Đang tải... (xem toàn văn)
(BQ) Part 2 book Comprehensive textbook of echocardiography presents the following contents: Echocardiography/ultrasound examination and training (epiaortic ultrasonography, intracardiac echocardiography, intravascular ultrasound imaging, intravascular ultrasound imaging,...), valvular heart disease (m aortic regurgitation echocardiographic evaluation of aortic disease,...).
CHAPTER 27 Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension Nina Ghosh, Judy R Mangion Snapshot Data Acquisi on 3D Echo Image Op miza on 3D Echo of the Mitral Valve 3D Echo of the Aor c Valve 3D Echo of the Pulmonic Valve 3D Echo of the Tricuspid Valve Case Examples of 3D Echo in Valvular Heart Disease Case Study 1: Paravalvular Leak Mechanical MV Case Study 2: MV Repair and Aor c Valve Replacement Case Study 3: S/P Cardiac Transplant with Right Heart Failure, Tricuspid Valve Replacement INTRODUCTION The history of people’s fascination with three-dimensional (3D) imaging dates back to the movies (Fig 27.1) In the late 1890s, the British film pioneer, William Friese-Greene filed a patent for a 3D movie process In 1922, the earliest confirmed 3D film shown to a paying audience was The Power of Love, using dual strip film and anaglyph glasses The anaglyph glasses were stereoscopic and allowed for the perception of depth By 1951, film attendance had fallen dramatically as television became more popular and Hollywood was looking for a way to lure audiences back In 1952, the first color 3D film, Bwana Devil, was notable for sparking the first 3D boom in the U.S motion picture industry It was not until 2003, however, that stereoscopic Case Study 4: Flail Middle-Scallop, Posterior Leaflet, MV Case Study 5: Bileaflet MV Prolapse, Moderate to Severe Mitral Insufficiency Case Study 6: Severe Aor c Stenosis, Evaluate for Possible TAVR Case Study 7: Rheuma c Mitral Stenosis Case Study 8: S/P Balloon Aor c Valvuloplasty Case Study 9: Mechanism and Severity of Eccentric Mitral Insufficiency Case Study 10: Ques on of Carcinoid Involvement of the Pulmonic Valve film-making became available, a breakthrough technology In 2009, Avatar was released in IMAX 3D theatres, and became the highest grossing film of all-time In many ways, the development of 3D movies reflects the development of 3D echocardiography (3DE), a process that has required continued technological advancement, but is finally making its way into mainstream clinical decision making DATA ACQUISITION To obtain excellent 3D echo images, the echocardiographer needs to be familiar with optimal data acquisition and 3D optimization methods Currently, there are two different methods for 3D echo data acquisition; real time or live 3D echo imaging (Figs 27.2A and B) and 516 Section 2: Echocardiography/Ultrasound Examination and Training electrocardiographically triggered single- and multibeat 3D echo imaging (Figs 27.3A and B) Live 3D imaging can be performed with narrow volumes to improve frame rates, and can be performed in a zoomed mode to focus on a particular area of interest, or can be obtained with a wide angle (full volume) as well as live 3D color Doppler Although live 3D echo overcomes the limitations of multibeat electrocardiographically triggered 3D echo imaging, including rhythm disturbances and/or respiratory motion, it is limited by poor temporal and spatial resolution 3D ECHO IMAGE OPTIMIZATION In general, it is desirable to obtain the best possible twodimensional (2D) image on the echo machine before acquiring 3D images, with the exception of setting overall gain With 3D imaging, low-gain results in echo drop out, and therefore we recommend obtaining 3D imaging at higher machine gains than would normally be obtained with 2D imaging, to avoid losing information Postprocessing controls on 3D workstations allow for adjustments between high- and low-gain settings after the image is acquired Both overall gain and compression should be set in the mid-range (approximately 50) and optimized further with overall time gain compensation (TGCs) Optimizing both lateral resolution (perpendicular to the ultrasound beam) and axial resolution (parallel to the ultrasound beam) remains equally important, as with 2D echocardiography (2DE) The American Society of Echocardiography has published guidelines for image acquisition and display of 3D echo images, which is an excellent reference for improving 3D echo data set quality.1 3D ECHO OF THE MITRAL VALVE Fig 27.1: Audience watching 3D movie and wearing anaglyph glasses, to allow for perception of depth (Special thanks to Eleanore Rhodes for assistance with the illustration) A To acquire optimal transthoracic echo images of the mitral valve (MV) (Figs 27.4A to C), it is best to obtain images from the parasternal long-axis or apical four-chamber views, both with and without color, and using both narrow angle and zoomed acquisitions (Movie clip 27.1) B Figs 27.2A and B: (A) Methods for 3D echo data acquisition includes live 3D narrow volume imaging, in which the 3D image is displayed in real time The image is acquired easily, although may not be of adequate size to capture the entire area of interest With live 3D Zoom; (B) imaging, the volume can be adjusted to include the entire area of interest, however, this may result in even lower frame rates Although live 3D overcomes the limitations imposed by rhythm disturbances or respiratory motion, it is limited by poor temporal and spatial resolution (AoV: Aortic valve; LA: Left atrium; LV: Left ventricle; MV: Mitral valve; RV: Right ventricle) Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension A 517 B Figs 27.3A and B: Electrocardiographically triggered multibeat 3D echo imaging (full volume), allows for the acquisition of larger data sets, and also allows for further refining of images using various postprocessing tools These data sets are usually obtained over 4-7 cardiac cycles (A), and provide for higher frame rates (B) The major limitation of full-volume multibeat acquisitions, include stitch artifacts that may be introduced by respiratory motion and irregular heart rhythms, and may be avoided by having the patient hold their breath, and acquiring only with regular rhythms (MV: Mitral valve; LA: Left atrium; LV: Left ventricle; RV: Right ventricle) A B C Figs 27.4A to C: Protocol for transthoracic 3D echo acquisition of the mitral valve (A) Parasternal long-axis view with and without color; (B) Apical four-chamber view with and without color; (C) Surgeons view of the mitral valve from the left atrium (MV: Mitral valve; LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle; TV: Tricuspid valve) 518 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 27.5A and B: Protocol for transesophageal 3D echo acquisition of the mitral valve (A) 0° to 120° mid esophageal views with and without color; (B) Zoomed acquisition surgeon’s view of the mitral valve from the left atrium (AoV: Aortic valve; MV: Mitral valve) The protocol for acquiring transesophageal echo (TEE) images of the MV (Figs 27.5A and B) involves midesophageal acquisitions from 0° to 120°, both with and without color (Movie clip 27.2) 3D images of the MV can be obtained efficiently, with relatively little probe manipulation 3DTEE for both native and prosthetic MV pathology is a top indication for a 3D exam, and is considered essential for both surgical and percutaneous MV repair (Movie clip 27.3) In general, examining the MV from the left atrium is best for visualizing prolapsing segments, mitral annular shape, and coaptation length, while examining the MV from the ventricular view is best for visualizing the anterior leaflet of the MV, chords, and papillary muscles.2 As 3D imaging permits visualization of the MV in a true short-axis dimension from either the atrial or ventricular side, it is the ideal modality through which to guide both cardiologists and surgeons in preoperative decision making.3 Several studies have demonstrated that real time 3DTEE offers excellent accuracy in identifying specific segmental prolapse, annular dimensions, billowing volume and height, and, in turn, provides important information relevant to surgical repair.3–11 In a study of 40 patients undergoing surgical MV repair, the accuracy of 2DTTE, 2DTEE, 3DTTE, and 3DTEE in distinguishing between functional or organic mitral regurgitation (MR) and the presence/ localization of prolapse was compared Although there was full agreement among all four modalities in identifying functional versus organic MR, 3DTEE had the best agreement with surgical findings in identifying anterior leaflet prolapse and in segmental leaflet analysis.12 Biaggi et al similarly showed the greater accuracy of 3DTEE in characterizing MV prolapse compared to 2DTEE They found that 3DTEE was more accurate (92–100%) than 2DTEE (80–96%) in identifying prolapsed segments, and in determining the height of prolapsed segments Finally, the authors observed that the complexity of MV anatomy as characterized by 3DTEE correlated with the complexity of MV repair Specifically, a greater number of prolapsed segments was associated with progressive enlargement of annular anteroposterior diameter, more complex MV repair, and larger annuloplasty bands.13 Thus, perioperative assessment of MV anatomy and hemodynamics by 3DTEE is largely becoming the standard of care An emerging method for quantifying MR severity by 3D methods includes direct measurements of the effective regurgitant orifice area (EROA) en face using manual and semiautomated methods It is increasingly recognized that conventional estimates of vena contracta (VC) using 2DE may not account for noncircular or slit-like orifices The ideal measure of VC would be in the short-axis view perpendicular to the MR flow Real time 3DE confers this ability, allowing the operator to directly assess the size and shape of VC area in this en face view circumventing the need to make assumptions regarding orifice geometry Kahlert et al performed real time 3DE in 57 patients with different etiologies of MR and compared manual tracing of the VC using 3DE to EROA calculated using the hemispheric and hemielliptic proximal isovelocity surface area method from four-chamber and two-chamber views They found that there was significant asymmetry of the VC area in functional compared to organic MR and that Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension estimation of EROA by hemispheric proximal isovelocity surface area (PISA) methods in these noncircular lesions significantly underestimated EROA compared to direct 3D measurements.14 Yosefy et al demonstrated the utility of real time 3DE in estimating the VC width of eccentric MR jets In 45 patients with at least mild MR, Yosefy et al correlated effective regurgitant area derived from the regurgitant stroke volume to 2D and 3D VC-derived EROAs They found that, for eccentric MR jets, en face 3D measurements of VC width yielded more accurate EROA estimates than 2D derived calculations 2DE tended to overestimate EROA compared to EROA assessed by regurgitant stroke volume Unlike en face measurements by 3DE, 2D overestimation may relate to an oblique orientation of the 2D plane relative to the true short-axis of the VC.15 Thus, 3DE allows more precise quantification of MV severity using VC and PISA methods by removing assumptions related to the shape of the EROA and by allowing the operator to identify the true short-axis VC neck of eccentric jets 3D echo has also been shown to be superior for quantifying mitral stenosis severity and in identifying the smallest orifice for direct planimetry of MV area Planimetry of MV area by 3D echocardiographic techniques appear to offer superior accuracy to 2D techniques and, unlike measures of MV area by pressure half-time and continuity equations, are relatively unaffected by hemodynamic changes.16–18 In a series of 80 consecutive patients with rheumatic mitral stenosis, Zamorano et al showed that, compared to 2D planimetry, real time 3DE planimetry had better agreement with invasively evaluated MV area as calculated with the Gorlin formula with similar interobserver variability between the two methods The authors attributed this result to the ability of 3DE to assess the valve in a multiplanar fashion and thus allow the operator to orient the MV in a plane that is truly “en face” to the smallest orifice This is critical in the context of a complex, funnel-shaped valve orifice.19 Indeed, a recent study showed that measures of MV area by real time 3DE planimetry were significantly lower than with 2D planimetry (mean difference –0.16 ± 22 cm2, P < 0.005).20 The authors also emphasize the ability of 3DTEE to provide detailed information about commissural fusion, which they grade as minimal, partial, or complete However, further studies are required to validate the clinical utility of this classification system particularly in relation to predicting the success of balloon valvuloplasty.21 Indeed one of the most important applications of echocardiography to the assessment of rheumatic MV 519 stenosis is predicting the success of balloon annuloplasty In a small feasibility study, a new real time 3DE score was assessed in 17 patients, validated in 74 patients, and compared to the Wilkins’s score The score was composed of 31 points and assessed thickness, mobility, calcification, and the subvalvular apparatus for each MV scallop Predictors of optimal percutaneous mitral valvuloplasty success by Wilkins’s score were leaflet calcification and subvalvular apparatus involvement, and those by real time 3DE score were leaflet mobility and subvalvular apparatus involvement The incidence and severity of MR postvalvuloplasty were associated with a highcalcification real time 3DE score.17 Widespread application of such scores will depend on the larger validation studies and the practicality of incorporating intensive score-based methods into busy echocardiographic practices However, it is clear that 3D techniques offer important primary and complementary information to traditional 2D techniques in the assessment of mitral stenosis 3DE has also been established as an important tool in the assessment of prosthetic MV function and dysfunction with several studies showing its utility in assessing prosthetic mitral orifice area, prosthetic valve dehiscence, paravalvular regurgitation, and prosthetic valve obstruction and thrombosis.22–24 Sugeng et al demonstrated that superb views of both bioprosthetic and mechanical valve components including leaflets, rings, and struts could be obtained using zoomed 3DTEE volume data in a single heartbeat acquisition thus avoiding stitch artifacts in patients with arrhythmias Views of mechanical MVs could be obtained from both the left ventricular and atrial perspectives with quality of images being partially impeded from the left ventricular perspective due primarily to acoustic shadowing Furthermore, prosthetic dysfunction including dehiscence of mechanical prosthetic valves and annuloplasty rings as well as obstructed leaflets were well delineated with excellent agreement with intraoperative findings.22 3DE is also a valuable tool in the assessment of mitral prosthetic paravalvular leaks As 2DTEE provides only a thin slice in a single plane, it may be difficult to characterize the full extent and location of paravalvular leaks Singh et al demonstrated the value of 3DTEE in patients undergoing surgical repair of prosthetic paravalvular regurgitation The authors used both B mode and color Doppler 3DTEE to obtain en face views of the prosthetic valve and to visualize sites of paravalvular regurgitation Paravalvular regurgitation was diagnosed using color Doppler suppression, outlining, and measuring 520 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 27.6A and B: Protocol for transthoracic 3D echo acquisition of the aortic valve (A) Parasternal long-axis view with and without color; (B) Apical five-chamber view with and without color (AoV: Aortic valve; MV: Mitral valve) A B Figs 27.7A and B: Protocol for transesophageal 3D echo acquisition of the aortic valve (A) 60° basal esophageal, short-axis view; (B) 145°, mid-esophageal long-axis view (zoomed or full-volume acquisition) (AoV: Aortic valve) the full extent of the paravalvular defect All 2DTEE and 3DTEE findings were correlated with surgical findings Compared to 2DTEE, 3DTEE resulted in more accurate localization of the defect, and estimation of defect size.24 Due to the aforementioned reasons, it is recommended that 3D echo of the MV at the current time be incorporated into routine clinical practice.1 3D ECHO OF THE AORTIC VALVE To acquire optimal transthoracic 3D echo images of the aortic valve, images are best obtained from either the parasternal long-axis view with and without color or the apical five-chamber view with and without color (narrow angle and zoomed acquisitions; Figs 27.6A and B; Movie clip 27.4) The protocol for acquiring transesophageal echo images of the aortic valve (Figs 27.7A and B) involves basal-esophageal acquisitions at 60° in the short-axis view, both with and without color, as well as 120° midesophageal long-axis views with and without color (Movie clip 27.5) Visualizing the aortic valve from the aortic perspective is best suited for assessing valve morphology, while visualizing the aortic valve from the ventricular perspective is best for evaluating vegetations, masses, or subvalvular obstruction 3D echo can improve aortic valve stenosis quantification with either direct planimetry of the aortic valve orifice or by using the continuity equation Offline imaging allows the operator to set a mid-systolic image Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension plane just at the cusp tips thereby avoiding aortic valve area (AVA) overestimation in planes more proximal to the cusp tips.25 Aortic valve area as determined by real time 3D TEE aortic planimetry was shown to be feasible in 94.9% of patients with moderate-to-severe aortic stenosis When compared to continuity equation determination of aortic valve area by transthoracic echocardiography, 3DTEE planimetry tended to measure smaller aortic valve areas.25 Real time short-axis thick slice “live 3D” comprised the 3D exam The aortic valve orifice area was traced off-line when the cusps were maximally opened in systole using the technically best 3D image The authors found that more of the aortic orifice perimeter could be visualized using 3D echo (78 ± 11%) compared to 56 ± 17% by the 2D technique (P < 0.001) Furthermore, 2D AVA could be obtained in only 30 patients (58%) while 3D AVA could be obtained in 50 patients (96%) with a good correlation between 2D and 3D AVA where both could be measured (correlation 0.831, P < 0.001) 3D AVA tended to be smaller than 2D AVA and had a better correlation to continuity equation derived AVA Indeed, these observations suggest that the “thick slice” image by 3D echo is more likely to record the entire effective valve orifice than is a “thin slice” standard 2D image 3D echo-guided planimetry may therefore more closely reflect the hemodynamic consequences produced by a stenotic orifice that is more of a tunnel than a flat ring.26 Finally, 3DE may identify congenital or acquired variations in aortic valve morphology such as unicuspid, bicuspid, and quadricuspid valves when 2D may not.27– 31 3D echo has also been useful for identification and characterization of subvalvular pathology such as discrete subaortic membranes.32,33 3D assessment of the aortic valve may also allow for direct measurement of the VC for quantifying aortic insufficiency.34–37 Unlike VC obtained from the 2D parasternal short-axis view, 3DE allows the operator to obtain the whole proximal aortic regurgitation (AR) jet and subsequently crop any plane that is exactly perpendicular to the AR jet and thus may provide a more accurate assessment of AR severity.35 The severity of chronic aortic regurgitation as assessed by conventional echo Doppler methods and by 3D echo Doppler methods were compared with results obtained by cardiac MRI 3D color Doppler was employed for aortic regurgitation VC measurement with the region of interest placed in the aortic valve region from the apical view 3D aortic regurgitation VC measurements were performed “en face” immediately below the aortic valvular plane in 521 mid-diastole Compared to 2D evaluation, 3D color Doppler evaluation had the best linear correlation with cardiac MRI.34 Chin et al assessed the correlation between 3D VC area and the aortic regurgitation idex (a composite of five echocardiographical parameters, including the jet width ratio, VC width, pressure half-time, jet density, and diastolic flow reversal in the descending aorta) Full volume of gated 3D flow data was acquired from seven cardiac cycles Off-line, the early diastolic phase of the AR jet was chosen from three orthogonal planes to obtain the VC from the plane that was exactly perpendicular to the AR jet from the parasternal view The 3D VC area increased proportionately with increasing AR severity using the AR index method and correlated well with effective regurgitant orifice (P < 0.001) The cutoff value of the VC area was < 30 mm2 (sensitivity = 90% and specificity = 88%) for predicting mild AR and > 50 mm2 (sensitivity = 92% and specificity = 87%) for predicting severe AR.35 Thus, 3D echo VC is a promising, simple, and potentially time-saving method of determining AR severity 3D echo has become an increasingly important tool in the periprocedural planning of transcatheter aortic valve implantation 3D echo can measure the distance from the aortic annulus to the coronary ostia, which is crucial for optimal placement of prosthetic valves via the percutaneous route The accuracy of 3D transesophageal echocardiography for assessing the distance between the left main coronary ostium to the aortic annulus was assessed in a series of 122 patients undergoing transcatheter aortic valve implantation.38 The authors found excellent preoperative correlation between 3DTEE measured and multidetector computed tomography (CT) measured aortic annulus to left main distance 3DE is also valuable in determining the extent and mechanism of aortic regurgitation post-transcatheter aortic valve implantation For instance, in a recent study of 135 patients with severe symptomatic aortic stenosis who underwent transcatheter aortic valve implantion (TAVI), calcification between the right coronary and noncoronary cusps and the area cover index as determined by 3DTEE were shown to be significant predictors of paravalvular aortic regurgitation following TAVI.39 We know from 3D echo that the aortic valve annulus is geometrically elliptical rather than round, and therefore annular measurements obtained with 3D echo are more accurate than those obtained with 2D methods.40 Accurate estimation of annular size is particularly important in the setting of TAVI to minimize post implantation paravalvular regurgitation The superior accuracy of 3D imaging techniques in determining 522 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 27.8A to C: (A) Protocol for transthoracic 3D echo acquisition of the pulmonic valve; (B) Parasternal right ventricular outflow tract view with and without color; (C) Parasternal short-axis view with and without color (zoomed and narrow angle acquisitions) (AoV: Aortic valve; PV: Pulmonic valve) annular size was demonstrated in a series of 49 patients with severe aortic stenosis undergoing transcatheter aortic valve implantation The authors found that the sagittal diameters determined by 2DTTE and TEE were smaller than coronal diameters measured by 3DTEE and dual source CT Furthermore, both coronal and sagittal diameters determined by 3DTEE were in high agreement with corresponding measurements by dual source CT.41 3D echo may also allow for better elucidation of the mechanism of aortic insufficiency as well as allow for visualization and measurement of multiple jets and the assessment of prosthetic aortic valve function.22,24 For these reasons, routine clinical use of 3D echo for assessing aortic valve pathology is supported.1 3D ECHO OF THE PULMONIC VALVE To acquire optimal transthoracic 3D echo images of the pulmonic valve, images are best obtained from the parasternal right ventricular outflow tract view with and without color (narrow angle and zoomed acquisitions; Figs 27.8A to C; Movie clip 27.6) The protocol for acquiring transesophageal echo images of the pulmonic valve (Figs 27.9A and B) involves 90° basal-esophageal acquisitions both with and without color, as well as 120° mid-esophageal long-axis views with and without color (Movie clip 27.7) Whereas 2D imaging allows visualization of only two cusps simultaneously, 3D imaging of the pulmonic valve allows all three leaflets of the pulmonic valve to be evaluated concurrently.42 With 3D imaging of the pulmonic valve, cusp number can be accurately evaluated, as can involvement with carcinoid disease, endocarditis, as well as supravalvular, valvular, and subvalvular measurements.42–47 Kelly et al performed live 3D transthoracic echocardiography and full-volume 3D transthoracic echocardiography to assess the feasibility of visualizing pulmonic valve morphology in 200 consecutive patients 3D images were acquired from Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension A 523 B Figs 27.9A and B: Protocol for transesophageal 3D echo acquisition of the pulmonic valve (A) 90° high esophageal view with and without color; (B) 120° three-chamber view with and without color (PV: Pulmonic valve) the long- and short-axis parasternal and apical fourchamber views with final volumes evaluated off-line to obtain a short-axis view of the pulmonic valve Pulmonic valve morphology could be obtained in 63% and 23% of patients using live 3D and full-volume 3D techniques Thus, 3DE can distinguish between tricuspid, bicuspid, and unicuspid leaflet morphology in the majority of cases.42 3D color methods can also quantify pulmonic regurgitation directly through direct measurement of the ERO Pothineni et al demonstrated the utility of 3DE in quantitating pulmonary regurgitation severity in 82 patients with at least mild pulmonic regurgitation reported on 2D imaging.44 Pulmonic regurgitation VC area was measured by planimetry with the cropping plane positioned parallel to the VC The VC was then viewed en face by cropping the 3D data set The authors found that 3D VC area had good correlation to 2D jet-width to right ventricular outflow tract width (r = 0.71) and 2D VC area (r = 0.79) Although there is no gold standard for the measurement of pulmonary regurgitation severity, the 3D method of measuring VC may circumvent the inaccuracies posed by D echo that only allows visualization of one or two dimensions of the proximal PR jet or VC The utility of 3D transthoracic and transesophageal echo for assessing carcinoid involvement of the pulmonic valve has been described as case reports in the literature.43,46 Dumaswala et al reported a case of carcinoid heart disease involving the tricuspid and pulmonic valves.48 3DTTE demonstrated thickening, restricted mobility, and noncoaptation of all three leaflets of the pulmonic valve In a similar case, 3DTEE permitted en face view of all three pulmonic valve cusps simultaneously, assessment of leaflet coaptation and delineation of the spatial relationship between the valve, subvalvular apparatus, and the endocardial surface of surrounding chambers.46 Although current American society of echocardiography (ASE) guidelines state there is not sufficient evidence to support the routine use of 3D techniques for assessing pulmonic valve disease, our lab has found it helpful in particular clinical situations, including confirming significant carcinoid involvement of the pulmonic valve in a patient undergoing tricuspid valve replacement for severe carcinoid involvement of the pulmonic valve.48 3D ECHO OF THE TRICUSPID VALVE To acquire optimal transthoracic 3D echo images of the tricuspid valve, images are best obtained from the apical four-chamber view and/or the parasternal right ventricular inflow view, with and without color (narrow angle and zoomed acquisitions; Figs 27.10A and B; Movie clip 27.8) The protocol for acquiring transesophageal echo images of the tricuspid valve (Figs 27.11A and B) involves 0° to 30° mid-esophageal four-chamber zoomed acquisitions both with and without color (Figs 27.12A and B), as well as 40° transgastric views with anteflexion with and without color (zoomed acquisition; Movie clip 27.9) 3D echo of the tricuspid valve has demonstrated that the tricuspid valve is saddle shaped, becoming more planar and circular with functional tricuspid insufficiency Anwar et al was able to visualize the tricuspid valve in 90% of 100 consecutive patients undergoing transthoracic 524 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 27.10A and B: 3D transesophageal echo of the pulmonic valve in a patient with carcinoid involvement (A) Live 3D long-axis view of the pulmonic valve; (B) En face view of the pulmonic valve from the pulmonary artery Note the markedly thickened and retracted leaflets (PV: Pulmonic valve) A B Figs 27.11A and B: Protocol for 3D transthoracic echo of the tricuspid valve (A) Apical four-chamber view with and without color; (B) Parasternal RV inflow view with and without color (TV: Tricuspid valve) 3DE en face from both the ventricular and atrial aspects to characterize annulus shape and size, leaflet shape, size and mobility, and commissural width They demonstrated that the tricuspid annulus shape is oval both in the normal and dilated state of the annulus They also showed that the leaflet visualized at the right ventricular free wall in the apical four-chamber view consistently corresponds to the anterior leaflet.49 The same group demonstrated the value of 3D transthoracic echocardiography in the assessment of the thickness, mobility, and calcification in rheumatic tricuspid stenosis at the level of each individual leaflet Furthermore, they demonstrated that, unlike 2D transthoracic echocardiography, all three commissures could be adequately evaluated with 3DE including commissural width during maximal tricuspid valve opening As expected, they found that patients with tricuspid stenosis had significantly smaller commissural widths at maximal tricuspid valve opening.50 3D echo of the tricuspid valve may help provide clinical insight into mechanisms of tricuspid insufficiency, and can help identify pacer and implantable cardiodefibrillator (ICD) lead position, as it transverses the tricuspid valve.51–55 For instance, Sukmawan et al used 3D transthoracic echocardiography to show that tricuspid regurgitation secondary to pulmonary hypertension was characterized by enlargement of the tricuspid tenting Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension A 525 B Figs 27.12A and B: Protocol for 3D transesophageal echo of the tricuspid valve (A) 0° to 30° mid-esophageal four-chamber view with and without color; (B) 80° transgastric view with anteflexion with or without color (TV: Tricuspid valve) volume and dilatation of the annulus Tenting volume was calculated as the volume enclosed between the annular plane and tricuspid leaflets.52 3D echo can also provide quantification of tricuspid regurgitation through direct measurement of EROA and has provided important insight into the geometrical determinants of the VC in tricuspid regurgitation.56–58 Real time 3D full-volume and color Doppler images were obtained in 52 patients with various degrees of functional TR The authors demonstrated that the cross-sectional shape of the VC is ellipsoidal (with a relatively longer anteroposterior direction) rather than circular suggesting that different VC cutoff values should be applied according to the plane of view in functional TR (56) Velayudhan et al measured tricuspid regurgitation (TR) VC area with 3DTTE by systematic and sequential cropping of the acquired 3DTTE data set in 93 consecutive patients and compared the results to various 2DTTE measurements of TR severity including the ratio of TR regurgitant jet area to right atrial area, right atrial jet area alone, and VC width and calculated VC area They found close correlation between VC area from 3DTTE and TR regurgitant jet area to right atrial area and right atrial jet area alone as determined from 2D TTE measurements Furthermore, they found that 3DTTE could differentiate between severe and torrential TR, as there were several patients with VC area > 1.0 cm2.58 As with carcinoid involvement with pulmonic valves, 3DE has proven to be an invaluable tool in providing detailed anatomic information of carcinoid involvement in tricuspid valves.43,46 Current published ASE guidelines support routine use of 3D echo for the evaluation of tricuspid valve disease CASE EXAMPLES OF 3D ECHO IN VALVULAR HEART DISEASE CASE STUDY 1: PARAVALVULAR LEAK MECHANICAL MV An 86-year-old male who underwent St Jude’s mechanical MV replacement in 2010 presented at our hospital complaining of exertional dyspnea and New York Heart Associaton (NYHA) Class II to III heart failure symptoms Transthoracic echo suggested a possible paravalvular leak TEE was performed with 3D imaging to confirm the presence of a paravalvular leak, and to also determine if it was amenable to percutaneous closure 2DTEE imaging confirmed a St Jude’s valve to be present in the mitral position, and to be stable Two paravalvular jets were identified, the largest of which originated from the septal aspect of the MV and was associated with at least moderate MR Both leaflets were noted to open and close well and normal washing jets were identified The second paravalvular leak was noted to emanate from the lateral aspect of the prosthesis, and hugged the lateral wall of the left atrium (Movie clip 27.10 and 27.11) Live 3D zoomed 526 Section 2: Echocardiography/Ultrasound Examination and Training imaging of the mitral prosthesis from the left atrial view confirmed that the prosthesis was well seated without rocking motion The largest of the two defects was noted to be crescentic in appearance, and was felt to be amenable to percutaneous closure (Movie clip 27.12) The patient was quoted a 10% risk of serious complications associated with percutaneous closure, and ultimately underwent successful percutaneous closure of both paravalvular leaks, without complication, and has clinically improved CASE STUDY 2: MV REPAIR AND AORTIC VALVE REPLACEMENT A 63-year-old male with a history of MV repair and aortic valve replacement in 1992 developed fevers and chills, which were associated with positive blood cultures while vacationing in Florida He was treated for an infected ICD with antibiotics and returned home for further evaluation TEE was requested at our institution to evaluate for valvular vegetations 2DTEE imaging confirmed no evidence of valvular vegetation and no evidence of mitral annular abscess The annuloplasty ring was noted to be partially dehisced and mild valvular MR was present There was no mitral paravalvular leak (Movie clips 27.13 to 27.15) Live 3D imaging of the mitral ring from the left atrial view, confirmed partial dehiscence of the ring along the posterior mitral annulus (Movie clip 27.16) 2D imaging of the aortic prosthesis demonstrated a moderate to large paravalvular leak that originated posteriorly and was directed anteriorly There was no evidence of prosthetic aortic vegetation and no evidence of aortic abscess (Movie clip 27.17) 3D imaging confirmed the mitral ring and aortic prosthesis to be stable, with no evidence of rocking (Movie clip 27.18 and 27.19) Despite the partially dehisced mitral ring and moderate posterior aortic paravalvular leak, the patient was clinically asymptomatic, and a decision was made to follow him medically CASE STUDY 3: S/P CARDIAC TRANSPLANT WITH RIGHT HEART FAILURE, TRICUSPID VALVE REPLACEMENT A 77 year-old-male with history of cardiac transplant presented to our hospital with worsening right heart failure and renal failure The patient had a history of a bioprosthetic tricuspid valve replacement, and initial 2D transthoracic imaging revealed a degenerated #31 Carpentier Edwards tricuspid prosthesis with pannus formation and moderate to severe tricuspid insufficiency The patient was not deemed to be an open surgical candidate, and was referred to us to determine if a #26 Edwards-Sapien percutaneous valve could be successfully placed within his #31 Carpentier Edwards tricuspid valve TEE with 3D reconstruction was requested to determine if the