Lissa Sugeng

EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography.

Roberto M. Lang, MD, FASE*‡, Luigi P. Badano, MD, FESC†‡, Wendy Tsang, MD*, David H. Adams, MD*, Eustachio Agricola, MD†, Thomas Buck, MD, FESC†, Francesco F. Faletra, MD†, Andreas Franke, MD, FESC†, Judy Hung, MD, FASE*, Leopoldo Pérez de Isla, MD, PhD, FESC†, Otto Kamp, MD, PhD, FESC†, Jaroslaw D. Kasprzak, MD, FESC†, Patrizio Lancellotti, MD, PhD, FESC†, Thomas H. Marwick, MBBS, PhD*, Marti L. McCulloch, RDCS, FASE*, Mark J. Monaghan, PhD, FESC†, Petros Nihoyannopoulos, MD, FESC†, Natesa G. Pandian, MD*, Patricia A. Pellikka, MD, FASE*, Mauro Pepi, MD, FESC†, David A. Roberson, MD, FASE*, Stanton K. Shernan, MD, FASE*, Girish S. Shirali, MBBS, FASE*, Lissa Sugeng, MD*, Folkert J. Ten Cate, MD†, Mani A. Vannan, MBBS, FASE*, Jose Luis Zamorano, MD, FESC, FASE†, and William A. Zoghbi, MD, FASE*

Dynamic three-dimensional echocardiography : methods and clinical potential

In this article, we will attempt to review basic requirements for three‐dimensional reconstruction, methods of cavity reconstruction, approaches to gray scale tissue‐depiction displays, and current clinical experience, and also present some directions for future development. (ECHOCARDIOGRAPHY, Volume 11, May 1994)

Two- and Three-Dimensional Transesophageal Echocardiography in Patient Selection and Assessment of Atrial Septal Defect Closure by the New DAS–Angel Wings Device Initial Clinical Experience

BACKGROUND Transcatheter closure of atrial septal defects (ASDs) has been feasible and successful. Two-dimensional echocardiography (2DE) was applied to patients before selection and during device deployment. Three-dimensional echocardiography (3DE) can provide unique anatomic perspectives that might aid in improving device closure of ASDs. METHODS AND RESULTS Twenty-two consecutive patients were enrolled in an initial protocol for ASD device closure by the new DAS-Angel Wings occluder device. On the basis of transesophageal (TEE) 2DE and 3DE, 13 patients were considered eligible for device closure (9 secundum ASDs and 4 with patent foramen ovale associated with a cerebral vascular accident). Maximal ASD diameter and surrounding rim tissues were compared by TEE 2DE and 3DE and with balloon sizing measurements at catheterization. ASD size measured by TEE 2DE and 3DE correlated well (y = 1.0x + 0.049, r = .95), with good limits of agreement. However, balloon-stretched diameter measurements were systematically larger than echocardiographic measurements. Rim tissue measurements correlated well; however, TEE 3DE could demonstrate the entire shape and perimeter of the defect. Two-dimensional imaging provided reliable information during device deployment and for closure of small ASDs. However, 3DE was superior for imaging the device, especially when abnormally placed. CONCLUSIONS Three-dimensional imaging provides unique images and projections that were essential for understanding the spatial relationship of the device to the atrial septum. Three-dimensional echocardiography significantly enhanced our understanding of two-dimensional images and provided an imaging conceptualization that should aid in future development of device closures.

Left ventricular assessment using real time three dimensional echocardiography

The ability to accurately assess left ventricular function non-invasively is essential for patient management since it has been known for years that left ventricular ejection fraction serves as an important predictor of long term survival. Although two dimensional (2D) echocardiography is routinely used in clinical practice to obtain information on left ventricular dimension, wall thickness, and function, this technique is limited because it relies heavily on geometrical assumptions to provide quantitative parameters of left ventricular function. In order to avoid these geometrical constraints, three dimensional (3D) reconstructions of the left ventricular cavity have been performed over the last 30 years using a variety of method. Although multiple studies have validated the superiority of 3D over 2D echocardiography to assess left ventricular function, 3D methods have not been embraced in clinical practice because of the cumbersome methodology used to date for both data acquisition and analysis. This manuscript will review prior 3D techniques used to quantitate left ventricular function and present an overview of the recently introduced matrix array transducer capable of generating real-time 3D transthoracic echocardiographic images. Estimations of left ventricular volumes were first performed using M mode echocardiography. Published data using this unidimensional technique reported a large volume discrepancy between this methodology and angiographic data. Although 2D echocardiography has improved left ventricular volume calculations, underestimations are still frequently reported when compared with gold standard methods such as angiography and magnetic resonance imaging (MRI).1–4 Three separate steps are required to assess left ventricular function using 3D echocardiography: (1) data acquisition, (2) image processing, and (3) data analysis. Acquisition of a 3D volume dataset may be obtained with a variety of methods such as free-hand scanning using mechanical or non-mechanical locators, gated sequential acquisition methods, and sparse and full matrix array transducers capable of obtaining real time data sets. …

