmented reality, and holography. Virtual reality
technology allows users to be immersed in a completely
virtual world.23 Augmented reality allows users to see both
real world and virtual objects.
Finally, bioprinting will revolutionize surgery as living
tissue could be replaced.23 3D bioprinting of vasculature,
myocardium, and valves has been reported.24–28
CONCLUSION
Echocardiography-derived 3D printing of intracardiac
structures is a promising technology in constant
evolution. In this book chapter we have presented the 3D
printing workflow emphasizing the importance of high
quality echocardiography image acquisition. The field
of 3D printing technology will revolutionize how three-
dimensional echocardiography improves patient care
in terms of surgical, interventional planning and device
manufacture.
REFERENCES
1. Cantinotti M, Valverde I, Kutty S. Three-dimensional printed models in
congenital heart disease. Int J Cardiovasc Imaging. 2017;33:137–44.
2. Valverde I. Three-dimensional printed cardiac models: Applications in
the field of medical education, cardiovascular surgery, and structural heart
interventions. Rev Española Cardiol (English Ed). 2017;70:282–91.
3. Vukicevic M, Mosadegh B, Min JK, Little SH. Cardiac 3D printing and its
future directions. JACC Cardiovasc Imaging. 2017;10:171–84.
4. Anwar S, Singh GK, Miller J et al. 3D printing is a transformative technology
in congenital heart disease. JACC Basic Transl Sci. 2018;3(2):294–312.
5. Moore RA, Riggs KW, Kourtidou S et al. Three-dimensional printing
and virtual surgery for congenital heart procedural planning. Birth Defects
Res. 2018;110:1082–90.
6. Harb SC, Rodriguez LL, Svensson LG et  al. Pitfalls and pearls for
3-dimensional printing of the tricuspid valve in the procedural planning
of percutaneous transcatheter therapies. JACC Cardiovasc Imaging.
2018;11:1531–4.
7. Hosny A, Shen T, Kuo AS et al. Unlocking vendor-specific tags: Three-
dimensional printing of echocardiographic data sets. J Thorac Cardiovasc
Surg. 2018;155:143–5.e1.
8. Fedorov A, Beichel R, Kalpathy-Cramer J et al. 3D Slicer as an image
computing platform for the quantitative imaging network. Magn Reson
Imaging. 2012;30:1323–41.
9. Scanlan AB, Nguyen AV,Ilina A et al. Comparison of 3D echocardiogram-
derived 3D printed valve models to molded models for simulated repair of
pediatric atrioventricular valves. Pediatr Cardiol. 2018;39:538–47.
10. Byrne N, Velasco Forte M, Tandon A, Valverde I, Hussain T. A systematic
review of image segmentation methodology, used in the additive
manufacture of patient-specific 3D printed models of the cardiovascular
system. JRSM Cardiovasc Dis. 2016;5. 204800401664546.
11. Ginty O, Moore J, Peters T, Bainbridge D. Modeling patient-specific
deformable mitral valves. J Cardiothorac Vasc Anesth. 2018;32:1368–73.
12. Cruz-González I, Barreiro-Pérez M, Valverde I. 3D-printing in
preprocedural planning of paravalvular leak closure: Feasibility/proof-of-
concept. Rev Esp Cardiol. 2019;72:342.
13. Daemen JHT, Heuts S, Olsthoorn JR, Maessen JG, Sardari Nia P.
Mitral valve modelling and three-dimensional printing for planning and
simulation of mitral valve repair. Eur J Cardio-Thoracic Surg. 2019;55:543–51.
14. Hermsen JL, Burke TM, Seslar SP et al. Scan, plan, print, practice,
perform: Development and use of a patient-specific 3-dimensional printed
model in adult cardiac surgery. J Thorac Cardiovasc Surg. 2017;153:132–40.
15. Valverde I, Gomez-Ciriza G, Hussain T et al. Three-dimensional printed
models for surgical planning of complex congenital heart defects: An
international multicentre study. Eur J Cardio-Thoracic Surg. 2017;52:1139–48.
16. Olivieri LJ, Krieger A, Loke YH et al. Three-dimensional printing of
intracardiac defects from three-dimensional echocardiographic images:
Feasibility and relative accuracy. J Am Soc Echocardiogr. 2015;28:392–7.
17. Yoo SJ, Spray T, Austin EH, Yun TJ, van Arsdell GS. Hands-on surgical
training of congenital heart surgery using 3-dimensional print models. J
Thorac Cardiovasc Surg. 2017;153:1530–40.
18. Nia PS, Heuts S, Daemen J et  al. Preoperative planning with three-
dimensional reconstruction of patient’s anatomy, rapid prototyping and
simulation for endoscopic mitral valve repair. Interact Cardiovasc Thorac Surg.
2017;24:163–8.
19. Ginty O, Moore J, Xia W, Bainbridge D, Peters T. Patient-specific
indirectly 3D printed mitral valves for pre-operative surgical modelling.
In: Medical Imaging 2017: Image-Guided Procedures, Robotic Interventions, and
Modeling. 2017;10135:1013517.
20. Samuel BP, Pinto C, Pietila T, Vettukattil JJ. Ultrasound-derived
three-dimensional printing in congenital heart disease. J Digit Imaging.
2015;28:459–61.
21. Fan Y, Yang F, Cheung GS-H et  al. Device sizing guided by
echocardiography-based three-dimensional printing is associated with
superior outcome after percutaneous left atrial appendage occlusion. J Am
Soc Echocardiogr. 2019;32(6):708–19.e1.
22. Mendez A, Hussain T, Hosseinpour A-R, Valverde I. Virtual reality
for preoperative planning in large ventricular septal defects. Eur Heart J.
2019;40(13):1092.
23. Duan B. State-of-the-art review of 3D bioprinting for c­ ardiovascular tissue
engineering. Ann Biomed Eng. 2017;45:​195–209.