pannus had sufficiently reduced the tricuspid annular diameter such that the smaller #26 Edwards-Sapien valve would stick 2D TEE confirmed the presence of moderate to severe prosthetic tricuspid insufficiency with significant pannus The mean transtricuspid gradient was markedly elevated at mmHg (Movie clip 27.20 and 27.21) Live 3D imaging of the tricuspid prosthesis was performed from the right atrium (Movie clip 27.22) Full volume multibeat 3D imaging of the tricuspid prosthesis from the mid-esophageal four-chamber view was performed with reconstruction to visualize the tricuspid annulus from the right atrium (Movie clip 27.23) The #31 Carpentier Edwards prosthetic tricuspid valve with pannus was measured at 2.5 cm × 2.2 cm and the patient was deemed to be a suitable candidate for percutaneous #26 mm Edwards Sapien valve in valve replacement, and the patient underwent this procedure successfully without complication The patient underwent 2D and 3D transthoracic echocardiography postprocedure that confirmed the #26 Edwards-Sapien valve to be in stable position within the #31 Carpentier Edwards bioprosthetic valve There were no paravalvular leaks and the mean transtricuspid gradient measured mm Hg at a hazard ratio (HR) of 81 bpm There was mild valvular tricuspid insufficiency (Movie clip 27.24 and 27.25) The patient feels well and progressively stronger postprocedure, and is pleased with the outcome CASE STUDY 4: FLAIL MIDDLESCALLOP, POSTERIOR LEAFLET, MV A 70-year-old male in good health with known MV prolapse and severe mitral insufficiency was referred for 3DTEE to further evaluate the mechanism of mitral insufficiency His pulmonary artery systolic pressure was noted to increase to 56 mm Hg with exercise, and the patient was being considered for elective MV repair The patient was asymptomatic and reported no shortness of breath, fatigue, or peripheral edema 2DTEE confirmed severe anteriorly directed mitral insufficiency with a flail posterior segment Live 3D imaging of the MV from the left atrial perspective confirmed a flail middle scallop of the posterior leaflet of the MV (P2; Movie clip 27.26 and 27.27) Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension Given the favorable anatomy, the patient chose to undergo elective surgery of the MV, and underwent successful repair and quadrangular resection of the P2 scallop He is currently doing well clinically CASE STUDY 5: BILEAFLET MV PROLAPSE, MODERATE TO SEVERE MITRAL INSUFFICIENCY A 65-year-old female with known bileaflet MV prolapse and moderate to severe mitral insufficiency presents to the cardiology clinic complaining of increasing dyspnea on exertion The patient was referred for exercise stress echo where she exercised for minutes and 45 seconds on a standard Bruce protocol, and her pulmonary artery systolic pressure increased from 36 mm Hg to 56 mm Hg She was subsequently referred for TEE with 3D imaging to determine if the valve was amenable for repair TEE confirmed the MV to be diffusely myxomatous with classic bileaflet MV prolapse (Barlow’s valve) At a blood pressure of 115 mm Hg systolic, moderate mitral insufficiency was identified by color Doppler There were two MR jets, both central in origin and direction Pulmonary venous flow was normal Live 3D imaging of the MV confirmed prolapse of A1, A2, A3, P1, P2, and P3 scallops (Movie clip 27.28 and 27.29) The patient was quoted a likelihood of successful MV repair to be 70% She was also noted to have diastolic dysfunction Given the complexity of repair and absence of severe mitral insufficiency, a decision was made to treat the patient medically with low doses of lasix and monitor carefully for worsening symptoms and/or regurgitation CASE STUDY 6: SEVERE AORTIC STENOSIS, EVALUATE FOR POSSIBLE TAVR A 63-year-old female presents with severe symptomatic aortic stenosis She has a cardiac history notable for coronary artery bypass grafting (CABG) and MV replacement in 1998, and is referred for TEE in preparation for possible transcatheter aortic valve replacement (TAVR) 2DTEE images confirmed the presence of severe calcific aortic stenosis The calculated aortic valve area via planimetry and the continuity equation was 0.5 cm2 By 2D methods the aortic annulus was measured at 2.5–2.6 cm The distance from the aortic annulus to the ostium of the right coronary artery measured 1.5 cm (Movie clips 27.30 and 27.31) 3D imaging with reconstruction was performed 527 to measure the distance from the annulus to the ostium of the left coronary artery from full-volume coronal views This distance was measured at 1.5 cm (Movie clip 27.32) As a result of these findings, the patient was deemed to be a suitable candidate for TAVR with the larger #26 Edwards Sapien valve Recently published ASE recommendations for echo in TAVR recommend that in general, a distance of greater than 10 mm is desirable from the aortic annulus to the ostium of the right and left coronary arteries for the #23 Edwards Sapien valve and a distance of greater than 11 mm is desirable for the #26 mm valve.5 2DTEE is able to define the annular-ostial distance for the right coronary artery In contrast, measurement of the distance from the annulus to the left main coronary artery requires 3DTEE, as the left main lies in the coronal plane These measurements are crucial, since an improperly sized prosthesis can obstruct coronary flow, resulting in coronary insufficiency, and may be life threatening CASE STUDY 7: RHEUMATIC MITRAL STENOSIS An 82-year-old Lebanese female develops acute heart failure following appendectomy Transthoracic echo confirms the presence of moderate to severe rheumatic mitral stenosis She presents to cardiology clinic for further evaluation of the need for balloon mitral valvuloplasty or surgical MV replacement Transthoracic echo confirmed rheumatic MV deformity with moderate mitral stenosis Her mean transmitral gradient was mm Hg at a HR of 69 bpm, and her MVA was calculated at 1.5 cm2 via pressure half-time and 1.6 cm2 via planimetry She was also noted to have moderate mitral insufficiency by color Doppler 3D imaging of the MV confirmed the presence of commissural fusion (Movie clip 27.33) Full-volume 3D reconstructions of the MV were performed to help improve the accuracy of planimetry, and confirmed the MV area to measure 1.5–1.6 cm2 (Movie clip 27.34) Due to the significant mitral insufficiency, she was not deemed to be an ideal candidate for balloon mitral valvuloplasty For now, she will be treated medically with beta-blockers, with careful clinical and echocardiographic follow-up CASE STUDY 8: S/P BALLOON AORTIC VALVULOPLASTY A 76-year-old female with severe calcific aortic stenosis and chronic obstructive pulmonary disease (COPD) is referred for balloon aortic valvuloplasty Transthoracic 528 Section 2: Echocardiography/Ultrasound Examination and Training echo is obtained postvalvuloplasty and demonstrates there is now moderate aortic insufficiency There remains severe aortic stenosis Live 3DTTE demonstrates that the native aortic valve has been disrupted (Movie clip 27.35) CASE STUDY 9: MECHANISM AND SEVERITY OF ECCENTRIC MITRAL INSUFFICIENCY A 69-year-old male with hypertension and lower extremity edema is noted to have eccentric and posteriorly directed mitral insufficiency of uncertain severity on transthoracic echo He is referred for TEE to further evaluate the mechanism of mitral insufficiency and its severity 2DTEE confirmed an eccentric posteriorly directed jet that by color Doppler appears mild at a BP of 90/60 mmHg and possibly moderate to severe following administration of Neosynephrine at a BP of 151/89 mm Hg (Movie clip 27.36) 3D full-volume imaging with reconstruction was performed with direct measurement of the EROA This confirmed the presence of severe prolapse of the A3 scallop with moderate mitral insufficiency The directly measured 3D ERO was 0.3 cm2 (Movie clip 27.37) These results confirmed that there was no need for surgical intervention at the current time CASE STUDY 10: QUESTION OF CARCINOID INVOLVEMENT OF THE PULMONIC VALVE A 60-year-old male with a history of carcinoid syndrome presented with severe tricuspid insufficiency and question of severe pulmonic insufficiency on transthoracic echo Since his overall survival rate was considered reasonable, it was recommended that he undergo surgical valve replacement to preserve his ventricular function 3DTEE was performed to determine the extent of carcinoid involvement of the pulmonic valve, since this was not adequately visualized by 2D methods Live 3D imaging of the pulmonic valve from the pulmonary perspective confirmed the valve was severely thickened and retracted with carcinoid involvement and severe wide open pulmonic insufficiency Live 3D imaging of the tricuspid valve from the right atrial perspective also confirmed severe carcinoid involvement of the tricuspid valve with severe wide open tricuspid insufficiency (Movie clip 27.38) These findings were confirmed at surgery, and the patient underwent successful bioprosthetic tricuspid and pulmonic valve replacement SUMMARY This comprehensive review with case presentations demonstrating the current status of 3D echo to evaluate valvular heart disease has hopefully solidified the value of an added dimension in every day clinical decision making using cardiac ultrasound Although 3D echo currently complements 2D echo in daily clinical practice, it is our belief, that its full potential has yet to be realized New technology, including single heartbeat full-volume data sets, live color 3D, the ability to make live 3D measurements, continued improvements in 3D spatial and temporal resolution and integration into digital PACS systems, and new automated quantitative tools, will continue to enhance the utility and efficiency of 3D echo for the assessment of valvular heart disease in daily clinical practice REFERENCES 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;25(1):3–46 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;19(4):413–21 Patel V, Hsiung MC, Nanda NC, et al Usefulness of live/real time three-dimensional transthoracic echocardiography in the identification of individual segment/scallop prolapse of the mitral valve Echocardiography 2006;23(6):513–8 Grewal J, Suri R, Mankad S, et al Mitral annular dynamics in myxomatous valve disease: new insights with real-time 3-dimensional echocardiography Circulation 2010;121 (12):1423–31 La Canna G, Arendar I, Maisano F, et al Real-time threedimensional transesophageal echocardiography for assessment of mitral valve functional anatomy in patients with prolapse-related regurgitation Am J Cardiol 2011;107(9): 1365–74 Chikwe J, Adams DH, Su KN, et al Can three-dimensional echocardiography accurately predict complexity of mitral valve repair? Eur J Cardiothorac Surg 2012;41(3):518–24 Otani K, Takeuchi M, Kaku K, et al Evidence of a vicious cycle in mitral regurgitation with prolapse: secondary tethering attributed to primary prolapse demonstrated by three-dimensional echocardiography exacerbates regurgitation Circulation 2012;126(11 Suppl 1):S214–21 Little SH Three-dimensional echocardiography to quantify mitral valve regurgitation Curr Opin Cardiol 2012;27(5): 477–84 Benenstein R, Saric M Mitral valve prolapse: role of 3D echocardiography in diagnosis Curr Opin Cardiol 2012; 27(5):465–76 Chapter 27: Three-Dimensional Examination to Evaluate Valvular Heart Disease: The Value of an Added Dimension 10 Ahmed S, Nanda NC, Miller AP, et al Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve Echocardiography 2003;20(2):203–9 11 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;25(7):758–65 12 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; 24(10):1079–85 13 Biaggi P, Gruner C, Jedrzkiewicz S, et al Assessment of mitral valve prolapse by 3D TEE angled views are key JACC Cardiovasc Imaging 2011;4(1):94–7 14 Kahlert P, Plicht B, Schenk IM, et al Direct assessment of size and shape of noncircular vena contracta area in functional versus organic mitral regurgitation using realtime three-dimensional echocardiography J Am Soc Echocardiogr 2008;21(8):912–21 15 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(7):978–83 16 Chu JW, Levine RA, Chua S, et al Assessing mitral valve area and orifice geometry in calcific mitral stenosis: a new solution by real-time three-dimensional echocardiography J Am Soc Echocardiogr 2008;21(9):1006–9 17 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(1):13–22 18 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(10):750–5 19 Zamorano J, Cordeiro P, Sugeng L, et al Real-time threedimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach J Am Coll Cardiol 2004;43(11):2091–6 20 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(6):580–8 21 Weyman AE Assessment of mitral stenosis: role of realtime 3D TEE JACC Cardiovasc Imaging 2011;4(6):589–91 22 Sugeng L, Shernan SK, Weinert L, et al Real-time threedimensional transesophageal echocardiography in valve disease: comparison with surgical findings and evaluation of prosthetic valves J Am Soc Echocardiogr 2008;21(12): 1347–54 23 Krim SR, Vivo RP, Patel A, et al Direct assessment of normal mechanical mitral valve orifice area by real-time 3D echocardiography JACC Cardiovasc Imaging 2012;5(5): 478–83 529 24 Singh P, Manda J, Hsiung MC, et al Live/real time threedimensional transesophageal echocardiographic evaluation of mitral and aortic valve prosthetic paravalvular regurgitation Echocardiography 2009;26(8):980–7 25 de la Morena G, Saura D, Oliva MJ, et al Real-time threedimensional transoesophageal echocardiography in the assessment of aortic valve stenosis Eur J Echocardiogr January, 2010;11(1):9–13 Epub October 4, 2009 26 Suradi H, Byers S, Green-Hess D, et al Feasibility of using real time “Live 3D” echocardiography to visualize the stenotic aortic valve Echocardiography 2010;27(8):1011–20 27 Brantley HP, Nekkanti R, Anderson CA, et al Threedimensional echocardiographic features of unicuspid aortic valve stenosis correlate with surgical findings Echocardiography 2012;29(8):E204–7 28 Unsworth B, Ma A, Barbieri A, et al Bicuspid aortic valve regurgitation: quantification of anatomic regurgitant orifice area by 3D transesophageal echocardiography reconstruction Echocardiography 2008;25(7):797–8 29 Mikhail GW Recognising bicuspid aortic stenosis in patients referred for transcatheter aortic valve implantation: routine screening with three-dimensional transoesophageal echocardiography Heart 2010;96(8):645 30 Singh P, Dutta R, Nanda NC Live/real time three-dimensional transthoracic echocardiographic assessment of bicuspid aortic valve morphology Echocardiography 2009; 26(4):478–80 31 Burri MV, Nanda NC, Singh A, et al Live/real time threedimensional transthoracic echocardiographic identification of quadricuspid aortic valve Echocardiography 2007;24(6): 653–5 32 Maréchaux S, Juthier F, Banfi C, et al Illustration of the echocardiographic diagnosis of subaortic membrane stenosis in adults: surgical and live three-dimensional transoesophageal findings Eur J Echocardiogr 2011;12(1):E2 33 Agrawal GG, Nanda NC, Htay T, et al Live three-dimensional transthoracic echocardiographic identification of discrete subaortic membranous stenosis Echocardiography 2003; 20(7):617–9 34 Perez de Isla L, 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(3):640–5 35 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(2):161–6 36 Pirat B, Little SH, Igo SR, et al Direct measurement of proximal isovelocity surface area by real-time threedimensional color Doppler for quantitation of aortic regurgitant volume: an in vitro validation J Am Soc Echocardiogr March, 2009;22(3):306–13 Epub January 24, 2009 37 Malagoli A, Barbieri A, Modena MG Bicuspid aortic valve regurgitation: quantification of anatomic regurgitant orifice area by 3D transesophageal echocardiography reconstruction Echocardiography 2008;25(7):797–8 530 Section 2: Echocardiography/Ultrasound Examination and Training 38 Tamborini G, Fusini L, Gripari P, et al Feasibility and accuracy of 3DTEE versus CT for the evaluation of aortic valve annulus to left main ostium distance before transcatheter aortic valve implantation JACC Cardiovasc Imaging 2012;5(6):579–88 39 Gripari P, Ewe SH, Fusini L, et al Intraoperative 2D and 3D transoesophageal echocardiographic predictors of aortic regurgitation after transcatheter aortic valve implantation Heart 2012;98(16):1229–36 40 Gaspar T, Adawi S, Sachner R, et al Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation J Am Soc Echocardiogr 2012;25(7):749–57 41 Furukawa A, Abe Y, Tanaka C, et al Comparison of twodimensional and real-time three-dimensional transesophageal echocardiography in the assessment of aortic valve area J Cardiol 2012;59(3):337–43 42 Kelly NF, Platts DG, Burstow DJ Feasibility of pulmonary valve imaging using three-dimensional transthoracic echocardiography J Am Soc Echocardiogr 2010;23(10):1076–80 43 Lee KJ, Connolly HM, Pellikka PA Carcinoid pulmonary valvulopathy evaluated by real-time 3-dimensional transthoracic echocardiography J Am Soc Echocardiogr 2008;21(4):407.e1–e2 44 Pothineni KR, Wells BJ, Hsiung MC, et al Live/real time three-dimensional transthoracic echocardiographic assessment of pulmonary regurgitation Echocardiography 2008; 25(8):911–7 45 Naqvi TZ, Rafie R, Ghalichi M Real-time 3D TEE for the diagnosis of right-sided endocarditis in patients with prosthetic devices JACC Cardiovasc Imaging 2010; 3(3):325–7 46 Bhattacharyya S, Tarkin J, Prasad S, et al Multi-modality imaging of apical aortic conduit Eur J Echocardiogr 2011; 12(12):975 47 Tagliareni F, D’Aleo A, Sanfilippo A, et al Isolated bicuspid pulmonary valve in adult diagnosed by three-dimensional transthoracic echocardiography J Cardiovasc Med (Hagerstown) 2012;13(6):395–6 48 Dumaswala B, Bicer EI, Dumaswala K, et al Live/Real time three-dimensional transthoracic echocardiographic assessment of the involvement of cardiac valves and chambers in carcinoid disease Echocardiography 2012;29 (6):751–6 49 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(6):717–24 50 Anwar AM, Geleijnse ML, Soliman OI, et al Evaluation of rheumatic tricuspid valve stenosis by real-time threedimensional echocardiography Heart 2007;93(3):363–4 51 Schnabel R, Khaw AV, von Bardeleben RS, et al Assessment of the tricuspid valve morphology by transthoracic realtime-3D-echocardiography Echocardiography 2005;22(1): 15–23 52 Sukmawan R, Watanabe N, Ogasawara Y, et al Geometric changes of tricuspid valve tenting in tricuspid regurgitation secondary to pulmonary hypertension quantified by novel system with transthoracic real-time 3-dimensional echocardiography J Am Soc Echocardiogr 2007;20(5): 470–6 53 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 realtime, 3-dimensional echocardiographic study Circulation 2006;114(1 Suppl):I492–8 54 Ton-Nu TT, Levine RA, Handschumacher MD, et al Geometric determinants of functional tricuspid regurgitation: insights from 3-dimensional echocardiography Circulation 2006;114(2):143–9 55 Ahlgrim AA, Nanda NC, Berther E, et al Three-dimensional echocardiography: an alternative imaging choice for evaluation of tricuspid valve disorders Cardiol Clin 2007; 25(2):305–9 56 Song JM, Jang MK, Choi YS, et al The vena contracta in functional tricuspid regurgitation: a real-time threedimensional color Doppler echocardiography study J Am Soc Echocardiogr 2011;24(6):663–0 57 Sugeng L, Weinert L, Lang RM Real-time 3-dimensional color Doppler flow of mitral and tricuspid regurgitation: feasibility and initial quantitative comparison with 2-dimensional methods J Am Soc Echocardiogr 2007;20 (9):1050–7 58 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(9):793–800 531 CHAPTER 28 Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures Muhamed Saric, Ricardo Benenstein Snapshot Fluoroscopy Versus Echocardiography in Guiding Percu- Device Closure of Cardiac Shunts Occlusion of the LeŌ Atrial Appendage Guidance of Electrophysiology Procedures Miscellaneous Procedures taneous IntervenƟons Transseptal Puncture: A Common Element of Many IntervenƟonal Procedures Valvular Disease INTRODUCTION Catheter-based transcutaneous repair of both congenital and acquired cardiovascular defects has been performed by interventional cardiologists and other interventional specialists for the past half a century This therapeutic approach was initially spearheaded by pediatric cardiologists Atrial balloon septostomy, later referred to as the Rashkind procedure, is generally considered to be the first catheter-based transcutaneous repair procedure The Rashkind procedure was first reported in 1971 as the initial treatment in neonates with transposition of the great arteries to improve mixing of venous and systemic blood through creation of an iatrogenic atrial septal defect (ASD).1 In the beginning, catheter-based transcutaneous repairs were developed as less invasive alternatives to established surgical procedure but have since evolved into novel ways of treating structural heart defects Catheterbased transcutaneous procedures to repair structural heart defects can be divided into the following groups: • • • • • Valvular disease – Mitral stenosis (percutaneous balloon valvuloplasty) – Mitral regurgitation [mitral valve (MV) clipping] – Aortic stenosis (transcatheter aortic valve replacement) – Closure of paravalvular prosthetic leaks Device closure of cardiac shunts – ASDs [secundum ASDs; patent foramen ovale (PFO)] – Ventricular septal defects (VSDs; congenital and acquired) – Patent ductus arteriosus (PDA) Occlusion of the left atrial appendage (LAA) – Intracardiac device closure of LAA – Epicardial suturing of LAA Guidance of electrophysiology ablation procedures – Pulmonary vein isolation for atrial fibrillation Miscellaneous procedures – Left ventricular pseudoaneurysm closure – Alcohol septal ablation for hypertrophic obstructive cardiomyopathy – Right ventricular endomyocardial biopsy 532 Section 2: Echocardiography/Ultrasound Examination and Training In the interventional suites, echocardiography is typically used in conjunction with X-ray-based fluoroscopy in guiding catheter-based transcutaneous repairs in real time Fluoroscopy and echocardiography images are typically presented side-by-side to interventionalists on adjacent monitors Recently, commercial products that dynamically combine (coregister) in real time threedimensional (3D) ultrasound and interventional X-ray images into one are becoming available Computed tomography (CT) and magnetic resonance imaging (MRI)— although often important in establishing the diagnosis of a structural heart defect—typically not readily provide real time imaging during percutaneous interventions in standard interventional suites Real time 3D transesophageal echocardiography (3D TEE) and intracardiac echocardiography (ICE) are the most useful echocardiographic techniques for real time procedural guidance as their images are typically superior to and/or more relevant to interventionalists compared to images obtained by either two-dimensional transesophageal echocardiography (2D TEE) or transthoracic echocardiography (TTE).2 In general, percutaneous coronary interventions (such as angioplasty and stenting) are not typically classified as catheter-based transcutaneous procedures to repair structural heart defects and thus will not be discussed in this chapter The use of intravascular ultrasound (IVUS) techniques in the diagnosis and treatment of vascular disease is provided elsewhere in this textbook FLUOROSCOPY VERSUS ECHOCARDIOGRAPHY IN GUIDING PERCUTANEOUS INTERVENTIONS Imaging is essential for the diagnosis, guidance, and assessments of results of all catheter-based transcutaneous procedures to repair structural heart defects Detailed description of basics of fluoroscopy and echocardiography are beyond the scope of this chapter; here we will discuss their advantages and shortcomings from the perspective of catheter-based transcutaneous interventional procedures X-ray-based fluoroscopy and contrast angiography have been historically considered as gold standards in guiding percutaneous repairs of structural heart defects These radiographic techniques, which are very familiar to interventionalists, tend to have poor depth resolution, lack ability to differentiate between various soft tissues, and require the use of ionizing radiation and iodinated contrast agents While in principle, TTE can be used to guide catheterbased interventions, its use is limited by both suboptimal imaging of relevant cardiac structures and by difficulties in acquiring TTE images in the sterile environment of an interventional suite 2D TEE and ICE imaging, although extensively used during percutaneous procedure, suffer from the 2D, cross-sectional nature of their images As a consequence, movement of wires, catheters, and devices used during interventions cannot be tracked appropriately In addition, neither 2D TEE nor ICE can typically provide en face views of structures of interest to interventionalists Furthermore, ICE typically provides only monoplane images It is also invasive and requires the use of expensive disposable transducers that are advanced under sterile condition into the heart via the venous system Examples of ICE use are provided in the section on percutaneous ASD closure below In our practice, modern 3D TEE imaging is the preferred echocardiography technique for guiding interventional procedures as it provides detailed dynamic images (included en face views) of relevant cardiac structures in real time, something that is not easily achievable by any other imaging technique.3 Although 3D TEE has been around for decades (primarily as an offline, postprocessed imaging technique), it has been revolutionized by the introduction of a 3D TEE probe with a matrix-array transducer having 3,000 elements in the first decade of the 21st century This approximately a 25–50-fold increase in the number of imaging elements compared with a standard 2D TEE probe has allowed for real time 3D imaging, making 3D TEE ideally suited for guidance of cardiac interventions General aspects of 3D echocardiographic imaging have previously been reviewed4–7 and are also discussed elsewhere in this textbook TRANSSEPTAL PUNCTURE: A COMMON ELEMENT OF MANY INTERVENTIONAL PROCEDURES Many catheter-based transcutaneous procedures (such as those involving the MV, LAA, and pulmonary veins) require a transvenous access to the left atrium In general, the left atrium is accessed after entering a peripheral vein (typically the femoral vein) followed by threading catheters and other hardware into the right atrium and then performing the transseptal puncture to bring the hardware across the interatrial septum into the left atrium Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures The general technique of transseptal puncture was originally described by Ross in 1959; further refinements were published in 1962 by Brockenbrough and colleagues.8,9 Briefly, a sharp needle that will be used to puncture the interatrial septum (referred to as Brockenbrough needle) is hidden inside a catheter (such as the MullinsTM catheter, Medtronic Inc., Minneapolis, MN) The catheter is advanced through the venous system into the right atrium and then pushed further to cause tenting of the interatrial septum (evagination of the interatrial septum toward the left atrium) Thereafter, the Brockenbrough needle is advanced through the catheter until it punctures the interatrial septum While the interventionalists’ tactile feedback, fluoroscopy and 2D echocardiography (such as 2D TEE and ICE) have been used for many years to guide transseptal puncture with a good safety record,10 real time 3D TEE provides distinct advantages that may enhance both the safety of the puncture procedure and the success of the subsequent percutaneous intervention in the left heart Among the several modalities of 3D TEE, biplane and 3D zoom imaging are particularly useful in guiding the transseptal puncture The key imaging aspect of guiding a transseptal puncture is to demonstrate the exact location of septal tenting prior to actual puncture Only after proper location of tenting is confirmed by imaging, the Brockenbrough needle is advanced and the transseptal puncture is performed.11 Biplane 3D TEE imaging assures that transseptal puncture is confined to the true interatrial septum while preventing piercing of the aorta, superior vena cava (SVC), and other cardiac structures such as the so-called lipomatous hypertrophy of the interatrial septum (Figs 28.1A to D; Movie clip 28.1A and B) The true interatrial septum is essentially confined to the floor of the fossa ovalis (Latin for “egg-shaped dugout”); the floor is derived from the septum primum The fossa ovalis is surrounded by the rim (also referred to in Latin as the limbus), which is formed by the septum secundum.12 The location, size, and shape of the fossa ovalis varies widely among individuals.13 The fossa ovalis is readily distinguished on en face views of the right atrial aspect of the interatrial septum as a lighter colored ovoid crater In contrast, the region of fossa ovalis cannot be readily recognized on the rather featureless left atrial aspect of the interatrial septum when standard image gain settings are used.14 However, at low gain setting, the area of fossa ovalis (which is thinner than the surrounding atrial walls) can be identified as an ovoid area of dropout especially in patients with a concomitant atrial septal aneurysm 533 (ASA; Figs 28.2A to D and Movie clip 28.2) In individuals with PFO, the opening in the floor of the fossa ovalis is present along the antero-superior rim of fossa ovalis In such individuals, transseptal puncture needle is often directed through the PFO opening On 3D TEE imaging can also readily characterize the size and the shape of the ASA, defined arbitrarily as a ≥ 10 mm sway of the interatrial septum in either direction from the midline.15 Anatomically, ASA is characterized by redundancy and floppiness of a typically enlarged fossa ovalis floor The knowledge of an ASA is important to interventionalists; ASA may make transseptal puncture more difficult by requiring septal stretching and/or increased force to traverse the septum.16 These maneuvers may increase the risk for cardiac perforation during transseptal puncture.17 It is important to emphasize that the term lipomatous hypertrophy of the interatrial septum is actually a misnomer as the fat accumulates not in the interatrial septum per se but rather outside of the heart in the groove between the muscular walls of the right and left atrium (Figs 28.3A to C and Movie clip 28.3) The groove is known to surgeons as either the Waterston’s or Søndergaard’s groove.18,19 Puncturing of the lipomatous hypertrophy area is dangerous as the needle exits the heart into the epicardial space En face 3D zoom views of the interatrial septum from the right and left atrial perspective during tenting allows for better selection of the puncture site Often transseptal puncture across the foramen ovale is the preferred route; however, for some procedures a puncture of a different portion of the interatrial septum may be more desirable (as, for instance, during closures of mitral paraprosthetic leaks) VALVULAR DISEASE Mitral Stenosis: Percutaneous Mitral Balloon Valvuloplasty Rheumatic heart disease remains the leading cause of mitral stenosis worldwide Rheumatic mitral stenosis is the most common form of valvular disease in developing parts of the world In contrast, rheumatic mitral stenosis in Japan, North America, and Northern and Western Europe is typically seen among immigrants from less developed parts of the world Rheumatic MV disease is a progressive lifelong autoimmune-like disorder triggered by and further exacerbated by recurrent group A streptococcal infections (typically pharyngitis).20 534 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.1A to D: 3D TEE guidance of trans-septal puncture (A and B) Biplane imaging of the interatrial septum demonstrates tenting of the interatrial septum (arrows) by the catheter containing the Brockenbrough needle Note that the tenting occurs in the central region of the interatrial septum and away from SVC and the aortic valve Movie clip 28.1B corresponds to this figure; (C) 3D TEE zoom image demonstrates the en face view of the right atrial aspect of the interatrial septum The dashed line follows the limbus of the fossa ovalis Note the location of trans-septal puncture (arrow) in the superior portion of the fossa ovalis; (D) 3D TEE zoom image demonstrates the en face view of the left atrial aspect of the interatrial septum Note the evagination of the interatrial septum into the cavity of the left atrium caused by the Brockenbrough needle assembly (asterisk) Movie clip 28.1A corresponds to this figure (AV: Aortic valve; IVC: Inferior vena cava; LA: Left atrium; MV: Mitral valve; RA: Right atrium; RUPV: Right upper pulmonary vein; SVC: Superior vena cava; TV: Tricuspid valve) Probably the very first description of rheumatic mitral stenosis anatomy was provided in 1668 by the British physician John Mayow (1641–1679), who recorded an “extreme constriction of the mitral orifice in a young man” 21 In 1715, Raymond Vieussens (1635–1715), a French physician, published the first comprehensive description of mitral stenosis.22 Rheumatic mitral stenosis is notable for several “firsts” in the history of medicine: it was the first valvular heart disease to be treated surgically; it was the first heart disease to be diagnosed by echocardiography and it was the first valvular disease to be treated with balloon valvuloplasty.23 In the 1920s, Elliot Cutler (1888–1947)24 and Sir Henry Souttar (1875–1964)25 working at the Brigham and Women’s Hospital in Boston were the first to attempt surgical relief of rheumatic mitral stenosis using procedures that they termed “valvulotomy” and “finger dilation,” respectively In the late 1940s, soon after World War II, techniques of rheumatic mitral stenosis surgery were rediscovered and improved by Charles Bailey and Dwight Harken, who also coined the procedural terms that are still used today.26 Bailey called his procedure “commissurotomy” while Harken coined the term “valvuloplasty.”27 In the 1950s, rheumatic mitral stenosis was the first heart disease visualized echocardiographically by Ingle Edler (1911–2001) and Carl Hertz (1920–1990), inventors of echocardiography.28 In the 1960s, rheumatic mitral stenosis was the first valvular disease to be treated with Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 535 Figs 28.2A to D: Anatomy of fossa ovalis There is a large variability in the size, shape and location of the fossa ovalis in humans In addition, the floor of the fossa ovalis (derived from the septum primum) can be either firm or floppy A floppy septum leads to formation of an atrial septal aneurysm These 3D TEE zoom images were obtained from two different patients (A and B) Images obtained from a patient with a small fossa ovalis (asterisk) (A) demonstrates the right atrial and; (B) the left atrial aspect of the interatrial septum Note that the fossa ovalis, with a pale floor and its darker rims, is easily recognized on the right atrial aspect of the interatrial septum In contrast, the location of the fossa ovalis (arrow) is less evident on the rather featureless left atrial aspect of the interatrial septum; (C and D) Images obtained from a patient with a large fossa ovalis and an ASA (C) demonstrates the right atrial and (D) the left atrial aspect of the interatrial septum In contrast to the patient from (A and B), the location of the fossa ovalis in now easily recognized on the left atrial aspect of the interatrial septum when the ASA protrudes away from the left atrium and into the right atrium as shown in (D) Movie clip 28.2 demonstrates the ASA from the posterior aspect of the left atrium (AV: Aortic valve; CS: Coronary sinus; IVC: Inferior vena cava; MV: Mitral valve; RUPV: Right upper pulmonary vein; SVC: Superior vena cava) a mechanical MV by Albert Starr (born 1926) and Lowell Edwards (1898–1982).29 Finally, in the 1980s, Kanji Inoue of Japan developed the ingenious balloon [Inoue balloon, Toray Industries (America) Inc., San Mateo, CA] and the technique of percutaneous mitral balloon valvuloplasty (PMBV), which remains the preferred treatment for the relief of rheumatic mitral stenosis in eligible patients.30 In the absence of contraindications, PMBV is recommended in following instances: • Symptomatic patients with moderate or severe