3d Echo Cardiology

Three-Dimensional Echocardiography: The Benefits of the Additional Dimension Roberto M. Lang, Victor Mor-Avi, Lissa Sugeng, Petra S.
Nieman, and David J. Sahn J. Am. Coll. Cardiol. 2006;48;2053-2069; originally published online Oct 31, 2006; doi:10.1016/j.jacc.2006.07.047 This information is current as of November 3, 2011 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://content.onlinejacc.org/cgi/content/full/48/10/2053
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Journal of the American College of Cardiology 2006 by the American College of Cardiology Foundation Published by Elsevier Inc.
Vol. 48, No. 10, 2006 ISSN 0735-1097/06/$32.00 doi:10.1016/j.jacc.2006.07.047
FOCUS ISSUE: CARDIAC IMAGING
State-of-the-Art Paper Three-Dimensional Echocardiography
Three-Dimensional Echocardiography
The Benets of the Additional Dimension
Roberto M. Lang, MD,* Victor Mor-Avi, PHD,* Lissa Sugeng, MD,* Petra S. Nieman, MD, David J. Sahn, MD Chicago, Illinois; and Portland, Oregon
Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenal of clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiologists decisions are based on images created from ultrasound wave reections. From the time ultrasound imaging technology provided the rst insight into the human heart, our diagnostic capabilities have increased exponentially as a result of our growing knowledge and developing technology. One of the most signicant developments of the last decades was the introduction of 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-line reconstruction to real-time volumetric imaging. While continuing its meteoric rise instigated by constant technological renements and continuing increase in computing power, this tool is guaranteed to be integrated in routine clinical practice. The major proven advantage of this technique is the improvement in the accuracy of the echocardiographic evaluation of cardiac chamber volumes, which is achieved by eliminating the need for geometric modeling and the errors caused by foreshortened views. Another benet of 3D imaging is the realistic and unique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3D imaging is extremely useful in the intraoperative and postoperative settings because it allows immediate feedback on the effectiveness of surgical interventions. In this article, we review the published reports that have provided the scientic basis for the clinical use of 3D ultrasound imaging of the heart and discuss its potential future applications. (J Am Coll Cardiol 2006; 48:2053 69) 2006 by the American College of Cardiology Foundation
Signicant advances in ultrasound, such as the transition from M-mode to 2-dimensional (2D) imaging, coupled with the addition of pulsed- and continuous-wave Doppler and color ow, have established echocardiography as one of the most clinically used diagnostic tools in daily cardiology practice. Although 2D echocardiography has impacted our ability to diagnose valvular and ischemic heart disease, the concept of 3-dimensional (3D) imaging has been envisioned by numerous investigators as a natural evolution of this technology. Initial efforts used echocardiography-gated 2D acquisition techniques based on freehand imaging from multiple acoustic windows or a single acoustic window, necessitating spatial tracking using a spark gap method or magnetic locators (17). This methodology resulted in wire-frame or surface-rendered reconstructions of the ventricular chambers, from which accurate calculations of ventricular volumes (35,79), mass (9 12), and ejection
From the Cardiac Imaging Center, Departments of Medicine and Radiology, University of Chicago, Chicago, Illinois; and the Cardiac Fluid Dynamics and Imaging Laboratory, Oregon Health and Science University, Portland, Oregon. Dr. Lang has received research and equipment grants and honoraria for the speakers bureau from Philips; Dr. Mor-Avi received a research grant from Philips; Dr. Sugeng received honoraria for the speakers bureau from Philips; Dr. Sahn is a consultant to General Electric Healthcare and Philips Medical Systems and received a research partnership grant from the National Institutes of Health with a subcontract with General Electric. Manuscript received May 10, 2006; revised manuscript received July 6, 2006, accepted July 10, 2006.