24. Duan B, Hockaday LA, Kang KH, Butcher JT. 3D Bioprinting of
heterogeneous aortic valve conduits with alginate/gelatin hydrogels. J
Biomed Mater Res Part A. 2013;101:1255–64.
25. Fukunishi T, Best CA, Sugiura T et al. Preclinical study of patient-
specific cell-free nanofiber tissue-engineered vascular grafts using
3-dimensional printing in a sheep model. J Thoracic Cardiovasc Surg.
2017;153(4):924–32.
26. Jana S, Lerman A. Bioprinting a cardiac valve. Biotechnol Adv.
2015;33:1503–21.
27. Lee JM, Sing SL, Tan EYS, Yeong W Y. Bioprinting in cardiovascular
tissue engineering: A review. Int J Bioprinting. 2016;2(2):27–36.
28. Tabriz AG, Hermida MA, Leslie NR, Shu W. Three-dimensional
bioprinting of complex cell laden alginate hydrogel structures. Biofabrication.
2015;7(4):045012.
3D Printing  267

A transposition of great arteries, 195
AATS, see American Association for Thoracic
Surgery
Abnormal masses, 246
Activation imaging mapping (AI mapping),
227
Acute aortic syndrome, 213; see also Aorta
Acute myocardial infarction (AMI), 156
Adult congenital heart disease, 176
anterior and posterior mitral valve cleft,
187
anterior mitral valve cleft and ostium
primum septal defect, 187
aortic endocarditis with pseudoaneurysm,
195
aortic root morphology assessment, 194
aortic valve variants, 193
atrial abnormalities, 183, 184
atrial septal defect, 177, 180–183, 200–202
atrioventricular septal defects, 188–190, 191
atrioventricular valve abnormalities,
183–185
baffle leak, 196
Barlow disease, 187
bidimensional and 3D TEE in cor
triatriatum sinister, 186
Carpentier classification, 184
color Doppler, 178
congenital aortic valve disease, 193–195
data acquisition modalities, 176–178
Ebstein anomaly, 186–188, 189, 190
en face view of secundum atrial septal
defect, 180, 183
enlarged ascending aorta, 194
guidance catheter intervention, 200–206
intra-atrial baffle obstruction, 196
LAVV failure after atrioventricular septal
defect repair, 192
left ventricular outflow tract obstruction,
192–193
lesions in unoperated adults, 180
LIVE 3D, 178
MitraClip, 202–204
mitral stenosis, 204
mitral supravalvular stenosis in Shone
syndrome, 186
mitral valve TEE imaging, 177
prosthetic valve leaks, 204–205
real-time 3D full-volume dataset, 177
real-time image of double-orifice mitral
valve, 187
repaired adults with CHD, 195–197
secundum atrial septal defect TEE imaging,
176
sinus of valsalva aneurysm, 195
structural complications after AV septal
defect repair, 182
superior sinus venosus atrial septal defect,
182
supravalvular ring, 185
systemic tricuspid valve, 197
3D echocardiography, 178–180
3D imaging techniques, 176
3D TEE in CHDs, 206
3D zoom, 177
transseptal puncture, 202
INDEX
tricuspid valve, 185–188, 189
TTE left atrial volumes and ejection
fractions, 177
2D simultaneous multiplane mode, 176
vena contracta in aortic regurgitation, 195
ventricular function in CHD, 197–200
ventricular septal defect, 202
ventricular septal defects, 190–192
AF, see Atrial fibrillation
AI mapping, see Activation imaging mapping
ALC, see Anterolateral commissure
Alcohol septal ablation (ASA), 58
American Association for Thoracic Surgery
(AATS), 158
American Society of Echocardiography (ASE),
35, 43
AMI, see Acute myocardial infarction
Amplatzer Amulet
closure device deployment assessment, 258
LAA occlude, 255
Anatomical valve area (AVA), 103
Angiosarcoma, 239; see also Cardiac masses
Anterolateral commissure (ALC), 68
Aorta, 208; see also Aortic regurgitation
aortic atheroma, 208
aortic dissection, 208–210
aortic ulcer, 212–213
intramural hematoma, 213–214
plaque, 208
systole and diastole in type A aortic
dissection, 211–212
TEE images of mobile plaques, 209
type B aortic dissection, 209
Aortic regurgitation (AR), 111, 147, 192, 208;
see also Aorta
aortic annulus morphology, 115
aortic root assessment, 113–114
aortic root components, 111
aortic valve and root anatomy, 111–112
aortic valve assessment, 114
classification, 112
coaptation length of cusps, 111, 112
cropped 3D dataset, 113, 114, 115, 116, 117,
118
mechanism of, 112
mechanisms, 210
quantification of, 114–118
technical consideration for imaging, 112
3D transesophageal echocardiography, 113
3D transthoracic echocardiography,
112–113
vena contracta measurement, 116
Aortic stenosis (AS), 103
aortic annular measurements, 107
aortic annulus multiplanar assessment,
106, 108
aortic valve/annulus morphology, 104–105
biplane from 3D TTE, 105
Edwards Sapien valve assessment, 109
effective aortic valve area, 107–109
elliptical left ventricular outflow tract, 106
en face view, 104, 105
left ventricular outflow tract hypoplasia, 104
planimetry of anatomical aortic valve area,
105–107
stroke volume assessment, 108
3D imaging of aortic valve and annulus, 103
transcatheter aortic valve replacement
imaging, 109
usefulness of 3D in, 104
Aortic syndrome, acute, 213; see also Aorta
Aortic valve (AV), 142
Aortic valve regurgitation, see Aortic
regurgitation
Apical sparing, 65; see also Hypertrophic
cardiomyopathy
Artificial valves, 158
aortic prosthesis, 168
atrial surgical view of mechanical mitral
prosthesis, 158
circumferential pannus around prosthesis
ring, 165
double paravalvular leak of mitral
prosthesis, 169
endocarditis, 170–171
gain dependence of paravalvular leak, 169
