An update on intraoperative three-dimensional transesophageal echocardiography

Abstract

Transesophageal echocardiography (TEE) was first used routinely in the operating rooms in the 1980s to facilitate surgical decision-making. Since then, TEE has evolved from the standard two-dimensional (2D) exam to include focused real-time three-dimensional (RT-3D) imaging both inside and outside the operating rooms. Improved spatial and temporal resolution due to technological advances has expedited surgical interventions in diseased valves. 3D imaging has also emerged as a crucial adjunct in percutaneous interventions for structural heart disease. With continued advancement in software, RT-3D TEE will continue to impact perioperative decisions.

Keywords: Three dimensional (3D); echocardiography; intraoperative.

Figure 1

3D quantification of the left ventricle (LV). (A) Multi-beat 3D acquisition of the left ventricle (LV); (B) automated 3D quantification software used to calculate end diastolic volume (EDV), end systolic volume (ESV), and ejection fraction (EF).

Figure 2

3D Multiplanar reconstruction (MPR) of aortic valve (AV) and left ventricular outflow tract (LVOT) obtained from a 3D gated acquisition. (A) 3D planimetry of LVOT area in mid-systole with green and blue boxes in perpendicular long axis (LAX) planes, red box in the short axis (SAX) plane; (B) 3D planimetry of AV area in mid-systole with green and blue boxes in perpendicular LAX planes, red box in the SAX plane.

Figure 3

En face view of the mitral valve (MV) with the aortic valve (AV) and the 12 o’clock position, and the left atrial appendage (LAA) at the 9 o’clock position and the MV leaflet segments A as anterior and P as posterior.

Figure 4

3D imaging of the mitral valve (MV) demonstrating complex pathology of mitral regurgitation: cleft and prolapse and improvement of spatial and temporal resolution with a multi-beat acquisition. (A) Narrow sector, single beat acquisition 3D of MV. Yellow arrow delineating small P1 prolapse (FR 6 Hz); (B) red arrow delineating cleft between P2/P2 segments; (C) 4 beat gated acquisition of the same MV demonstrating improved temporal resolution (FR 28 Hz), spatial resolution, and visualization of P1 prolapse (yellow arrow) (FR 6 Hz); (D) 4 beat gated acquisition of the same MV demonstrating improved temporal resolution (FR 28 Hz), spatial resolution, and visualization of cleft (red arrow).

Figure 5

Calculation of mitral valve area. (A) MPR of 3D multi-beat CFD acquisition during mid-systole with planimetry of the functional mitral valve (MV) orifice. The green plane is the anterior-posterior diameter of the MV, and the red plan is the medial-lateral diameter of the MV; (B) MPR of 3D multi-beat acquisition during mid-systole with planimetry of the anatomic mitral valve (MV) orifice of a different valve. The green plane is the anterior-posterior diameter of the MV, and the red plane is the medial-lateral diameter of the MV.

Figure 6

Percutaneous edge-to-edge MV repair. (A) MV enface view to orient the clip perpendicular to the MV coaptation line; (B) double orifice of the MV after deployment of 1 clip; (C) multi-beat acquisition of color flow Doppler (CFD) to assess residual mitral regurgitation (MR) with two jets seen (green arrows); (D) two separate regurgitant jets seen in MPR of the 3D CFD data set, with the anterior jet (yellow arrow) appearing larger and the target for the second clip.

Figure 7

Analysis of mitral valve paravalvular leak (MV PVL), and guidance of PVL closure. (A) Single beat 3D CFD acquisition of PVL (green arrow), showing a large posteromedial PVL with the aortic valve (AV) in the 12 o’clock position and the left atrial appendage (LAA) in the 9 o’clock position; (B) single beat narrow sector 3D image of the procedural catheter (red arrow) engaging the PVL; (C) quantification of the size of the PVL (green arrow) with multiplayer reconstruction (MPR) with two orthogonal planes (red, green) and tracing the short axis (blue plane); (D) single beat narrow sector 3D image of the well-seated closure device (yellow arrow).

Figure 8

Analysis of 3D multi-beat acquisition of the AV. 3D planimeter area of the AV annulus in the green plane with the two diameters (D1, D2) shown in the red and blue planes.

Figure 9

3D narrow sector acquisition of the tricuspid valve (TV). (A) En face view of the TV with the leaflets labeled and the orientation such that the septal leaflet is at 6 o’clock; (B) MPR with green and red plane orthogonal to the blue, short axis plan to determine the TV annular area in mid-diastole.

Figure 10

Atrial septal defect (ASD). (A) Quantitative analysis of 3D CFD gated data acquisition with green and red planes orthogonal to the blue plane, where planimetry of the ASD functional size is performed (yellow arrow, ASD); (B) well-seated closure device seen from the left atrial (LA) side in a single beat 3D narrow sector acquisition (red arrow, procedural catheter).