fraction (EF) (35,79) could be obtained. In addition, this approach provided a more in-depth understanding of the saddle shape of the mitral valve apparatus and thus redened our diagnostic criteria for mitral valve prolapse (13). Continued efforts led to sequential data acquisition, gated to echocardiography and respiration using either a rotational, fan-like, or parallel approach. From either a transthoracic or transesophageal xed acoustic window, 2D images collected at smaller increments enabled volume-rendered 3D reconstructions of ventricular or valvular structures with more anatomical detail and spatial relationships in complex congenital heart disease, not seen with previous 3D images (14 16). Visualization of color ow jets in 3 dimensions was also achieved using this technique (17,18). Although it became readily apparent that 3D echocardiography provides more accurate and reliable measurements of chamber size and function and improved delineation of valvular and congenital abnormalities, the complex acquisition and lengthy data analysis have limited the use of 3D echocardiography in daily clinical practice. To overcome these limitations, investigators and manufacturers teamed to develop faster imaging strategies coupled with on-line rendering, which could be used for quantication of chamber size and function. One of the rst attempts at volumetric imaging used a sparse array matrix transducer (2.5 or 3.5
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Lang et al. 3D Echocardiography
JACC Vol. 48, No. 10, 2006 November 21, 2006:205369
CLINICAL APPLICATIONS
Abbreviations and Acronyms 2D 2-dimensional 3D 3-dimensional EF ejection fraction LV left ventricle/ventricular MRI magnetic resonance imaging TEE transesophageal echocardiography
MHz) containing 256 elements that were activated nonsimultaneously to generate a 60 60 pyramidal volume within a single heartbeat. Images were displayed in 2 orthogonal (B-scan) and 2 to 3 parallel short-axis planes (19,20). This approach was advantageous for stress testing (21,22) and also resulted in accurate left ventricular (LV) volumes and EF (2325). Although the sparse array transducer was capable of generating on-line different cut-planes from a 3D volume, it was unable to display in real-time rendered 3D images. In addition, poor image quality, large transducer footprint, and the lack of portability hampered the use of this system. Signicant advances in ultrasound, electronic, and computer technology have thrust the eld forward toward the development of a fully sampled matrix array transducer and on-line 3D display of rendered images (Fig. 1), as well as software for postprocessing and quantication. The ease of data acquisition, the ability to image the entire heart nearly in real time, as well as the ability to focus on a specic structure in a single beat have brought 3D echocardiography closer to routine clinical use (Fig. 2). Within several years of its inception, real-time 3D technology has sparked new endeavors in research and opened a glimpse into the future of echocardiography.
Since the early 1990s, the usefulness of 3D echocardiography has been shown in several areas, including: 1) direct evaluation of cardiac chamber volumes without the need for geometric modeling and without the detrimental effects of foreshortened views (26 41); 2) unique noninvasive realistic views of cardiac valves (13,4258) and congenital abnormalities (59 71), extremely helpful for showing a variety of pathologies (72) and assessing the effectiveness of surgical or percutaneous transcatheter interventions (63,73 82); 3) direct 3D assessment of regional LV wall motion aimed at objective detection of ischemic heart disease at rest (37,83 86) and during stress testing (21,87), as well as quantication of systolic asynchrony to guide ventricular resynchronization therapy (88 92); 4) 3D color Doppler imaging with volumetric quantication of regurgitant lesions (18,67,93,94), shunts (95), and cardiac output (96,97); and 5) volumetric imaging and quantication of myocardial perfusion (98 102). In some instances, the scientic evidence seems strong enough to endorse the use of 3D echocardiography as a new standard in the clinical assessment of the heart (40,103106). Chamber quantication. One of the main reasons for requesting an echocardiogram in routine clinical practice is the assessment of global and regional LV function. To date, this assessment is predominantly performed using visual interpretation or eye-balling of dynamic ultrasound images of the beating heart, which requires adequate training and experience to accurately estimate LVEF and evaluate wall motion. However, the limitations of this subjective interpretation have been long recognized, and consequently the use of quantitative techniques has been recommended. Thus, multiple methods of measuring LV size and function
Figure 1. The transition from 2-dimensional (2D) to 3-dimensional (3D) imaging. Although 2D imaging is based on scanning a single cross-sectional plane of the heart at a time (left), 3D imaging scans a pyramidal volume (right). RT3D real-time 3D echocardiography.
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Figure 2. Different modes of data acquisition using the matrix-array transducer. These include narrow-angled scan (left), zoom mode (middle), and wide-angled scan (right). Reproduced, with permission, from Sugeng et al. (32).