hypomobility of medial leaflet, 164
large intraprosthetic thrombus, 165
mitral prosthesis, 159, 160
mitral prosthesis obstruction, 167
pannus at ventricular side of mechanical
aortic prosthesis, 166
paravalvular leaks of mitral valve
prosthesis, 169, 170
prosthetic mitral valve, 164
prosthetic valve obstruction, 161–164
prosthetic valve regurgitation, 164–170
reduced disk motion of mitral prosthesis,
163
3D echocardiography in valve evaluation,
170
3D TEE in malfunctioning transcatheter,
171
3D TEE in malfunctioning valve, 161
transcatheter implanted aortic valve,
171–172
transcatheter implanted mitral valve, 172
transcatheter implanted pulmonary valve,
172–173
transcatheter implanted tricuspid valve, 172
AS, see Aortic stenosis
ASA, see Alcohol septal ablation
ASD, see Atrial septal defect
ASE, see American Society of
Echocardiography
Atrial abnormalities, 183, 184
Atrial fibrillation (AF), 126, 249
Amplatzer Amulet closure device
deployment assessment, 258
echocardiography for left atrial thrombus,
250
echocardiography for risk stratification,
249
echocardiography in, 253
electrical cardioversion, 253–254
heart failure, 252–253
intracardiac echocardiography and
CARTOSound, 256
left atrial appendage assessment, 251, 256
left atrial appendage closure, 255–258
left atrial appendage dimension, 250, 252
left atrial appendage volume and ejection
fraction assessment, 253
269
Atrial fibrillation (AF) (Continued)
left atrial phasic function assessment, 254
radiofrequency catheter ablation, 254–255
spontaneous echocardiographic contrast
on 3D TEE, 250
stroke, 249–252
superior pulmonary vein ablation, 255
Atrial septal defect (ASD), 43, 177, 180, 200–
202, 264; see also Adult congenital
heart disease
echocardiographic evaluation of, 181, 182
en face view of secundum, 180, 183
shape and size assessment, 183
superior sinus venosus, 182
types of, 181
Atrioventricular septal defects (AVSDs), 186,
188–190, 191
repair and LAVV failure, 192
Atrioventricular valve abnormalities, 183–185
Carpentier classification, 184
structural complications after repair, 182
supravalvular ring, 185
Atrioventricular valves, 3D echocardiogram-
derived pediatric, 265; see also 3D
printing
AV, see Aortic valve
AVA, see Anatomical valve area
AVSDs, see Atrioventricular septal defects
B Carney complex, 238
Baffle leak, 196
Barlow disease, 187
BAV, see Bicuspid aortic valve
Bicuspid aortic valve (BAV), 142
Biomechanical constraints, 218; see also Speckle
tracking
Biplane 3D echocardiography, 49
LAA assessment, 46
patent foramen ovale from, 48
Block matching, 23
Bull’s-eye plot, 64, 65
C Mitral stenosis
Cardiac 3D imaging, see Echocardiography, 3D
Cardiac computed tomography (CCT), 131,
235
Cardiac imaging, 1; see also 3D
echocardiographic imaging
Cardiac implantable electronic devices
(CIEDs), 120
Cardiac magnetic resonance (CMR), 43, 98,
235
Cardiac masses, 235; see also Cardiac tumors
abnormal vascular structures, 246
anatomical structures with mass effect
pathology, 245–246
atrial myxoma, 236
cardiac tumors, 237–241
coronary aneurysm, 245
coronary sinus, 245, 246
echocardiographic and cardiac computed
tomographic images, 236
echocardiographic differences of benign
and malignant, 237
fatty material around tricuspid annulus,
247
ligament of Marshall, 246, 247
liquefactive necrosis, 245
masses in endocarditis, 243–245
normal anatomical structures with mass
effect, 246–248
270 Index 
obstructive myxoma, 237
pericardial effusion, 245
pleuropericardial cysts, 237
preferential location of tumors, 235
3D TEE cropping, 237
thrombus, 241–243
Cardiac mechanics, 215; see also Speckle
tracking
Cardiac resynchronization therapy (CRT), 231
Cardiac tumors, 237; see also Cardiac masses
benign primary tumors, 237–239
differential diagnosis between vegetation
and valvular lesions, 237
fibromas, 238–239
intramyocardial metastases, 241
Lambl excrescence in closed mitral valve,
238
lipomas and lipomatous hypertrophy of
atrial septum, 238, 239
lung metastases with intravascular
extension, 241
malignant tumors, 239–240
mesothelioma, 240
metastatic tumors, 240–241
myxoma, 237–238
papillary fibroelastoma, 238
primary malignant tumors, 239
rhabdomyomas, 239
sarcoma, 239–240
Carpentier classification, 184
Catheter-based treatment, 147
CCT, see Cardiac computed tomography
ccTGA, see Congenitally corrected TGA
CDS, see Clip delivery system
CE, see Continuity equation
CFM, see Color flow mapping
CHD, see Congenital heart disease
CHF, see Chronic heart failure
Chronic heart failure (CHF), 83
CIEDs, see Cardiac implantable electronic
devices
Classical noninvasive methods, 97; see also
Clip delivery system (CDS), 78
CMR, see Cardiac magnetic resonance
Color flow mapping (CFM), 158
Complete transposition of the great arteries
(D-TGA), 195
Computed tomography (CT), 43, 105, 147, 208,
260
Congenital aortic valve disease, 193–195
Congenital heart disease (CHD), 176, 264
Congenital heart disease, adult, see Adult
congenital heart disease
Congenitally corrected TGA (ccTGA; L-TGA),
195
Continuity equation (CE), 105
Continuous-wave (CW), 37
Doppler, 55
Conventional 2D; see also Stress
echocardiography
PISA method, 98
stress echocardiography, 28
Coronary aneurysm, 245; see also Cardiac masses
Coronary sinus (CS), 180, 245; see also Cardiac
masses