mitral stenosis • In asymptomatic patients with moderate or severe mitral stenosis, PMBV is indicated when there is pulmonary artery systolic pressure is > 50 mm Hg at rest or > 60 mm Hg with exercise, or when there is new onset atrial fibrillation • PMBV may also be considered in symptomatic patient with mild mitral stenosis (valve area > 1.5 cm2) when pulmonary artery systolic pressure greater > 60 mm Hg, pulmonary artery wedge pressure > 25 mm Hg, or mean MV gradient > 15 mm Hg during exercise Contraindication for PMBV include unfavorable MV Wilkins score (greater than or equal to 10; see below), more than moderate mitral regurgitation and the presence of intracardiac thrombus.31 536 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 28.3A to C: Lipomatous hypertrophy of the interatrial septum Lipomatous hypertrophy of the interatrial septum (also referred to as lipomatous atrial septal hypertrophy, LASH) is an important finding that should be communicated to the interventionalist performing the trans-septal puncture LASH represents accumulation of epicardial fat in the interatrial fold and not in the true interatrial septum Thus, in LASH the fossa ovalis remains thin but its rims appear unusually thick When there is LASH, the trans-septal puncture should be performed through the fossa ovalis and not through the accumulated fat (A and B) Biplane 3D TEE image from a patient with marked LASH Note the dumbbell appearance of the interatrial septum The fossa ovalis has a thin floor (asterisk); its rims are demarcated by epicardial fat accumulation (arrows) Movie clip 28.3 corresponds to this figure; (B and C) 3D TEE zoom image of the right atrial aspect of the interatrial septum from a patient with LASH Note how the fossa ovalis (white dashed line) is surrounded by unusually tall rims (arrows) These raised rims are due to accumulation of epicardial fat (AV: Aortic valve; IVC,: Inferior vena cava; LA: Left atrium; RA: Right atrium; SVC: Superior vena cava) The role of 3D TEE in PMBV is threefold: confirmation of the diagnosis of mitral stenosis, possible refinement of the MV Wilkins score and guidance of PMBV per se.32 MV planimetry by 3D transthoracic or transesophageal echocardiography is becoming the gold standard for the anatomic assessment of the severity of mitral stenosis.33 The MV is funnel shaped with its narrowest area located in the left ventricle and often in a plane that is not parallel with standard imaging planes of 2D echocardiography Using 3D echocardiography (3DE) techniques of multiplane reconstructions one can overcome the limitations of 2D planimetry and measure the area of at the very tip of the MV funnel MV area can also be measured on zoomed en face views of the MV either semiquantitatively using calibrated grids or even quantitatively using newer software techniques of on-image planimetry (Figs 28.4A to D and Movie clip 28.4) 3D TEE may also help in calculating the MV Wilkins’s score, an essential prerequisite for PMBV The Wilkins’s score was originally developed in the late 1980s using 2D transthoracic echocardiography and is based on mitral leaflet thickness, calcifications, and mobility as well as the thickness of the subvalvular apparatus.34 Each of the four categories is graded on a scale of (normal) to (severely abnormal) A normal MV, thus, has a score of The most unfavorable score is 16 PMBV is contraindicated when mitral score is > 10 Significant thickening, calcifications, and immobility of mitral leaflets and well as significant thickening of the mitral subvalvular apparatus predispose MV to leaflet tear, a known complication of PMBV that may lead to significant de novo mitral regurgitation 3D TEE may enhance the scoring through its superior ability to visualize leaflet mobility and the details of the subvalvular mitral apparatus Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 537 Figs 28.4A to D: 3D TEE diagnosis of mitral stenosis 3D TEE images obtained from a 53-year-old woman with rheumatic mitral stenosis who grew up in the former Soviet Union (A), (B) and (C) demonstrate 3D TEE zoom images of the MV from the left ventricular perspective; (D) is a multiplane reconstruction image (A) 3D TEE image demonstrates typical features of rheumatic mitral stenosis: commissural fusions (arrows) and the doming of the anterior mitral leaflet (AML) On the accompanying Movie clip 28.4 there is also diminished mobility of the posterior mitral leaflet (PML); (B), (C) and (D) demonstrates various 3D TEE methods of calculating the MV area: quantitative on-image planimetry (A), semiquantitative method using a mm grid (B), and the multiplane reconstruction method (C) By all three methods, the patient has severe mitral stenosis with a MV area of approximately 0.6 cm2 3D TEE provides guidance throughout the PMBV procedure which is performed in the following fashion After obtained venous access (typically using the femoral vein), transseptal puncture of the interatrial septum is performed as described earlier in this chapter Subsequently a deflated Inoue valvuloplasty balloon is brought into the left atrium through the transseptal puncture Given its ability to visualize the left atrial aspect of the MV en face, 3D TEE can precisely guide positioning of the valvuloplasty balloon across the MV Once positioned across the MV, the balloon is inflated under 3D TEE and fluoroscopy guidance with the intent to separate the two leaflets of the MV along the commissures fused by the rheumatic process (Figs 28.5A to D and Movie clip 28.5A to C) The outcome of PMBV can be assessed in real time by 3D TEE; en face views of the left ventricular (LV) side of the MV are particularly useful The desired outcome is a controlled commissural tear that enlarges the MV orifice and does not create de novo or worsens preexisting mitral regurgitation 3D TEE can also visualize the mechanism of unfavorable outcome, namely a noncommissural leaflet tear often leading to significant de novo acute mitral regurgitation (Figs 28.6A to D and Movie clip 28.6) 538 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.5A to D: Guidance of percutaneous mitral balloon valvuloplasty Percutaneous mitral balloon valvuloplasty (PMBV) is the preferred method for alleviating mitral stenosis in appropriate patients 3D TEE in conjunction with fluoroscopy provides excellent PMBV guidance (A), (B), and (C) demonstrate 3D TEE zoom images of MV from the left atrial perspective; (D) is a fluoroscopy image (A) Following the trans-septal puncture, 3D TEE is used to guide the deflated Inoue valvuloplasty Inoue balloon into the orifice of the MV Movie clip 28.5C corresponds to this figure; (B) In the next step, the balloon (arrow) is advanced through the mitral orifice and partly inflated; (C) In the final step, the balloon (arrow) is fully inflated in an attempt to relieve the mitral stenosis Movie clip 28.5B corresponds to this figure; (D) Fully inflated Inoue balloon seen on a fluoroscopy image in the anteroposterior projection Arrows point to the balloon’s waist which should be in the plane of the mitral orifice Movie clip 28.5A corresponds to this figure (AML: Anterior mitral leaflet; AV: Aortic valve; LAA: Left atrial appendage; PML: Posterior mitral leaflet) Mitral Regurgitation: MV Clipping Medical management improves symptoms but does not alter the natural progression of mitral regurgitation Current guidelines recommend surgical correction of moderateto-severe or severe mitral regurgitation in patients with symptoms and/or evidence of LV dysfunction.31 In general, surgical MV repair is preferable over surgical valve replacement for correction of mitral regurgitation with lower hospital mortality, longer survival, better preservation of ventricular function, fewer thromboembolic complications, and reduced risk of endocarditis.35,36 To date, there are no commercially available techniques of percutaneous valve replacements for native MV disease In contract, there is a commercially available alternative to surgical MV repair, namely MV clipping to treat selected forms of native MV regurgitation The techniques of MV repair have been pioneered in the 1970s by the French surgeon Alain Carpentier.37 (He also coined the term “bioprosthesis” and was instrumental in developing bioprosthetic valves a few years earlier).38 Most MV repair techniques rely on leaflet reduction, chordal alteration, and annuloplasty ring insertion These complete repairs cannot be replicated Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 539 Figs 28.6A to D: Outcomes of percutaneous mitral balloon valvuloplasty 3D TEE zoom images from patients with rheumatic mitral stenosis demonstrate the left ventricular aspect of the MV (A) demonstrates severe mitral stenosis before percutaneous mitral balloon valvuloplasty (PMBV); (B) demonstrates the result of a successful PMBV Note the increase in the MV area due to separation of commissures of the MV (arrows); (C) demonstrates torn AML (arrow), an unfavorable outcome of PMBV which resulted in severe de novo mitral regurgitation seen in figure D Movie clip 28.6 which corresponds to figure D shows that the jet of mitral regurgitation is eccentric and directed laterally (AML: Anterior mitral leaflet; LA: Left atrium; LV: Left ventricle; PML: Posterior mitral leaflet RV: Right ventricle) yet with current commercially available percutaneous techniques although many are in development.39 In the 1990s the Italian surgeon Ottavio Alfieri developed a simple technique for surgical correction of MV regurgitation that entails placement of a surgical stitch to approximate the free edges of the leaflets at the site of regurgitant jet origin Typically, the stitch is placed centrally between A2 and P2 scallops of the MV that results in a double orifice MV Alfieri called his technique “edge-to-edge repair” but the technique has since become known colloquially as the Alfieri stitch.40,41 MV clipping is essentially the percutaneous version of the edge-to-edge surgical repair MV clipping using the MitraClip® device (Abbott Vascular, Abbott Park, IL) is approved for general use in Europe and is undergoing clinical trials in the United States In the randomized Endovascular Valve Edge-to-Edge Repair Study (EVEREST II) trial, mitral clipping using the MitralClip® device was associated with superior safety and similar improvements in clinical outcomes but was less effective at reducing mitral regurgitation compared to conventional surgery.42 540 Section 2: Echocardiography/Ultrasound Examination and Training Echocardiography, including 3D TEE, is essential in selecting appropriate patients for MV clipping, guiding of the procedure, and assessing the success of the procedure Selection of Patient Eligible for MV Clipping All eligible patients should have the following: • Chronic moderate-to-severe or severe mitral regurgitation originating centrally between A2 and P2 scallops of the MV • Mitral regurgitation may be functional (due to LV dysfunction) or degenerative (due to prolapsed or flail mitral leaflet) with certain anatomic limitations (for degenerative mitral regurgitation: flail gap < 10 mm; flail width < 15 mm; for functional mitral regurgitation: coaptation depth < 11 mm; coaptation length > mm).43 • Either symptomatic with a left ventricular ejection fraction (LVEF) of more than 25% or asymptomatic with at least one of the following: an LVEF of 25–60%, a LV end-systolic diameter of 40–55 mm, new atrial fibrillation, or pulmonary hypertension Details of echocardiographic diagnosis of MV prolapse44 or degenerative mitral regurgitation is discussed elsewhere in this textbook It suffices to say here that 3D TEE (especially its en face views) allow for detailed evaluation of MV anatomy and precise establishment of the mechanism of mitral regurgitation 3D TEE Guidance of MV Clipping The MitraClip device is a mm-wide polyester-covered cobalt–chromium implant with two arms mounted on a sophisticated catheter-based delivery system After obtaining femoral venous access and using standard transseptal approach over a guide wire and tapered dilator, the clip delivery system is brought into the left atrium through a guide catheter.45 Echocardiographic guidance for transseptal puncture is provided in a standard fashion as described earlier in the chapter but with an important modification regarding the location of trans-septal puncture The site of transseptal puncture is extremely important for the success of MV clipping In general, a more posterior and superior puncture site is preferred A distance of at least cm between the site of puncture and the clip landing site on the MV is recommended.46 In particular, passage across PFO—the route commonly used in other percutaneous procedures in the left heart—should be always avoided during MV clipping Passage through a PFO usually results in a position that is too inferior and anterior Furthermore, tunnel-type PFOs may impede free movement of the clip delivery system Following successful transseptal puncture, the clip with its arms closed and attached to the delivery system is brought into the left atrium through the guide catheter After the clip delivery system emerges into the left atrium through the guide catheter, its tip is then bent toward the MV The arms of the clip are opened and subsequently oriented perpendicular to the leaflet coaptation line 3D TEE guidance is absolutely essential in guiding this orthogonal clip orientation (Figs 28.7A to D and Movie clip 28.7) In the next step, the open clip is advanced below the mitral leaflet tips into the left ventricle The arms of the clip are then partially closed and the delivery system is pulled back until the mitral leaflets are captured in the arms of the clip Using 3D TEE and color Doppler, the position and the degree of residual mitral regurgitation are assessed as the arms of the clip are gradually closed to complete the edgeto-edge repair and form a double-orifice MV Occasionally, placement of a second clip may be necessary to treat residual mitral regurgitation However, this increases the chance of procedure-related mitral stenosis (Figs 28.8 to D and Movie clip 28.8) Aortic Stenosis: Transcatheter Aortic Valve Replacement Calcification of a seemingly normal trileaflet or a congenital bicuspid valve resulting from an atherosclerosis-like process is the most common form of acquire aortic stenosis Rheumatic aortic stenosis is rare in the United States and other developed countries It results from commissural fusion and leaflet calcifications, and is invariable associated with concomitant rheumatic MV disease.47 Once severe aortic stenosis becomes symptomatic, the survival is dismal (only a few years)48 and not much different from many metastatic cancers.49 No medical therapy has ever been shown to alter the natural history of aortic stenosis; aortic valve replacement is the only effective therapy Surgical aortic valve replacement (SAVR) has been shown to improve symptoms and is generally accepted to prolong survival based on Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 541 Figs 28.7A to D: Guidance of MV clipping (A and B) Biplane 3D TEE image demonstrates proper positioning of the mitral clip (arrows) prior to clip closure The clip should be perpendicular to the MV closure line and placed in the region of A2 and P2 scallops of the MV Movie clip 28.7 corresponds to this figure; (C and D) 3D TEE zoom image of the MV from the left atrial perspective; (C) demonstrates improper clip positioning (clip is parallel to the mitral coaptation line); (D) demonstrates proper clip positioning (clip is perpendicular to the mitral coaptation line) (AML: Anterior mitral leaflet; AV: Aortic valve; LA: Left atrium; LV: Left ventricle; PML: Posterior mitral leaflet) historical comparisons and extensive experience over the past 50 years.50 The first orthotopic SAVR, albeit for aortic insufficiency, was performed in 1960 by the American surgeon Dwight Harken.51 Currently, about 13,000 SAVR are performed annually in the United States for relief of aortic stenosis.52 Historically, two percutaneous alternatives to SAVR have been proposed: aortic balloon valvuloplasty (ABV) and transcatheter aortic valve replacement (TAVR) also referred to at transcatheter aortic valve implantation (TAVI) BAV was first performed in 1986 by Alain Cribier in France.53 In contrast to PMBV (which is the treatment of choice for relief of mitral stenosis with good long-term outcomes), percutaneous ABV is used primarily as a bridge to aortic valve replacement; used alone ABV has high restenosis and complication rates.54 The first TAVR in a human was performed in 2002 by Alain Cribier in France55 using a balloon expandable valve similar in design to the one tested in animals by Danish inventors a decade earlier.56 TAVR is the only intervention for aortic stenosis shown to prolong survival in a randomized trial.57 It is currently indicted for patients with severe aortic stenosis who are at high risk or unsuitable for SAVR Currently, there are two TAVR valves with or near market approval in various parts of the world: (1) balloon expandable Sapien® valve (Edwards Lifesciences Inc., Irvine, CA); and (2) self-expandable CoreValve® (Medtronic 542 Section 2: Echocardiography/Ultrasound Examination and Training A C B D Figs 28.8A to D: Delivery of mitral clip (A and B) Fluoroscopy images of mitral clips In (A), the mitral clip is still attached to its delivery catheter and is being opened in preparation for grasping of mitral leaflets; In (B) obtained from a different patient, one mitral clip is already deployed (Clip #1), the other is being deployed (Clip #2) (C and D) 3D TEE zoom images of the MV during diastole with one clip (arrows) fully deployed; (C) demonstrates the left atrial aspect and (D) demonstrates the left ventricular aspect of the MV Note that clip deployment creates a double-orifice MV Movie clip 28.8 corresponds to (C) (AML: Anterior mitral leaflet; AV: Aortic valve; PML: Posterior mitral leaflet) Inc., Minneapolis, MN) Echocardiographers should be familiar with the basic design and mode of delivery of these two valves Both are bioprosthetic pericardial valves suspended on a metal frame (Figs 28.9A and B) Sapien® valve is currently made of bovine pericardium suspended on a chrome–cobalt alloy frame A collapsed Sapien® valve is mounted on a deflated balloon in a similar fashion used for coronary stents Upon delivery, Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B Figs 28.9A and B: Transcatheter aortic valve prostheses (A) Sapien™ aortic valve is a balloon expandable prosthesis placed across the aortic annulus; (B) CoreValve™ is a self-expanding aortic valve prosthesis A deployed CoreValve™ prosthesis extends from the LVOT to the ascending aorta Source: (A) Image is courtesy of Edwards Lifesciences, Irvine, CA Source: (B) Image is courtesy of Medtronic Inc., Minneapolis, MN the Sapien® valve is balloon expanded across the stenosed native aortic valve In contrast, CoreValve® is made of porcine pericardium suspended on a nitinol alloy frame Prior to CoreValve® implantation, balloon valvuloplasty of the native aortic valve is performed Subsequently, a collapsed CoreValve® is brought into the ascending aorta that then self-expends across the stenosed native valve after it emerges from the delivery sheath Both valves can be implanted using various arterial access points: the femoral artery, LV apex, or ascending aorta.58 The role of echocardiography including 3D TEE is twofold: to identify appropriate patients and to provide intraprocedural monitoring Selection of Patient Eligible for TAVR Echocardiography is essential in establishing the presence of the only currently approved indication for TAVR: severe acquired calcific stenosis of a trileaflet valve (senile calcific aortic stenosis) TAVR is currently not indicated for aortic stenosis of a bicuspid aortic valve although, as mentioned earlier, the very first TAVR performed by Alain Cribier was in a patient with severe bicuspid aortic valve stenosis.53 Can 3DE improve on standard techniques of assessing aortic stenosis severity discussed elsewhere in this chapter? Using the multiplane reconstruction techniques, 543 3D TEE can provide accurate measurements of the left ventricular outflow tract (LVOT), aortic annulus and the aortic annulus-to-left coronary artery ostium distance Calculation of the aortic valve area (AVA) by continuity equation is the principal echocardiographic method of assessing anatomic severity of aortic stenosis The major source of error in AVA calculation by continuity equation is miscalculation of the cross sectional area of the LVOT due to mismeasurement of the LVOT diameter and/or faulty geometric assumption of a circular LVOT shape.59 Using multiplane reconstruction techniques of either CT or 3DE (Figs 28.10A to D) one can demonstrate that LVOT is typically ovoid rather than circular in shape.60,61 In addition, it can also be demonstrated that the LVOT “diameter” measured by 2DE is often a geometric chord rather than a true diameter Since a chord (a line connecting two points on the circumference that does not cross the center) is by definition shorter than a diameter, 2DE will often underestimated the size of LVOT area and thus overestimate the severity of aortic stenosis The size of the aortic annulus is another measurement that is important for TAVR as the size of the replacement valve is based on the patient’s annular size 2DE systematically underestimates the annular size compared to CT or MRI.62 In contrast, 3D TEE sizing of the annular size (Figs 28.11A to D) are superior to 2D TEE and may be used when good CT data are unavailable for TAVR sizing.63 Prior to Sapien® valve placement, the annular to left coronary artery ostium height is important as well in selecting appropriate replacement valve size Echocardiographically, this height cannot be measured by 2D TEE; however, such a measurement is possible with multiplane reconstruction techniques of 3D TEE (Figs 28.12A to D).64 Theoretically, AVA can also be measured by 3D planimetry However, aortic valve calcifications create image dropout making this measurement imprecise TAVR: Intra- and Postprocedural Monitoring by 2D/3D TEE Both 2D and 3D TEE are used during TAVR to help guide the valve insertion, monitor for intraprocedural complications, and assess postimplantation success In contrast to MV procedures where 3D TEE plays the principal role in guidance, TAVR placement is performed primarily under fluoroscopic and CT guidance Nonetheless, 2D and 3D TEE is used to provide important 544 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.10A to D: 3D TEE assessment of the LVOT Multiplane reconstruction 3D TEE imaging of the LVOT in a patient prior to CoreValve placement demonstrates an ovoid-shaped LVOT measuring 2.2 × 2.5 cm in diameters and having an area of 4.5 cm2 (LA: Left atrium; LVOT: Left ventricular outflow tract) A Figs 28.11A and B B Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures C 545 D Figs 28.11A to D: 3D TEE assessment of the aortic annulus Multiplane reconstruction 3D TEE imaging of the aortic annulus in a patient prior to CoreValve placement demonstrates a near-circular aortic annulus measuring 2.3 × 2.4 cm in diameters (LA: Left atrium; LVOT: Left ventricular outflow tract) A B C D Figs 28.12A to D: 3D TEE assessment of the annulo-ostial distance Multiplane reconstruction 3D TEE imaging of the aortic annulus in a patient prior to Sapien valve placement demonstrates how to measure the distance between the aortic annulus and the left main coronary artery (annulo-ostial distance) Note that the ostium of the left main coronary artery is first localized in the short axis and the distance is then measured in the corresponding long-axis (in this case, Long Axis #2) (LA: Left atrium; LCA: Left main coronary artery; LVOT: Left ventricular outflow tract; RA: Right atrium) 546 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.13A to D: TEE guidance of transcutaneous aortic valve replacement (A) Prior to percutaneous aortic valve replacement, balloon valvuloplasty (arrow) of the native aortic valve is performed; (B) 3D TEE zoom image demonstrates a catheter (arrow) crossing the native aortic valve in preparation for percutaneous aortic valve replacement; (C and D) 3D TEE biplane image of the newly placed CoreValve (arrows) during diastole In the right portion of this figure, one can seen closed prosthetic leaflets in the short-axis of the valve (Asc Ao: Ascending aorta; LA: Left atrium; LV: Left ventricle; RA: Right atrium) real time information regarding aortic valve anatomy and function, and to observe for complications such as pericardial effusion or ventricular dysfunction Moreover, guide wires, catheters, valvuloplasty balloons and the replacement valve (Figs 28.13A to D) can continuously be observed by echocardiography; in this respect 3D TEE is often superior to 2D TEE Immediately post TAVR, Doppler echocardiography plays crucial role is assessing the success of the procedure Color Doppler is used to assess for paravalvular regurgitation (Figs 28.14A to D), which may be present in at least 10% of TAVR patients and which portends poorer prognosis.65 Spectral Doppler reordered from transgastric windows in used to assess the gradients across the newly implanted TAVR (Figs 28.15A to C) Closure of Paravalvular Prosthetic Leaks The reported prevalence of clinically important paravalvular leaks (PVL) due to valve dehiscence ranges between 3% and 12.5% of all surgically implanted prosthetic valves.66 In the early postsurgical period, prosthetic valve dehiscence is typically due to procedural mishaps (e.g a loose suture in a patient with calcified native annulus) Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 547 Figs 28.14A to D: Assessment of paravalvular aortic regurgitation post-transcutaneous aortic valve replacement (A) Implanted CoreValve (arrows) seen on fluoroscopy; (B) Mild paravalvular regurgitation (arrow) in a patient with CoreValve Frequently the paravalvular leak is located adjacent to the AML; (C) Severe paravalvular regurgitation (arrows) in another patient with CoreValve Note the large amount of color flow along the entire posterior aspect of the prosthetic valve After placement of another CoreValve using the valve-in-valve technique, the severe aortic regurgitation disappeared; (D) Spectral Doppler of severe paravalvular regurgitation seen in (C) Note the rapid deceleration slope of the aortic regurgitant jet (pressure half-time of 200 ms) (AML: Anterior mitral leaflet LA: Left atrium; LV: Left ventricle; RA: Right atrium; RV: Right ventricle) Late-onset prosthetic dehiscence is usually due to infective endocarditis Irrespective of its cause, prosthetic valve dehiscence leads to paravalvular regurgitation and hemolytic anemia The magnitude of hemolytic anemia does not necessarily correlates with the severity of paravalvular regurgitation.67 Heart failure and transfusion-dependent anemia are major indications for PVL closure Until recently, redo open heart surgery was the only means of closing clinically significant PVLs However, reoperation is associated with high morbidity and mortality, with reported in-hospital mortality rates of 13%, 15%, and 37% for the first, second, and third reoperations, respectively.68 It appears that in 1987 the first percutaneous PVL closure was performed.69 Percutaneous closure of PVLs is emerging as an alternative to redo surgery.70 Most initial experience has been with closure of mitral PVLs71 but techniques are being developed for PVLs of prosthetic aortic valves as well.72 Percutaneous closure is becoming the treatment of choice for most clinically significant PVLs; surgery is still reserved for very large PVLs (involving more than 25% of the prosthetic ring circumference) or PVLs related to active endocarditis.73 At present, there are no closure devices that are specifically designed for PVL closure; instead either vascular plugs or occluders designed for ASD, VSD, or PDA closure are used off label 548 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 28.15A to C: Assessment of aortic valve gradients before and after transcutaneous aortic valve replacement Aortic valve gradients before (A) and after (C) percutaneous implantation of the Sapien aortic valve; the valve is seen on fluoroscopy in (B) Depending of PVL size, one or more devices may be needed to successfully close the leak.74 Improvements in 3D TEE imaging are the major driving force behind the development of percutaneous PLV closures 3D TEE is important both for establishing the precise diagnosis of PVL and for monitoring of percutaneous closure 3D TEE Diagnosis of PVL The diagnosis of a PVL can be established by 2DE However, 3D TEE provides incremental information regarding the exact location, size, and shape of a PVL (Figs 28.16A and B) This information is crucial for the success of PVL closure procedure With its ability to provide en face views of the entire MV, 3D TEE demonstrates PVLs in an intuitive and accurate It is essential to use color Doppler to confirm the location of PVLs and to avoid mischaracterization of periprosthetic image dropouts as PVLs In summary, 3D TEE can accurate identify patients with suitable anatomy for percutaneous PVL closure 3D TEE Monitoring of Percutaneous PVL Closure For percutaneous closure of mitral PVLs, standard transseptal approach is used 3D TEE is instrumental in guiding transseptal puncture as discussed earlier in this chapter Occasionally, transaortic or transapical approach may be used Irrespective of the approach used, 3D TEE is used intraprocedurally to guide placement of wires, catheters, and closure devices (Fig 28.17) Without 3D TEE guidance many PVL closure procedures would be either impossible to perform using fluoroscopy alone or would expose the patient significant radiation Postprocedurally, 2DE and 3DE is used to assess for residual regurgitation and to evaluate for possible prosthetic valve malfunction due to closure device impingement In general, closure of mitral PVL located laterally (Figs 28.17A to D) is technically easier than the closure of those located medially (Figs 28.18A to C) DEVICE CLOSURE OF CARDIAC SHUNTS Surgical closure of cardiac shunt predates many other forms of cardiac surgery and was practiced well before the advent of cardiopulmonary bypass in the 1960s Percutaneous closure has become the treatment of choice for many cardiac shunts including PDA, secundum ASDs, and muscular VSDs with surgery typically being reserved for complex cases Closure of PDAs Ductus arteriosus is an arterial communication between the left pulmonary artery and the proximal descending thoracic aorta that develops embryologically from the left sixth aortic arch Ductus arteriosus is an essential component of the normal fetal circulation; it directs Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A 549 B Figs 28.16A and B: 3D TEE diagnosis of paravalvular mitral regurgitation (A) 3D TEE en face zoom view of the St Jude mechanical mitral prosthesis; prosthetic leaflets in the open position during ventricular diastole (asterisk) are seen Arrow points to the location of the paravalvular leak between the aortic valve and the LAA; (B) 3D TEE color Doppler of the St Jude mechanical prosthesis visualized in the same orientation as in figure A Note the location, size and the shape of the paravalvular leak (arrow) Also note the physiologic (‘washing’) jets inside the prosthetic valve (asterisks) (AV: Aortic valve; LAA: Left atrial appendage) the blood away from the very high-resistance fetal pulmonic circulation of the collapsed lungs to the lower resistance systemic circulation (physiologic right-to-left shunt) During fetal life, ductus arteriosus is kept open by vasodilators such as prostaglandin PGE2, which is believed to be produced both locally in the ductus and by the placenta Soon after delivery, pulmonary vascular resistance drops below the systemic vascular resistance leading to shunt reversal; this left-to-right shunt is transient in most infants The high oxygen content of ductal blood activates an oxygen-sensitive potassium channel that leads to contraction of the ductal muscular layers and cessation of ductal flow In the majority of infants scarring completely obliterates ductus arteriosus by the end of the neonatal period.75 PDA results from the failure of physiologic closure of ductus arteriosus past the first year of life It can be isolated or may be associated with a variety of other forms of congenital heart disease Typically, PDAs presents with a left-to-right shunt; however, shunt reversal can occur if pulmonary vascular resistance rises above the systemic vascular resistance PDA is the first congenital heart defect to be closed successfully by surgery and was the first congenital heart defect to be closed percutaneously The first successful ligation of a PDA was performed in 1938 by Robert E Gross, then the chief surgical resident, and John P Hubbard at Boston Children’s Hospital.76 The first successful percutaneous closure of a PDA was reported by Werner Portsmann and colleagues working at Charité Hospital located in what was then East Germany.77 Percutaneously or surgically closure of a PDA is indicated for the following:78 • Left atrial and/or LV enlargement or if pulmonary arterial hypertension is present, or in the presence of net left-to-right shunt • Prior endarteritis • It is reasonable to close an asymptomatic small PDA by catheter device Surgical repair by a surgeon experienced in congenital heart disease is recommended when: • PDA is too large for device closure • Distorted ductal anatomy precludes device closure PDA closure is contraindicated in patients with pulmonary arterial hypertension and net right-to-left shunt General aspects of PDA diagnosis are discussed elsewhere in this textbook From the percutaneous or surgical point of view, the role of imaging is to establish the general anatomy of a PDA Typically, PDAs have a conical shape with the wider opening at the aortic side and the smaller one at the pulmonary artery side However, a variety of shapes have been described.79 There are limited data on the use of 3DE in the diagnosis of PDA80 and for guidance of PDA closure (Figs 28.19A to D).81,82 In general, 550 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.17A to D: 3D TEE guidance of a lateral mitral paravalvular leak closure 3D TEE en face zoom view of the mitral bioprosthetic valve is seen from the same perspective in all four figures (A) Arrow points to the location of the lateral paravalvular leak at approximately 10 o’clock (arrow) on the standard surgical view of the MV located between the LAA and the native aortic valve (AV); (B) 3D TEE imaging is used to guide the transseptal catheter (arrow) to the paravalvular leak; (C) A vascular plug (arrow) is placed in the paravalvular leak; (D) Because leak closure was incomplete after first plug placement, another plug is delivered adjacent to the first plug The two plugs (arrows) were able to close the leak successfully TEE allows for continuous monitoring of PDA flow during percutaneous closure; this minimizes X-ray exposure of concomitant fluoroscopy (Figs 28.20A and B).83 Closure of ASDs There are at least four different types of ASDs in the descending order of prevalence: secundum ASD, primum ASD, sinus venosus ASD (which may be of the superior or inferior vena cava type), and unroofed coronary sinus Following bicuspid aortic valve, ASD is the most common congenital anomaly in adults occurring in approximately out of 1,000 individuals.84 Successful surgical closure of ASDs predates the advent of cardiopulmonary bypass In 1952, closure of an ASD in a 5-year-old girl by F John Lewis was the first successful open heart operation (performed under general hypothermia and inflow occlusion) at the University of Minnesota.85 In 1953, ASD closure by John Gibbon in Philadelphia was the very first successful cardiac surgery using cardiopulmonary bypass.86 The first percutaneous closure of an ASD was performed in 1975 by King and Mills at Ochsner Medical Center in New Orleans, LA.87 At present, closure of secundum ASDs is the only approved indication for current percutaneous closure devices Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures Major indications for surgical or percutaneous ASD closure are as follows:78 • Right atrial and right ventricular enlargement with or without symptoms • Closure of an ASD is reasonable in the presence of paradoxical