have been developed, validated, and rened for both M-mode and 2D B-mode images, and subsequently for reconstructed 3D images and more recently for volumetric real-time 3D data sets. The relative inaccuracy of the 1-dimensional and 2D echocardiographic approaches has been attributed to the need for geometric modeling of the ventricle. The missing dimensions have also been consistently referred to as the main source of the relatively wide intermeasurement variability of the echocardiographic estimates of ventricular size and function. In addition, the frequently encountered limitations in endocardial visualization, particularly in the apical-lateral segments of the LV, are commonly compensated for by tilting the transducer. This maneuver generally improves endocardial visualization, but at the same time generates oblique or foreshortened views of the ventricle, resulting in even less accurate and reproducible measurements. In this regard, the biggest advantage of 3D echocardiography is the lack of dependence
on geometric modeling and image plane positioning, which theoretically should result in accurate chamber quantication (Fig. 3). Nevertheless, almost all studies that have directly compared the accuracy of 3D measurements of LV volumes and EF have shown the superiority of the 3D approach over the 2D methodology, which was shown to consistently underestimate LV volumes. This superiority was shown in both accuracy and reproducibility when compared against independent reference techniques, such as radionuclide ventriculography or magnetic resonance imaging (MRI) (3,4,12,21,30,34,35,40,107110). These improvements have been shown irrespective of the 3D acquisition strategy used. Although in earlier 3D studies, quantication of LV size and function relied on tedious, manual, or at best semiautomated tracing of endocardial boundaries in multiple planes, today it is based on near fully automated frame-by-frame detection of the 3D endocardial surface
Figure 3. Dynamic analysis of real-time 3-dimensional data. Biplanar display (left) can be used to detect left ventricular (LV) endocardial surface at each time point (middle), which allows the calculation of LV volume over time throughout the cardiac cycle (right).
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Figure 4. Effects of volumetric imaging on the accuracy of left ventricular (LV) mass measurements. End-diastolic apical 4- (A4C) and 2-chamber (A2C) views of the LV obtained in a patient using conventional 2-dimensional (2D) imaging (top) and anatomically correct apical 4- and 2-chamber cut planes selected from a real-time 3-dimensional (3D) data set obtained in the same subject (middle). Manually traced endocardial and epicardial boundaries used to calculate LV mass are shown on the images. The LV long-axis dimension was measured on such images in 19 patients (bottom). Note the increase in the length of the LV in both apical views, as assessed by the 3D technique in most patients (large circles and error bars represent mean SD, *p 0.05). Reproduced, with permission, from Mor-Avi et al. (114).
from real-time 3D data sets. Recently, a similar approach was implemented in commercial imaging systems, is rapidly gaining widespread popularity because of its accuracy and ease of use (111), and is poised to become part of the mainstream assessment of LV function. Another clinically important variable that is frequently assessed by echocardiography is LV mass. Measurement of LV mass relies not only on endocardial but also on epicardial visualization, which is known to be even more challenging because of the difculties in identifying the epicardial border. This difculty is in addition to the limitations previously discussed for the measurements of LV volumes, such as inaccurate modeling and foreshortening. Again, the use of 3D images seems to have overcome these limitations,
as several studies have reported signicant improvements in the accuracy and reproducibility of 3D estimates of LV mass compared with their traditional M-mode and 2D counterparts (10,11,106,112115) (Fig. 4). Similar results conrming improved accuracy and reproducibility of the 3D approach were reported by investigators who compared 2D and 3D echocardiographic measurements of left and right atrial volumes against an independent gold standard (3,39,116,117). These ndings may have important clinical implications on the diagnosis and management of patients with atrial brillation, diastolic dysfunction, and acute myocardial infarction. Because of its complex geometrical crescent shape, the estimation of right ventricular volumes based on geometric modeling from 2D images has been extremely challenging. Thus, not surprisingly, the intrinsic ability of 3D imaging to directly measure right ventricular volumes without the need for geometrical modeling has resulted in signicant improvements in accuracy and reproducibility compared with previously used 2D techniques (26,31,118 120). Diagnosis of regional wall motion abnormalities in echocardiographic studies is routinely performed by visually integrating regional endocardial motion and wall thickness. The reproducibility of this interpretation is limited because of its subjective nature, which is also extremely dependent on the experience of the reader. This is of particular concern in patients with suboptimal image quality that impedes endocardial visualization. Not only may endocardial segments that are poorly visualized be incorrectly interpreted as having abnormal wall motion, but also discrete areas of hypokinesis may be missed because they are simply not visualized in the standard imaging planes. It is not uncommon for an echocardiographer performing the test to slightly change transducer orientation to better see a specic myocardial segment. Such maneuvers can make a myocardial segment look like an area of hypokinesis, or alternatively, can make an apparent wall motion abnormality disappear, and thus affect the diagnostic accuracy of the test. In this regard, volumetric imaging is different because the 3D data set contains the complete dynamic information on LV chamber contraction and lling. Importantly, such data sets are acquired virtually instantaneously, and any 2D view can be obtained from them simply by cropping out or peeling off the rest of the information. In addition, the function of any ventricular wall can be objectively assessed by measuring a variety of wall motion parameters (37) (Fig. 5). For these reasons, 3D data sets are extremely appealing for the evaluation of regional LV function. Real-time 3D imaging has been recently used during dobutamine stress testing and found to be feasible and useful for the detection of stress-induced wall motion abnormalities (121) (Fig. 6). Several other studies have explored the potential of quantitative evaluation of regional LV function based on segmental analysis of the dynamic 3D endocardial surface (37,83 86). The use of
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Figure 5. Volumetric analysis of regional left ventricular (LV) function. Example of LV endocardial surface detected from a 3-dimensional (3D) data set at 3 different phases of the cardiac cycle, superimposed on a cross-sectional long-axis plane (top left). Schematic representation of the 3D segmentation model: A2C, A3C, and A4C apical 2-, 3-, and 4-chamber planes, respectively; Ao central point of the aortic annulus; MV central point of the mitral valve (top right). Shaded area is an example of an LV endocardial surface segment representing the midseptal (m-sp) wall. Below are examples of regional volume and wall motion time curves and regional shortening fraction (RSF) in 6 apical segments, obtained in a normal subject (left) and a patient with coronary artery disease (CAD) (right) and hypokinesis in the lateral wall (arrow). Ant anterior; asp anteroseptal; inf inferior; lat lateral; %RR percent of electrocardiogram RR-interval; pst posterior; sp septal.