Cortriatriatum dexter (CTD), 183
Coumadin ridge, 246
Crista terminalis, 247
CRT, see Cardiac resynchronization therapy
CS, see Coronary sinus
CT, see Computed tomography
CTD, see Cortriatriatum dexter
CW, see Continuous-wave
D
DICOM format (Digital Imaging and
Communications in Medicine), 260
D-TGA, see Complete transposition of the great
arteries
E
EACTS, see European Association for Cardio-
Thoracic Surgery
Ebstein anomaly, 186–188
real-time 3D echocardiography, 190
rotation of functional tricuspid orifice, 190
transthoracic apical four-chamber view, 189
2D echocardiographic features, 189
ECG, see Electrocardiograph
Echocardiography, 120, 215, 243; see also 3D
printing
advantages, 131
-derived 3D printing, 267
Echocardiography, 2D, 13, 22, 95
assessment of RV size, 35
basics of, 1–3
in patient with obstructive hypertrophic
cardiomyopathy, 60
pitfalls of, 16
RV systolic function determination, 35–37
speckle tracking analysis, 22, 23
for subaortic stenosis, 193
subcostal views of atrial septum, 182
vs. 3D cardiac imaging, 11
vs. 3D echocardiography and MRI, 41
Echocardiography, 3D, 1, 33; see also Stress
echocardiography
acquisition, 13
advantage, 97
block matching, 23
blood pool Doppler image, 9
cardiac imaging, 5–7
data rendering, 6
dataset display, 13–14
datasets, 8, 9
focal point, 3
guidelines, 43
high-frame-rate imaging, 3–5
in infective endocarditis, 131
instantaneous full-volume, 88
interatrial septal puncture, 48
interatrial septum, 47
left atrial anatomy, 43, 44
left atrial appendage by, 45–47
left atrial mass by, 48–49
left atrial volume measurement, 43–44
of left ventricle, 14
limitations and future developments, 7,
9–11
LV volumes measurement methods, 16
multislice imaging, 30, 123
phased-array transducer, 3
pitfall of RV volume determination, 38
reconstruction of ultrasound sector images, 3
reference values for LV volumes and
ejection fraction, 17
requirements for, 1
role in hypertrophic cardiomyopathy,
57–64
RV EDV and RV EF, 39–40
sequential scanning, 5
vs. speckle tracking analysis, 23
 speckle tracking strain measurement, 24
stitching artifacts, 13
technical consideration, 112
TEE investigation in mild mitral
regurgitation, 10
transmitted ultrasound pulse and
encountered scatterers, 2
vs. 2D echocardiography and MRI, 41
vs. 2D imaging, 11
vena contracta area assessment by, 88
EDV, see End-diastolic volume
Edwards Sapien valve, 109; see also Aortic
stenosis
EF, see Ejection fraction
Effective orifice area (EOA), 160
Effective regurgitant orifice area (EROA), 74,
87
Ejection fraction (EF), 35, 228, 249
Electrical cardioversion, 253–254
Electrocardiograph (ECG), 5, 112
End-diastolic volume (EDV), 39, 197
End-systolic volume (ESV), 39, 197
EOA, see Effective orifice area
EROA, see Effective regurgitant orifice area
eSie Valves, 87
ESRD, see External sewing ring diameter
ESV, see End-systolic volume
European Association for Cardio-Thoracic
Surgery (EACTS), 158
External sewing ring diameter (ESRD), 158
F TEE study of LV outflow tract, 63
FAC, see Fractional area change
Flexi-Slice tool, 134
FMR, see Functional MR
FO, see Fossa ovalis
Focal point, 3; see also 3D echocardiographic
imaging
Fossa ovalis (FO), 180
Fractional area change (FAC), 35
Frame rate, 3
Functional MR (FMR), 70
Functional tricuspid regurgitation (FTR), 120,
126
G ICD, see Implantable cardioverter-defibrillator
Gorlin’s method, 97; see also Mitral stenosis
H Image registration, 216, 218; see also Speckle
Healthy control, 219; see also Speckle tracking
athlete, 219
4D deformation analysis for, 220
Heart failure, 252–253
Heart failure with preserved ejection fraction
(HFpEF), 252
Heart failure with reduced ejection fraction
(HFrEF), 252
HFpEF, see Heart failure with preserved
ejection fraction
HFrEF, see Heart failure with reduced ejection
fraction
High-frame-rate; see also 3D echocardiographic
imaging
imaging, 3–5
to 3D imaging, 5
Hypertension, 220; see also Speckle tracking
4D deformation analysis for, 221
Hypertrophic cardiomyopathy (HCM), 51, 57,
220; see also Speckle tracking
anterior movement of MV, 61
apical sparing, 65
AV and LV outflow tract, 61
bull’s-eye plot, 64, 65
causes of adverse outcomes, 51
causes of LV systolic obstruction, 57
color Doppler 2D echocardiography, 53–54
continuous-wave spectral Doppler scan, 58
contrast-enhanced 2D echocardiography,
55
deformation myocardial imaging in,
64–65
diagnosis of, 51
differential diagnosis of, 65
distribution and quantification of LV
hypertrophy, 57–58
distribution in left ventricle, 53
four-chamber apical view, 55
4D deformation analysis, 221
LA size evaluation, 58–59
LA volume measurement, 60
LV outflow tract area evaluation of, 59–63
LV volume measurement of, 59
mitral regurgitation assessment, 63–64
M-mode echocardiography, 51, 52, 53
nonobstructive, 56
physiopathological mechanisms, 51
pulsed-and continuous-wave Doppler,
55–57
role of 3D echocardiography in, 57–64
spectral pulsed-wave Doppler, 57
systolic contact of mitral valve, 56
tissue Doppler imaging, 64
transesophageal 3D color-Doppler
echocardiography, 63
triplane 2D acquisition, 59
2D echocardiography in obstructive, 60
2D echocardiography, 51–53
2D short-axis view of left ventricle, 54
2D TEE, 54
I dimension measurement, 252, 256
IAS, see Interatrial septum