embolism or orthodeoxia-platypnea Closure of an ASD is contraindicated in patients with severe irreversible pulmonary hypertension and no evidence of a left-to-right shunt 3D TEE is instrumental in both the diagnosis of an ASD and guidance of percutaneous ASD closure A 551 3D TEE Diagnosis of ASDs Appropriate patient selection is of utmost importance for the success of percutaneous ASD closure.88 One should first establish the diagnosis of a secundum ASD, the only ASD type amenable to percutaneous closure at present.89 After obtaining 3D TEE images of the interatrial septum, we use the so-called TUPLE (tilt up then left) maneuver to obtain en face images of the interatrial septum in anatomically correct orientations (Figs 28.21A to C and Movie clip 28.21A and Movie clip 28.21B) Briefly, the TUPLE maneuver is a B C Figs 28.18A to C: 3D TEE guidance of a medial mitral paravalvular leak closure (A) 3D TEE color Doppler en face zoom view of the mitral bioprosthetic valve demonstrates a medial paravalvular leak at approximately o’clock (arrow) on the standard surgical view of the MV The leak is located adjacent to the interatrial septum (IAS) and away from the aortic valve (AV); (B) 3D TEE en face zoom view of the mitral bioprosthesis demonstrates two vascular plugs (arrows) used to close the medial paravalvular leak successfully; (C) The appearance of the two vascular plugs on fluoroscopic image in the cranially angulated right anterior oblique projection A Figs 28.19A and B B 552 Section 2: Echocardiography/Ultrasound Examination and Training C D Figs 28.19A to D: 2D/3D TEE diagnosis of PDA (A) 3D TEE biplane image demonstrating the aortic side (arrows) of a PDA; (B) Spectral Doppler tracings demonstrate flow velocity pattern typical of a PDA with a left-to-right shunt and normal pulmonary artery pressures There is high pressure gradient between the aorta and the pulmonary artery throughout the cardiac cycles (higher in systole than in diastole); (C) 3D TEE en face zoom view of the aortic orifice of the PDA (arrow); (D) 3D TEE zoom view demonstrates the PDA in its long axis The PDA appears as a tube between the aorta (Ao) and the pulmonary artery (PA) A B Figs 28.20A and B: Fluoroscopy during PDA closure (A) Prior to PDA closure, PDA is imaged using contrast injection into the descending aorta The contrast exits the aorta (Ao) into the pulmonary artery (PA) via the PDA (arrows); (B) A PDA closure device (arrows) is being deployed into the PDA The device is still attached to its delivery cable seen in the pulmonary artery (PA) three-step process in which the initial 3D zoom image of the interatrial septum is tilted up to reveal the right atrial aspect of the interatrial septum The image is then rotated counterclockwise in the Z-axis until the SVC is located at 12 o’clock Finally, the image is then rotated to the left to reveal the left atrial aspect of the interatrial septum.90 After using the TUPLE maneuver one can easily determine ASD type, location, shape, and size Secundum ASDs (Figs 28.22A to D) are located in the fossa ovalis and come in a variety of shapes (circular, ovoid, triangular).91 They may contain fenestrations (cribriform ASD) or may be associated with an atrial septal aneurysm.92 Sizing of an ASD involves measuring of ASD diameters and determining the size of surrounding ASD rims; these data are essential for choosing an appropriate closure device The three most commonly used ASD closure devices (Figs 28.23A to C) are as follows: • AmplatzerTM atrial septal occluder (St Jude Medical, St Paul, MN) It consists of two discs (the left atrial disc being larger than the right atrial disc) connected Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B 553 C Figs 28.21A to C: TUPLE maneuver for orienting the interatrial septum TUPLE (Tilt-Up-Then-Left) is a simple maneuver for orienting the interatrial septum into an anatomically correct orientation (A) Interatrial septum is first visualized on 2D TEE at 0° Then the corresponding 3D TEE zoom image of the interatrial septum is obtained; (B) The 3D TEE image is tilted up to reveal the right atrial aspect of the interatrial septum Note that the superior vena cave is located at 12 o’clock; (C) The 3D TEE image is then rotated to the left to reveal the left atrial side of the interatrial septum Movie clip 28.21A corresponds to this Figure Note: If the 2D TEE image is obtained at any angle other than 0° the 3D TEE image is figure is not only tilted up but also rotated counterclockwise until the SVC is at 12 o’clock Movie clip 28.21B demonstrates this modification of the TUPLE maneuver (ASD: Atrial septal defect; SVC: Superior vena cava) by a waist; it comes in a variety of sizes based on waist diameter (from mm to 38 mm) Device selection is based on the measured diameter of the defect, which should correspond to the waist diameter of the device This device is used to close nonfenestrated secundum ASDs • AmplatzerTM multifenestrated septal occluder (St Jude Medical, St Paul, MN) is used to close fenestrated (cribriform) secundum ASDs It contains two discs of equal diameter connected by a thin shaft; it comes in a variety of size based on the diameter of the left atrial disc (from 18 mm to 35 mm) Device selection is ultimately based on the measured diameter of the defect, which should be proportional to the disc diameter of the device • Gore-Helex atrial septal occluder (W L Gore & Associates, Inc., Flagstaff, AZ) contains two equal-sized discs mounted on a spiral shaft; it comes in a variety sizes based on the disc diameter (from 15 mm to 35 mm) The occluder size selected for the defect should achieve at least a 2:1 ratio between disc diameter and defect diameter When selecting an ASD closure device, the maximum diameter of a secundum ASD cannot exceed devicespecific cutoff value and there should be sufficient ASD rim to anchor the device Historically, the device size was selected based on an invasive measurement of ASD diameter using sizing balloons placed across an ASD (Figs 28.24A and B) and gradually inflated until no color Doppler flow across the ASD is seen on 2D TEE (so-called stop-flow diameter) More recently, device selection is based on direct ASD diameter measurements by 3D TEE (Figs 28.25A to C) The maximum ASD diameter amenable to closure with an AmplatzerTM atrial septal occluder is 38 mm; for a Gore-Helex device the maximum ASD diameter is 18 mm 3D TEE imaging is also important in measuring rims that surround a secundum ASD (Figs 28.26A and B) There are several different nomenclatures of ASD rims; we prefer the system that labels rims based on the surrounding structure (e.g aortic rim)93 rather than on their anatomic orientation (e.g antero-superior rim).94 In general, there are five distinct ASD rims listed in a clockwise direction: SVC rim, aortic room (adjacent to the aortic valve), atrioventricular rim (adjacent to the tricuspid and MV), inferior vena cava (IVC) rim, and posterior rim (the rim opposite the aortic rim) In general, the rims should be “sufficient”—that is, they have to exceed certain minimum distance This minimum rim size is device specific For instance, for the AmplatzerTM septal occluder the rims should be at least mm For the AmplatzerTM multifenestrated septal occluder, the SVC and the aortic rim should be at least mm Absence of the inferior vena cave rim is considered a contraindication for device closure of a secundum ASD 554 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.22A to D: Anatomic variations of secundum ASDs 3D TEE zoom images of the right atrial side of the interatrial septum demonstrate variations in the size, shape and location of secundum ASDs In each image the SVC is located at approximately 12 o’clock (A) Secundum ASD asterisk) has a near circular shape; (B) Secundum ASD (asterisk) has a triangular shape; (C) Secundum ASD (asterisk) has an ovoid shape and is located in the superior portion of the fossa ovalis The inferior portion of the fossa ovalis floor is aneurismal (arrow); (D) Fenestrated secundum ASD with multiple holes (asterisks) separated by remnants of the fossa ovalis floor 3D TEE Monitoring of Percutaneous ASD Closure 3D TEE allows for continuous visualization of the tip of the guiding catheter, as well as of the closure device as it is being delivered After the secundum ASD is sized and deemed amenable to percutaneous repair by 3D TEE, the interventionalist may decide to confirm the ASD size using a balloon Color Doppler echocardiography is used during balloon inflation When no flow between the balloon and ASD margins is seen by color Doppler, the interventionalist measures the ASD diameter on fluoroscopy image (stopflow diameter) Subsequently, a delivery catheter is brought into the left atrium across the ASD using a transvenous approach (typically via the femoral vein) A collapsed ASD closure device is advanced through the catheter into the left atrium The left atrial disc is opened first and apposed against the left atrial side of the defect The right atrial disc is then opened and maneuvered until the device is firmly attached to the rims of the ASD 3D TEE imaging is used to ascertain proper positioning of the closure device Both discs can be visualized by 3D TEE although right atrial disc may be more difficult to visualize than left atrial disc This is due to the fact that relative to the TEE probe located in the esophagus the right atrial disc in the far field and partly shadowed by the left atrial disc (Figs 28.27 and 28.28) In addition, 3D TEE helps determine if sufficient tissue rim is caught in between the two plates of the device When Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B 555 C Figs 28.23A to C: ASD closure devices (A) Amplatzer™ atrial septal occluder (St Jude Medical, St Paul, MN); (B) Amplatzer™ multifenestrated septal occluder (St Jude Medical, St Paul, MN); (C) Gore-Helex atrial septal occluder (W L Gore & Associates, Inc., Flagstaff, AZ) rim capture is insufficient, 3D TEE can be used to guide repositioning of the device At the end of the procedure, the device is fully deployed after its release from the delivery shaft 2D- and 3D TEE color Doppler imaging is crucial for assessing the success of percutaneous ASD closure On color Doppler, ideally there should be no residual para-device leak (i.e flow around the device between ASD rims and the edge of the device); the absence of such a leak is indicative of a complete ASD closure Small amounts of color Doppler flow across rather than around the device may be normal; such flows will cease upon endothelialization of the device ICE is an alternative to 3D TEE for monitoring of ASD closure (Figs 28.29A to C) Closure of PFOs Foramen ovale, a communication between the right and left atrium at the level of fossa ovalis, is an essential part of fetal circulation It allows for shunting of oxygen-rich blood (arriving into the right atrium via umbilical veins) to systemic circulation After birth, the communication closes in the majority of children but remains open in about a quarter of adult population.95 The persistence of this communication is referred to as PFO PFO has been implicated in the pathogenesis of cryptogenic stroke96 and its surgical or percutaneous closure has been advocated in prevention of recurrent systemic embolism The role of 3D TEE in percutaneous PFO closure is similar to that described for ASD closure 556 A Section 2: Echocardiography/Ultrasound Examination and Training B Figs 28.24A and B: ASD sizing balloon (A) ASD sizing balloon seen on fluoroscopy extending from the right atrium (RA) to the left atrium (LA) Note that the central portion of the balloon (waist) is located in the ASD The balloon is inflated gradually until color flow across the ASD ceases on TEE imaging At that moment, the waist diameter is measured; it represents the so-called stop-flow diameter and is used to choose appropriate ASD closure device size; (B) 3D TEE zoom image demonstrates the left atrial aspect of the sizing balloon (AV: Aortic valve; MV: Mitral valve; RUPV: Right upper pulmonary vein; SVC: Superior vena cava) A B C Figs 28.25A to C: 3D TEE sizing of ASDs ASDs can be sized on 3D TEE using a variety of methods In this figure the ASD is seen from the right atrial perspective (A) ASD sizing using an overlay grid; in this instance the distance between the dots is mm; (B) ASD sizing using direct on-image calipers; (C) ASD sizing using the multiplane reconstruction method Also note the difference between the true ASD diameters and a chord Distances presumed to be diameters on 2D TEE are frequently chords rather than true diameters Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A 557 B Figs 28.26A and B: 3D TEE visualization of ASD rims 3D TEE zoom view of the interatrial septum and surrounding structures from the right atrial (A) and left atrial perspective (B) Five ASD rims are depicted in each figure: (1) SVC rim; (2) aortic rim next to the aortic valve (AV); (3) atrioventricular rim next to the tricuspid and mitral valve; (4) IVC rim; and (5) posterior rim A B Figs 28.27A and B: 3D TEE appearance of Amplatzer ASD occluder Amplatzer ASD occluder (arrow) is well visualized from the right atrial side (A) and the left atrial side (B) (AV: Aortic valve; IVC: Inferior vena cava; RUPV: Right upper pulmonary vein; SVC: Superior vena cava) PFOs are typically closed percutaneously with devices that are specifically designed for PFO closure (Figs 28.28A to C) such as the STARFlex occluder (previously referred to as CardioSEAL device; NMT Medical, Boston, MA) and Amplatzer PFO Occluder (St Jude Medical, St Paul, MN) Percutaneous PFO closure was first reported in 1992 using the Bard Clamshell Septal Occluder, a predecessor of the STARFlex device.97 Randomized trials have thus far failed to demonstrate clear benefit of PFO closure with either STARFlex or Amplatzer PFO Occluder.98,99 Closure of VSDs There are several types of VSDs: perimembranous (infracristal); muscular (further subdivided into inlet, trabecular and infundibular, or supracristal); and atrioventricular defect (a communication between the left ventricle and the right atrium).100 Perimembranous VSDs often have a windsock appearance due to evagination of the membranous septum.101 Colloquially, the term “muscular VSD” if often used synonymously with the trabecular VSD Muscular VSD 558 A Section 2: Echocardiography/Ultrasound Examination and Training B C Figs 28.28A to C: 3D TEE and fluoroscopic appearance of ASD and PFO closure devices (A) Gore-Helex atrial septal occluder (W L Gore & Associates, Inc., Flagstaff, AZ); (B) Amplatzer™ multifenestrated (“cribriform”) septal occluder (St Jude Medical, St Paul, MN); (C) STARFlex occluder (previously referred to as CardioSEAL device; (NMT Medical, Boston, MA) may be congenital or acquired (e.g following myocardial infarction or trauma).102 Closure of a VSD should be considered if one of the following criteria is present: • Qp/Qs (pulmonary-to-systemic blood flow ratio) ≥ 2.0 and clinical evidence of LV volume overload • History of infective endocarditis Closure of a VSD may also be considered if: • Qp/Qs > 1.5 with pulmonary artery pressure less than two thirds of systemic pressure and pulmonary vascular resistance less than two-thirds of systemic vascular resistance • Net left-to-right shunting is present at Qp/Qs > 1.5 in the presence of LV systolic or diastolic failure Closure of a VSD is contraindicated in patients with severe irreversible pulmonary arterial hypertension (who typically present with pulmonary vascular resistance greater than two-thirds of systemic vascular resistance) Percutaneous closure of a VSD was first performed in 1987 at Harvard Medical School.103 At present, percutaneous closure devices in the United States are approved for use in patients who are at high risk for standard surgical VSD closure and whose VSD is not in the proximity of cardiac valves Thus, percutaneous closure is primarily performed in patients with congenital muscular VSDs Nonetheless, off-label use for percutaneous closure of postinfarction VSDs has been reported.104 One such device approved in the United States is the AmplatzerTM ventricular septal occluder (St Jude Medical, St Paul, MN) It consists of two discs of equal diameter (a LV disc and a right ventricular disc) separated by a waist that fits within the VSD Device comes in a variety of sizes based on the waist diameter (from mm to 18 mm) Outside the United States, a specially designed device with eccentric discs is used to close perimembranous VSDs.105 Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures 559 A B C Figs 28.29A to C: Guidance of ASD closure using intracardiac echocardiography (ICE) ICE images demonstrate steps in secundum ASD closure using an Amplatzer ASD occluder (A) The ASD closure assembly is brought into the left atrium and the left atrial disc is unfurled; (B) The right atrial disc is unfurled and the closure device is placed within the ASD The device is still attached to the delivery cable; (C) The ASD device is fully deployed and released from its delivery cable Color Doppler imaging demonstrates no residual shunt 3D TEE is important for both the diagnosis and for guidance of percutaneous closure of a VSD.106 With its unique ability to provide en face views, 3D TEE allows for accurate visualization of the VSD location, size, and shape (Figs 28.30A to E) The information is important in establishing the feasibility of device closure and selecting the proper size of the closure device During percutaneous VSD closure, the role of 3D TEE imaging is similar to that described for percutaneous ASD closures 3D TEE visualization of intracardiac wires and catheters is helpful in guiding placement of a closure device into the defect Postdeployment, 2D and 3D TEE color Doppler imaging is crucial for assessing whether VSD closure was successful or not (Figs 28.31A to D) With complete VSD closure there should be no residual paradevice leak (i.e flow around the device between VSD rims and the edge of the device) on color Doppler imaging In contrast, small amounts of color Doppler flow across rather than around the device may be normal; such flows will disappear upon endothelialization of the device OCCLUSION OF THE LEFT ATRIAL APPENDAGE Atrial fibrillation, the most common sustained cardiac arrhythmia, is a risk factor for intracardiac thrombus formation and thromboembolism; it accounts for approximately 15% of all ischemic strokes.107 In nonvalvular atrial fibrillation, the LAA is the primary site of thrombus formation accounting for 91% of all atrial fibrillationassociated intracardiac thrombi Even in valvular atrial fibrillation (which is related to rheumatic heart disease and this uncommon in high-income countries) LAA thrombi account for 57% of all thrombi.108 Anticoagulation with warfarin or other oral agents is the standard of care 560 Section 2: Echocardiography/Ultrasound Examination and Training A B C D E Figs 28.30A to E: Echocardiographic diagnosis of perimembranous VSD (A) 2D TEE image obtained at 145° demonstrates a perimembranous VSD with left to right shunt (arrow) from the left ventricular outflow tract (LVOT) to the right ventricle (RV); (B) 3D TEE color Doppler visualization of the VSD jet The arrow points to the vena contract of the jet at the level of VSD; (C) Spectral Doppler demonstrates flow typical of a restrictive VSD Note the high velocity systolic flow and only a low-velocity diastolic flow; (D and E) 3D TEE en face zoom view of the VSD orifice (arrow) from the left ventricular; (D) and the right ventricular side (E) The VSD measures × mm and has an area of 36 mm2 (LA: Left atrium; LCC: Left coronary cusp of the aortic valve; NCC: noncoronary cusp; PV: Pulmonic valve; RCC: Right coronary cusp) for prevention of thromboembolism in atrial fibrillation In patients who cannot take anticoagulant, exclusion of LAA from the body of the left atrium is an alternative for prevention of thromboembolism LAA exclusion can be achieved either surgically or percutaneously Surgical techniques of LAA exclusion include LAA amputation,109 clipping,110 and ligation.111 Surgical LAA exclusion is usually performed only as Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 561 Figs 28.31A to D: Echocardiographic visualization of a VSD closure device The patient underwent perimembranous VSD closure in China; such a procedure is not available in the United States unless part of an investigational study (A and B) 2D transthoracic echocardiography demonstrates a closure device obliterating a perimembranous VSD in the parasternal long-axis (A) and the parasternal short-axis view (B); (C and D) 3D TEE en face zoom view of a VSD closure device (arrow) obliterating a perimembranous VSD seen from the left ventricular perspective (C) and the right ventricular perspective (D) (AV: Aortic valve; LA: Left atrium; LV: Left ventricle; NCC: Noncoronary cusp of the aortic valve; RA: Right atrium; RCC: Right coronary cusp; RV: Right ventricle) an adjunct to another cardiac surgery (such coronary bypass grafting or valvular surgery) that limits the number of patients who could benefit from LAA exclusion Furthermore, surgical LAA exclusion is frequently incomplete.112 Percutaneous LAA exclusion can be achieved either by implantation of an endocardial occluder device or via transpericardial placement of an epicardial suture at the LAA ostium 2D and 3D TEE imaging is important for patient selection and guidance of percutaneous LAA exclusion.113 Endocardial Device Closure of LAA Although several occluders have been used, general principles of percutaneous closure of LAA using the endocardial approach are the same Using a venous access (typically the femoral vein) and the previously described transseptal puncture, a delivery catheter is advanced through the venous system into the right atrium and then across the interatrial septum into the left atrium near the ostium of the LAA Subsequently, the occluder is brought through the catheter into the LAA and deployed LAA occluders consist of a nitinol wire frame covered with cloth To date, they have only been approved for investigational use in the United States Three LAA occluders have been evaluated in clinical trials: PLAATO, WatchmanTM, and AmplatzerTM cardiac plug (Figs 28.32A to C).114 PLAATO (Appriva Medical, Inc., Sunnyvale, CA) was the first device that was specifically designed for percutaneous LAA occlusion Despite promising results, 562 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 28.32A to C: Devices used for percutaneous closure of LAA The greatest clinical experience to date is with the Watchman device The PLAATO device is no longer available The Amplatzer cardiac plug is currently in clinical trials in the United States A B Figs 28.33A and B Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures C 563 D Figs 28.33A to D: Sizing of LAA by 2D TEE On 2D TEE, LAA is visualized on multiple acquisition angles (typically 0°, 45°, 90° and 135°) Both the orifice diameter and the appendage depth are measured in each view PLAATO device has been discontinued Enrollment for the AmplatzerTM cardiac plug (St Jude Medical, St Paul, MN) trial is in progress WatchmanTM (Boston Scientific, Natick, MA) is the only LAA occluder whose clinical trials have been completed In the PROTECT-AF trial, LAA exclusion with a WatchmanTM device was shown to be noninferior to warfarin therapy.115 However, it is important to emphasize that all patients who received Watchman device were also treated with warfarin for weeks and dual antiplatelet therapy (aspirin and clopidogrel) for months postdevice implantation Aspirin therapy was then continued for life 2D- and 3D TEE in used for both patient selection and procedure guidance TEE imaging can be used to accurately visualize the LAA prior to the procedure and to measure its size.116 For device placement, both the orifice size and LAA length are important Historically, LAA was sized using 2D TEE imaging at various acquisition angles, typically at 0°, 45°, 90°, and 135° (Figs 28.33A to D) 3D TEE imaging allows for more precise sizing of the LAA; both 3D zoom and multiplane reconstruction imaging are helpful (Figs 28.34A to D) On 3D TEE en face views, the LAA orifice is often ovoid rather than circular in shape Using on-image calipers, the orifice diameters can be measured precisely For proper device implantation, LAA must have a minimum length (the distance between the LAA orifice and LAA tip) This distance can be measured very accurately on multiplane reconstruction of 3D TEE images of LAA Multiplane imaging allows for keeping the plane of the LAA orifice constant across imaging planes, something that is very difficult with 2D TEE imaging 3D TEE is used in conjunction with fluoroscopy during LAA device closure (Figs 28.35A to C) 3D TEE allows for visualization of intracardiac trajectories of catheters and introducers, which helps with the transseptal puncture and deployment of an LAA occluder device (Figs 28.36A to D) An LAA occluder device is properly placed when its long axis is parallel to the long-axis of the LAA Improper off-angle positions of the occluder are much easier to demonstrate by 3D TEE than by 2D techniques 2D and 3D color Doppler imaging is crucial for ascertaining that no significant residual communication between the LAA and the left atrium (para-device leak) persists after occluder device placement For the WatchmanTM device, the residual para-device jet should be either absent or at least no larger than mm in width If the device is placed improperly at first attempt, 3D TEE is used to guide recapture and redeployment of the device Epicardial Suturing of LAAs (Lariat Procedure) The major downside of above described endocardial LAA occluders is the need for continued use of anticoagulation and antiplatelet therapy for several weeks postimplantation In contrast, the Lariat procedure—in which LAA is occluded epicardially—does not require the use of postprocedural anticoagulation therapy The Lariat procedure utilized both endocardial and epicardial access The endocardial portion of the procedure is conceptually similar to the Watchman procedure except 564 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 28.34A to D: Sizing of LAA by 3D TEE 3D TEE provides for more precise sizing of the LAA using either the multiplane imaging (A, B and C) or 3D TEE en face zoom imaging and utilizing on-image calipers A Figs 28.35A and B B Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures 565 C Figs 28.35A to C: Guidance of Watchman procedure by fluoroscopy (A) After trans-septal puncture, a sheath is brought from the right atrium (RA) into the left atrium (LA) in preparation for the Watchman procedure A pigtail catheter is advanced through the sheath and its tip is then placed into the LAA; (B) Iodinated contrast is then injected through the pigtail catheter to obtain the LAA gram; (C) In the final step the pigtail catheter is removed and the delivery catheter containing the Watchman device is advanced through the sheath and delivered into the LAA A B C D Figs 28.36A to D: Guidance of Watchman procedure by 2D/3D TEE (A) LAA orifice (arrow) is visualized en face on 3D TEE; (B) 3D TEE aids in guiding the pigtail catheter (arrow) into the LAA; (C) 3D TEE is then used to guide deployment of the Watchman device Arrow points to a fully deployed Watchman device obliterating the LA orifice; (D) On 2D TEE color Doppler imaging, no residual communication between the LA and LAA is seen indicative of a successful Watchman procedure 566 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 28.37A and B: Lariat procedure guidance by fluoroscopy (A) Two magnet-tipped wires are seen connected to each other in preparation for Lariat-based obliteration of the LAA On the left side is the endocardial wire with its tip in the apex of the LAA This wire is deployed into the LAA transvenously after a transseptal puncture On the right side is the epicardial wire which is advanced through the pericardial space until it meets the endocardial wire; (B) After the two wires are connected magnetically, a snare is placed over the orifice of the LAA epicardially To prevent slippage of the snare, a balloon attached to the endocardial wire is inflated inside the LAA Thereafter, the snare is tightened and a stitch is placed epicardially to complete exclusion of the LAA from the body of the left atrium that no occluder device is placed in the LAA Using established transvenous and transseptal techniques, a magnet-tipped guide wire is threaded through the venous system, passed across the interatrial septum, and placed in the tip of the LAA Another magnet-tipped guide wire is threaded epicardially through a pericardial access until it binds magnetically to the already placed LAA wire (Figs 28.37A and B) Due to the need for this pericardial access, prior history of pericardial adhesions (such as due to pericardiotomy or pericarditis) is a contraindication for the Lariat procedure In the next step, the LariatTM Suture Delivery Device (SentreHEART, Inc.; Palo Alto, CA) is introduced into the pericardial space over the epicardial wire to deliver a pretied suture loop over the LAA This delivery device was not specifically designed for LAA occlusion; it has been used for soft tissue closure in other organ systems As the suture loop is being lassoed over the LAA orifice, a balloon attached to the endocardial wire is inflated at the LAA orifice to prevent the suture from slipping away from the orifice When the suture is nearly completely tied, the endocardial wire is removed from the LAA (Figs 28.38A to D) At the end of the procedure, the suture is completely tied and the LAA is excluded from the body of the left atrium (Figs 28.39A and B) 2D and 3D color Doppler imaging is crucial for ascertaining that no significant residual communication between the LAA and the left atrium is present In addition, TEE imaging is crucial in monitoring for possible procedure-related pericardial effusion The feasibility and safety of the Lariat procedure has been demonstrated in case series but the outcomes data are still lacking.117 Specifically, there are no long-term data on the risk of pericardial injury related to pericardial access used in the Lariat procedure GUIDANCE OF ELECTROPHYSIOLOGY PROCEDURES The role of TEE prior to or during electrophysiology procedures is well established 2D- and 3D TEE is routinely used to exclude left heart thrombus prior to cardioversion118 or to guide transseptal puncture 3D TEE is valuable in visualizing the right atrial structures of special interest to electrophysiologists such as the cavotricuspid isthmus and crista terminalis.119 In addition, 3D TEE is now being utilized to guide pulmonary vein isolation during atrial fibrillation ablation Pulmonary Vein Isolation for Atrial Fibrillation As pointed out in the section on the LAA exclusion, atrial fibrillation is the most common sustained cardiac arrhythmia whose prevalence increases in age Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 567 Figs 28.38A to D: Lariat procedure guidance by 3D TEE (A) After a trans-septal puncture, the endocardial wire and its sheath (arrow) are guided toward the orifice of the LAA (LAA); (B) The endocardial wire (arrow) is seen entering the LAA; (C) In preparation for snaring of the LAA from the epicardial side, a balloon attached to the endocardial wire (arrow) is inflated at the orifice of the LAA; (D) 3D TEE en face zoom image of the ligated LAA orifice (arrow) after completion of the Lariat procedure (MV: Mitral valve) A Figs 28.39A and A1 A1 568 Section 2: Echocardiography/Ultrasound Examination and Training B B1 Figs 28.39A and B: LAA appearance before and after Lariat procedure Appearance of the LAA before (A) and after the Lariat procedure (B) Each figure has a 3D TEE en face zoom image (left) and 2D TEE image (right) (LA: Left atrium; LAA: Left atrial appendage; LV: Left ventricle) (from 1% in general population to about 10% in the octogenarians).120 Atrial fibrillation may present with disabling symptoms, thromboembolism and tachycardiainduced cardiomyopathy Despite its disorderly rhythm, atrial fibrillation is often triggered in an orderly fashion by ectopic beats in the region of pulmonary vein ostia This insight led to development of techniques for catheterbased pulmonary vein isolation121 and isolation of other atrial foci.122 Collectively these procedures are referred to as atrial fibrillation ablation Catheter-based atrial fibrillation ablation has been shown in a randomized trial to be more effective than drug therapy in preventing recurrence of paroxysmal atrial fibrillation.123 At present, catheter ablation is indicated for maintenance of sinus rhythm in selected patients with significantly symptomatic paroxysmal atrial fibrillation who have failed treatment with an antiarrhythmic drug and have normal or mildly dilated left atria, normal or mildly reduced LV function, and no severe pulmonary disease Additionally, catheter ablation is reasonable to treat symptomatic persistent atrial fibrillation or symptomatic paroxysmal atrial fibrillation in patients with significant left atrial dilatation or with significant LV dysfunction.124 In a typical clinical scenario, prior to atrial fibrillation ablation patients undergo either CT or MRI of the chest to define the anatomy of the pulmonary veins and other cardiac structures Subsequently, patients are brought the electrophysiology suite where 2D TEE imaging is used primarily to exclude intracardiac thrombus and to further delineate cardiac anatomy.125 Patients then undergo atrial fibrillation ablation guided by electrical mapping and fluoroscopy The major shortcomings of such a scenario that CT, MRI, TEE, fluoroscopy, and electrical mapping are not done simultaneously and image integration from various modalities is still a challenge Some electrophysiologists opt to use ICE for real time imaging during the ablation procedure.126,127 In addition to imaging cardiac structures, ICE can also visualize the esophagus and thus monitor for esophageal injury (left atrio-esophageal fistula), a rare but serious complication of the ablation procedure.128 However, ICE has its own shortcomings: it is invasive, costly, and provides only 2D cross-sectional images 3D TEE imaging during atrial fibrillation imaging overcomes more of the shortcomings of other imaging modalities It can provide en face views of pulmonary veins and other cardiac structures in real time.129 Thus, one can determine the number and location of pulmonary vein ostia There are typically two pulmonary vein ostia on the right and two ostia on the left (Figs 28.40A to D) However, there are many variations; the most frequent one being the common ostium (antrum) of the two left pulmonary veins or three pulmonary ostia on the right (with the right middle pulmonary vein entering the left atrium directly rather than being a tributary of the right upper pulmonary vein (RUPV; Figs 28.41A and B).130 During the ablation procedure, 3D TEE can be used to guide the transseptal puncture In addition, 3D TEE can provide real time 3D anatomic guidance for placement of mapping and ablation catheters that cannot be achieved at present by any other imaging technique (Figs 28.42A to C).131,132 Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A B C D 569 Figs 28.40A to D: 3D TEE appearance of typical pulmonary vein ostia 3D TEE zoom views of pulmonary vein ostia in the left atrium (LA) With current 3D TEE, all four pulmonary vein ostia cannot be seen at once Instead one visualizes separately right-sided then left-sided pulmonary vein ostia (A and B) Ostia of the right-sided pulmonary veins seen en face (A) and in the long axis (B); (C and D) Ostia of the left-sided pulmonary veins seen en face (A) and in the long axis (B) (LUPV: Left upper pulmonary vein; LLPV: Left lower pulmonary vein RUPV: Right upper pulmonary vein; RLPV: Right lower pulmonary vein) 2D and 3D TEE can also be used to monitor for procedural complications such as the pericardial effusion Doppler imaging is used to assess for pulmonary vein stenosis, a long-term complication of pulmonary vein ablation Pulmonary vein stenosis is defined as a combination of a diminished diameter of the pulmonary vein ostium (< 0.7 cm; normal ~1.5 cm) and an increase in the peak velocity of the pulmonary vein diastolic (D) wave (> 100 cm/sec; normal 40-60 cm/sec).125 MISCELLANEOUS PROCEDURES The utility of 3DE has also been demonstrated in a variety