this methodology in clinical practice requires further studies to be performed in larger groups of patients. A clinically useful byproduct of the 3D quantication of regional LV wall motion is the ability to quantify the temporal aspects of regional endocardial systolic contraction, which have been used for objective serial diagnosis of LV systolic asynchrony as a guide for resynchronization therapy (90,91), despite the relatively low temporal resolution of real-time 3D imaging. The standard deviation of the regional ejection times (interval between the R wave and peak systolic endocardial motion) has been used as an index of myocardial synchrony. This approach has been used to assess the short- and long-term benets of biventricular pacing (Fig. 7). A recent study has shown a direct relationship between overall LV performance and synchronicity (92). In this study, this approach has also
been shown to be useful for identifying patients with severe heart failure and asynchronous LV contraction who could theoretically benet from resynchronization therapy but would not be considered candidates based on their QRS duration (92). Also, real-time 3D intracardiac imaging has been successfully used to guide the positioning of pacing catheters during interventional electrophysiology (89). Recently, it has become feasible to perform multiplanar simultaneous tissue Doppler-based strain rate imaging using a matrix array transducer (Fig. 8). The clinical benets of this approach versus the existing single plane strain and strain rate imaging have yet to be determined. Contrast-enhanced 3D echocardiography. The ability of conventional contrast-enhanced echocardiographic imaging to provide accurate information on the extent and
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Figure 6. Off-line viewing of real-time 3-dimensional data obtained during dobutamine stress test. These data sets can be used to extract multiple short-axis views at different levels of the left ventricle (left). Example of such views extracted from data sets obtained at rest and during peak dobutamine stress (right).
severity of either wall motion or perfusion abnormalities is also limited by its 2D nature. Despite the obvious appeal of the 3D imaging in this context, its use in humans has not been explored until recently. This is because this approach relied on off-line reconstruction from multiple planes, signicantly complicating volumetric assessment of LV function. The feasibility of applying
volumetric analysis to contrast-enhanced real-time 3D data sets obtained in patients with suboptimal image quality was recently tested. This approach allows quantication of global (122) as well as regional (123) LV function when used with selective dual triggering at end systole and end diastole to reduce the destructive effects of ultrasound on contrast microbubbles (Fig. 9).
Figure 7. Assessment of the improvement in synchrony of left ventricular (LV) contraction with pacing. Regional volume time curves (left) obtained in a patient with LV dyssynchrony without (top) and with (bottom) biventricular pacing. Endocardial surfaces reconstructed from each data set are shown with segmentation and color coding according to regional time to end ejection (middle) along with the bulls-eye representation of the same data (right). Note the changes in colors with pacing reecting the effects of resynchronization therapy in this parametric display. Ant anterior; Ant-Sept anteroseptal; EF ejection fraction; Inf inferior; Lat lateral; Post posterior; Sept septal.
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Figure 8. Simultaneous multiplanar strain rate imaging. Matrix-array technology allows quantitative assessment of strain rate in multiple myocardial segments by analysis of tissue Doppler data obtained from the apical approach.
Before the development of real-time 3D imaging, assessment of myocardial perfusion had to remain limited to either visualization of perfusion defects (98) or at best quantication of their size (99,100). Quantication of tissue blood ow would require repeated contrast maneuvers, such as bolus injections, which are necessary to assess ow dynamics for each imaging plane, rendering this methodology clinically inapplicable. In contrast, real-time 3D echocardiography offers an opportunity for online volumetric imaging of the entire heart during a single contrastenhancement maneuver. The feasibility of volumetric perfusion imaging was recently tested (101,102) in conjunction with a new technique for volumetric quantitative analysis of myocardial perfusion from contrast-enhanced real-time 3D echocardiography data sets (102) (Fig. 10).