iASD, see Iatrogenic atrial septal defect
Iatrogenic atrial septal defect (iASD), 148
ICE, see Intracardiac echocardiography
ID, see Internal orifice diameter
IE, see Infective endocarditis
tracking
Implantable cardioverter-defibrillator (ICD),
127
Infective endocarditis (IE), 128, 131, 244
aortic valve, 139
aorto-left atrial fistula, 137–138
echocardiographic hallmarks of, 131
Flexi-Slice tool, 134
infective endocarditis after Bentall
procedure, 136
of mitral valve, 132, 139
on native mitral valve, 133
with small vegetation, 132
systematic evaluation with 2D TEE,
133, 134
3D echocardiography in infective
endocarditis, 131
3D TEE and intracardiac fistulas, 135
3D TEE and location and description of
paravalvular abscesses, 135
3D TEE and location and sizing of
pseudoaneurysms, 135
3D TEE and location and sizing of
vegetations, 131–135
3D TEE and paravalvular leaks,
140–141
3D TEE and valve perforation,
135, 140
3D zoom en face view of mitral valve, 138
vegetation on atrial side of posterior mitral
leaflet, 135
Inferior vena cava (IVC), 180
Interatrial septum (IAS), 182
Internal orifice diameter (ID), 158
Intra-atrial baffle obstruction, 196
Intracardiac echocardiography (ICE), 15
Intramitral ring, 185
Intramural hematoma, 213–214; see also Aorta
Intraoperative 2D/3D echocardiography, 75
Intraprosthetic regurgitation (IPR), 164
Intraventricular dyssynchrony, 20, 33
IPR, see Intraprosthetic regurgitation
Isovolumic myocardial acceleration (IVA), 200
IVA, see Isovolumic myocardial acceleration
IVC, see Inferior vena cava
K
KBR, see Knowledge-based reconstruction
Knowledge-based reconstruction (KBR), 200
L
LA, see Left atrium
LAA, see Left atrial appendage
LAVV, see Left atrioventricular valve
LCS, see Left coronary sinus
Left atrial appendage (LAA), 45, 249
anatomical requirements for closure
devices, 256
assessment, 251
assessment with biplane 3D
echocardiography, 46
dimensions assessment, 250
LAA sizing before device implantation, 47
simulating LAA closure, 43
TEE evaluation of, 46
by 3D echocardiography, 45–47
transcatheter closure, 255–258
volumes and ejection fraction assessment,
253
Left atrioventricular valve (LAVV), 181, 188
Left atrium (LA), 43, 49–50, 68
anatomy, 44
appendage by 3D echocardiography, 45–47
appendage shapes, 46
biplane 3D echocardiography, 49
body surface area corrected left atrial
volume, 45
focus on interatrial septum, 47
function measurement, 44–45
guidelines for 3D echocardiography, 43
interatrial septal puncture, 48
LAA sizing before device implantation, 47
mass, 48–49
needle positioning before septal puncture, 49
patent foramen ovale, 48
rendered volume of LA thrombus, 49
simulating LAA closure, 43
TEE evaluation of appendage, 46
3D echocardiography and 3D printing, 43
volume-derived indexes of function, 45
volume measurement, 43–44
Left coronary sinus (LCS), 195
Index 271
Left ventricle (LV), 13, 35, 103
anatomies, 19
banana-shaped left ventricle, 16
clinical value of 3D echocardiography, 15
3D echocardiography acquisition and
display of, 13–14
diastolic function, 20
display modes of 3D datasets, 14
dyssynchrony, 20–21
ejection fraction, 13
fully automated software packages, 18
hypertrophy, 21
mass, 21–22
myocardial mechanics, 22–24
pitfalls in 2D echocardiography, 16
semiautomated software packages, 18
shape, 22
size and systolic function, 14–20
speckles, 22
sphericity index in normal, 22
torsion calculation, 23
volumes and ejection fraction, 17
volumes measurement, 16
Left ventricular assist device (LVAD), 41
Left ventricular outflow tract (LVOT), 51, 103
Ligament of Marshall, 246, 247
Liquefactive necrosis, 245; see also Cardiac
masses
LIVE 3D, 178
L-TGA, see Congenitally corrected TGA
LV, see Left ventricle
LVAD, see Left ventricular assist device
LVOT, see Left ventricular outflow tract
M Hypertrophic cardiomyopathy
Magnetic resonance imaging (MRI), 30, 35,
43, 227, 260
Masses in endocarditis, 243; see also Cardiac
masses
periannular extension, 244–245
vegetation, 243–244
MC ring, 144
MDCT, see Multidetector row computed
tomography
Mechanical dyssynchrony, 20
MitraClip, 76–79, 89–93, 202–204; see also
Adult congenital heart disease;
Mitral regurgitation 3D assessment
Mitral regurgitation (MR), 68
Mitral regurgitation 3D assessment, 69; see also
Primary mitral regurgitation
etiologies, 74
mechanisms, 69–74
MitraClip, 76–79
percutaneous management, 76
quantification of regurgitation, 74–75
surgical management, 75–76
3D TEE studies, 71, 72, 73, 74, 75
treatment, 75–79
2D and 3D TEE images, 72
Mitral stenosis (MS), 95, 204; see also Adult
congenital heart disease
advantages and limitations of mitral valve
area evaluation methods, 99
commissural tearing assessment, 100
conventional 2D PISA method, 98
en face view of mitral valve, 96, 100
functional assessment, 96–99
Gorlin’s method, 97
interatrial transseptal puncture, 101
mitral valvular area assessment by MRI, 99
monitoring of percutaneous mitral
valvuloplasty, 101
272 Index 
monitoring percutaneous mitral
valvuloplasty, 99–101
morphological assessment, 95–96
PHT method, 96
RT3DE, 95
subvalvular mitral apparatus assessment, 96
3D proximal isovelocity surface area
volume automatic calculation, 99
Mitral valve (MV), 68, 83, 95, 142, 147
Mitral valve annulus (MVA), 68
Mitral valve components 3D assessment, 68; see