of other percutaneous procedures such as the closure of the LV pseudoaneurysm, alcohol septal ablation, and right ventricular endomyocardial biopsy Left Ventricular Pseudoaneurysm Closure LV pseudoaneurysm is a rare but potentially serious complication of myocardial Infarction or cardiac surgery It represents a rupture of the LV free wall that is contained by adherent pericardium or scar tissue The goal of therapy is to prevent conversion of this contained rupture into complete rupture leading to pericardial tamponade and possibly death Unrepaired LV pseudoaneurysm has high mortality 570 A Section 2: Echocardiography/Ultrasound Examination and Training B Figs 28.41A and B: 3D TEE appearance of common pulmonary vein variants (A) 3D TEE zoom en face image demonstrates the most common variant of right sided pulmonary vein ostia, namely the right middle pulmonary vein (RMPV) having a separate left atrial ostium This is in contrast to most normal individuals in whom the RMPV is a tributary of the RUPV; (B) 3D TEE zoom en face image of the most common variant of left-sided pulmonary ostia, namely the common antrum created by the confluence of the left upper pulmonary vein (LUPV) and the left lower pulmonary vein (LLPV) Irrespective of whether there is one common or two separate left-sided pulmonary ostia, the ligament of Marshall, also known as the left atrial or Coumadin ridge (arrow) separates the pulmonary ostia from the LAA (RLPV: Right lower pulmonary vein) A B C Figs 28.42A to C: 3D TEE guidance of atrial fibrillation ablation 3D TEE zoom images demonstrate steps of the atrial fibrillation ablation procedure using pulmonary vein isolation; (A) In the first step, the mapping catheter referred to as the lasso catheter is paced into the ostium of a pulmonary vein (PV); (B) After the lasso catheter is deployed inside a pulmonary vein, electrical mapping is performed Thereafter, an ablation catheter is guided toward a pulmonary vein ostium to deliver lesions along the perimeter of a pulmonary vein ostium; (C) In the final step, lesions to additional left atrial structures are delivered This image demonstrates the ablation catheter delivering lesions to the carina, the left atrial tissue between the pulmonary ostia (PV: Pulmonary vein; RUPV: Right upper pulmonary vein; RLPV: Right lower pulmonary vein) Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures A 571 B Figs 28.43A and B: 2D/3D appearance of left ventricular pseudoaneurysm (A) 2D TEE transgastric view demonstrating a large left ventricular (LV) pseudoaneurysm (PsA) in a patient with prior inferior wall myocardial infarction Note the appearance of spontaneous echo contrast (“smoke”) in the pseudoaneurysm space; (B) Full-volume 3D TEE image of the LV pseudoaneurysm The external wall of the pseudoaneurysm is cropped out to reveal the defect in the inferior wall which creates the orifice of the LV pseudoaneurysm There is spontaneous echo contrast (“smoke”) in the pseudoaneurysm space (Movie clip 28.43B corresponds to Figure 28.43B) Courtesy: Images in this figure by Jan R Purgess, Department of Anesthesiology, New York University School of Medicine and New York Veterans Affairs Hospital, New York, NY Historically, surgery has been the only means of repairing LV pseudoaneurysm (Figs 28.43A and B and Movie clip 28.43B); however, such surgeries themselves have significant mortality and morbidity as well.133 Percutaneous closure of an LV pseudoaneurysm was first reported in 2004 from a hospital in the United Kingdom with an off-label use of the AmplatzerTM atrial septal occluder.134 Experience with percutaneous LV pseudoaneurysm closures is limited to case series, the largest to date consisting of seven patients.135 Multimodality imaging, including 3DE, is essential for the success of percutaneous LV pseudoaneurysm closure.136 Utility of 3D TEE of LV pseudoaneurysm closure is similar to that of VSD closure described earlier in this chapter Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy Alcohol septal ablation, first reported in 1995, is an alternative to surgical myomectomy used for relief of LV obstruction is hypertrophic obstructive cardiomyopathy.137 It entails intracoronary injection of alcohol into the septal perforator branch supplying the myocardium in the region asymmetric septal hypertrophy Successful alcohol septal ablation leads to limited iatrogenic septal infarction, septal thinning, and subsequent diminution of mitral septal contact and LV outflow obstruction The role of 2DE is well established including the off-label use of microbubble echo contrast injected intra-arterially into the septal perforator branch.138 3D TEE imaging may improve localization of the mitral-septal contact, which is often displaced eccentrically within the LVOT However, in contrast to most other percutaneous interventions, 3D TEE imaging cannot provide immediate assessment of procedural success of alcohol septal ablation since LV obstruction relief is expected to occur hours or days after septal infarct completion Right Ventricular Endomyocardial Biopsy Right ventricle (RV) is the primary site of endomyocardial biopsies which are used in the diagnostic workup of myocarditis, infiltrative cardiomyopathies, cardiac transplant rejection, and other myocardial disorders Although endomyocardial biopsy is often performed using fluoroscopic guidance alone, both TEE and ICE139 may help define the anatomy better, guide the deployment of the bioptome tip to the desired region of the heart, and potentially increase the safety of the procedure [by avoidance of the tricuspid valve (TV) apparatus, for instance] The utility of 3DE in RV endomyocardial biopsy has been shown in case reports and case series.140,141 ACKNOWLEDGMENTS We would like to express our gratitude to Dr James Slater, Director of Cath Lab, Dr Larry Chinitz, Director of the Electrophysiology Lab, and Dr Doff McElhinney of Pediatrics and their teams at New York University Langone Medical Center for their collaboration performing the percutaneous procedures described in this chapter 572 Section 2: Echocardiography/Ultrasound Examination and Training REFERENCES Rashkind WJ Palliative procedures for transposition of the great arteries Br Heart J 1971;33(Suppl):69–72 Saric M, Gila P, Ruiz C, et al Chapter 11: Catheter-based procedures to repair structural heart diseases In: Lang RM, Shernan SK, Shirali G, editors Comprehensive Atlas of 3D Echocardiography Har/Psc ed Philadelphia, PA: Lippincott Williams & Wilkins; December 20, 2012:219–54 Garcia Fernandez MA, Perk G, Saric M, et al Chapter 12: Real time three-dimensional transesophageal echocardiography for guidance of catheter based interventions In Badano LP, Lang RM, Zamorano JL, editors Textbook of Real time Three-Dimensional Echocardiography 1st ed New York, NY: Springer; March 9, 2011: 121–34 Houck RC, Cooke JE, Gill EA Live 3D echocardiography: a replacement for traditional 2D echocardiography? AJR Am J Roentgenol 2006;187(4):1092–106 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(6):446–9 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;22(10):1087–99 Sudhakar S, Khairnar P, Nanda NC Live/real time threedimensional transesophageal echocardiography Echocardiography 2012;29(1):103–11 Ross J Jr Transeptal left heart catheterization: a new method of left atrial puncture Ann Surg 1959;149(3): 395–401 Brockenbrough EC, Braunwald E, Ross J Jr Transseptal left heart catheterization A review of 450 studies and description of an improved technic Circulation 1962;25:15–21 10 De Ponti R, Cappato R, Curnis A, et al Trans-septal catheterization in the electrophysiology laboratory: data from a multicenter survey spanning 12 years J Am Coll Cardiol 2006;47(5):1037–42 11 Silvestry FE, Kerber RE, Brook MM, et al Echocardiographyguided interventions J Am Soc Echocardiogr 2009;22(3): 213–31; quiz 316 12 Ho SY, Chang SD, Liang CC Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery J Chin Med Assoc 2010; 73(12):655–9 13 Ho SY Embryology and anatomy of the atrial septum In: Thakur R, Natale A, (editors) Transseptal catheterization and interventions Minneapolis, MN: Cardiotext; 2010:| 11-26 14 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 15 Webster MW, Chancellor AM, Smith HJ, et al Patent foramen ovale in young stroke patients Lancet 1988;2(8601):11–2 16 Tomlinson DR, Sabharwal N, Bashir Y, et al Interatrial septum thickness and difficulty with transseptal puncture during redo catheter ablation of atrial fibrillation Pacing Clin Electrophysiol 2008;31(12):1606–11 17 Wieczorek M, Hoeltgen R, Akin E, et al Use of a novel needle wire in patients undergoing transseptal puncture associated with severe septal tenting J Interv Card Electrophysiol 2010;27(1):9–13 18 Waterston DS Léčení Fallotovy tetralogie u děí jednogo roku věki [Treatment of Fallot’s tetralogy in infants under the age of one year.] [Article in Czech] Rozhl Chir 1962;41:181–3 19 Søndergaard T, Gotsche H, Ottoson P, et al Surgical closure of interatrial septal defects by circumclusion Acta Chir Scand 1955;109:188–96 20 Kronzon I, Saric M, Lang RM Chapter 9: Mitral stenosis In: Lang R, Goldstein SA, Kronzon I, Khanderia BK, editors Dynamic Echocardiography: A Case-Based Approach ed New York, NY: Springer; July 1, 2010:38–45 21 Fleming PR A Short History of Cardiology Amsterdam, Netherlands—Atlanta, GA: Editions Rodopi Bv; January 1997 22 Vieussens R Traité nouveau de la structure et des causes du mouvement naturel du coeur [Treatise on the structure of the heart and the causes of its natural motion] Toulouse, France;1715 23 Chandrashekhar Y, Westaby S, Narula J Mitral stenosis Lancet 2009;374(9697):1271–83 24 Cutler EC, Levine SA Cardiotomy and valvulotomy for mitral stenosis Experimental observations and clinical notes concerning an operated case with recovery Boston Med Surg J 1923;188:1023–7 25 Souttar HS The surgical treatment of mitral stenosis Br Med J 1925;2(3379):603–6 26 Gonzalez-Lavin L Charles P Bailey and Dwight E Harken— the dawn of the modern era of mitral valve surgery Ann Thorac Surg 1992;53(5):916–9 27 Matthews AM The development of the Starr-Edwards heart valve Tex Heart Inst J 1998;25(4):282–93 28 Edler I, Hertz CH The use of ultrasonic reflectoscope for the continuous recording of the movements of heart walls 1954 Clin Physiol Funct Imaging 2004;24(3):118–36 29 Starr A, Herr RH, Wood JA The present status of valve replacement Special issue on the VII Congress of the International Cardiovascular Society held Sept 14–18, 1965, in Philadelphia J Cardiovasc Surg 1965:95–103 30 Inoue K, Owaki T, Nakamura T, et al Clinical application of transvenous mitral commissurotomy by a new balloon catheter J Thorac Cardiovasc Surg 1984;87(3):394–402 31 Bonow RO, Carabello BA, Kanu C, 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 Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons Circulation August 1, 2006;114(5):e84–231 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(6):580–8 Perk, G., Ruiz, C., Saric, M., et al Real-time threedimensional transesophageal echocardiography in transcutaneous, catheter-based procedures for repair of structural heart diseases Curr Cardiovasc Imaging Rep 2009;2(5):363–74 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(4):299–308 Yun KL, Miller DC Mitral valve repair versus replacement Cardiol Clin 1991;9(2):315–27 Oliveira JM, Antunes MJ Mitral valve repair: better than replacement Heart 2006;92(2):275–81 Carpentier A Cardiac valve surgery–the “French correction.” J Thorac Cardiovasc Surg 1983;86(3):323–37 Binet JP, Carpentier A, Langlois J, et al [Implantation of heterogenic valves in the treatment of aortic cardiopathies] CR Hebd Seances Acad Sci, Ser D, Sci Nat 1965;261(25):5733–4 Feldman T, Cilingiroglu M Percutaneous leaflet repair and annuloplasty for mitral regurgitation J Am Coll Cardiol 2011;57(5):529–37 Fucci C, Sandrelli L, Pardini A, et al Improved results with mitral valve repair using new surgical techniques Eur J Cardiothorac Surg 1995;9(11):621–6; discuss 626 Alfieri O, Maisano F, De Bonis M, et al The doubleorifice technique in mitral valve repair: a simple solution for complex problems J Thorac Cardiovasc Surg 2001; 122(4):674–81 Feldman T, Foster E, Glower DD, et al.; EVEREST II Investigators Percutaneous repair or surgery for mitral regurgitation N Engl J Med 2011;364(15):1395–406 Maisano F, Michev I, La Canna G, et al Brief description of the percutaneous mitral repair procedure using the MitraClip® device http://www.ctsnet.org/portals/ endovascular/evolvingtechnology/exp_tech1.html, accessed on April 13, 2013 Benenstein R, Saric M Mitral valve prolapse: role of 3D echocardiography in diagnosis Curr Opin Cardiol 2012;27(5):465–76 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(11):2134–40 Faletra FF, Pedrazzini G, Pasotti E, et al Role of real-time three dimensional transoesophageal echocardiography as guidance imaging modality during catheter based edge-toedge mitral valve repair Heart 2013;99(16):1204–15 Saric M, Kronzon I Aortic stenosis in the elderly Am J Geriatr Cardiol 2000;9:321–9, 345 573 48 Ross J Jr, Braunwald E Aortic stenosis Circulation 1968; 38(1 Suppl):61–7 49 Schwarz F, Baumann P, Manthey J, et al The effect of aortic valve replacement on survival Circulation 1982;66(5): 1105–10 50 Webb JG, Wood DA Current status of transcatheter aortic valve replacement J Am Coll Cardiol 2012;60(6):483–92 51 Harken DE, Soroff HS, Taylor WJ, et al Partial and complete prostheses in aortic insufficiency J Thorac Cardiovasc Surg 1960;40:744–62 52 Brown JM, O’Brien SM, Wu C, et al Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database J Thorac Cardiovasc Surg 2009;137(1):82–90 53 Cribier A, Savin T, Saoudi N, et al Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1(8472):63–7 54 Ben-Dor I, Pichard AD, Satler LF, et al Complications and outcome of balloon aortic valvuloplasty in high-risk or inoperable patients JACC Cardiovasc Interv 2010;3(11): 1150–6 55 Cribier A, Eltchaninoff H, Bash A, et al Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description Circulation 2002;106(24):3006–8 56 Andersen HR, Knudsen LL, Hasenkam JM Transluminal implantation of artificial heart valves Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs Eur Heart J 1992;13(5):704–8 57 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(23):2187–98 58 Forrest JK Transcatheter aortic valve replacement: design, clinical application, and future challenges Yale J Biol Med 2012;85(2):239–47 59 Gila P, Kronzon I, Saric M Chapter 9: Aortic valve In: Lang RM, Shernan SK, Shirali G, editors Comprehensive Atlas of 3D Echocardiography Har/Psc ed Philadelphia, PA: Lippincott Williams & Wilkins; December 20, 2012: 183–200 60 Gaspar T, Adawi S, Sachner R, et al Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation J Am Soc Echocardiogr 2012;25(7):749–57 61 Otani K, Takeuchi M, Kaku K, et al Assessment of the aortic root using real-time 3D transesophageal echocardiography Circ J 2010;74(12):2649–57 62 Jabbour A, Ismail TF, Moat N, et al Multimodality imaging in transcatheter aortic valve implantation and post-procedural aortic regurgitation: comparison among cardiovascular magnetic resonance, cardiac computed tomography, and echocardiography J Am Coll Cardiol 2011;58(21):2165–73 574 Section 2: Echocardiography/Ultrasound Examination and Training 63 Jilaihawi H, Doctor N, Kashif M, et al Aortic annular sizing for transcatheter aortic valve replacement using crosssectional 3-dimensional transesophageal echocardiography J Am Coll Cardiol 2013;61(9):908–16 64 Smith LA, Dworakowski R, Bhan A, et al Real-time threedimensional transesophageal echocardiography adds value to transcatheter aortic valve implantation J Am Soc Echocardiogr 2013;26(4):359–69 65 Jilaihawi H, Chakravarty T, Weiss RE, et al Meta-analysis of complications in aortic valve replacement: comparison of Medtronic-Corevalve, Edwards-Sapien and surgical aortic valve replacement in 8,536 patients Catheter Cardiovasc Interv 2012;80(1):128–38 66 Latson LA Transcatheter closure of paraprosthetic valve leaks after surgical mitral and aortic valve replacements Expert Rev Cardiovasc Ther 2009;7(5):507–14 67 Maraj R, Jacobs LE, Ioli A, et al Evaluation of hemolysis in patients with prosthetic heart valves Clin Cardiol 1998;21(6):387–92 68 Echevarria JR, Bernal JM, Rabasa JM, et al Reoperation for bioprosthetic valve dysfunction A decade of clinical experience Eur J Cardiothorac Surg 1991;5(10):523–6; discussion 527 69 Hourihan M, Perry SB, Mandell VS, et al Transcatheter umbrella closure of valvular and paravalvular leaks J Am Coll Cardiol 1992;20(6):1371–7 70 Sorajja P, Cabalka AK, Hagler DJ, et al Percutaneous repair of paravalvular prosthetic regurgitation: acute and 30-day outcomes in 115 patients Circ Cardiovasc Interv 2011;4(4):314–21 71 Kronzon I, Sugeng L, Perk G, et al Real-time 3-dimensional transesophageal echocardiography in the evaluation of post-operative mitral annuloplasty ring and prosthetic valve dehiscence J Am Coll Cardiol 2009;53(17):1543–7 72 Hoffmayer KS, Zellner C, Kwan DM, et al Closure of a paravalvular aortic leak: with the use of AMPLATZER devices and real-time 2- and 3-dimensional transesophageal echocardiography Tex Heart Inst J 2011;38(1):81–4 73 Rihal CS, Sorajja P, Booker JD, et al Principles of percutaneous paravalvular leak closure JACC Cardiovasc Interv 2012;5(2):121–30 74 Ruiz CE, Jelnin V, Kronzon I, et al Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks J Am Coll Cardiol 2011;58(21):2210–7 75 Saric M, Kronzon I Chapter 108: Patent ductus arteriosus In: Lang R, Goldstein SA, Kronzon I, Khanderia BK, editors Dynamic Echocardiography: A Case-Based Approach ed New York, NY: Springer; July 1, 2010: 451–4 76 Gross RE, Hubbard JP Surgical ligation of a patent ductus arteriosus Report of first successful case JAMA 1939; 112(8):729–31 77 Porstmann W, Wierny L, Warnke H [The closure of the patent ductus arteriosus without thoractomy (preliminary report)] Thoraxchir Vask Chir 1967;15(2):199–203 78 Warnes CA, Williams RG, Bashore TM, et al ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: a report of the American College 79 80 81 82 83 84 85 86 87 88 89 90 91 92 of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease) Circulation 2008;118(23):e714–833 Krichenko A, Benson LN, Burrows P, et al Angiographic classification of the isolated, persistently patent ductus arteriosus and implications for percutaneous catheter occlusion Am J Cardiol 1989;63(12):877–80 Roushdya A, El Fikyb A, Ezz el Dine D Visualization of patent ductus arteriosus using real-time threedimensional echocardiogram: Comparative study with 2D echocardiogram and angiography Journal of the Saudi Heart Association 2012;24(3):177–86 Marek T, Zelizko M, Kautzner J Images in cardiovascular medicine Real-time 3-dimensional transesophageal echocardiography imaging: adult patent ductus arteriosus before and after transcatheter closure Circulation 2009;120(12):e92–3 Chuang YC, Yin WH, Hsiung MC, et al Successful transcatheter closure of a residual patent ductus arteriosus with complex anatomy after surgical ligation using an amplatzer ductal occluder guided by live three-dimensional transesophageal echocardiography Echocardiography 2011;28(5):E101–3 Lam J, Tanke RB, van Oort A, et al The use of transesophageal echocardiography monitoring of transcatheter closure of a persistent ductus arteriosus Echocardiography 2001; 18(3):197–202 Saric M, Kronzon I Chapter 105: Congenital heart disease in adults In: Lang R, Goldstein SA, Kronzon I, Khanderia BK, editors Dynamic Echocardiography: A Case-Based Approach ed New York, NY: Springer; July 1, 2010:438–9 Lewis FJ, Taufic M Closure of atrial septal defects with the aid of hypothermia; experimental accomplishments and the report of one successful case Surgery 1953;33(1):52–9 Gibbon JH Jr Application of a mechanical heart and lung apparatus to cardiac surgery Minn Med 1954;37(3):171– 85; passim King TD, Mills NL Nonoperative closure of atrial septal defects Surgery 1974;75(3):383–8 Vaidyanathan B, Simpson JM, Kumar RK Transesophageal echocardiography for device closure of atrial septal defects: case selection, planning, and procedural guidance JACC Cardiovasc Imaging 2009;2(10):1238–42 Roberson DA, Cui W, Patel D, et al Three-dimensional transesophageal echocardiography of atrial septal defect: a qualitative and quantitative anatomic study J Am Soc Echocardiogr 2011;24(6):600–10 Saric M, Perk G, Purgess JR, et al Imaging atrial septal defects by real-time three-dimensional transesophageal echocardiography: step-by-step approach J Am Soc Echocardiogr 2010;23(11):1128–35 Vettukattil JJ, Ahmed Z, Salmon AP, et al Defects in the oval fossa: morphologic variations and impact on transcatheter closure J Am Soc Echocardiogr 2013;26(2):192–9 Razzouk L, Saric M, Slater JN Placement of a large GoreHelex atrial septal occluder device in a patient with Chapter 28: Three-Dimensional Echocardiographic Guidance of Percutaneous Procedures 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 deficient aortic rim and large atrial septal aneurysm Closing Remarks Newsletter, Spring 2013; Issue XXII Amin Z Transcatheter closure of secundum atrial septal defects Catheter Cardiovasc Interv 2006;68(5):778–87 Mathewson JW, Bichell D, Rothman A, et al Absent posteroinferior and anterosuperior atrial septal defect rims: Factors affecting nonsurgical closure of large secundum defects using the Amplatzer occluder J Am Soc Echocardiogr 2004;17(1):62–9 Hagen PT, Scholz DG, Edwards WD Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts Mayo Clin Proc 1984;59(1):17–20 Lechat P, Mas JL, Lascault G, et al Prevalence of patent foramen ovale in patients with stroke N Engl J Med 1988;318(18):1148–52 Bridges ND, Hellenbrand W, Latson L, et al Transcatheter closure of patent foramen ovale after presumed paradoxical embolism Circulation 1992;86(6):1902–08 Furlan AJ, Reisman M, Massaro J, et al.; CLOSURE I Investigators Closure or medical therapy for cryptogenic stroke with patent foramen ovale N Engl J Med 2012; 366(11):991–99 Meier B, Kalesan B, Mattle HP, et al.; PC Trial Investigators Percutaneous closure of patent foramen ovale in cryptogenic embolism N Engl J Med 2013;368(12):1083–91 Minette MS, Sahn DJ Ventricular septal defects Circulation 2006;114(20):2190–7 Razzouk L, Applebaum RM, Okamura C, et al The windsock syndrome: subpulmonic obstruction by membranous ventricular septal aneurysm in congenitally corrected transposition of great arteries echocardiography 2013 Jul doi: 10.1111/echo.12279 [Epub ahead of print] Saric M, Kronzon I Chapter 107: Ventricular septal defect and Eisenmenger syndrome In: Lang R, Goldstein SA, Kronzon I, Khanderia BK, editors Dynamic Echocardiography: A Case-Based Approach ed New York, NY: Springer; July 1, 2010:446–50 Lock JE, Block PC, McKay RG, et al Transcatheter closure of ventricular septal defects Circulation 1988;78(2):361–8 Holzer R, Balzer D, Amin Z, et al Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: Results of a U.S Registry Catheter Cardiovasc Interv 2004;61(2):196–201 Masura J, Gao W, Gavora P, et al Percutaneous closure of perimembranous ventricular septal defects with the eccentric Amplatzer device: multicenter follow-up study Pediatr Cardiol 2005;26(3):216–9 Halpern DG, Perk G, Ruiz C, et al Percutaneous closure of a post-myocardial infarction ventricular septal defect guided by real-time three-dimensional echocardiography Eur J Echocardiogr 2009,10:702–3 Anonymous Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation Analysis of pooled data from five randomized controlled trials Arch Intern Med July 11, 1994;154(13):1449–57 575 108 Blackshear JL, Odell JA Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation Ann Thorac Surg 1996;61(2):755–9 109 Cox JL, Sundt TM 3rd The surgical management of atrial fibrillation Annu Rev Med 1997;48:511–23 110 Salzberg SP, Plass A, Emmert MY, et al Left atrial appendage clip occlusion: early clinical results J Thorac Cardiovasc Surg 2010;139(5):1269–74 111 Kim R, Baumgartner N, Clements J Routine left atrial appendage ligation during cardiac surgery may prevent postoperative atrial fibrillation-related cerebrovascular accident J Thorac Cardiovasc Surg 2013;145(2):582–9; discussion 589 112 Katz ES, Tsiamtsiouris T, Applebaum RM, et al Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study J Am Coll Cardiol 2000;36(2):468–71 113 Perk G, Biner S, Kronzon I, et al Catheter-based left atrial appendage occlusion procedure: role of echocardiography Eur Heart J Cardiovasc Imaging 2012;13(2):132–8 114 Cruz-Gonzalez I, Yan BP, Lam YY Left atrial appendage exclusion: state-of-the-art Catheter Cardiovasc Interv 2010;75(5):806–13 115 Holmes DR, Reddy VY, Turi ZG, et al.; PROTECT AF Investigators 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):534–42 116 Shah SJ, Bardo DM, Sugeng L, et al Real-time threedimensional transesophageal echocardiography of the left atrial appendage: initial experience in the clinical setting J Am Soc Echocardiogr 2008;21(12):1362–8 117 Bartus K, Han FT, Bednarek J, et al Percutaneous Left Atrial Appendage Suture Ligation Using the LARIAT Device in Patients With Atrial Fibrillation: Initial Clinical Experience J Am Coll Cardiol 2013;62(2):108–18 118 Klein AL, Grimm RA, Murray RD, et al.; Assessment of Cardioversion Using Transesophageal Echocardiography Investigators Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation N Engl J Med 2001;344(19):1411–20 119 Faletra FF, Ho SY, Auricchio A Anatomy of right atrial structures by real-time 3D transesophageal echocardiography JACC Cardiovasc Imaging 2010;3(9):966–75 120 Go AS, Hylek EM, Phillips KA, et al Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study JAMA 2001;285(18):2370–75 121 Haïssaguerre M, Jaïs P, Shah DC, et al Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins N Engl J Med 1998;339(10):659–66 122 Pappone C, Rosanio S, Oreto G, et al Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomic approach for curing atrial fibrillation Circulation 2000;102(21):2619–28 576 Section 2: Echocardiography/Ultrasound Examination and Training 123 Wilber DJ, Pappone C, Neuzil P, et al.; ThermoCool AF Trial Investigators Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial JAMA 2010;303(4):333–40 124 Fuster V, Rydén LE, Cannom DS, et al.; American College of Cardiology Foundation/American Heart Association Task Force 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on practice guidelines Circulation 2011;123(10):e269–367 125 To AC, Gabriel RS, Park M, et al Role of Transesophageal Echocardiography Compared to Computed Tomography in Evaluation of Pulmonary Vein Ablation for Atrial Fibrillation (ROTEA study) J Am Soc Echocardiogr 2011;24(9): 1046–55 126 Marrouche NF, Martin DO, Wazni O, et al Phasedarray intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications Circulation 2003; 107(21):2710–6 127 Jongbloed MR, Bax JJ, de Groot NM, et al Radiofrequency catheter ablation of paroxysmal atrial fibrillation; guidance by intracardiac echocardiography and integration with other imaging techniques Eur J Echocardiogr 2003;4(1):54–8 128 Schmidt M, Nölker G, Marschang H, et al Incidence of oesophageal wall injury post-pulmonary vein antrum isolation for treatment of patients with atrial fibrillation Europace 2008;10(2):205–9 129 Faletra FF, Nucifora G, Regoli F, et al Anatomy of pulmonary veins by real-time 3D TEE: implications for catheterbased pulmonary vein ablation JACC Cardiovasc Imaging 2012;5(4):456–62 130 Pinheiro L, Nanda NC, Jain H, et al Transesophageal echocardiographic imaging of the pulmonary veins Echocardiography 1991;8(6):741–8 131 Purgess JR, Bernstein S, Saric M Real-time 3D transesophageal echocardiography: development of a protocol for use in atrial fibrillation ablation procedures Anesth Analg 2012;114(Suppl):1–94 132 Ottaviano L, Chierchia GB, Bregasi A, et al Cryoballoon ablation for atrial fibrillation guided by real-time threedimensional transoesophageal echocardiography: a feasibility study Europace 2013;15(7):944–50 133 Frances C, Romero A, Grady D Left ventricular pseudoaneurysm J Am Coll Cardiol 1998;32(3):557–61 134 Clift P, Thorne S, de Giovanni J Percutaneous device closure of a pseudoaneurysm of the left ventricular wall Heart 2004;90(10):e62 135 Dudiy Y, Jelnin V, Einhorn BN, et al Percutaneous closure of left ventricular pseudoaneurysm Circ Cardiovasc Interv 2011;4(4):322–26 136 Kapadia SR, Tuzcu EM Plugging holes: expanding horizon for structural interventions Circ Cardiovasc Interv 2011;4(4):308–10 137 Sigwart U Non-surgical myocardial reduction for hypertrophic obstructive cardiomyopathy Lancet 1995;346(8969):211–4 138 Faber L, Seggewiss H, Gleichmann U Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: results with respect to intraprocedural myocardial contrast echocardiography Circulation 1998;98(22):2415–21 139 Silvestry FE, Kerber RE, Brook MM, et al Echocardiographyguided interventions J Am Soc Echocardiogr 2009; 22(3):213–31; quiz 316 140 McCreery CJ, McCulloch M, Ahmad M, deFilippi CR Realtime 3-dimensional echocardiography imaging for right ventricular endomyocardial biopsy: a comparison with fluoroscopy J Am Soc Echocardiogr 2001;14(9):927–33 141 Scheurer M, Bandisode V, Ruff P, et al Early experience with real-time three-dimensional echocardiographic guidance of right ventricular biopsy in children Echocardiography 2006;23(1):45–9 CHAPTER 29 Three-Dimensional Echocardiography in the Operating Room Ahmad S Omran Snapshot Mitral Valve Disease AorƟc Valve Disease Tricuspid Valve Disease NaƟve Valve EndocardiƟs INTRODUCTION Three-dimensional echocardiography is a new dimension in cardiac ultrasound representing a major innovation in cardiovascular imaging Three-dimensional transesophageal echocardiography (3D TEE) is the only available imaging modality in the cardiac operating room for preoperative assessment of cardiac pathology and facilitates appropriate surgical intervention Immediate postoperative assessment ensures the cardiac surgery team of the operation outcome In this chapter, the role of 3D TEE in the operating room in different cardiac pathologies is discussed In each section, examples of pre- and postoperative images and related movie clip(s) have been provided I have attempted to present echo images of every case with related surgical clips for correlation It is worth mentioning that all cases discussed in this chapter have been operated in the last years in our cardiac center MITRAL VALVE DISEASE The mitral valve (MV) lies between the left atrium (LA) and the left ventricle (LV) Normal area of the MV is ProstheƟc Valve DysfuncƟon Cardiac Masses LimitaƟons of 3D TEE, Future DirecƟons typically about to cm2 The MV consists of mitral leaflets (which resembles Bishop’s miter), saddle-shaped mitral annulus, and subvalvular apparatus composed of chordae tendineae and two papillary muscles attached to the wall of LV Mitral annulus is a part of the cardiac skeleton with four dense bands or fibrous rings which surround all four heart valves, the pulmonary trunk, and the aorta Figure 29.1B demonstrates an anatomic diagram of the transverse section of the heart (viewed from the posterior of the heart) showing relation of the mitral with other valves (Sobotta Atlas of Human Anatomy, 1998, Williams & Wilkins, Baltimore) Figure 29.1A and Movie clip 29.1, show the correlation between anatomy and 3D TEE fullvolume acquisition Pulmonic valve (PV) cannot be shown in the same cut plane because location of this valve is slightly higher than other valves The MV consists of two leaflets The anterior MV leaflet (AMVL) is the longer leaflet and is attached to the anterior mitral annulus which consists of one third of the mitral annular circumference The posterior MV leaflet (PMVL) is shorter and is attached to the posterior annulus which occupies about two third of the mitral annulus The anterior mitral annulus extends from the 578 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.1A and B: Four-valve view of the heart at the base, correlation between 3D TEE full-volume acquisition of the base of the heart with anatomical diagram (A) 3D TEE view shows severely stenotic mitral valve (arrow), normal tricuspid, and aortic valves Note: pulmonic valve (PV) cannot be visualized in the 3D TEE at the same cut-plane because PV location is higher than the level of the other three valves; (B) Anatomic diagram of the heart at the same level 3D TEE, three-dimensional transesophageal echocardiography (AMVL: Anterior mitral valve leaflet; AT: Anterior tricuspid leaflet; IVC: Inferior vena cava; LAA: Left atrial appendage; LCC: Left coronary cusp of the aortic valve; NCC: Noncoronary cusp; P: Posterior tricuspid leaflet; PMVL: Posterior mitral valve leaflet; RCC: Right coronary cusp; RVOT: Right ventricular outflow tract; S: Septal tricuspid leaflet) right to the left fibrous trigones and is adjacent to the tricuspid valve (TV) and noncoronary sinus of Valsalva on the right and left coronary sinus of the Valsalva and left main coronary artery on the left Mitral leaflets are attached to the papillary muscles by about 25 primary chordae tendineae and several secondary chordae AMVL has about chordae and PMVL about 14 Chordae of each mitral leaflet are equally distributed between the two papillary muscles Each commissure of the MV is attached to a corresponding papillary muscle by a large fan-shaped chord In some patients, a small commissural leaflet can be seen Coronary sinus runs beside the right posterior annulus, and circumflex artery is behind the left posterior annulus Functional anatomy and classification of the MV were described by the pioneering cardiac surgeon Alain Carpentier and published in 1983 as the “French correction.”1 It was believed for many years that anterior mitral annulus could not dilate because of its connection with firm right and left fibrous trigones; therefore, insertion of a posterior annuloplasty ring during repair of the degenerative MV was assumed to be sufficient to prevent future dilatation Recent autopsy and 3D imaging studies have proven that, in fact, anterior annulus dilates in pathologic conditions and a complete annuloplasty ring is likely the better choice.2 Many studies have shown that two-dimensional (2D) TEE can accurately predict MV anatomy and suitability for repair.3 This assessment is very operator dependent and requires 3D mental reconstructions for decision making about preoperative pathology, the best appropriate technique for repair and postoperative evaluation of the result.4 Moreover, because of the 3D nature of the MV anatomy, 2D demonstration of the valve in preoperative assessment is not very attractive for the operating cardiac surgeon The 3D TEE surgical view of the MV creates a “common language” for the surgeons and makes it easy for them to understand the pathology and apply the best technique to tackle it MV is the best ideal structure inside the heart to be assessed by 3D TEE because of its location and orientation which is perpendicular to the ultrasound beam coming from the TEE probe inside the esophagus Thicker leaflets of the MV compared to aortic and TVs as well as their slow opening and closing, makes the MV more compatible with low resolution and low frame rate existing in current 3D echocardiography technology The 3D TEE en face view of MV can create a surgical view exactly as the surgeon would see during inspection after left atriotomy.5 If prolapse of the mitral scallops and segments is not severe, detection of the abnormality is difficult in en face view Angled views, in which the images can be assessed obliquely from medial, lateral, anterior, or posterior angulation, are very useful to recognize mild prolapses.6 After 180° Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 579 B Figs 29.2A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view (surgeon’s view) of the normal mitral valve (A) with anatomic correlation after left atriotomy (B) Based on Carpentier’s classification, mitral valve leaflets consist of eight segments and scallops Posterior mitral leaflet (PMVL) has three scallops with indentation between them which sometimes are very deep and mimic a congenital cleft Anterior mitral leaflet (AMVL) does not have scallops but can be divided arbitrarily in to three segments corresponding with posterior scallops There are two commissural segments which in some cases consist of small leaflets Each commissure is attached to the papillary muscles by one fan-shaped chorda, and rupturing