Figure 9. Real-time 3-dimensional (3D) visualization of myocardial perfusion. Contrast-enhanced 3D data set obtained in a patient with severe discrete left anterior descending artery stenosis (left). A region in the interventricular septum shows lack of contrast enhancement, indicating a perfusion defect that was supported by abnormal wall motion. This defect was visible in multiple cross-sections (right), allowing easy estimation of its extent.
The future uses of contrast enhancement for endocardial surface delineation and volumetric myocardial perfusion imaging and quantication will be determined in larger trials, which will also require expanded software capabilities. Valvular heart disease. Most studies using 3D echocardiography have focused on the evaluation of the mitral valve. These studies have played a crucial role in describing and quantifying the geometry of the mitral annulus, leaet surface, tethering distances, and tenting volumes. These studies have also dened and quantied the relationship between the mitral apparatus and the position of the papillary muscles, thus providing insight into the pathophysiology of mitral regurgitation. Initially, 3D visualization of the mitral valve used a wire-frame display, which was instrumental in describing the saddle shape of the mitral annulus and redening the diagnostic criteria for mitral valve prolapse (13). A variety of mitral valve abnormalities have been shown by 3D reconstructions using gated transesophageal echocardiography (TEE) acquisition and volume-rendered display (124). The recent development of a fully sampled matrix array transducer has enabled real-time volumetric imaging of the mitral valve from the transthoracic approach (125) (Fig. 11, top). The feasibility of this approach has been recently demonstrated in a study that showed that the mitral valve could be adequately reconstructed in 70% of consecutive patients (125). The anterior mitral valve leaet was more readily visualized compared with the posterior leaet, probably because of its larger size. The mitral leaets, commissures, and mitral valve orice were also easily viewed. Of note, this study found that the posterior leaet is best visualized from the parasternal window, whereas the ante-
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Figure 10. Volume rendering of the mitral valve obtained from real-time 3-dimensional data. The data set on the left was obtained in a patient with a perforated anterior mitral leaet, which was conrmed by an intraoperative image (right). Reproduced, with permission, from Schwalm et al. J Am Soc Echocardiogr 2004;17:919 22.
rior mitral leaet was equally well seen from either the parasternal or the apical window. The utility of real-time 3D echocardiography in the evaluation of mitral stenosis and accuracy of mitral valve area measurements has been established by multiple studies (46,51,57,126 130). The main advantage of 3D echocardiography is the ability to achieve a perpendicular en-face cut plane of the mitral valve orice, enabling accurate mitral valve area measurements. These measurements have been
found more accurate when performed from the ventricular orientation. When compared with traditional 2D and Doppler measurements, such as 2D planimetry, pressure half-time, and ow convergence, 3D echocardiography best agreed with mitral orice area calculations derived using the Gorlin formula during cardiac catheterization (51,57,129). Importantly, the 3D measurements had the additional advantage of having lower intraobserver and interobserver variability (51,57,129). The ease of acquisition and on-line
Figure 11. Real-time volumetric imaging and analysis of the mitral valve. (Top) Baseline image before mitral balloon valvuloplasty (A) shows a restricted mitral valve opening with bicommissural fusion. After valvuloplasty, splitting of the medial commissure and posterior leaet tear can be seen (B). (Bottom) Example of 3-dimensional reconstruction of the mitral annulus (C) and leaets (D) obtained in a patient with dilated cardiomyopathy, showing the saddle shape of the annulus and increased leaet tenting volume. IVS interventricular septum; LA left atrium; LV left ventricle; M medial; P posterior; RV right ventricle.