also Primary mitral regurgitation
advantages and limitations, 69
mitral annulus assessment, 68–69
mitral valve leaflet assessment, 68
subvalvular apparatus assessment, 69
3D TEE studies, 69, 70
Mitral valve navigation (MVN), 98
Mitral valvular orifice area (MVA), 95, 185
MPI, see Myocardial performance index
MPR, see Multiplanar reconstruction
MR, see Mitral regurgitation
MRI, see Magnetic resonance imaging
MS, see Mitral stenosis
Multidetector row computed tomography
(MDCT), 105
Multiplanar reconstruction (MPR), 29, 89, 178
MV, see Mitral valve
MVA, see Mitral valve annulus; Mitral valvular
orifice area
MVN, see Mitral valve navigation
Myocardial
acute myocardial infarction, 156
deformation imaging, 64–65; see also
global function, 14
hypertrophy, 64; see also Hypertrophic
cardiomyopathy
Myocardial performance index (MPI), 36
N PHT, see Pressure half-time
NCS, see Noncoronary sinus
Noncoronary sinus (NCS), 195
Nonsurgical transcatheter treatment, 147; see
also Non-valvular heart disease
clip procedure for mitral regurgitation,
148, 149
closure of paravalvular aortic valve
regurgitation, 147–148
closure of paravalvular mitral
regurgitation, 150–152
edge-to-edge mitral valve clip repair, 149
intraprocedural echocardiography,
148–150
non-valvular heart disease, 153
3D TEE, 151
3D TEE images of aortic valve, 147
transcatheter aortic valve replacement, 147
transcatheter mitral valve replacement,
152–153
transcatheter procedures for mitral valve
disease, 148
transcatheter replacement, 150, 151
tricuspid valve procedures, 153
2D and 3D TEE showing iatrogenic atrial
septal defect, 149
valvular heart disease, 147
Non-valvular heart disease, 153; see also
Nonsurgical transcatheter treatment
atrial septal defect closure, 156
patent foramen ovale/atrial septal defect/
ventricular septal defect closure,
153–155
ventricular septal defect closure, 156
NRRD file (n-dimensional Nearly Raw Raster
Data format), 260
O
Operating room (OR), 142
OR, see Operating room
Organic tricuspid regurgitation (OTR), 120;
see also Tricuspid regurgitation
OTR, see Organic tricuspid regurgitation
P
Papillary muscles (PMs), 83
Paravalvular leaks (PVLs), 140, 204; see also
Adult congenital heart disease;
Infective endocarditis
in prosthetic valves, 204–205
Paravalvular regurgitation (PVR), 164
Patent foramen ovale (PFO), 47, 153
PBMV, see Percutaneous balloon mitral
valvuloplasty
PCVs, see Prosthetic cardiac valves
Peak early filling rate (PFR), 20
Pediatric atrioventricular valves, 3D
echocardiogram-derived, 265; see
also 3D printing
Penetrating aortic ulcer, 212–213; see also Aorta
Percutaneous balloon mitral valvuloplasty
(PBMV), 204
Percutaneous mitral valve repair (PMVR), 76
Percutaneous mitral valvuloplasty (PMV), 95
Pericardial effusion, 245; see also Cardiac
masses
PET, see Positron emission tomography
PFO, see Patent foramen ovale
PFR, see Peak early filling rate
Phased-array transducer, 3; see also 3D
echocardiographic imaging
PISA, see Proximal isovelocity surface area
Planimetric orifice area (POA), 158
PMC, see Posteromedial commissure
PMs, see Papillary muscles
PMV, see Percutaneous mitral valvuloplasty
PMVR, see Percutaneous mitral valve repair
POA, see Planimetric orifice area
Positron emission tomography (PET), 243
Posteromedial commissure (PMC), 68
Pressure half-time (PHT), 96; see also Mitral
stenosis
Primary mitral regurgitation, 68, 79–80
advantages and limitations of
echocardiography, 69
MitraClip, 76–79
mitral annulus assessment, 68–69
mitral valve components assessment,
68–69, 70
mitral valve leaflet assessment, 68
percutaneous management, 76
quantification, 74–75
subvalvular apparatus assessment, 69
surgical management, 75–76
3D assessment, 69–79
3D TEE studies, 69, 70, 71, 72, 73, 74, 75
treatment, 75–79
2D and 3D TEE images, 72
Prosthetic cardiac valves (PCVs), 158
Prosthetic valve endocarditis (PVE), 131
Proximal isovelocity surface area (PISA), 74,
87, 97, 116, 142, 185
Pseudoaneurysm, 135
Pulmonary hypertension, 126
Pulmonary valve (PV), 183 mechanism and etiology of, 84
Pulmonary vein isolation, 254 mitral annulus reconstruction, 84
PV, see Pulmonary valve mitral valve morphology, 84–87
PVE, see Prosthetic valve endocarditis offline reconstruction of mitral annulus, 84
PVLs, see Paravalvular leaks physiopathology of, 83–84
PVR, see Paravalvular regurgitation role of 3D during MitraClip therapy, 89–93
tethering of mitral valve leaflets, 84
Q 3D multiplanar reconstruction, 91, 92
3D quantification of, 87–89
QCT, see Quad-chamber tracking 2D and 3D TEE, 91
Quad-chamber tracking (QCT), 226 2D TEE, 90
Sequential scanning, 5; see also 3D
R echocardiographic imaging
Shape models, 218; see also Speckle tracking
RA, see Right atrium Sinotubular junction, 111
Radiofrequency (RF), 2 Sinus of Valsalva aneurysm (SVA), 195
catheter ablation, 254–255 SMR, see Secondary mitral regurgitation
RCS, see Right coronary sinus Society of Thoracic Surgeons (STS), 158
Real-time 3D echocardiography, 41, 176 Speckles, 22
Real-time 3D full-volume dataset, 177 Speckle tracking, 215, 220, 221
Real-time 3D imaging, 11 alternative approaches, 216
Real-time 3D TTE, 204 anatomical directions of myocardial
Realtime Three-Dimensional motion and deformation, 216
Echocardiography (RT3DE), 95; see biomechanical constraints, 218