of these chorda can cause mitral regurgitation Note: aortic valve (AV) is located anterior to the surgeon and should be positioned at the top of the 3D image, and the left atrial appendage (LAA) is located to the left hand of the surgeon (A1: Lateral segment of the AMVL; A2: Middle segment of AMVL; A3: Medial segment of the AMVL; ALC: Anterolateral commissure; Lat: Lateral; Med: Medial; P1: Lateral scallop of the PMVL; P2: Middle scallop of the PMVL; P3: Medial scallop of the PMVL; PMC: Posteromedial commissure) A B Figs 29.3A and B: (A) Angled view of the mitral valve (MV) in the previous image Medial anterior angulation of the surgical view demonstrates very mild prolapse of A3 and P3, which were not appreciated in en face view; (B) Rotating previous image, showing left ventricular side of the MV Note: fish-mouth opening of the mitral valve in diastole with long anterior and short posterior mitral leaflets can be appreciated This view provides a good chance for planimetry of the mitral valve orifice by 3D image grid or direct measurement which is available in the newer version of the echo machines (Lat: Lateral side of the MV; LVOT: Left ventricular outflow tract; Med: Medial aspect of the MV) rotation of the image, MV can be seen by 3D TEE from LV side; however, the surgeon does not have this advantage (Figs 29.2 and 29.3 and Movie clips 29.2 and 29.3A and B) Degenerative MV disease (myxomatous changes) is the most common cause of mitral regurgitation in the Western world Prolapse and flail posterior mitral leaflet 580 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.4A and B: En face view (surgical view) of the mitral valve with degenerative changes (myxomatous) in a patient with severe mitral regurgitation (MR) (A) Flail, large, bulky P2 with ruptured chorda; (B) Same view with full-volume color mode demonstrates severe anteriorly directed jet of mitral regurgitation (MR) There is no prolapse of other segments of the mitral valve (AV: Aortic valve; LAA: Left atrial appendage; P2: Middle scallop of the posterior mitral leaflet) due to ruptured chordae are more common than anterior mitral leaflet Flail middle scallop (P2) of the posterior mitral leaflet constitutes about 70% of the pathology in all myxomatous MV and is the easiest pathology to repair compared to more extensive bileaflet disease (Barlow’s disease) Alain Carpentier was the first to describe the repair technique of flail P2 in “French correction” based on quadrangular resection of the P2 and sliding plasty of other scallops of the posterior leaflet Later, many modification techniques were introduced based on less resection or no resection of the leaflets This concept is called “American correction” which is “respect the tissues not resects or resect with respect.” After the repair of posterior mitral leaflet, the remaining height of the leaflet should not exceed cm; otherwise, chances of having SAM (systolic anterior motion of the mitral leaflets) and LV obstruction increase Figures 29.3 to 29.10 and Movie clips 29.4A and B, 29.6A to G, and 29.10A and B demonstrate series of examples of pathology in the posterior mitral leaflet and their surgical repair Partial flail of the anterior mitral leaflet or complete flail with ruptured chordae tendineae need skills of a more experienced surgeon to repair Chordal transfer of the posterior leaflet to the anterior was the initial technique developed in Europe Chordal replacement by the artificial chordae (GoreTex) was introduced by Tirone David in Toronto and other centers in North America and is currently the standard technique to repair the flail anterior leaflet.7 Figures 29.11 to 29.17 and Movie clips 29.11A to G and 29.17A to C demonstrate the examples of flail anterior mitral leaflet or bileaflet prolapse and the role of the 3D TEE to help the surgeon to repair these more demanding mitral pathologies Three-dimensional transesophageal echocardiography has a great role in preoperative assessment of the rheumatic MV and decision making for repair or replacement Thickening and calcification of the leaflets and fusion of the commissures can be appreciated well It is possible to calculate the MV area by direct 3D planimetry of the MV orifice from the left atrial side or the LV side This calculation is available by calibrating 3D grid in older generation echo machines but in newer machines can be measured directly Calculation of the MV area is possible using multiplanar reconstruction (MPR) mode of 3D QLAB as well The two above-mentioned techniques for calculation of the MV area (MVA) are added by 3D echocardiography to previous standard techniques of pressure half-time (PHT) and 2D planimetry for measuring MVA These 3D techniques are validated by many studies and not have the limitations of the PHT in catheterization laboratory during percutaneous mitral balloon valvuloplasty.8,9 3D TEE is very useful to assess the function of the bioprosthetic and mechanical MV after valve replacement.10 Any paravalvular regurgitation can be detected with exact size and location of the leak (Figs 29.18 to 29.24 and Movie clips 29.18A to E and 29.21A to D) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 581 B Figs 29.5A and B: Surgical repair of the mitral valve in the previous case (A) Myxomatous posterior mitral valve leaflet (PMVL) is seen with large flail middle scallop (P2) Multiple ruptured chorda is shown attached to the P2 scallop (blue arrows); (B) Classic surgical technique of quadrangular resection of P2 scallop is demonstrated Sliding plasty of the base of PMVL for shortening of the leaflet and insertion of an annuloplasty ring are other parts of this technique which were initially described by Carpentier in 1980 as the so-called French correction (P1: Posterolateral scallop; P3: Posteromedial scallop; Quad rese: Quadrangular resection) A B Figs 29.6A and B: Three-dimensional transesophageal echocardiography (3D TEE) of mitral valve with surgical correlation in a 45-year-old man (A) Flail middle scallop of the posterior mitral valve leaflet (P2) with ruptured chorda (white arrow); (B) Corresponding surgical view of the same patient demonstrating large floppy P2 with ruptured chorda (black arrow) (AV: Aortic valve; LAA: Left atrial appendage) In functional mitral regurgitation which is because of mitral leaflets tethering with or without mitral annular dilation, 3D TEE has a major role in preoperative and postoperative assessment of the MV.11 The 3D TEE en face view shows the exact origin of the mitral regurgitation The size of the annuloplasty ring can be estimated by measuring the length of the anterior mitral leaflet in 2D TEE long-axis view or the distance between two mitral commissures in 3D TEE surgical view This view is very similar to the surgical measurement of the size of ring by 582 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.7A and B: Three-dimensional transesophageal echocardiography (3D TEE) full-volume color acquisition of the mitral valve (MV) in the previous patient (A) Surgical view of the MV shows severe eccentric anteriorly directed jet of mitral regurgitation (between two arrows); (B) Color-suppress mode of the same view demonstrating large gap (between two arrows) because of flail middle scallop of the posterior mitral valve leaflet causing severe regurgitation A B Figs 29.8A and B: Carpentier’s technique of mitral valve repair in the previous patient (A) Quadrangular resection (Quad rese) of the flail middle scallop of the posterior mitral leaflet (P2); (B) Insertion of a complete semi-rigid annuloplasty ring (Physio ring) to prevent future mitral annular dilatation the operating surgeon (Figs 29.25 to 29.27) Postoperative evaluation of the result of the repair by 3D TEE is very useful to detect any transvalvular or para-annular residual mitral regurgitation Calculation of the MV area by PHT immediately after repair is not valid but mean gradient across the valve should be measured Many surgeons use posterior annuloplasty band or half-ring to secure the posterior mitral annulus but the new trend now is toward using full semirigid ring (Physio ring) to prevent further mitral annular dilatation (Figs 29.25 to 29.30 and Movie clips 29.25A to K) AORTIC VALVE DISEASE Aortic valve (AV) is not an ideal structure of the heart to be assessed by 3D TEE as compared to MV The AV lies obliquely toward the ultrasound beam coming from TEE Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 583 B Figs 29.9A and B: Postoperative mitral valve repair assessment by three-dimensional transesophageal echocardiography (3D TEE) in the previous patient (A) Semi-rigid, complete annuloplasty ring (Physio ring) is seen well seated; (B) Full-volume, 3D color Doppler demonstrates trivial residual mitral regurgitation (Res MR) Note: saddle shape of the ring, number, and position of the suture lines can be appreciated nicely by 3D TEE images A B Figs 29.10A and B: Three-dimensional transesophageal echocardiographic (3D TEE) en face view of the mitral valve in a patient with severe mitral regurgitation and corresponding surgical view Multiple ruptured chorda (black arrows) attached to the middle scallop of the posterior mitral valve leaflet (P2) can be seen in 3D view (A) and during surgical direct inspection (B) probe inside the esophagus Aortic cusps are very thin and open in less than 20 milliseconds Therefore, with low resolution and low frame rate available 3D echo technology it is difficult to acquire a good image Extra hole appears at the middle of cups (when gain is too low) due to artifact, which should not be taken as fenestrations, and always be correlated with same view of color Doppler Preoperative evaluation of the AV can be done by 2D TEE but 3D TEE can provide surgical view as is seen in Figure 29.31 and Movie clip 29.31 Aortic surgical view is obtained by 3D TEE long-axis view and rotation of the image in a way that noncoronary cusp (NCC) is located at the bottom of the picture This cusp is the closest cusp to the surgeon during conventional aortotomy In this 584 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.11A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgery correlation in a patient with flail middle segment of the anterior mitral valve leaflet (A2) (A) Surgical view of the mitral valve shows flail A2 with multiple ruptured chorda (black arrows); (B) Direct surgical inspection confirmed the diagnosis of flail A2 with multiple ruptured chorda (black arrows) (AV: Aortic valve; LAA: Left atrial appendage) A B Figs 29.12A and B: Three-dimensional (3D) full-volume color acquisition of mitral valve in the previous patient (A) Severe eccentric anteriorly directed jet of mitral regurgitation (MR) is demonstrated because of flail middle segment (A2) of the anterior mitral valve leaflet; (B) Color-suppress mode of the same view confirmed the origin of the MR Note: two ruptured chorda (Rup chord) attached to the tip of A2 (arrows) view, the right coronary cusp (RCC) and the right sinus of Valsalva are located to the front and right of the surgeon, while the left coronary cusp (LCC) and the left sinus of Valsalva are located to the front and left of the surgeon.12 Preoperative assessment of the AV with rheumatic aortic regurgitation or stenosis through the use of 3D TEE is very informative Aortic leaflets retraction, lack of coaptation, commissural fusion, and leaflets calcification can be evaluated 3D TEE underestimates the degree of calcification compared to 2D TEE and surgical inspection Aortic annular dimensions for selecting suitable size prosthesis are more accurate by 2D TEE measurement.13–15 Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 585 B Figs 29.13A and B: Three-dimensional (3D), full-volume color demonstrating severe mitral regurgitation (MR) for quantitating degree of MR by proximal isovelocity surface area (PISA) method (A) Severe MR jet is noted from left ventricle (LV) to the left atrium (LA) Color sector bar has been moved toward the MR jet shows Nyquist limit of +39.4 cm/s; (B) PISA hemisphere is visualized in 3D view and radius (r) is measured by calibrating 3D grid which shows r = 1.1 cm In newer versions of echo machines, this measurement of radius can be done directly without calibrating the 3D grid A B Figs 29.14A and B: Surgical repair of the previous mitral valve (MV) (A) Flail middle segment of the anterior mitral valve leaflet (A2) is shown Ruptured chorda is replaced by synthetic GoreTex materials (blue arrows), which connect leaflet’s tip to the corresponding papillary muscle; (B) Saline test by syringe filled the left ventricle and is bulging the mitral leaflets toward the left atrium This is the technique that a surgeon can use to initially assess the result of mitral valve repair Mitral leaflet coaptation line (closure line) should show a regular “happy face” appearance with no flail tip Degree of the residual regurgitation and origin of the leak can be appreciated by the surgeon in this saline test; however, evaluation is not as accurate as post-op echo study because the former is assessing the residual leak in an arrested heart and the latter in a physiologic, dynamic status Vena contracta of the aortic regurgitation (AI) jet to quantitate the degree of AI can be measured by 3D TEE in different angles (Figs 29.32 to 29.35 and Movie clips 29.32A and B and 29.34A to F) 3D TEE adds two more methods to calculate aortic valve area (AVA) beside the previous conventional methods of continuity equation and direct 586 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.15A and B: Measuring mitral annuloplasty ring size by preoperative three-dimensional transesophageal echocardiographic (3D TEE) assessment of mitral valve in the previous patient and comparison with surgical direct measurement (A) Ring size can be measured during mitral leaflets closure and full extension of the anterior mitral leaflet Diameter between two commissures (ALC-PMC) can be measured by 3D grid or directly by new version echo machine; (B) Surgically direct measurement from commissure to commissure or trigon to trigon (right and left fibrous trigon) by commercially available ring sizer (M 30, black arrows) Suitable ring should fit the length between two commissures and the area of the ring should be same as the area of the surface of the anterior mitral valve leaflet (AMVL) Mismatching of these two areas may cause postoperative mitral regurgitation, mitral stenosis, or systolic anterior motion of the mitral valve (SAM) Note: in this patient both methods correlate very well and showed ring size of 30 mm (ALC: Anterolateral commissure; PMC: Posteromedial commissure) A B Figs 29.16A and B: Three-dimensional transesophageal echocardiographic (3D TEE), postoperative assessment of the mitral valve repair in the previous patient (A) Complete semi-rigid annuloplasty ring (Physio ring) is seated well; (B) 3D full-volume color showed no residual mitral regurgitation planimetry The first is direct planimetry of the AV in en face view after cropping the image to the level of leaflets tips The second method, which is probably more accurate, is MPR method In this method, AVA can be traced at the level of the tips of leaflets in short axis (Figs 29.35 to 29.40 and Movie clips 29.36A to D and 29.39A to D) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 587 B Figs 29.17A and B: Extensive myxomatous changes (Barlow’s disease) in a patient presented with severe mitral regurgitation (A) Three-dimensional transesophageal echocardiographic (3D TEE) surgical view of the mitral valve demonstrating “lumpy bumpy” appearance of all scallops and segments Excessive leaflet tissue, increasing surface area of both leaflets and severe dilatation of the mitral annulus are the hallmark of Barlow’s disease Note: severe prolapse of P2 and P3 scallops with deep indentation (deep indent) or cleft at the middle Middle segment of anterior mitral valve leaflet (A2) is showing moderate prolapse as well; (B) Surgical inspection of the mitral valve confirmed 3D TEE findings No ruptured chorda was found during surgical exploration but most of them were thickened and elongated Although this type of mitral valve pathology is difficult to repair, this patient had successful repair by quadrangular resection of P2 and multiple chordal replacement of the anterior leaflet (A3: Medial segment of the anterior mitral valve leaflet; P2: Middle scallop of the posterior mitral valve leaflet (PMVL); P3: Medial scallop of the PMVL) A B Figs 29.18A and B: Three-dimensional transesophageal echocardiography (3D TEE) demonstration of severely stenotic mitral valve (MV) in a 68-year-old male patient (A) Surgical view of the MV showing severe calcification (Ca++) of the leaflets and commissures; (B) Same view of the MV with 3D full-volume color in diastole visualizing mitral orifice from the left atrial (LA) side Mitral valve area (MVA) is calculated by calibrated 3D grid which came 0.6 cm2 In the latest version of the echo machine, this orifice area can be traced directly without using the 3D grid (AV: Aortic valve; LAA: Left atrial appendage) 588 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.19A and B: Excised mitral valve (MV) in the previous patient (A) Mitral valve is demonstrated from the left atrial side with severe calcification (Ca++) of both leaflets at the body and free margins Commissures are fused; (B) Same specimen is seen from left ventricular side with multiple calcification and thickened, fused chorda (Chor), and subvalvular apparatus (AMVL: Anterior mitral valve leaflet; PMVL: Posterior mitral valve leaflet) A B Figs 29.20A and B: Mitral valve replacement of the previous patient with a bioprosthetic valve (A) Bioprosthetic valve visualized in systole from the left atrial side appears well seated Prosthetic valve cusps and surgical suture lines are well recognized; (B) The valve seen from the left ventricular side in diastole shows three equal-sized cups opened well Struts of the valve and their orientation are visualized Note: proximity of the prosthetic valve with left ventricular outflow tract (LVOT) can be visualized in this view and is evaluated in different angles to be sure there is no LVOT obstruction by the prosthetic mitral valve and its struts Three-dimensional TEE is very helpful during preoperative assessment of the patient with aortic regurgitation due to fenestration of leaflets secondary to endocarditis or foreign body-like protruding stents of the coronary arteries (Figs 29.41 to 29.43 and Movie clips 29.41A to H) Role of 3D TEE in endocarditis is discussed in the relevant subsection 3D TEE can help the surgeon to choose the suitable size of newer generation valves like suture-less valves and assess their postoperative function (Fig 29.44 and Movie clips 29.44A and B) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 589 B Figs 29.21A and B: Three-dimensional transesophageal echocardiographic (3D TEE) surgical view of the mitral valve in a 52-year-old male patient and correlation with surgical inspection in the operating room (A) Severely stenotic mitral valve with tight orifice viewing from the left atrial side Leaflets are calcified and both commissures are fused; (B) Surgical exploration of the valve confirmed 3D TEE findings (ALC: Anterolateral commissure; AMVL: Anterior mitral valve leaflet; LAA: Left atrial appendage; PMC: Posteromedial commissure) A B Figs 29.22A and B: Multi-planar reconstruction view (MPR) of the mitral valve in the previous patient (A) Simultaneously display of sagittal, coronal, and transverse slices of the mitral valve to obtain cross-section of the mitral orifice; (B) Magnified blue box Mitral valve area can be calculated by 3D QLAB software built in the echo machine to trace the area of mitral orifice (MVA = 0.5 cm2) TRICUSPID VALVE DISEASE The TV, “the forgotten valve,” is composed of the annulus, leaflets and chordal, and papillary muscle apparatus.16 Anterior tricuspid valve leaflet (ATVL) is the largest cusp and in echocardiography views is always located beside the right atrial appendage (RAA) Septal tricuspid valve leaflet (STVL) is located beside the aortic root and superior vena cava (SVC) and coronary sinus (CS) Posterior tricuspid valve leaflet (PTVL) is the smallest cusp and is located beside the inferior vena cava (IVC) PTVL is the most posteriorly located part of the TV In 2D TEE, it is 590 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.23A and B: Three-dimensional (3D) planimetry of the mitral valve orifice in the previous patient (A) 3D planimetry from the left atrial side After calibration of the image by 3D grid, mitral valve area (MVA) can be traced easily, which came to 0.5 cm2 in this patient; (B) Same planimetry is done from the left ventricular side, which showed the same MVA Based on unpublished data from our echo lab, this direct planimetry of 3D image for MVA has excellent reproducibility compared to the conventional method of pressure half-time (PHT) but underestimates the MVA This method is very useful for the calculation of MVA in cath lab after mitral balloon valvuloplasty while PHT is not valid because in the former method, pre- and postoperative MVA are measured by the same method Note: in newer versions of 3D echo machines, this planimetry can be done directly without calibrating by 3D grid A B Figs 29.24A and B: Mitral valve replacement in the previous patient with mechanical double disc (Carbomedics) prosthesis (A) Threedimensional (3D) zoom mode shows discs in a closed position; (B) Mechanical discs are open symmetrically during diastole (arrows) Note: The normal anatomic orientation of the mitral valve leaflets is parallel to the aorta Most surgeons implant mechanical mitral valves with the two discs perpendicular to the aorta This is referred to as "anti-anatomic orientation (LAA: Left atrial appendage) impossible to visualize three cusps of the TV at the same time but in 3D TEE, it is possible to obtain a good en face view (surgical view) of the TV in about 60% to 70% of patients.17 It is easier to obtain good 3D images of TV when leaflets are thickened and diseased Limitations of 3D TEE in imaging TV are because of thin and fast moving cusps and location of TV being far away from the TEE probe in the esophagus In secondary tricuspid regurgitation (TR) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 591 B Figs 29.25A and B: Three-dimensional transesophageal echocardiographic (3D TEE) surgical view of the mitral valve (MV) in a 74-year-old female undergoing coronary artery bypass grafting (CABG) and MV repair (A) Mitral leaflets structurally appear normal but are functionally abnormal Lack of coaptation of leaflets is noted with two large gaps creating severe mitral regurgitation (MR); (B) Full-volume color acquisition demonstrates severe ischemic (functional or secondary) MR, originating from two gaps Cause of MR in this type of pathology is functional due to the downward displacement of the papillary muscles (as a result of ischemia or infarction) and “tethering” of the mitral leaflets This tethering is causing systolic restriction and lack of coaptation of the leaflets A B Figs 29.26A and B: Preoperative measurement of annuloplasty ring size in the previous patient (A) Two-dimensional transesophageal echocardiographic (2D TEE) long-axis view of the mitral valve (MV) for estimation of the size of annuloplasty ring that surgeons may use during MV repair While this is the optimal view for measurement of the mitral annulus there are few studies that confirm this with direct sizing by the surgeon (white arrow = 28 mm); (B) Three-dimensional (3D) TEE surgical view of the MV showing the distance between two mitral commissures or two trigons (right and left fibrous trigon), which is the same (28 mm) as was measured by 2D TEE Note: ring sizer should cover the area of the AMVL as demonstrated in this 3D view Implantation of a larger size ring may leave residual mitral regurgitation (MR) and a smaller size ring may create systolic anterior motion of the MV (SAM) in postoperative In ischemic MR, surgeons like to downsize the ring one or two as is shown in the next figure 592 A Section 2: Echocardiography/Ultrasound Examination and Training B Figs 29.27A and B: Direct surgical inspection of the mitral valve in the previous patient (A) Surgical demonstration of the mitral valve (MV) shows that both the anterior and posterior mitral valve leaflets (AMVL and PMVL) are normal in structure Chorda tendina (arrows) are intact and not elongated or ruptured In the moving heart, these chorda are tethered and have systolic restriction; (B) Direct measurement of annuloplasty ring size by a Cosgrove-Edward ring sizer Although annuloplasty ring size should be #28, by preoperative 2D and 3D measurement shown in the previous figure, the operating surgeon preferred to downsize the ring to #26 A B Figs 29.28A and B: Surgical repair of the mitral valve in the previous patient (A) Sutures have been placed in the posterior mitral annulus for securing the annuloplasty ring No resection of the leaflets was done because there is no excessive tissue; (B) The annuloplasty ring size #26 is being prepared for placement The operating surgeon preferred to place a half-ring (Cosgrove-Edwards ring) to decrease the circumference of the annulus and to prevent future dilatation Some surgeons believe that mitral annular dilatation occurs mostly from posterior annulus (from trigon to trigon) and that protecting this part of the annulus is enough, as opposed to a second group that thinks that the entire annulus may dilate and a complete ring is an appropriate choice (AMVL: Anterior mitral valve leaflet; PMVL: Posterior mitral valve leaflet) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 593 B Figs 29.29A and B: Surgical demonstration of the repaired mitral valve in the previous patient and three-dimensional (3D) image correlation (A) Posterior annuloplasty ring in position Note: mitral leaflets are visualized after surgical saline test, which shows nice coaptation and no residual leak; (B) 3D transesophageal echocardiography (TEE) immediately after coming off the pump showing the half-ring well seated (between two arrows) Surgical suture lines can be recognized clearly (AV: Aortic valve) A B Figs 29.30A and B: Immediate postoperative assessment of the mitral valve (MV) repair in the previous patient (A) Dual volume layout option of the new version of echo machine can display MV from two sides simultaneously (A) MV is shown from the left atrial side and the left ventricular side; (B) Full-volume color acquisition reveals successful result with no residual mitral regurgitation which is mostly because of lack of leaflets coaptation, tricuspid annulus dilates in axes from anteroseptal commissure to the anteroposterior commissure Based on ECS guidelines, surgery should be considered in patients with mild to moderate secondary TR and dilated tricuspid annulus (>40 mm or 21 mm/m2) undergoing left-sided valve surgery.18 Etiology of the TR in 90% of the cases is secondary.19 The 3D TEE surgical view of the TV can be obtained by long-axis view (120°) and rotation of image to bring the septal leaflet below the picture This leaflet is the closest cusp to the surgeon during TV inspection (Figs 29.45 to 29.47 and Movie clips 29.46A to E) 594 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.31A and B: Two- and three-dimensional transesophageal echocardiographic (2D TEE and 3D TEE) views of normal aortic valve (A) 2D TEE long-axis view in systole shows trileaflet aortic valve (AV) Interatrial septum (IAS) is a good landmark in both views because the noncoronary cusp (NCC) is always adjacent to it; (B) Surgical view of the AV by 3D TEE NCC is the closest cusp in this view to the surgeon and located at the bottom of the image of three cusps In the moving loop of this view, ostia of the right and left coronary arteries can be appreciated (LA: Left atrium; LCC: Left coronary cusp; NA: Nodule of Aranti (small nodules at the free margins of cusps which are normal findings); RA: Right atrium; RCC: Right coronary cusp; RV: Right ventricle; TV: Tricuspid valve) A B Figs 29.32A and B: Three-dimensional (3D) intraoperative transesophageal echocardiography (TEE) in a 24-year-old man with severe aortic regurgitation (AI) (A) 3D TEE echo view (not surgical view) of the aortic valve (AV) showing trileaflet valve with mildly thickened and retracted cusps and large gap at the middle causing severe aortic regurgitation (AI); (B) 3D TEE long-axis view with color Doppler demonstrates severe eccentric AI Vena contracta of AI can be measured in this view (arrow) by 3D grid or direct measurement in newer machines (LA: Left atrium; LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) Tricuspid annular dimensions and area can be measured by 3D grid or direct measurement in recent generation of echo machines This evaluation can be repeated after TV repair and annuloplasty.20 There is no widely accepted surgical method of TV repair among the surgeons Classic De Vega repair, reducing annular Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 595 B Figs 29.33A and B: Preoperative three-dimensional transesophageal echocardiography (3D TEE) surgical view of the aortic valve (AV) in the previous patient with surgical correlation (A) AV in systole shows mildly thickened cusps with retracted free margins compatible with rheumatic AV with predominantly aortic regurgitation in a young patient; (B) Direct surgical inspection showed no commissural calcification This valve was attempted to repair but failed week later and had to be replaced (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) A B Figs 29.34A and B: Three-dimensional (3D) intraoperative transesophageal echocardiography (TEE) in a 41-year-old man with rheumatic mixed lesion of aortic stenosis and aortic regurgitation (AS and AI) (A) Long-axis view shows thickened aortic leaflets with severe systolic doming Aortic annulus in this view is measured by 3D grid as 21 mm, which will be the size of the prosthetic valve; (B) 3D full-volume color acquisition in diastole demonstrating severe AI with vena contracta of mm dimensions by placing purse sutures at the annulus without ring, is abounded by most surgeons Key-stitch annuloplasty and bicuspidization technique without insertion of the ring are used in our center by some surgeons C-shape annuloplasty ring which spares A–V node area is another widely accepted annuloplasty ring for repair of the TV (Figs 29.48 to 29.55 and Movie clips 29.48A to H, 29.51A to D, and 29.53A to E) Blunt chest trauma is one cause of primary tricuspid regurgitation and happens because of rupture of the anterior leaflet 596 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.35A and B: Preoperative three-dimensional transesophageal echocardiography (3D TEE) surgical view of the aortic valve in the previous patient, correlating with direct inspection (A) 3D view shows trileaflet valve with fused commissure between NCC and LCC creating a “functional bicuspid” aortic valve; (B) Direct surgical inspection demonstrates severely calcified leaflets with fusion line (Fus) between NCC and LCC (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) A B Figs 29.36A and B: Comparison between 3D TEE echo view and surgical view of the aortic valve (AV) in a 53-year-old female with severe aortic stenosis (A) 3D TEE echo view of the AV is obtainable at short axis (40–50°) NCC is always beside the interatrial septum (IAS) RCC can be visualized adjacent to the right ventricle; (B) 3D TEE surgical view of the AV can be acquired in long-axis view (120°) This view is always recommended in the operating room because it creates a "common language" with the surgeon In this view, the NCC is located closest to the surgeon at the bottom of the image RCC is located at the right and anterior and LCC is located at the left and anterior of the surgeon Ostia of the left main and right coronary arteries can be visualized in both echo and surgical views 3D TEE, three-dimensional transesophageal echocardiography (LA: Left atrium; LCC: Left coronary cusp; NCC Noncoronary cusp; RA: Right atrium; RCC: Right coronary cusp; RVOT: Right ventricular outflow tract) or of the papillary muscle.21 Clinical manifestations may present many years after the initial trauma because of tolerable nature of the TR in a patient with no other cardiac abnormality Ruptured papillary muscle can be resuspended successfully (Figs 29.56 and 29.57 and Movie clips 29.56A to C) In patients with long-standing severe TR Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 597 B Figs 29.37A and B: Calculation of the aortic valve area (AVA) in the previous patient with two different methods in 3D TEE (A) Planimetry of aortic valve in short-axis surgical view by calibrated grid; (B) Multiplanner reconstruction (MPR) method which can obtain short axis of the valve at the level of the cusps tip and measure the area In both the methods, AVA is in the critical aortic stenosis range Note: in preoperative transthoracic echo study, this patient had a peak gradient of 140 mm Hg across the aortic valve 3D TEE, threedimensional transesophageal echocardiography (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) A B Figs 29.38A and B: Surgical inspection of the aortic valve in the previous patient (A) Surgical aortotomy to explore the aortic valve (AV); (B) Demonstration of the aortic cups Severe inflammation of the leaflets is noted without calcification Result of pathology was reported as myxoid fibrinoid degeneration This patient underwent aortic valve replacement (IVC: Inferior vena cava; LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) or redo surgery TV may not be preserved and needs to be replaced Mechanical prosthesis is not a good option for tricuspid position because of higher chance of clotting Although bioprosthetic valve has a chance of degeneration it is still a better choice (Figs 29.58 to 29.60 and Movie clips 29.58A to F) NATIVE VALVE ENDOCARDITIS Echocardiography is diagnosis of infective criteria It is also the complications of IE, the major imaging modality for endocarditis (IE) based on Duke’s best available technique to detect which often necessitate surgical 598 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.39A and B: Three-dimensional transesophageal echocardiography (3D TEE) imaging compared with surgical inspection of the same patient in a 39-year-old male with severe aortic stenosis undergoing valve replacement (A) Preoperative 3D full-volume acquisition shows bicuspid aortic valve with tight orifice (arrows) Calcifications may be underestimated in 3D echo imaging compared to 2D imaging due to inferior resolution in 3D echo; (B) Surgical inspection demonstrates severely stenotic bicuspid aortic valve (Inset: B) Aortic valve after resection is zoomed from left ventricular side which shows severely calcified valve (LA: Left atrium; RA: Right atrium) A B Figs 29.40A and B: Three-dimensional transesophageal echocardiography (3D TEE) of calcific aortic stenosis in a 68-year-old patient compared with the surgical finding (A) 3D TEE echo view (not surgical view) showing trileaflet aortic valve Calcifications of the cusps are less appreciated compared to surgical demonstration; (B) Direct inspection shows heavy calcification of the entire aortic valve except for the leaflet free margins and commissures The contrasts sharply with the appearance of rheumatic aortic stenosis where the free margins and commissures are more diseased intervention and strongly affects patient outcomes 3D TEE provides enhanced display of anatomic–spatial relationships allowing more precise delineation of complex pathology, particularly of the complications of native valve endocarditis (NVE)-like perforation of the leaflets, perivalvular abscess formation, and fistulous communications with neighboring structures.22 Sensitivity of the 3D TEE to detect small vegetations is less than that of Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 599 B Figs 29.41A and B: Three-dimensional transesophageal echocardiography (3D TEE) views of aortic root in a 36-year-old lady with severe aortic regurgitation This patient had myocardial infarction month ago and had a stent deployed in the right coronary artery (RCA) and the left main coronary artery (LMCA) (A) 3D zoom mode showing stent in RCA protruding in to the lumen of aortic root Wire of the stent is visualized, touching the right coronary cusp (RCC) of the aortic valve during systole; (B) Same