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review of real-time 3D echocardiography facilitates immediate assessment of the mitral valve commissural splitting, stretching, or tearing after percutaneous balloon mitral valvuloplasty (PBMV) in the cardiac catheterization laboratory. Immediately after PBMV, changes in left atrial and ventricular compliance together with irregularities of the mitral valve orice limit the utility of the pressure half-time method and 2D planimetry. The high accuracy and reproducibility of 3D echocardiography before and after PBMV compared with the pressure half-time method and 2D echocardiography have been shown in a recent article (130). Characterization of the mitral valve apparatus using 3D echocardiography (Fig. 11, bottom) has shed new light on the pathophysiology of mitral regurgitation in patients with nonischemic and ischemic cardiomyopathy. It has been shown that functional mitral regurgitation is associated with annular dilatation and reduced cyclic variations in annular shape and area (52). Further investigations showed differences in patients with ischemic mitral regurgitation compared with normal subjects in mitral annular shape with increased intercommissural and anteroposterior diameters and increased leaet tenting, indicating chordal tethering (28,47,58,131). Also, patients with anterior wall myocardial infarction have attened mitral annulus, which is more pronounced than with posterior myocardial infarction (132). Three-dimensional echocardiography has also been used to evaluate the differences in the shape and dynamics of 2 types of mitral rings: although the Duran ring seemed nonplanar and showed changes in annular area throughout the cardiac cycle, the Carpentier ring was planar and did not effectively change its area (133). Although the additional information provided by 3D imaging may aid in surgical planning and design of future mitral prostheses and rings, it has been recognized that changes in mitral annular deformation may not be the sole cause of ischemic mitral regurgance (MR). Several studies have reported that MR caused by ischemia occurs in conjunction with remodeling of the ischemic region, leading to LV dilatation with subsequent papillary muscle displacement (134,135). This results in increased chordal tethering and leaet tenting, which in turn leads to mitral regurgitation caused by decreased leaet apposition. Interestingly, an animal 3D echocardiographic study showed that MR resolved after plication of the infarct region (135). Hence, the insights provided by 3D echocardiography have shown that the presence of MR in patients with dilated or ischemic cardiomyopathy is a disease of the remodeled myocardium rather than being caused by a true valvular abnormality. Compared with the mitral valve, the collective experience in visualizing aortic valve disease is limited. Most of the aortic valve imaging has been performed using gated 3D acquisition from the transesophageal approach (43,48,55,94,136 141). The challenges with the 3D imaging of the aortic valve are related to the fact that aortic leaets are thinner and frequently present with heavy calcication, both resulting in drop-out artifacts. Neverthe-
less, it was found that adequate to excellent reconstruction of the aortic valve is feasible in over 80% of patients, more frequently in native than in prosthetic valves (142). Similar to mitral stenosis, in patients with aortic stenosis, TEEbased planimetry of the aortic valve is more accurate with 3D than 2D imaging (48). Three-dimensional echocardiography also results in improved visualization and thus more accurate diagnosis of bicuspid aortic valves, valvular vegetation, prosthetic aortic valve leaks, and subaortic pathology. However, the additional information that 3D echocardiography may offer in this context remains to be determined in future studies. The utility of 3D echocardiography in the evaluation of tricuspid valve disease has not been explored in depth. There have been numerous case reports describing tricuspid abnormalities such as tricuspid stenosis, cleft tricuspid valve, and a ail tricuspid leaet (143147). Initial observations made in the pediatric population, pertaining to the tricuspid annulus and its dynamic interaction with the mitral valve annulus, were that during systole, the area of the tricuspid annulus decreased more in lateral diameter compared with the mitral annulus, and that the tricuspid annulus retained its shape more than the mitral annulus throughout systole (148). Characterization of the tricuspid annulus and leaets in patients with rheumatic heart disease with mitral stenosis and severe tricuspid regurgitation was performed using gated 3D TEE, which showed thickened leaets with restricted motion, together with annular dilatation (149). Volumetric color Doppler imaging. Three-dimensional color ow imaging did not come to fruition until gated TEE methods and computer software allowed reconstruction of 3D color ow jets superimposed on the reconstructed gray scale data (Fig. 12). With the ability to combine 3D color ow with gray scale information, it became possible to detect the origin and direction of jets, to measure regurgitant orice areas, and to improve the delineation of valvular leaks, paravalvular leaks, and multiple jets (18,94,150,151). Initially, reconstructive 3D methods have been used to obtain 3D measurements of stroke volume using Doppler velocities perpendicular to the outow or inow tracts (152,153). With this approach, the surface projection allowed removal of the known limitation of Doppler imaging (i.e., its angle dependency). Although acquisition times were still long, the time required for reconstruction was signicantly shortened. Multiple studies have been published on the accuracy of this method by several investigators (154,155). Multiplanar TEE 3D color ow imaging, however, has many drawbacks because of the long time required for data acquisition, which may result in temporal and spatial misregistration. Another disadvantage is the extended time required for analysis, which has limited the clinical utility of this methodology. Volumetric color ow imaging has overcome some of these limitations and proved useful for estimating regurgitant volumes, stroke volumes, and cardiac output, together with the delineation of valve regurgitation in pediatric
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Figure 12. Color ow volume rendering. These data were obtained in a patient with mitral stenosis depicting a 3-dimensional (3D) mitral regurgitant (MR) jet in systole (A). Both regurgitant jet and left atrium (LA) could be manually traced to estimate the MR and LA volume, displayed as a surface-rendered images superimposed on the 3D image (B and C). The vena contracta (arrows) of the regurgitant jet is shown in two orthogonal views (D and E). The level of the vena contracta is visualized along with the gray-scale information (F).