also Mitral stenosis conservation of speckles over consecutive
Refracted wave, 2 frames, 219
Region of interest (ROI), 23 deformation analysis in healthy athlete, 220
Regurgitant orifice (RO), 74 deformation analysis in healthy subject, 219
Regurgitant volume (RV), 74, 87 deformation analysis in hypertensive
RF, see Radiofrequency patient, 221
Right atrium (RA), 183 deformation analysis in hypertrophic
Right coronary sinus (RCS), 195 cardiomyopathy, 221
Right ventricle (RV), 35; see also Left ventricle deformation quantification, 217
additional testing, 40 hypertension, 220
clinical implications, 41 hypertrophic cardiomyopathy, 220
meta-analysis of RV EDV, 37 image registration, 216, 218
meta-analysis of RV EF, 38 measuring motion and deformation, 216
pitfall in RV volume determination by 3D myocardial motion and deformation,
echocardiography, 38 215–216
preoperative transesophageal practical examples, 219
echocardiography, 39 principles of tracking, 216
right heart function determinants, 35 recommendations for 3D, 218
size assessment, 35 shape models, 218
systolic function determination, 35–37 standardization and validation, 218
3D TEE image of, 35 temporal derivatives of displacement and
2D vs. 3D echocardiography and MRI, 41 strain, 217
volume by postsurgical 3D TEE, 40 tissue Doppler, 218
volume by presurgical 3D TEE, 40 3D tissue deformation, 217
volumes and EF normals, 39–40 values quantified in strain in 1D and 3D, 216
Right ventricle ejection fraction (RV EF), 38 Speckle tracking echocardiography (STE), 223
Right ventricular end-diastolic volume (RV Spectral Doppler (SD), 158
EDV), 37 Specular reflection, 2
Right ventricular outflow tract (RVOT), 35, 196 SSD, see Sum of squared differences
RO, see Regurgitant orifice STE, see Speckle tracking echocardiography
ROI, see Region of interest Stitching artifacts, 13
RT-TT3DE, see Real-time 3D TTE Strain, 224
RV, see Regurgitant volume Stress echocardiography, 28
RV, see Right ventricle acquisition, 28
RV EDV, see Right ventricular end-diastolic acquisition of full-volume 3D data, 29
volume artifacts limiting use of 3D data in, 30
RV EF, see Right ventricle ejection fraction clinical studies, 30–33
RVOT, see Right ventricular outflow tract conventional 2D, 28
data display, analysis, and interpretation,
S 29–30
diagnostic accuracy of, 32
SAM, see Systolic anterior motion limitations, 33
Scatterers, 2 multislice imaging in 3D echocardiography, 30
SD, see Spectral Doppler perspectives, 32–33
SDI, see Systolic dyssynchrony index qualitative visualization of regional wall
Secondary mitral regurgitation (SMR), 83 motion abnormalities, 31
en face view of mitral valve, 85 scan time reduction using 3D vs. 2D, 32
eSie Valves, 87 side-by-side visualization of multislice
lack of coaptation in asymmetric tethering images, 31
of mitral valve leaflets, 86 single-beat acquisition, 28
workflow using matrix array transducers,
28–29
Stroke, 249–252
Structural valve deterioration (SVD), 162
STS, see Society of Thoracic Surgeons
Subaortic stenosis, 192
Sum of squared differences (SSD), 224
Superior vena cava (SVC), 180
Supramitral ring, 185
Surgical management, 142
aortic valve surgery, 142, 144
bicuspid valve images of 3D TEE and 2D
TEE, 144
calcified bicuspid aortic valve, 144
mass in right atrium, 145
mitral valve surgery, 142
severe mitral valve regurgitation, 143
surgery for cardiac mass, 144
surgery for congenital heart disease, 145
tricuspid valve surgery, 144
2D TEE after MV replacement in operating
room, 143
SVA, see Sinus of Valsalva aneurysm
SVC, see Superior vena cava
SVD, see Structural valve deterioration
SVs, see Systolic volumes
Systolic anterior motion (SAM), 51, 171
Systolic dyssynchrony index (SDI), 198
Systolic volumes (SVs), 69
T
TA, see Tricuspid annulus
TAPSE, see Tricuspid annular plane systolic
excursion
TAVR, see Transcatheter aortic valve
replacement
TDI, see Tissue Doppler imaging
TEE, see Transesophageal echocardiography
Tei index, see Myocardial performance index
Tetralogy of Fallot (TOF), 196
3D, see Three-dimension
3D echocardiogram-derived pediatric
atrioventricular valves, 265; see also
3D printing
3D echocardiographic imaging, see
Echocardiography, 3D
3D full-volume color Doppler (3D FVCD), 89
3D FVCD, see 3D full-volume color Doppler
Three-dimension (3D), 1
3D printing, 260
accuracy, 261–262
adequate imaging acquisition, 260
of atrial septal defect, 265
clinical applications, 262
congenital heart disease, 264
device sizing, 266
of intracardiac defects, 264
LA appendage occlusion, 264
limitations and future directions, 264–267
mitral valve, 263
multimodality imaging fusion, 263
pediatric AV valves, 265
postprocessing software, 261
solid and hollow 3D printed models, 262
technique, 261
3D echocardiography acquisition, 260–261
tricuspid valve, 263–264
workflow, 260, 261
3D rendering of data, 6
3D wall motion tracking (3D WMT), 223
3D WMT, see 3D wall motion tracking
3D zoom, 177
Time-velocity integral (TVI), 107
Index 273
Tissue Doppler, 218; see also Speckle tracking
Tissue Doppler imaging (TDI), 200
Tissue tracking, 3D, 223
activation imaging, 226–227
applications of, 228
area change ratio, 226
area strain, 224, 226
cardiac dyssynchrony imaging, 229, 231
effects of rotation and translation, 224