long-axis view of the aortic root with angulation demonstrates stent in the ostium of LMCA Note: stent is protruding in to the lumen slightly and is not touching any cusps A B Figs 29.42A and B: Three-dimensional transesophageal echocardiography (3D TEE) with full-volume color acquisition showing mechanism of aortic regurgitation (AI) in the previous patient (A) Long-axis view of the aortic root demonstrates protruding stent pushing downward the right coronary cusp resulting in prolapse of this cusp and severe AI; (B) Multiplanner reconstruction (MPR) mode of the same view shows origin of the AI in long-axis, short-axis, and coronal view 2D TEE because of lower spatial and temporal resolution Low frame rate 3D TEE acquisition (Zoom mode) may miss fast moving, oscillating vegetations on the valves; therefore, a combined use of these two methods is necessary for decision making Bicuspid AV, previous dental manipulation, underlying rheumatic and degenerative valvular heart diseases, and diabetes mellitus are the risk factors for NVE The most common microorganism identified in a group of patients who underwent operation for NVE, were Streptococcus 600 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.43A and B: Surgical inspection of the aortic root in the previous patient (A) Stent of the right coronary artery is shown protruding in to the aortic root lumen about 1.5 cm from the ostium Stent wire pushes over the RCC Extra portion of the stent was resected by the surgeon RCC was examined and showed extensive damage of this cusp, not amenable to repair A decision was made to replace this aortic valve with a bioprosthetic valve; (B) Three-dimensional transesophageal echocardiography (3D TEE) immediately after surgery shows bioprosthetic aortic valve (AVR) in long-axis view (LA: Left atrium; LV: Left ventricle; RCC: Right coronary cusp) A B Figs 29.44A and B: Sutureless Perceval (Sorin Group) bioprosthetic aortic valve in a 78-year-old high-risk female patient (A) Medium size valve in place This valve is made of porcine pericardium and is self-expandable The valve has only three sutures which are connected to three commissural posts of the native aortic annulus and positioned by a special holder through a conventional aortotomy Pump time of replacing an aortic valve with a Perceval valve is less than half the time of a conventional aortic valve replacement; (B) Three-dimensional transesophageal echocardiography (3D TEE) surgical view of the same patient (LA: Left atrium; RA: Right atrium) viridans and Staphylococcus AV was more common than MV and men were more affected than women in this group of patients.23 One of the rare causes of the NVE is brucella endocarditis Early diagnosis and appropriate antibiotic therapy may preserve the integrity of the involved valves Delay in Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 601 B Figs 29.45A and B: Diagram of surgical view of the tricuspid valve (A) Diagram of normal tricuspid valve (TV) During operation on TV, the surgeon rotates the heart in a way that the right atrium is at the top and the left atrium is located at the bottom Septal leaflet of the TV is the closest cusp to the surgeon The large anterior leaflet is in front of the surgeon and the smaller posterior leaflet is located toward the right hand of the surgeon The A–V node is located at the triangle of the Koch and should be avoided from manipulation during TV repair; (B) Diagram shows the longest axis of the tricuspid annular dilatation secondary to tricuspid regurgitation (TR) Dilatation happens in axis from anteroseptal commissure to anteroposterior commissure (red arrow) In recent European Society of Cardiology (ESC) guidelines, dilation in this axis more than cm even with the presence of mild to moderate TR is an indication for TV repair if the patient is going for left side heart surgery A B Figs 29.46A and B: Comparison between three-dimensional transesophageal echocardiography (3D TEE) echocardiographic view and surgical view of a normal tricuspid valve (TV) (A) 3D TEE echocardiographic view obtained from long-axis view (120°) showing TV, IVC, and CS; (B) 180° counterclockwise rotation of same image provides surgical view of TV CS is a landmark for septal leaflet, and IVC is a landmark for posterior leaflet of the TV due to their close proximity Note: SVC and aorta are parallel to each other and both are running on the left side of the surgeon (CS: Coronary sinus; IVC: Inferior vena cava; SVC: Superior vena cava) medical treatment can lead to complications of infection, such as perivalvular abscess formation In case of the aortic root abscess, surgical radical resection of the abscess and AV replacement are recommended Aortic homograft with coronary reimplantation is a superior choice.24–26 Preoperative assessment of the infected valve by 3D TEE can show the degree of the valvular destruction, location, and extension of the perivalvular abscess At the same 602 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.47A and B: Surgical view of the tricuspid valve (TV) in the previous patient with different angulation (A) 3D TEE of the TV with more clear visualization of the IVC; (B) Same view with more rotation away from the surgeon to show aortic root (A: Anterior TV leaflet; IVC: Inferior vena cava; LA: Left atrium; P: Posterior TV leaflet; RAA: Right atrial appendage; S: Septal TV leaflet; SVC: Superior vena cava) A B Figs 29.48A and B: Intraoperative 3D TEE in a 36-year-old male with severe rheumatic mitral stenosis and severe tricuspid regurgitation (TR) (A) 3D TEE en face view (surgical view) of the tricuspid valve (TV) from right atrial side showing all three cusps with dilated annulus and lack of leaflets coaptation; (B) Tricuspid leaflets are seen from the right ventricular side 3D TEE, three-dimensional transesophageal echocardiography; (An: Anterior tricuspid valve leaflet; LA: Left atrium; P: Posterior tricuspid valve leaflet; S: Septal tricuspid valve leaflet) time postoperative evaluation can delineate the function of the prosthetic root, LV function, and possible coronary reimplantation complications (Figs 29.61 to 29.63 and Movie clips 29.61A to F) As was discussed earlier, bicuspid AV is the most common risk factor for NVE Recent studies have shown that annual incidence of IE in this common congenital heart disease is about 2%.27 Compared to other NVE, bicuspid Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 603 B Figs 29.49A and B: Pre- and postoperative three-dimensional transesophageal echocardiography (3D TEE) with full-volume color of previous patient (A) Preoperative surgical view shows severe tricuspid regurgitation (TR) due to lack of leaflets coaptation; (B) Immediate postoperative TEE demonstrates trivial residual TR A B Figs 29.50A and B: Surgical technique to repair previous tricuspid valve (TV) “Key-stitch repair,” which is a couple of interrupted pledget sutures (Pled Sut) positioning at the tricuspid annulus, was used in this patient (A) Surgical examination of the leaflets prior to the repair; (B) Pledget sutures in place at the annulus around the anterior and posterior leaflets (An: Anterior tricuspid leaflet; P: Posterior tricuspid leaflet; S: Septal tricuspid leaflet) AV endocarditis has more chance of complications, such as cusp perforation, valve destruction, valvular, perivalvular, and myocardial abscess Acute heart failure may happen as a consequence of these complications Extension of perivalvular abscess to the A–V node and bundles can create bundle branch block or a complete A–V block Mortality rate and recurrence of the infection in patients with aortic root abscess is high Early detection and prompt surgical intervention are crucial.28,29 3D TEE is very helpful for detection and visualization of valve perforation, degree of aortic regurgitation, and extension of the aortic root abscess Preoperative full assessment 604 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.51A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view of the tricuspid valve (TV) in a 53-year-old female diagnosed with idiopathic severe tricuspid regurgitation (TR) (A) En face view of the TV shows severely dilated tricuspid annulus with thin pliable leaflets; (B) 3D TEE with full-volume color acquisition demonstrated severe TR due to lack of leaflets coaptation A B Figs 29.52A and B: Surgical exploration and repair of the tricuspid valve (TV) in the previous patient (A) Direct inspection shows dilated tricuspid annulus with no primary leaflet disease; (B) Repair of the TV using “bicuspidization technique,” which converts trileaflet valve in to a bicuspid valve by suturing anteroposterior commissure with septal posterior commissure With this suture, posterior leaflet would be ligated and inactive (An: Anterior tricuspid leaflet; P: Posterior tricuspid leaflet; S: Septal tricuspid leaflet) of the AV and root can help the surgeon choose the best surgical option In patients with early medical treatment of endocarditis, small perforation can happen on the cusps and patients may present with chronic aortic regurgitation later (Figs 29.64 to 29.68 and Movie clips 29.64A to D, 29.66A to H) Preoperative delineation of this perforation by 3D TEE may help the surgeon to repair the cusp and preserve the AV Chapter 29: Three-Dimensional Echocardiography in the Operating Room 605 B A Figs 29.53A and B: Intraoperative assessment of the tricuspid regurgitation (TR) in a 50-year-old male with severe aortic stenosis (A) Three-dimensional transesophageal echocardiography (3D TEE) surgical view of the tricuspid valve with severely dilated tricuspid annulus; (B) Full-volume color acquisition shows severe TR due to lack of leaflets coaptation B A Figs 29.54A and B: Immediate postoperative assessment of the tricuspid valve (TV) repair in the previous patient (A) Three-dimensional transesophageal echocardiography (3D TEE) surgical view shows TV repair with insertion of annuloplasty ring Edwards MC3 ring was used for this repair Ring is seated well The open part of the ring is toward the location of the A–V node to prevent A–V block; (B) 3D full-volume color acquisition confirmed no residual tricuspid regurgitation Many studies have shown that repair with annuloplasty ring has the best long-term outcome among the different techniques introduced for TV repair PROSTHETIC VALVE DYSFUNCTION In the Euro Heart Survey, 28% of patients with valvular heart disease had undergone previous valvular intervention 18% of which was valve repair and 82% valve replacement.30 In mitral and TV repair, most surgeons use prosthetic annuloplasty rings for prevention of future annular dilatation These rings can be only a pericardial band, commercial half-ring, or complete flexible or rigid rings Ring dehiscence is one of the uncommon complications which bring patients back to the hospital because of new valvular regurgitation Valve replacement 606 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.55A and B: Surgical demonstration of the tricuspid valve repair with insertion of annuloplasty ring (A) Edwards MC3 #32 is being prepared for placement This ring is oval-shaped conforming to the configuration of a normal tricuspid orifice Ring size is selected based on the measurement of the septal leaflet attachment; (B) Ring is in position and appears seated well Open portion of the ring is toward the anteroseptal commissure A B Figs 29.56A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 68-year-old man with a history of blunt chest trauma and signs of right side heart failure (A) 3D TEE modified surgical view shows flail tip of the anterior tricuspid valve leaflet (arrow) due to ruptured head of right ventricular papillary muscle; (B) Same view with full-volume color demonstrates severe tricuspid regurgitation is possible by mechanical or bioprosthetic valves Xenograft valves are either stented or stentless but both types have limited durability and after 10 to 15 years will be degenerated and calcified and need to be re-replaced Suture-less valves are newly developed technology These valves need only three reference sutures to implant the valve and save the pump-time to almost half; therefore, they are an ideal option for high risk patients Suture-less valves are currently available for aortic position None of the abovementioned prosthetic valves is perfect to substitute native Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 607 B Figs 29.57A and B: Surgical repair of the tricuspid valve (TV) in the previous patient (A) Flail tip of anterior (An) tricuspid leaflet is seen due to ruptured head of anterior papillary muscle of right ventricle This finding is not uncommon in patients who have had blunt chest trauma because the TV is a very anteriorly located structure compared to the other valves; (B) Flail tip was sutured to the papillary muscle and repair was completed by insertion of a size #34 MC3 annuloplasty ring Postoperative TEE showed excellent result (S: Septal tricuspid leaflet) A B Figs 29.58A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 54-year-old female with a history of mitral valve replacement and long-standing tricuspid regurgitation (TR) (A) Surgical view of the tricuspid valve shows severely dilated annulus with a large gap at the middle in systole; (B) The same view during diastole demonstrates how the tricuspid annulus can be measured by calibrated 3D grid or directly in newer echo machines Tricuspid annulus in this case was measured at 5.3 × 5.3 cm valves In fact, we are changing one disease (diseased native valve) to another type of disease (prosthetic valve) Patient-prosthesis mismatch, thrombosis of the mechanical discs, pannus formation of the sewing ring, prosthetic valve endocarditis (PVE), periprosthetic abscess formation, and dehiscence of the valve are the most common complications in mechanical valves which create prosthetic valve dysfunction (PVD) Transvalvular 608 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.59A and B: (A) Intraoperative three-dimensional transesophageal echocardiography (3D TEE) with full-volume color acquisition in the previous patient shows severe tricuspid regurgitation (TR); (B) The same after tricuspid valve replacement by a bioprosthetic valve A B Figs 29.60A and B: (A) Modified surgical view of the tricuspid valve in the previous patient shows insertion of the suture lines to implant a bioprosthetic valve inside the native valve (valve-in-valve) Severe dilatation of the tricuspid annulus and third redo-surgery was the main reason to decide to replace this valve as opposed to repair; (B) Bioprosthetic valve size #33 Magna was placed Postoperative transesophageal echocardiography (TEE) showed normal functioning prosthetic valve or paravalvular regurgitation may happen following the above-mentioned complications Transesophageal echo and 3D TEE are the only available imaging modality in the operating room which can detect PVD immediately after surgery and provide the surgeon with an opportunity to go back on pump and solve the problem This modality is an ideal imaging technique to assess prosthetic valves which are 3D objects in nature Annuloplasty ring dehiscence is one of the uncommon late complications of the MV repair.31,32 It may happen because of endocarditis but in most cases it is because of the small size ring used during repair Mitral annular Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 609 B Figs 29.61A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 15-year-old boy with a history of brucella endocarditis and aortic root abscess (A) Long-axis view of the aortic root shows large vegetation on the aortic valve Huge abscess cavity is visualized at the posterior aspect of the aortic root adjacent to the roof of the LA Abscess cavity has communication with the left ventricular outflow tract (arrow) and is bulging toward the LA; (B) 3D TEE with full-volume color demonstrates to and fro flow to the abscess cavity through the communication site (Abs: Abscess; AV: Aortic valve; LA: Left atrium; LV: Left ventricle A B Figs 29.62A and B: Three-dimensional transesophageal echocardiography (3D TEE) of the previous patient showing abscess cavity (A) 3D TEE short-axis view shows bicuspid aortic valve with multiple vegetations Large abscess cavity (Abs cavi) is visualized posterior to the aortic root with multiple septation (honeycomb appearance); (B) 3D full-volume reconstruction of the base of the heart demonstrates location of the abscess cavity (between two black arrows) Abscess is bulging toward the left atrium (LA) from its roof but does not communicate with LA This 3D view is well correlated with surgical exploration showed in Figure 29.63 (AOV: Aortic valve; BAV: Bicuspid aortic valve; MV: Mitral valve; TV: Tricuspid valve) geometry changes during cardiac cycle and tension on the ring is the likely cause of suture dehiscence 3D TEE can detect the site and extension of the suture dehiscence and evaluate the degree of the para-annular mitral regurgitation (Figs 29.69 to 29.73 and Movie clips 29.69A to H and 29.69A to H) 610 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.63A and B: Surgical exploration of the aortic root in the same patient (A) Aortic root is visualized through the conventional aortotomy Cauliflower-shaped multiple vegetations are seen; (B) The aortic root is demonstrated after resection of the vegetations The internal communication site between the abscess cavity and the posterior aortic root is shown (red arrow) Body of the cavity can be seen from outside toward the roof of the left atrium (black arrows) This patient underwent aortic root replacement by a homograft Left main coronary artery (LMCA) button is prepared for reimplantation A B Figs 29.64A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 41-year-old male patient with a history of long-standing infective endocarditis and aortic regurgitation (A) The bicuspid aortic valve is shown in systole The larger conjoin cusp is located anteriorly, and the smaller cusp is located posteriorly; (B) Same view in diastole demonstrates large fenestration at the middle of the posterior cusp (red arrows) (LA: Left atrium; RV: Right ventricle) Bioprosthetic valves degenerate within 10 to 15 years Some conditions in patient may accelerate this natural process.33 Preoperative 3D TEE can investigate the degree of degeneration, presence of leaflets fenestration and calcification, and degree of the transvalvular regurgitation (Figs 29.74 to 29.76 and Movie clips 29.74A to C and 29.76A and B) Paravalvular regurgitation (PVR) after surgical valve replacement is more common in mitral position Early PVR may happen immediately in the operating room because Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 611 B Figs 29.65A and B: Preoperative three-dimensional transesophageal echocardiography (3D TEE) showing aortic regurgitation (AI) and surgical confirmation (A) 3D TEE with full-volume color acquisition shows two jets of AI The larger jet is originated from the large fenestration at the middle of the posterior cusp (red arrow) and the smaller jet is coming from severe prolapse of the conjoined cusp (white arrow); (B) Surgical demonstration of the aortic valve after resection Fenestration can be seen at the middle of the posterior cusp (red arrow) Note: conjoined cusp at the left coronary side is damaged by endocarditis (white arrow) and was prolapsing during diastole A B Figs 29.66A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 67-year-old man with endocarditis of aortic valve (AV) and severe aortic regurgitation (A) Long-axis view of the aortic valve shows multiple vegetations on the right and left coronary cusps (white arrows) (B) Same view with slight counterclockwise rotation demonstrates perforation on the body of the right coronary cusp of AV (black arrow) (LA: Left atrium; LV: Left ventricle) of technical factors 3D TEE can detect the location and size of the PVR If it is hemodynamically significant, the surgeon can go back on pump and solve the problem (resuturing or re-replacement) Late-appearing PVR is associated with suture dehiscence because of infection, previous annular calcification, or friable/weak tissue at the site of suturing Small paravalvular leak can create hemolysis but large PVR has hemodynamic consequences and may cause heart failure Surgical reoperation is the standard choice but if the patient is high risk and leak site 612 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.67A and B: (A) Preoperative three-dimensional transesophageal echocardiography (3D TEE) with full-volume color shows severe eccentric posteriorly directed jet of aortic regurgitation (AI) secondary to a large perforation on RCC; (B) Short-axis view of the aortic valve (surgical view) demonstrates the perforation at the body of the aortic valve (Per) This finding correlates with surgical inspection showed in Figure 29.68 (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) A B Figs 29.68A and B: Surgical inspection of the previous patient (A) Large vegetations are seen at the ventricular side of RCC and LCC; (B) Large perforation on the body of RCC is demonstrated at the same location as was described in three-dimensional transesophageal echocardiography (3D TEE) short-axis view in Figure 29.67 (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) is small and regular, device closure is an alternative choice Multiple leaks can be closed by multiple devices as well if they have favorite sites and sizes 3D TEE has a great role in catheterization laboratory to guide the interventionist for PVR device closure.34,35 In the operating room, preoperative assessment of the prosthetic valve dehiscence by 3D TEE is crucial for decision making.36 After accurate mapping of the entire sewing ring by 3D TEE, the surgeon may decide to resuture the dehisced area or re-replace the prosthetic valve (Figs 29.77 to 29.79 and Movie clips 29.77A to C) Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 613 B Figs 29.69A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in an 18-year-old boy with a history of mitral valve (MV) repair year ago (A) 3D TEE surgical view shows large dehiscence of posterior aspect of annuloplasty ring (arrows); (B) Triple display of the same view demonstrates 3D view at the top (a), original 2D TEE view at the bottom left (b), and orthogonal view of that at the bottom right (c) (AV: Aortic valve; CS: Coronary sinus) A B Figs 29.70A and B: Three-dimensional transesophageal echocardiography (3D TEE) full-volume color in the previous patient (A) Mitral valve from left atrial (LA) side shows that severe para-annular mitral regurgitation (MR) originates mostly through the large dehiscence gap (black arrows) Only a small jet of MR is transvalvular (red arrow); (B) Looking at the MV from the left ventricular side (LV) demonstrates large preflow acceleration (arrows) Prosthetic MV obstructive and nonobstructive thrombosis may happen because of inadequate anticoagulation or other factors, such as prosthesis thrombogenicity and patientrelated risk factors Recent European guidelines ranked echocardiography (TTE+TEE)/fluoroscopy as first line for detection and follow up of these patients.18 3D TEE has an advantage over the fluoroscopy for mitral prosthesis because it can visualize restricted disc motion or total stuck disc, as well as the size and burden of the clots If medical anticoagulation or fibrinolytic therapy was the preferred choice for the patient, 3D TEE is the best tool to follow the disc motion or size of the clot.37 If surgical option was the choice, 614 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.71A and B: Surgical exploration of the mitral valve in the previous patient (A) Annuloplasty ring is shown totally dehisced from posterior circumference (arrows); (B) Edward-Physio ring is extracted and demonstrated in surgical orientation Saddle shape of this ring is very compatible with physiologic function of the mitral annulus Note: anterior (An) wing of the ring is higher than the other wings Lateral (L) and medial (M) wings have different height as well This patient underwent redo mechanical mitral valve replacement (P: Posterior wing) A B Figs 29.72A and B: Preoperative three-dimensional transesophageal echocardiography (3D TEE) in a 46-year-old male patient with a history of coronary artery bypass grafting (CABG) and mitral valve repair with annuloplasty ring months ago (A) 3D TEE short-axis view at the level of base of the heart shows dehisced annuloplasty ring (arrows); (B) Surgical zoomed view of the mitral valve with clear visualization of the dehiscence (AV: Aortic valve; LAA: Left atrial appendage; TV: Tricuspid valve) again 3D TEE is the best imaging modality for preoperative and postoperative assessment of the procedure (Figs 29.80 and 29.81 and Movie clips 29.80A and B) Aortic valve (AV) replacement with a pulmonary autograft (valve switch or Ross procedure) is a complex operation which provides excellent hemodynamic results in most patients This surgery is a good choice for children and young child-bearing females who not want to use anticoagulation Dilatation of the pulmonary autograft in aortic position is the most common late complication.38 Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 615 B Figs 29.73A and B: (A) Three-dimensional transesophageal echocardiography (3D TEE) with full-volume color acquisition of previous patient shows two large jets of mitral regurgitation (MR), paravalvular (para MR), and transvalvular (Val MR); (B) Surgical inspection confirmed preoperative TEE findings (arrow) Patient underwent mechanical mitral valve replacement A B Figs 29.74A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view of bioprosthetic mitral valve in a 72-year-old female who had mitral valve replacement 15 years ago (A) Bioprosthetic valve leaflets are severely degenerated with prolapse of two cusps (arrows); (B) Severe mitral regurgitation seen due to prolapsed leaflets (arrows) False aneurysm formation of the LV outflow tract and aortic autograft because of dehiscence of the sutures is another uncommon late complication of this procedure.39 Preoperative assessment by 3D TEE can delineate exact site of this suture dehiscence and guide the surgeon for re-repair of this complication (Figs 29.82 to 29.84 and Movie clips 29.82A to E) Prosthetic valve endocarditis (PVE) is the most severe and dangerous form of IE PVE happens in 1% to 6% of all replaced valves and occurs equally in mechanical and bioprosthetic valves Aortic PVE is more common in men, whereas prosthetic MV endocarditis is more common in female patients.40 TTE is the first line imaging modality for diagnosis but TEE is mandatory when PVE 616 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.75A and B: Surgical extraction of the bioprosthetic valve in the previous patient (A) Prosthetic valve from left atrial side shows degeneration and severe prolapse of two cusps (arrows); (B) Same valve from the left ventricular side A B Figs 29.76A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view of bioprosthetic mitral valve in a 69-year-old male who had mitral valve replacement 10 years ago Patient presented with severe mitral regurgitation (A) Preoperative 3D TEE shows degenerated bioprosthetic mitral valve with torn leaflet; (B) Surgical inspection of the valve confirmed the preoperative findings This patient underwent redo mechanical mitral valve replacement (LAA: Left atrial appendage) is suspicious Negative TEE does not rule out PVE Based on ESC guidelines, surgical intervention is urgent when signs of uncontrolled local infection, such as abscess, false aneurysm, fistula, and enlarging vegetations are present.41 3D TEE is the best imaging modality to detect all of these lethal complications and facilitates decision making for urgent surgical intervention (Figs 29.85 to 29.87 and Movie clips 29.85A to E) Thrombosis of mechanical AV is less common than mitral position but echocardiographic diagnosis is more challenging than prosthetic MV obstruction Direct visualization of two aortic discs and opening and closing of them by TTE and even TEE is not easy in every patient Fluoroscopy is superior to TEE in this complication Any sudden increase in transvalvular aortic gradient should increase the suspicion (Figs 29.88 to 29.92 and Movie clips Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 617 B Figs 29.77A and B: Three-dimensional transesophageal echocardiography (3D TEE) in a 35-year-old male patient who had mechanical mitral valve replacement (MVR) 23 years ago (A) 3D TEE angled view shows dehiscence of large area of sewing ring adjacent to the left atrial appendage (LAA) down to the posterior annulus (arrows); (B) En face view of the MVR demonstrates the large gap created at the dehisced segment (arrows) A B Figs 29.78A and B: (A) Same view of the previous patient with full-volume color shows severe paravalvular mitral regurgitation (MR) originating from the large gap at dehisced area; (B) Color-suppressed mode to confirm the origin of the MR (LAA: Left atrial appendage) 29.88A and B) Based on ESC guidelines, treatment options for thrombosis of aortic and mitral prosthesis are same; however, fibrinolytic therapy may be slightly superior to surgical treatment in aortic position.42–44 Cardiac CT without contrast is an excellent alternative imaging modality to assess function of double-disc mechanical AV and serial follow up during medical treatment.45 CARDIAC MASSES There are several normal structures inside the heart which may mimic cardiac masses during echocardiography study, such as Eustachian valve, lipomatous hypertrophy of the interatrial septum, Warfarin ridge, inverted left atrial appendage (LAA), spinal cord, and Lambl’s 618 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.79A and B: Surgical exploration of the mechanical mitral valve in the previous patient (A) Surgical view of the valve shows area of the sewing ring dehiscence exactly as demonstrated by three-dimensional transesophageal echocardiography (3D TEE) (between two arrows); (B) Excised valve from the left atrial side This patient underwent redo mechanical mitral valve replacement A B Figs 29.80A and B: Three-dimensional transesophageal echocardiography (3D TEE) of mechanical mitral valve in a 30-year-old female patient who presented to our center with acute pulmonary edema (A) 3D TEE surgical view of the prosthetic valve in diastole shows that the medial disc is stuck (stuck disc) Lateral disc (moving disc) opened well; (B) Same view with a slight angulation demonstrates that the medial disc is stuck at the semi-open position (arrow) (LAA: Left atrial appendage) excrescence Massive hiatus hernia may mimic a left atrial mass Abnormal intracardiac masses are thrombi and vegetations, and primary and secondary tumors Echocardiography plays a major role in initial diagnosis of cardiac masses; however, other imaging modalities, such as CT and cardiac MRI, may have a complementary role for final decision making Intraoperative TEE, especially 3D TEE, is again the only imaging tool available in the operating room to help the surgeon if resection of the mass is indicated Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 619 B Figs 29.81A and B: (A) Same surgical view of the previous patient with color flow in diastole shows large flow from the left atrium to the left ventricle through the lateral disc (LD) but only small flow is crossing the medial disc (small flow); (B) Fluoroscopy of the same patient confirms 3D TEE findings As demonstrated in this image, during diastole, the lateral disc is fully open but the medial disc is stuck at the semi-open position This patient was discharged with medical treatment Note: orientation of the image in fluoroscopy is different from 3D TEE surgical view A B Figs 29.82A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 25-year-old lady with a history of Ross operation years ago (A) Long-axis view shows dilated aortic autograft with large communication at the site of suturing to the previous native aortic annulus (black arrow) Huge false aneurysm (False aneu) pocket seen at the posterior aspect of the aortic root between the aorta and the roof of the left atrium; (B) False aneurysm pocket between the aortic root and the left atrium (red arrow) (AV: Aortic valve (autograft); LA: Left atrium; LVOT: Left ventricular outflow tract; RA: Right atrium) Left atrial appendage is a common site for clot formation if pressure inside the LA is high or the patient is in atrial fibrillation Visualization of the LAA clot by 2D TTE is not very sensitive 3D TTE with its ability to acquire entire LAA in 3D, increases this sensitivity and specificity.46,47 3D TEE is the modality of choice to detect the clot, site of its attachment and differentiation with normal pectina muscle (Fig 29.93 and Movie clip 29.93) It 620 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.83A and B: Three-dimensional transesophageal echocardiography (3D TEE) with full-volume color showing communication between false aneurysm and aortic autograft (A) Long-axis view of the aortic root in systole shows flow from LVOT going into false lumen through the two entrances (black arrows) False aneurysm is expanded in systole due to collection of blood inside the pocket; (B) During diastole, blood from the false aneurysm goes back into the left ventricle (black arrows) acting like an aortic regurgitation Autograft aortic valve (AV) has valvular regurgitation as well due to geometric changes (red arrow) Note: the false aneurysm pocket became smaller in diastole (AOV: Aortic valve; LA: Left atrium; LVOT: Left ventricular outflow tract) A B Figs 29.84A and B: Surgical inspection of the aortic root in the same patient (A) All three cusps of aortic autograft seen intact and clean There is a large whole (between red arrows) just beneath the NCC which communicates the left ventricular outflow tract to the false aneurysm posterior to the aortic root; (B) Communication site was patched by a bovine pericardial patch After closing the aortic root, a false aneurysm pocket was opened from the outside, the blood inside was drained, and the aneurysm was sutured (LCC: Left coronary cusp; NCC: Noncoronary cusp; RCC: Right coronary cusp) is now routinely used before percutaneous mitral balloon valvuloplasty and in the operating room before surgery for rheumatic MV 3D TEE can detect clot in IVC, right atrium, and pulmonary arteries; however, TEE is not the first line imaging modality for diagnosis of acute pulmonary embolism (Fig 29.94 and Movie clip 29.94) Preoperative TEE can detect unnoticed massive pulmonary embolism occurring in the operating room during preparation of the Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 621 B Figs 29.85A and B: Three-dimensional transesophageal echocardiography (3D TEE) in a 74-old-male patient with a history of bioprosthetic aortic valve replacement (AVR) years ago Patient presented with month history of fever (A) Bioprosthetic AVR seen in long-axis view with dehiscence from anterior circumference (red arrow); (B) 3D TEE in short-axis view shows honeycomb appearance all around the bioprosthetic AVR compatible with aortic root abscess (red arrows) (Asc Aorta: Ascending aorta; LA: Left atrium; NCC: Noncoronary cusp; RA: Right atrium; RCC: Right coronary cusp) A B Figs 29.86A and B: Three-dimensional transesophageal echocardiography (3D TEE) in the same previous patient (A) Transgastric view shows dehiscence of the bioprosthetic aortic valve (Bio AVR) from posterior aspect (red arrow); (B) 3D TEE with color demonstrates severe paravalvular and transvalvular aortic regurgitation (between arrows) (LA: Left atrium; LVOT: Left ventricular outflow tract) patient with legs rising.48 The chance of developing an LV clot after an acute myocardial infarction depends on the size and location of the infarction Large anterior transmural infarction with subsequent LV aneurysm is a risk factor for mural clot formation.49 2D TTE is the main imaging modality, but 3D TTE has additional benefits in terms of identifying the exact location, liquefaction of the clot, and its mobility which has prognostic implications.50 3D TEE can provide better image quality in the operating room especially if there is any suspicion for primary or secondary cardiac tumor (Fig 29.95 and Movie clips 29.95A to D) Primary cardiac tumors are rare compared to secondary (metastatic) involvement of the heart Most of the primary tumors are benign Myxoma, lipoma, and 622 