populations (17,156 159). It has recently been shown that 3D color Doppler imaging can provide accurate measurements of ow in the great vessels and ventricles (Fig. 13) by sampling the entire cross-sectional ow prole through the ventricular outow tract, thus allowing the calculation of valvular ow volume, regurgitant volume, fraction, and orice area (160). Although 3D Doppler laminar ow measures were originally developed using reconstructive 3D, real-time color Doppler volumes are much less time consuming; they reduce respiratory artifacts and allow immediate review without lengthy reconstruction (155). This approach was initially validated in an in vitro setup and in open-chest animals (96,161), and more recently in humans (97). However, there are several issues that continue hampering the daily use of 3D color ow imaging, including: 1) reliance on acquisition of multiple cardiac cycles that may result in stitch artifacts because of the patients inability to maintain a breath hold over 7 to 10 beats; 2) limited sector angle that may not allow complete visualization of eccentric jets; and 3) compromised visualization of 3D gray-scale information when acquired simultaneously with the color. Single-beat acquisition with wider sector and improved resolution as well as online quantication tools are the issues that need to be addressed for 3D color ow imaging to become clinically useful.
Surgical or transcatheter interventions. There has been interest in intraoperative application of 3D imaging as well as intraprocedural guidance of transcatheter interventions in the catheterization laboratory (162,163). Also, in the electrophysiology laboratory, electroanatomical mapping using electromagnetic sensor localization has become widely adopted for complicated procedures (164,165). Intraoperative real-time 3D imaging has mostly been performed from the epicardial surface using narrow-angled acquisition, which only allows the visualization of a relatively thin slice of the heart. One disadvantage of epicardial imaging is the difculty in maintaining acoustic coupling between the transducer and the beating heart. In addition, the use of wide-angled acquisition in this context is limited because it requires cropping of the data set to visualize the structure of interest and thus does not provide easy and immediate visual feedback to the surgeon. Despite these difculties, several groups have used real-time 3D imaging of the beating heart during on-pump procedures to visualize suture closure of atrial septal defects in animal models (166 168). Perinatology and fetal heart. Dynamic 3D echocardiography originally developed for the radiology and perinatology market also has been used for cardiac imaging in the fetus and sometimes in newborns. A curved ultrasound array with a motorized handle can develop 3D images of the fetus
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Figure 13. Real-time 3-dimensional color Doppler stroke volume computation. Dynamic analysis of Doppler velocities in the left ventricular outow tract (LVOT) throughout the cardiac cycle allows accurate quantication of left ventricular stroke volume. AV aortic valve.
in a wide or narrow eld with a rapid mechanical sweep fast enough to stop the heart, therefore avoiding motion artifacts. For resolving heart motion, the mechanical sweep can be either fast (15 or 30 frames/s, covering a narrow eld of view over the fetal chest) or slow with realignment sweeping across the eld with high line density. Then the temporal integration is computed, realigning frames that are matched to the phases of the cardiac cycle by correlating the position of the major interfaces, especially on technically good
images when the fetus does not move or the mother is not breathing. These provide dynamic sequences at 16 to 18 frames per cycle that are measurable for cardiac volumes with acceptable accuracy (169,170) (Fig. 14). This method will gradually be replaced by smaller, larger-aperture matrix technology that requires a higher frequency than is currently available on real-time adult cardiac 3D systems. The original work in this type of realignment (171,172) was followed by other methods of
Figure 14. Real-time 3-dimensional (3D) fetal echocardiography. (A) A 3D image obtained in a 23-week fetus with tetralogy of Fallot and absent pulmonary valve showing a small pulmonary annulus with no valve tissue and a dilated main pulmonary artery. (B) Spatio-temporal image correlation slow-sweep image of ventricular lling in a normal 21-week fetus.