Trends in Aortic Valve Replacement for Elderly Patients in the United States, 1999-2011

IMPORTANCE There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge. OBJECTIVE To assess procedure rates and outcomes of surgical AVR over time. DESIGN, SETTING, AND PARTICIPANTS A serial cross-sectional cohort study of 82,755,924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011. MAIN OUTCOMES AND MEASURES Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates. RESULTS The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100,000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%- 4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011. CONCLUSIONS AND RELEVANCE Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially. Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked. Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments.

Dynamic three-dimensional echocardiographic assessment of intracardiac blood flow jets

Transthoracic dynamic 3-dimensional reconstruction of the heart with tissue depiction has been proved to be feasible when using various methods of data acquisition. The same method can theoretically be applied to color Doppler flows to generate dynamic 3-dimensional images of intracardiac blood flow jets. To explore the feasibility of this approach, we studied 41 patients with various valvular disorders or intracardiac shunts. We acquired sequential 2-dimensional images along with color Doppler information using rotational scanning from a transthoracic or a subcostal window. Images were digitized and processed for 3-dimensional reconstruction using dedicated software. After adequate segmentation, the flow jets were displayed in 3 dimensions in a gray scale format. With use of this approach, 3-dimensional reconstruction of color Doppler flows was possible in all but 1 patient. Still frames allowed immediate appreciation of the shape of the jets, their location in the cardiac chambers, and their size related to that cavity. Dynamic display was even more striking by showing the flow in real time. Dynamic 3-dimensional images enabled visualization of flow jets in projections not available in conventional color flow Doppler, looking directly at the views of shunt and regurgitant flows, and also permitted 3-dimensional delineation of flow convergence zones. We conclude that dynamic visualization of various intracardiac flows in 3 dimensions using transthoracic echocardiography is possible. It provides a better understanding of the shape and size of the jets, and can potentially aid in flow quantification by displaying the actual shape of flow convergence regions.

Accuracy of aortic annular measurements obtained from three-dimensional echocardiography, CT and MRI: human in vitro and in vivo studies

Objectives To determine the accuracy of calcium-containing rings measurements imaged by three-dimensional echocardiography (3DE), multi-slice CT (MSCT) and cardiac magnetic resonance (CMR) under ideal conditions against the true ring dimensions. To compare the accuracy of aortic annulus (AoA) measurements in ex vivo human hearts using 3DE, MSCT and CMR. To determine the accuracy of AoA measurements in an in vivo human model. Design 3DE, MSCT and CMR imaging were performed on 30 calcium-containing rings and 28 explanted human hearts. Additionally, 15 human subjects with clinical indication for MSCT underwent 3DE. Two experts in each modality measured the images. Main outcome measures Bias and intraclass correlation coefficient for accuracy of imaging measurements when compared with actual ring dimensions. Bias, intraclass correlation coefficient and variability were obtained: (1) when comparing explanted human heart AoA measurements from the two remaining imaging modalities with the most accurate one as determined from the ring measurements and (2) in in vivo human AoA measurements. Analysis was repeated on explanted heart subgroups divided by aortic valve Agatston score. Results Against the known ring dimensions, CMR had the highest accuracy and the lowest variability. MSCT measurements had high accuracy but wider variability and 3DE had the lowest accuracy with the largest variability. When 3DE and MSCT were compared with CMR, 3DE underestimated and MSCT overestimated AoA dimensions, but inter-measurement variability of 3DE and MSCT were similar. When divided by Agatston score, both 3DE and MSCT measurements were larger and showed greater variability with increasing calcium burden. The in vivo study showed that the correlation between 3DE and MSCT measurements was high; however, 3DE measurements were smaller than those measured with MSCT. Conclusions In the in vitro model, CMR measurements were the most accurate for assessing the actual dimensions suggesting that further investigations on its role in AoA measurement in TAVR are needed. However from the in vivo model, MSCT and 3DE are reasonable alternatives with the understanding that they can slightly overestimate and underestimate annular dimensions, respectively.

Transthoracic real-time three-dimensional echocardiography using a fan-like scanning approach for data acquisition: methods, strengths, problems, and initial clinical experience.