heart failure and cardiomyopathy, 229
images before and after, 231
left ventricular dyssynchrony, 230
longitudinal strain apical sparing, 230
multimodality assessment in LV lateral ACP
ablation, 233
plastic bag image, 224, 225
quad-chamber tracking by 3D STE, 228
radial, longitudinal, and circumferential
strain in, 226
reference value from healthy subjects, 229
regional torsion, 226
rotation, twist, and torsion to base in, 227
RV and LV activation imaging before and
after CRT, 232
3D speckle tracking echocardiography
limitation, 232
3D strain, 227
3D wall motion tracking, 223–224
2D and 3D algorithms, 225
2D and 3D speckle tracking
echocardiography, 225
2D vs. 3D speckle tracking analysis, 228
2D vs. 3D strain, 227
volume verification with cardiac MRI,
227–228
wall motion tracking technology, 223
TMVR, see Transcatheter mitral valve
replacement
TOF, see Tetralogy of Fallot
TPVR, see Transcatheter pulmonary valve
replacement
Transcatheter aortic valve replacement
(TAVR), 104, 142, 147, 171–172; see
also Artificial valves
Transcatheter left atrial appendage closure,
255–258
Transcatheter mitral valve replacement
(TMVR), 172; see also Artificial valves
Transcatheter pulmonary valve replacement
(TPVR), 172–173; see also Artificial
valves
Transcatheter tricuspid valve replacement
(TTVR), 172; see also Artificial valves
Transeptal puncture, 202; see also Adult
congenital heart disease
Transesophageal echocardiography (TEE), 7,
43, 68, 98, 208, 235
evaluation of left atrial appendage, 46
in normal mitral valve, 177
preoperative, 39
in secundum atrial septal defect, 176
Transesophageal echocardiography, 3D,
113; see also Adult congenital heart
disease
274 Index 
in CHDs, 206
RV volume by postsurgical, 40
Transposition of great arteries, 195
Transseptal puncture (TS puncture), 78
Transthoracic 3D echocardiography, 125
multislice display of tricuspid valve
apparatus by, 123
Transthoracic echocardiography (TTE), 15,
43, 68, 158, 235
rendered volume of LA thrombus after
resection of LA posterior wall by, 49
subvalvular mitral apparatus assessment, 96
3D, 112–113
Tricuspid annular plane systolic excursion
(TAPSE), 35, 36, 200
Tricuspid annulus (TA), 120
Tricuspid regurgitation (TR), 37, 120
anatomical variability of tricuspid valve
leaflets, 121
anatomy of tricuspid valve apparatus, 120
asymmetry of regurgitation orifice, 124
carcinoid heart disease, 127
carcinoid valve disease, 124
cardiac implantable electronic device
induced, 127
congenital, 127
elliptical tricuspid annulus, 122
functional, 125, 126–127
infective endocarditis of tricuspid valve,
128–129
mixed tricuspid valve dysfunction, 123
multiplanar reconstruction of tricuspid
vegetation, 128
multislice display of tricuspid valve
apparatus, 123
organic, 120, 124, 127–129
rheumatic, 128
saddle-shaped geometry of tricuspid
annulus and leaflets reconstruction,
122
severe, 122
traumatic, 128
tricuspid valve endocarditis, 125
tricuspid valve imaging, 121, 125–126
tricuspid valve prolapse, 127–128
variability of imaging tricuspid valve
leaflets, 121
Tricuspid valve (TV), 35, 120, 180, 185–188,
189
Barlow disease, 187
Ebstein anomaly, 186–188, 189, 190
mitral supravalvular stenosis, 186
mitral valve cleft, 187
ostium primum septal defect, 187
real-time 3D transthoracic image of
double-orifice mitral valve, 187
TEE in cor triatriatum sinister, 186
3D imaging of systemic, 197
ventricular septal defect with tricuspid and
aortic valves, 192
TS puncture, see Transseptal puncture
TTE, see Transthoracic echocardiography
TTVR, see Transcatheter tricuspid valve
replacement
TV, see Tricuspid valve
TVI, see Time-velocity integral
2D, see Two-dimension
Two-dimension (2D), 1
U
Ultrasound-derived 3D printing of atrial septal
defect, 265; see also 3D printing
Univentricular hearts (UVHs), 176
UVHs, see Univentricular hearts
V
Valvular heart disease, 147; see also Nonsurgical
transcatheter treatment
clip procedure for mitral regurgitation,
148, 149
closure of paravalvular aortic valve
regurgitation, 147–148
closure of paravalvular mitral
regurgitation, 150–152
edge-to-edge mitral valve clip repair, 149
intraprocedural echocardiography,
148–150
TEE images of aortic valve, 147
TEE of iatrogenic atrial septal defect, 149
transcatheter aortic valve replacement, 147
transcatheter mitral valve replacement,
152–153
transcatheter procedures for mitral valve
disease, 148
transcatheter replacement, 150, 151
tricuspid valve procedures, 153
VC, see Vena contracta
VCA, see Vena contracta area
Vena contracta (VC), 74, 87, 167
assessment by 3D echocardiography, 88
Vena contracta area (VCA), 74
Ventricular function in congenital heart
disease, 197; see also Adult congenital
heart disease
global function variables, 200
left ventricle in CHD, 197
longitudinal function variables, 199–200
pulmonary bioprosthesis, 198
right ventricle in adult CHD, 199
Ventricular septal defects (VSDs), 156, 190–
192, 202; see also Adult congenital
heart disease
left ventricular outflow tract obstruction,
192–193
relationship with tricuspid and aortic
valves, 192
Ventricular septal rupture (VSR), 156
Virtual ring, 111
VSDs, see Ventricular septal defects
VSR, see Ventricular septal rupture
W
WATCHMAN device, 255, 264
WBC, see White blood cell
White blood cell (WBC), 131