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FUTURE DIRECTIONS
Future advances in transducer and computer technology will allow wider angle acquisition and color ow imaging to be completed in a single cardiac cycle, which will shorten data acquisition time and eliminate stitching artifacts. The transducers will have a smaller footprint and weight with higher spatial and temporal resolution. In addition, transducers capable of 2D imaging only will be gradually phased out and replaced by new probes that will be versatile in their capability of imaging in different modes, including 2D, 3D, and color and tissue Doppler. With these multitasking transducers, it may be possible to signicantly reduce the number of steps required to complete an echocardiographic examination, and thus reduce the time required for the test. For example, the standard 2D views could theoretically be obtained from a single volumetric data set and used for diagnostic purposes, assuming that both spatial and temporal resolution are sufciently high. Signicant improvements from the current state of the art are needed in the temporal resolution as well as in the spatial resolution in the far eld. We also anticipate that the quantication of all cardiac chambers, including ow dynamics, will be performed on the imaging system in an increasingly automated fashion, thus gradually eliminating the need for off-line analysis. This is of crucial importance, in particular in the interventional settings of the catheterization laboratory and the operating room, where immediate visual and quantitative feedback is important. For the purposes of interpretation and storage, it is vital that the 3D data sets are incorporated into digital information systems with full rendering and quantication capabilities.
Figure 15. Real-time 3-dimensional imaging of the right ventricle. Subcostal data set shows both inlet and outow components of the right ventricle required for accurate right ventricular volume determination. MB moderator band; OS INF os infundibulum or opening of the right ventricular outow tract; LV left ventricle;. PV pulmonary valve; TV tricuspid valve.
achieving cardiac gating for fetal wide-eld views, include navigator-type gating of the image data itself, or using a separate waveform derived, for instance, from an umbilical arterial trace. Congenital heart disease. Although it is known that complex anatomy can be more easily understood by 3D navigation, most studies to date have applied this technology to relatively simple congenital diagnostic questions, such as atrioventricular valvular structure and atrioventricular canal en-face views of atrial and ventricular septal defects for sizing (173175). The concept was also put forth that with the real-time 3D imaging, the entire examination might be completed rapidly using a small number of wide-angled acquisitions, thus avoiding the need for pediatric and infant sedation. Nonetheless, excellent renderings of intraventricular anatomical abnormalities, congenital heart valvular disease, and aortic arch and vascular abnormalities have been published (176,177). Although in adult patients most attention has been focused on the 3D quantication of the LV volumes and mass, in congenital heart disease the key focus has been on serial assessment of right ventricular volume. Surgical planning and postoperative status of many patients with congenital heart disease rests with accurate direct quantication of right ventricular function. Most published outcomes studies have involved MRI quantications of right ventricular volume and EFs, but many MRI studies have used an oversimplied approach that does not fully image the inow and outow tracts. Accordingly, a more sophisticated multiplanar approach incorporating RV inow and outow components for volume and mass quantication has been described for both MRI and ultrasound applications (168,178) (Fig. 15).
CONCLUSIONS
In summary, in the coming years, we anticipate that real-time 3D imaging will continue to be integrated into the routine echocardiographic examination. Presently there is sufcient evidence to prove that 3D imaging is superior to the traditional 2D techniques and should be routinely used in 2 clinical scenarios: 1) quantication of LV volume, EF, and mass; and 2) quantication of the mitral valve area in mitral stenosis. Future clinical applications of this technology are likely to include stress testing with real-time volumetric or simultaneous multiplane imaging from a single transducer position. Volumetric assessment of ventricular asynchrony will be used as an additional tool to guide resynchronization therapy. Also, miniaturization of the matrix-array transducer technology will enable both the acquisition of real-time 3D transesophageal images and the development of small-footprint probes suited for pediatric transthoracic and fetal imaging.
Reprint requests and correspondence: Dr. Roberto M. Lang, University of Chicago MC5084, 5841 South Maryland Avenue, Chicago, Illinois 60637. E-mail: rlang@medicine.bsd.uchicago.edu.
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Three-Dimensional Echocardiography: The Benefits of the Additional Dimension Roberto M. Lang, Victor Mor-Avi, Lissa Sugeng, Petra S. Nieman, and David J. Sahn J. Am. Coll. Cardiol. 2006;48;2053-2069; originally published online Oct 31, 2006; doi:10.1016/j.jacc.2006.07.047 This information is current as of November 3, 2011
Updated Information & Services References including high-resolution figures, can be found at: http://content.onlinejacc.org/cgi/content/full/48/10/2053 This article cites 174 articles, 68 of which you can access for free at: http://content.onlinejacc.org/cgi/content/full/48/10/2053#BIB L This article has been cited by 28 HighWire-hosted articles: http://content.onlinejacc.org/cgi/content/full/48/10/2053#other articles Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://content.onlinejacc.org/misc/permissions.dtl Information about ordering reprints can be found online: http://content.onlinejacc.org/misc/reprints.dtl
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Three-Dimensional Echocardiography: The Benefits of the Additional Dimension Roberto M. Lang, Victor Mor-Avi, Lissa Sugeng, Petra S.

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