Three‐dimensional echocardiography is an emerging clinical method to assess cardiovascular disorders. The feasibility of using a linear mode scanning (parallel slicing) for transthoracic data acquisition has been demonstrated. In this study, we evaluated the feasibility of real‐time transthoracic three‐dimensional imaging of the heart using a fan‐like scanning mode of echocardiographic data acquisition. We used a computer‐driven motor to sequentially angulate transthoracic transducers over a fan‐like arc up to 90°. With careful ECG and respiratory gating, we acquired basic two‐dimensional data set via parasternal and subcostal windows and performed dynamic three‐dimensional reconstructions. The problems encountered included the need to repeat data acquisition sequences because of transducer movement or inappropriate gain and grayscale settings. From 15 scanning sequences in four patients, we were able to use ten sets of data. These yielded good quality three‐dimensional studies projecting normal valves, a stenotic mitral valve, and an atrial septal defect, in a number of novel views. The valves could be visualized from above and fioni below as well as in other orientations, and the detailed anatomy appraised. Spatial relationships of the atrial septal defect with inferior and superior vena cava, coronary sinus, or tricuspid annulus could be uniquely displayed through views from the right side of the heart. This technique provided adequate new imaging planes not available from two‐dimensional echocardiography. This experience demonstrates for the first time that transthoracic three‐dimensional echocardiography using a fan‐like scanning mode of data acquisition is feasible, and that it provides adequate visualization ofintra‐cardiac structures in unique projections. This article presents the first clinical experience with this approach. Further developments of this technique could propel three‐dimensional echocardiography in day‐to‐day clinical practice.

New Insights and Observations in Three-Dimensional Echocardiographic Visualization of Ventricular Septal Defects Experimental and Clinical Studies

BACKGROUND The positions, sizes, and shapes of ventricular septal defects (VSDs) can be difficult to assess by 2-dimensional echocardiography (2DE). Volume-rendered 3-dimensional echocardiography (3DE) can provide unique views of VSDs from the left ventricular (LV) side, allowing complete assessment of their circumference and spatial orientations to other anatomic structures. METHODS AND RESULTS Seventeen experimentally created defects of various locations, sizes, and shapes were imaged and reconstructed in 9 explanted porcine hearts. From an en face projection, major and minor axis diameters of the defects were measured, and these data were compared with direct anatomic measurements. Optimal reconstructions of the VSDs were obtained in all heart specimens, accurately depicting their positions and shapes. The correlations between 3DE and anatomy for the VSD major and minor axis diameters were y=1.0x+0.3 (r=0.88, P<0.001) and y=1.0x-1.4 (r =0.89, P<0.001), respectively. Good agreement between the 2 methods was demonstrated for all measurements. Our experience from the in vitro model was then applied to patient studies. Optimal LV en face reconstructions were obtained in 45 of 51 patients, permitting detailed assessment of the positions, sizes, and shapes of the VSDs. In the 25 patients with comparative surgical measurements, the correlations between 3DE and surgery for the VSD major and minor axis diameters were y =0. 81x+2.1 (r=0.92, P<0.001) and y=0.73x+2.0 (r=0.91, P<0.001), respectively. Good agreement was demonstrated between measurements made by 3DE and those obtained at surgery. CONCLUSIONS 3DE provides excellent visualization of various types of VSDs. From an LV en face projection, the positions, sizes, and shapes of VSDs can be accurately determined. Such precise imaging will be beneficial for surgical and catheter-based closure of difficult perimembranous and singular or multiple muscular VSDs.

Volume-rendered, three-dimensional echocardiographi determination of the size, shape, and position of atrial septal defects: Validation in an in vitro model

Accurate evaluation of atrial septal defect (ASD) size and shape is very important for the selection of patients for transcatheter occlusion. The ability of volume-rendered, three-dimensional echocardiography (3DE) in displaying ASDs in a dynamic mode has been demonstrated; however, its accuracy in sizing ASDs is unknown. To assess this, we performed 3DE of 10 explanted pig hearts in which ASDs of various locations, sizes, and shapes had been experimentally created. From en face 3DE views of the atrial septum containing the defects, major and minor diameters of the defect were measured by a blinded observer, and these data were compared to direct anatomic measurements. The correlations between 3DE and anatomy for the major and minor ASD diameters were y = 0.83x + 3.4 (r = 0.97, p < 0.0001) and y = 0.92x + 1.3 (r = 0.92, p < 0.0001) respectively. The correlation between the measures for major and minor axis ratio was y = 1.06 x - 0.052, r = 0.91, p < 0.0002. Good agreement between both methods of measurements was demonstrated for all measurements. In addition, 3DE portrayed the location and shape of the defects accurately. Thus 3DE provides excellent visualization of ASD and is able to accurately define the size of the defects. These qualitative and quantitative capabilities enhance the clinical potential of this technique in the appraisal of ASDs for decisions regarding application of closure devices.