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.87A and B: Surgical inspection of the aortic root in the previous patient (A) Bioprosthetic aortic valve seen degenerated with multiple vegetations and abscess cavities Almost two-thirds of the circumference of the sewing ring is dehisced from native aortic annulus (red curve) Valve is connected with small attachment to the annulus and preoperative TEE during systole showed flying jerky motion of the valve toward the ascending aorta; (B) Explanted valve demonstrates left ventricular side of the prosthetic valve with extensive pannus formation (SR: Sewing ring) A B Figs 29.88A and B: Two-dimensional transesophageal echocardiography (2D TEE) in a 37-year-old man who presented with shortness of breath This patient had mechanical aortic valve replacement (AVR) 13 years ago in our center and in all previous echo studies, the gradient across the AVR was less than 30 mm Hg (A) Long-axis view shows severe systolic turbulence across the AVR; (B) In transgastric view, peak gradient (PIG) across the AVR was measured at 57 mm Hg (LA: Left atrium; LV: Left ventricle) fibroelastoma are the three most common benign tumors in adults Myxoma accounts for 25% of all and is located in the LA in 75% of the cases Eighteen percent of myxoma is in right atrium, 4% in LV, and 4% in RV LA myxoma is usually attached to interatrial septum but it can originate from other parts of LA like the roof, the posterior wall, or MV A large LA myxoma may obstruct LV filling and present with clinical manifestations of mitral stenosis Smaller LA Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 623 B Figs 29.89A and B: Three-dimensional transesophageal echocardiography (3D TEE) of the previous patient (A) Live 3D TEE in shortaxis view shows only one disc is opening and closing (moving disc); other disc was not well seen; (B) 3D TEE zoom mode in short-axis view again showed only one disc moving Note: 3D TEE for assessing opening and closing of the mechanical aortic valve discs is not as good as in mechanical mitral valve due to low frame rate of 3D echocardiography Fluoroscopy and likely CT are the best modalities for aortic position as is shown in the next figures A B Figs 29.90A and B: Fluoroscopy of mechanical aortic valve in the previous patient (A) In this view only one disc is seen and was moving The other disc was not seen well; (B) Both discs are seen but are not very clear Moving disc (MD) and stuck disc (SD) are demonstrated myxoma may be discovered during echocardiography for other indications Surgical resection is the only choice for treatment The 3D TEE preoperative assessment can play a crucial role in terms of confirmation of the diagnosis, size, location, and site of attachment of the mass in relation with other structures, such as MV, aortic root, and pulmonary veins LA myxoma can have a broad base attachment The 3D TEE images are very important for the surgeon to apply best approach to access the tumor (left or right atriotomy).51–53 LA myxoma should be resected from the base with some 624 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.91A and B: Noncontrast CT in previous patient (A) In systole, one disc showed reasonable opening (moving disc, MD), but the other disc is stuck (SD); (B) In diastole, the moving disc is closed but the other disc is stuck (SD) in a semi-open position Courtesy: Dr Ahmed AL Saileek, KACC A B Figs 29.92A and B: Surgical inspection of the prosthetic valve in the previous patient (A) Mechanical prosthesis is shown with one clean moving disc and second stuck disc covered by clots; (B) Valve was explanted The mechanical valve is shown from left ventricular outflow tract (LVOT) side The stuck disc is covered with clots Note: No significant pannus formation was seen at the LVOT side of the valve after 13 years normal tissue (safety margin) to prevent recurrence (Figs 29.96 to 29.104 and Movie clips 29.96A and B, 29.98A and B, 29.100A to C, and 29.103A to C) Papillary fibroelastoma or papilloma is the third most common benign tumor of the heart in adults Its appearance is like sea anemones It is attached to the valve most of the time AV is the most common involved valve Fibroelastoma can be multiple on one valve or multiple valves Its size varies from mm to cm Fibroelastoma has tendency for embolization especially in aortic position Surgery is recommended in patients who had embolic events, if tumor is larger than cm, or if it is highly mobile.54–56 Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 625 B Figs 29.93A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 36-year-old man with severe mitral stenosis undergoing mitral valve replacement (A) Short-axis view at the base of the heart shows the four valves together A large clot is seen in the left atrial appendage (LAA) protruding into the left atrium (LA); (B) 3D TEE surgical view of the LAA demonstrates the same clot toward the left of the surgeon (AOV: Aortic valve; MV: Mitral valve; MPA: Main pulmonary artery; TV: Tricuspid valve) A B Figs 29.94A and B: Three-dimensional transesophageal echocardiography (3D TEE) in a 65-year-old male patient admitted in to the cardiology ward to have coronary artery bypass grafting (CABG) The patient developed sudden onset of shortness of breath and hypotension when walking to the bath room (A) TEE showed multiple clots in the right atrium, right ventricle, and pulmonary arteries; (B) The patient was taken to the operating room and all of these clots were removed from the right side chambers (RA: Right atrium; RV: Right ventricle) Preoperative 3D TEE assessment is the best tool to evaluate the size, location, and degree of invasion to the leaflet which are necessary information for the surgeon to preserve the valve (Figs 29.105 to 29.108 and Movie clips 29.105A and B and 29.108A and B) Metastatic involvement of the heart is relatively common compared to primary malignant tumor of the heart In one of the largest autopsy series of patients dying of cancer, 8% had metastasis of the heart.57 Metastasis to the heart can happen from direct invasion from the 626 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.95A and B: Three-dimensional transesophageal echocardiography (3D TEE) and surgical exploration in a 38-year-old male with a history of myocardial infarction months ago The patient has a history of right leg amputation due to peripheral embolic event (A) 3D TEE full volume shows a large mass attached to the left ventricular apex likely representing a clot (black arrows); (B) After weeks of treatment with heparin, a decision was made to take the patient to the operating room and the mass was resected Pathology examination confirmed diagnosis of organized clot (LA: Left atrium; LV: Left ventricle) A B Figs 29.96A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 68-year-old female who presented with palpitations (A) 3D TEE surgical view of the left atrium (LA) shows broad base mass (arrows) attached to the roof of the LA adjacent to the aortic root; (B) Long-axis view demonstrates location of the mass in relation with the aortic valve (AOV) (IAS: Interatrial septum; MV: Mitral valve; TV: Tricuspid valve) mediastinum to the pericardium and the heart, tumor growth from IVC or hematogenous invasion Most common metastatic tumors of left heart are melanoma, lung cancer, and breast cancer Metastasis to the right side of the heart are more common from soft tissue sarcomas, renal cell carcinoma and hypernephroma, esophageal cancer, hepatocellular carcinoma, thyroid cancer, and leiomyomatosis and leiomyosarcoma There is high prevalence of metastasis to the heart with leukemia and lymphoma Metastatic osteosarcomas of the heart are not Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 627 B Figs 29.97A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view of the mass in the previous patient compared to excised mass (A) Mass weight can be estimated by calibrated 3D grid Mass dimensions are about 2.2 × 2.0 × 1.5 cm, which gives mass weight of about to g; (B) Surgically excised mass is demonstrated with a weight of g Result of pathology was left atrial myxoma (AOV: Aortic valve; MV: Mitral valve; TV: Tricuspid valve) A B Figs 29.98A and B: Large left atrial myxoma in a 57-year-old man who presented with palpitations (A) Two-dimensional (2D) TEE fourchamber view shows large left atrial myxoma attached to the fossa ovalis; (B) Three-dimensional (3D) TEE full volume demonstrates large myxoma with wide pedicle attached to the fossa ovalis Weight of the mass can be estimated by 3D grid (LA: Left atrium; LV: Left ventricle; TEE: Transesophageal echocardiography) common but can happen in right and left heart Palliative surgery and debulking of the tumor combined with chemotherapy is recommended.58 Leiomyosarcoma is a rare tumor with poor survival It can metastasize the right and left heart In the LA mimics LA myxoma but usually pulmonary veins are involved.59 Follicular carcinoma of the thyroid metastasizing the heart is extremely rare Extended tumor thrombus may cause SVC syndrome Radical resection of the tumor and reconstruction of SVC is the treatment of choice60,61 (Figs 29.109 to 29.111 and Movie clips 29.109A and B, 29.110A and B, 29.111A) 628 Section 2: Echocardiography/Ultrasound Examination and Training B A Figs 29.99A and B: Three-dimensional transesophageal echocardiography (3D TEE) surgical view of the left atrial myxoma in the previous patient compared to excised mass (A) 3D TEE in long-axis view shows that mass drops into the mitral orifice during diastole; (B) Surgically excised mass is demonstrated with weight of about 100 g Result of pathology was left atrial myxoma (LA: Left atrium; LV: Left ventricle; AOV: Aortic valve) B A Figs 29.100A and B: Intraoperative transesophageal echocardiography (TEE) in a 39-year-old male presented to our center due to stroke (A) 2D TEE long-axis view shows large left atrial myxoma attached to the base of the aortic root; (B) 3D TEE in a triple-display format demonstrates broad base attachment of myxoma to the roof of the left atrium and aortic root Tumor does not interfere with the function of the mitral valve (AOV: Aortic valve; LA: Left atrium; LV: Left ventricle) LIMITATIONS OF 3D TEE, FUTURE DIRECTIONS Three-dimensional (3D) echocardiography and 3D TEE like any other new technique has its own limitations such as the following: It is a transitional technique; therefore, 2D TEE is still needed for confirmation of diagnosis It has a challenging learning curve It has lower spatial and temporal resolutions compared to 2D TEE Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 629 B Figs 29.101A and B: (A) Triple-display of three-dimensional transesophageal echocardiography (3D TEE) in the same patient to demonstrate exact location of the myxoma attachment This view shows that mass is away from the mitral valve (MV) but relation with interatrial septum (IAS) is not clear; (B) Surgical view of the myxoma demonstrates that most of the attachment of the myxoma is with left atrial roof and aortic root (black arrows) Only a small portion of the mass is attached to the IAS (red arrow) Definition of this attachment is important for the surgeon to choose right or left atriotomy for mass resection (CS: Coronary sinus; MV: Mitral valve) A B Figs 29.102A and B: (A) Excised myxoma from the posterior side shows broad attachment site to the roof of the left atrium and aortic root (black arrows) Only a small portion was attached to the interatrial septum (red arrows) as was defined by preoperative threedimensional transesophageal echocardiography (3D TEE) Myxoma was resected via right atriotomy; (B) Mass is shown from anterior side with gelatinous appearance Motion and stitch artifacts during full-volume acquisition with or without color are a substantial limitation (Fig 29.112 and Movie clips 29.112A and B) This problem can be overcome in the operating room by stopping the breathing machine for 10 to 20 seconds and acquiring the image There is no valid direct measurement on 3D images Existing 3D grid and calibration measures 2D distance on a 3D image without measuring the depth of the image Future direction of 3D echocardiography should be toward improving spatial resolution and single beat acquisition with a high frame rate 630 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.103A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 49-year-old man who presented to our hospital with stroke (A) A mass is seen attached to the left atrial (LA) side of the interatrial septum (IAS) A second highly mobile mass was seen (black arrow), which appeared in some view as another separate mass; (B) 3D triple-display format demonstrates that there is only one mass but has a long snake-shaped tail The base of the mass is attached to the posterior fossa ovalis close to the entrance of the inferior vena cava (IVC) (LA: Left atrium; RA: Right atrium) A B Figs 29.104A and B: Excellent correlation between preoperative three-dimensional transesophageal echocardiography (3D TEE) image of the previous patient and surgical specimen (A) Preoperative image shows attachment of the mass, bulky base, and 4- to 5-cm long snake-shaped tail; (B) At surgery from right atrial approach, all 3D findings were confirmed A small segment of interatrial septum (between black arrows) were resected with the mass and then directly sutured Mass was sent to pathology which confirmed diagnosis of left atrial myxoma SUMMARY AND CONCLUSION Three-dimensional echocardiography provides a new dimension in cardiovascular imaging In fact, it has been a revolution in the field of echocardiography to assess cardiac pathology and guide the appropriate intervention 3D TEE creates a common language between cardiologist, cardiac surgeon, and interventionist in the operating room and in the cath laboratory for decision making Like any other new technique, 3D echo has its own limitations and needs further technical improvement Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 631 B Figs 29.105A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in an 81-year-old man who presented to our hospital with acute pulmonary edema Preoperative echo showed normal systolic function Coronary angiography was normal (A) Long-axis view shows two mobile masses on the aortic side of the leaflets (arrows); one measured at 1.0 × 0.5 cm and the second at 0.5 × 0.5 cm; (B) In short-axis view, a larger mass is connected to the commissure between the left coronary cusp (LCC) and the right coronary cusp (RCC) (LA: Left atrium; LV: Left ventricle; NCC: Noncoronary cusp; RA: Right atrium; RV: Right ventricle) A B Figs 29.106A and B: Surgical findings in the previous patient (A) A larger mass is seen attached to the commissure between the left coronary cusp (LCC) and the right coronary cusp (RCC) by a long pedicle Mass was resected; (B) A second smaller mass was seen attached to the LCC and was resected Aortic valve needs some minor repair which was done Postoperative TEE showed no aortic regurgitation Frozen section pathology examination was done in the operating room and the result was fibroelastoma in both masses (NCC: Noncoronary cusp) Note: cause for presenting acute pulmonary edema in this patient was likely intermittent closure of the ostium of the left main coronary artery by the larger mass During year follow-up, this pulmonary edema has not occurred again 632 A Section 2: Echocardiography/Ultrasound Examination and Training B Figs 29.107A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 40-year-old man who presented to our center with stroke (A) Long-axis view shows a large mass measured at 1.5 × 1.8 cm attached to the left ventricular (LV) side of the anterior mitral valve leaflet (AMVL); (B) Mass seen from the LV side and appears to invade into the AMVL tissue (red arrows) No Doppler signs of mitral regurgitation or stenosis were found (LA: Left atrium; LVOT: Left ventricular outflow tract) A B Figs 29.108A and B: Surgical exploration of the previous patient (A) Surgical view from the left atrial side demonstrates mass invasion to the ventricular side of the anterior mitral valve leaflet (AMVL) tip Care was given to resect the mass with part of the AMVL tissue to have a safety margin to prevent recurrence; (B) This view shows at least two chorda (black arrows) are involved by the mass which had to be resected Mass was sent to the pathology laboratory inside the operating room for initial diagnosis Result was reported as fibroelastoma AMVL was reconstructed by a treated autologous pericardial patch and two chorda were replaced Postoperative transesophageal echocardiography (TEE) showed no mitral stenosis or regurgitation Chapter 29: Three-Dimensional Echocardiography in the Operating Room A 633 B Figs 29.109A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 22-year-old lady with osteosarcoma metastasis to the right atrium (RA) (A) 3D TEE bicaval view shows large mass filling the inferior vena cava (IVC) and invading into the RA Due to risk of obstruction to the tricuspid valve, this patient was taken to the operating room for debulking the tumor; (B) Surgical resection of the mass from IVC (black arrows) Pathology confirmed the metastasis (LA: Left atrium; SVC: Superior vena cava) A B Figs 29.110A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) in a 50-year-old female with years’ history of leiomyosarcoma (A) Preoperative TEE shows a huge mass occupying the entire left atrium (LA) Mass is likely attached to the posterior wall of the LA; (B) Mass was resected surgically Pedicle was attached to the junction of the right upper pulmonary vein to the LA Mass weighing 110 g Pathology examination confirmed the diagnosis of metastatic leiomyosarcoma to the LA (AOV: Aortic valve; RA: Right atrium) 634 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 29.111A and B: Intraoperative three-dimensional transesophageal echocardiography (3D TEE) assessment of a 53-year-old female patient with a history of follicular cancer of the thyroid (A) 3D TEE shows a large mass invading from superior vena cava (SVC) to the right atrium (RA) Mass demonstrates liquefaction at the middle likely due to necrosis; (B) Tumor was resected A B Figs 29.112A and B: Stitch artifact in three-dimensional (3D) full-volume acquisition when machine is stitching 7, 10, or 14 beats together to create a full-volume 3D data set This artifact is one of the most common limitations of 3D echocardiography It is more common in patients with arrhythmia or due to cardiac motion and translation Asking the patient to hold breath for 10 to 20 seconds or stopping the anesthesia machine in the operating room may decrease the chance of this artifact (A) Stitch artifact after Amplatzer device implantation for atrial septal defect (black arrows); (B) Stitch artifact in a patient after mechanical mitral valve replacement (black arrows) ACKNOWLEDGMENTS I would like to thank Dr Hani Najm, Head of Cardiac Surgery at our center, for the majority of the surgical cases in this chapter and his great effort in providing quality surgical movies I would also like to thank our other talented surgeons, Dr Al-Khaldi, Dr Arifi and Dr Al-Ghamdi for their contributions I would like to offer special thanks to the operating room nursing team who made the extra effort to expertly record movies of these surgical cases The support of the chairman of the cardiac center, Dr Muayed Al-Zaibag, my colleagues and cardiac sonographers while preparing this chapter is greatly appreciated I am grateful for the patience and encouragement of my wife Rokhsareh and my children, Sina and Setareh which made this work possible Chapter 29: Three-Dimensional Echocardiography in the Operating Room REFERENCES Carpentier A Cardiac valve surgery—the “French correction.” J Thorac Cardiovasc Surg 1983;86(3):323–37 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(6):2063–8; discussion 2068 Omran AS, Woo A, David TE, et al Intraoperative transesophageal echocardiography accurately predicts mitral valve anatomy and suitability for repair J Am Soc Echocardiogr 2002;15(9):950–7 Omran AS Role of transesophageal echocardiography in mitral valve repair In: Hutchison SJ, editor Principles of Echocardiography and Intracardiac Echocardiography 1st ed Philadelphia: Elsevier-Saunders; 2012:337–69 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;25(1): 3–46 Biaggi P, Gruner C, Jedrzkiewicz S, et al Assessment of mitral valve prolapse by 3D TEE angled views are key JACC Cardiovasc Imaging 2011;4(1):94–7 David TE, Omran A, Armstrong S, Sun Z, Ivanov J Longterm results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures J Thorac Cardiovasc Surg 1998;115(6):1279–85; discussion 1285 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(10):750–5 Schlosshan D, Aggarwal G, Mathur G, Allan R, Cranney G Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis JACC Cardiovasc Imaging 2011;4(6):580–8 10 Scandura S, Cammalleri V, Caggegi A, et al Threedimensional echocardiographic and surgical findings in mitral mechanical valve dysfunction J Cardiovasc Med (Hagerstown) 2013;14(4):317–18 11 Greenhouse DG, Dellis SL, Schwartz CF, et al Regional changes in coaptation geometry after reduction annuloplasty for functional mitral regurgitation Ann Thorac Surg 2012;93(6):1876–80 12 Haj-Ali R, Marom G, Ben Zekry S, et al A general threedimensional parametric geometry of the native aortic valve and root for biomechanical modeling J Biomech 2012; 45(14):2392–7 13 Sohmer B, Hudson C, Atherstone J, et al Measuring aortic valve coaptation surface area using three-dimensional transesophageal echocardiography Can J Anaesth 2013; 60(1):24–31 635 14 Furukawa A, Abe Y, Tanaka C, et al Comparison of twodimensional and real-time three-dimensional transesophageal echocardiography in the assessment of aortic valve area J Cardiol 2012;59(3):337–43 15 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 normals and clinical implications Circ Cardiovasc Imaging 2013; 6(1):99–108 16 Mascherbauer J, Maurer G The forgotten valve: lessons to be learned in tricuspid regurgitation Eur Heart J 2010; 31(23):2841–3 17 Anwar AM, Soliman OI, Nemes A, et al Value of assessment of tricuspid annulus: real-time three-dimensional echocardiography and magnetic resonance imaging Int J Cardiovasc Imaging 2007;23(6):701–5 18 Vahanian A, Alfieri O, Andreotti F, et al.; ESC Committee for Practice Guidelines (CPG); Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS) Guidelines on the management of valvular heart disease (version 2012): 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;42(4):S1–44 19 Badano LP, Muraru D, Enriquez-Sarano M Assessment of functional tricuspid regurgitation Eur Heart J 2013;34(25): 1875–85 20 Kirkpatrick JN, Lang RM Surgical echocardiography of heart valves: a primer for the cardiovascular surgeon Semin Thorac Cardiovasc Surg 2010;22(3):200.e1–200.22 21 Aykut K, Kaya M, Acikel U Rupture of the tricuspid valve due to smashing the chest into the steering wheel Ann Thorac Cardiovasc Surg 2013;19(3):222–4 22 Castonguay MC, Burner KD, Edwards WD, Baddour LM, Maleszewski JJ Surgical pathology of native valve endocarditis in 310 specimens from 287 patients (19852004) Cardiovasc Pathol 2013;22(1):19–27 23 Sedgwick JF, Burstow DJ Update on echocardiography in the management of infective endocarditis Curr Infect Dis Rep 2012;14(4):373–80 24 Raju IT, Solanki R, Patnaik AN, Barik RC, Kumari NR, Gulati AS Brucella endocarditis - A series of five case reports Indian Heart J 2013;65(1):72–7 25 Sadat K, Joshi D, Sudhakar S, et al Incremental role of three-dimensional transesophageal echocardiography in the assessment of mitral-aortic intervalvular fibrosa abscess Echocardiography 2012;29(6):742–4 26 Okada K, Okita Y Surgical treatment for aortic periannular abscess/pseudoaneurysm caused by infective endocarditis Gen Thorac Cardiovasc Surg 2013;61(4):175–81 636 Section 2: Echocardiography/Ultrasound Examination and Training 27 Siu SC, Silversides CK Bicuspid aortic valve disease J Am Coll Cardiol 2010;55(25):2789–800 28 Ruparelia N, Lawrence D, Elkington A Bicuspid aortic valve endocarditis complicated by mitral valve aneurysm J Card Surg 2011;26(3):284–6 29 Hara T, Soeki T, Niki T, et al Bicuspid aortic valve endocarditis complicated by perivalvular abscess J Med Invest 2012;59(3-4):261–5 30 Iung B, Baron G, Butchart EG, et al A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease Eur Heart J 2003;24(13):1231–43 31 Kronzon I, Sugeng L, Perk G, et al Real-time 3-dimensional transesophageal echocardiography in the evaluation of post-operative mitral annuloplasty ring and prosthetic valve dehiscence J Am Coll Cardiol 2009;53(17):1543–7 32 Aggarwal G, Schlosshan D, Mathur G, et al Recurrent ischaemic mitral regurgitation post mitral annuloplasty due to suture dehiscence evaluated using real time three dimensional transoesophageal echocardiography Heart Lung Circ 2012;21(12):844–6 33 Meyer SR, Suri RM, Wright RS, et al Does metabolic syndrome influence bioprosthetic mitral valve degeneration and reoperation rate? J Card Surg 2012;27(2):146–51 34 Zamorano JL, Badano LP, Bruce C, et al EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease J Am Soc Echocardiogr 2011;24(9):937–65 35 Nikolic A, Schranz D, Hristov N, et al Amplatzer occlusion of paravalvular leak of mitral mechanical prosthesis following a reoperation for thrombosed mitral mechanical prosthesis Interact Cardiovasc Thorac Surg 2008;7(5): 941–2 36 Yildiz M, Duran NE, Gökdeniz T, et al The value of realtime three-dimensional transesophageal echocardiography in the assessment of paravalvular leak origin following prosthetic mitral valve replacement Turk Kardiyol Dern Ars 2009;37(6):371–7 37 Armellini I, Rubimbura V, Morocutti G, et al Thrombotic obstruction of mechanical prosthetic valve in mitral position the old “x-ray” fights the new 3-dimensional transesophageal echocardiography J Am Coll Cardiol 2012;59(6):e11 38 David TE, Omran A, Ivanov J, et al Dilation of the pulmonary autograft after the Ross procedure J Thorac Cardiovasc Surg 2000;119(2):210–20 39 Shahid MS, Al-Halees Z, Khan SM, Pieters FA Aneurysms complicating pulmonary autograft procedure for aortic valve replacement Ann Thorac Surg 1999;68(5):1842–3 40 Lee JH, Burner KD, Fealey ME, et al Prosthetic valve endocarditis: clinicopathological correlates in 122 surgical specimens from 116 patients (1985-2004) Cardiovasc Pathol 2011;20(1):26–35 41 Habib G, Hoen B, Tornos P, et al.; ESC Committee for Practice Guidelines Guidelines on the prevention, diagnosis, and 42 43 44 45 46 47 48 49 50 51 52 53 54 treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC) Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer Eur Heart J 2009;30(19):2369–413 Cáceres-Lóriga FM, Pérez-López H, Morlans-Hernández K, et al Thrombolysis as first choice therapy in prosthetic heart valve thrombosis A study of 68 patients J Thromb Thrombolysis 2006;21(2):185–90 Yay K, Boysan E, Irdem A, et al Treatment of mechanical aortic valve thrombosis: fibrinolytic treatment versus surgical intervention: result of eight cases Innovations (Phila) 2010;5(6):439–43 Shapira Y, Vaturi M, Sagie A Obstructive left-sided prosthetic valve thrombosis Acute Card Care 2009;11(3):160–8 Chan J, Marwan M, Schepis T, et al Images in cardiovascular medicine Cardiac CT assessment of prosthetic aortic valve dysfunction secondary to acute thrombosis and response to thrombolysis Circulation 2009;120(19):1933–4 Kumar V, Nanda NC Is it time to move on from twodimensional transesophageal to three-dimensional transthoracic echocardiography for assessment of left atrial appendage? Review of existing literature Echocardiography 2012;29(1):112–16 Manjunath CN, Srinivasa KH, Panneerselvam A, et al Incidence and predictors of left atrial thrombus in patients with rheumatic mitral stenosis and sinus rhythm: a transesophageal echocardiographic study Echocardiography 2011;28(4):457–60 Jha NK, Rezk AI, Omran AS, et al Acute pulmonary thromboembolism during mitral valve repair Heart Lung Circ 2008;17(2):159–61 Visser CA, Kan G, Meltzer RS, et al Embolic potential of left ventricular thrombus after myocardial infarction: a two-dimensional echocardiographic study of 119 patients J Am Coll Cardiol 1985;5(6):1276–80 Duncan K, Nanda NC, Foster WA, et al Incremental value of live/real time three-dimensional transthoracic echocardiography in the assessment of left ventricular thrombi Echocardiography 2006;23(1):68–72 Pearce AW, Rana BS, O’Donovan DG Lesson of the month (2) Stroke in a 53-year-old woman: getting to the heart of the problem Diagnosis LA myxoma Clin Med 2013;13(1):106–9 Aroca A, Mesa JM, Dominguez F, et al Multiple recurrence of a “sporadic” (non-familial) cardiac myxoma Eur J Cardiothorac Surg 1996; 10(10):919–21 Garatti A, Nano G, Canziani A, et al Surgical excision of cardiac myxomas: twenty years experience at a single institution Ann Thorac Surg 2012;93(3):825–31 Evans AJ, Butany J, Omran AS, et al Incidental detection of an aortic valve papillary fibroelastoma by echocardiography in an asymptomatic patient presenting with hypertension Can J Cardiol 1997;13(10):905–8 Chapter 29: Three-Dimensional Echocardiography in the Operating Room 55 Buppajarntham S, Satitthummanid S, Chantranuwatana P, et al Aortic valve papillary fibroelastoma associated with severe aortic regurgitation: a comprehensive assessment with 2- and 3-dimensional transesophageal echocardiography J Am Coll Cardiol 2012;60(23):e41 56 Val-Bernal JF, Mayorga M, Garijo MF, et al Cardiac papillary fibroelastoma: Retrospective clinicopathologic study of 17 tumors with resection at a single institution and literature review Pathol Res Pract 2013; Feb 27 [Epub ahead of print] 57 Silvestri F, Bussani R, Pavletic N, et al Metastases of the heart and pericardium G Ital Cardiol 1997;27(12): 1252–5 637 58 Iyigun T, Ciloglu U, Ariturk C, et al Recurrent cardiac metastasis of primary femoral osteosarcoma: a case report Heart Surg Forum 2010;13(5):E333–5 59 Deniz H, Koruk S, Kirbas A, et al Leiomyosarcoma protruding into the left ventricle during diastole: report of a case Heart Surg Forum 2011;14(2):E133–4 60 Catford SR, Lee KT, Pace MD, et al Cardiac metastasis from thyroid carcinoma Thyroid 2011;21(8):855–66 61 Wada N, Masudo K, Hirakawa S, et al Superior vena cava (SVC) reconstruction using autologous tissue in two cases of differentiated thyroid carcinoma presenting with SVC syndrome World J Surg Oncol 2009;7:75 CHAPTER 30 Epiaortic Ultrasonography Dheeraj Arora, Yatin Mehta Snapshot ¾¾ Background for Epiaortic Ultrasonography Examination ¾¾ Indications ¾¾ Epiaortic Probe and Preparation INTRODUCTION Intraoperative echocardiography, particularly transeso phageal echocardiography (TEE) has become an important diagnostic and monitoring tool in cardiac surgery However, the diagnosis and extent of pathology in the distal ascending aorta and aortic arch are not accurately assessed by TEE due to interposition of the right main stem bronchus with air between probe and ascending aorta.1 The most common finding in these areas is the atherosclerotic plaque which is often missed by TEE or underestimated by surgical palpation Atherosclerosis of the ascending aorta and arch is an important determinant of neurological events after cardiac surgery particularly in elderly population.2 Therefore, epiaortic ultrasonography (EAU) since a decade has gained importance in detecting aortic pathology intraoperatively Recently, the Society of Cardiovascular Anesthesiologists (SCA), the American Society of Anesthesiologists (ASA), and the American Society of Echocardiography (ASE) have published guidelines specifically focused on acquisition techniques and indications for EAU.3 BACKGROUND FOR EPIAORTIC ULTRASONOGRAPHY EXAMINATION The incidence of perioperative neurological morbidity, especially stroke, varies from 1.9% to 8.8% after a variety ¾¾ Imaging Views/Planes ¾¾ Role of Epiaortic Ultrasonography in Aortic Pathology ¾¾ Advantages of Three-Dimensions over Two-Dimensions in Epiaortic Ultrasonography of cardiac surgical procedures.4,5 Advanced age, female sex, history of cerebrovascular disease and/or peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent surgery, cardio pulmonary bypass (CPB) duration > hours, massive transfusion of blood or blood products, and proximal aortic atherosclerosis or a calcified aorta are major risk factors for perioperative stroke.6,7 Identification of aortic atheromatous plaque has been found to be superior with EAU examination than with TEE8 and surgical techniques have also been modified by the use of EAU.9 INDICATIONS3 • Increased risk for perioperative embolic stroke includ ing those patients with a history of cerebrovascular or peripheral vascular disease • Evidence of aortic atherosclerosis or calcification by other imaging modalities like TEE, magnetic resonance imaging, CT scan, or chest radiograph EPIAORTIC PROBE AND PREPARATION Epiaortic ultrasonography requires placement of the ultrasonic probe on the surface of aorta under strict aseptic precautions Due to the proximity of the probe to the aorta, these techniques typically use higher frequency probes (5–12 MHz; Fig 30.1) The images may only be Chapter 30: Epiaortic Ultrasonography 639 Fig 30.1: Ultrasonic probes for epiaortic scanning Fig 30.2: Placement of ultrasonic probe on the ascending aorta obtained by a surgeon or echocardiographer under aseptic precautions wearing a sterile gown and gloves The probe is placed in a sterile sheath along with sterile ultrasound transmission gel or saline in order to optimize acoustic transmission Warm sterile saline should also be poured into the mediastinal cavity to further enhance acoustic transmission from the probe to the aortic surface (Figs 30.2 and 30.3) Depth, transmit focus, gain, and transducer frequency may further be adjusted Three types of transducers are used for EAU examination providing different quality of aortic images: • Linear sequential array transducer: It creates a rectan gular image and the entire aorta is not included in a single image • Phased array transducer: The probe (>7 MHz) is placed approximately cm above the aorta for an optimal fan or sector shape image The entire aorta can usu ally be seen in a single long-axis (LAX) imaging plane • Matrix-array transducer: It gives real time, threedimensional (3D) images in the form of a pyramidal volume It enables two-dimensional (2D) images in two planes, thus avoiding physically turning the probe to obtain LAX and short-axis (SAX) image Moreover, it provides better resolution of the ascending aorta of the ascending aorta from the sinotubular junction to the origin of the innominate artery, and the aortic arch.3 The SAX and LAX views (Figs 30.4 and 30.5) should examine the ascending aorta in proximal, mid, and distal segments LAX view should also include visualization of the proximal arch and origin of the three arch vessels The ASE/SCA guidelines also recommend that the ascending aorta be divided into 12 areas including the anterior, posterior, left, and right lateral walls within the proximal, mid, and distal ascending aorta segments (Figs 30.4 and 30.5) • Proximal segment: It is defined as the region from the sinotubular junction to the proximal intersection of the right pulmonary artery (RPA) • Mid segment: It is the portion of the aorta that is adjacent to the RPA • Distal segment: It extends from the distal intersection of the RPA to the origin of the innominate artery SAX—The ultrasound probe is positioned on the ascending aorta proximal to the aortic valve (AV), with the orientation marker directed toward the patient’s left shoulder to obtain an imaging window that is perpen dicular to the LAX of the aorta After identifying the proximal ascending aorta and AV, slowly advancing the probe distally in a cephalad direction along the aorta allows visualization of the mid ascending aorta, and the distal ascending aorta toward the aortic arch at the origin of the innominate artery Further advancement will lead to visualization of proximal aortic arch.3 IMAGING VIEWS/PLANES ASE/SCA-recommended epiaortic ultrasound exami nation includes a minimum of five views for the evaluation 640 Section 2: Echocardiography/Ultrasound Examination and Training Fig 30.3: Placement of probe in a sterile sheath Fig 30.5: Long-axis view of ascending aorta showing proximal, mid, and distal segments (RPA: Right pulmonary artery) LAX—This view can be achieved by rotating the probe 90° from the SAX orientation Sinus of Valsalva, sinotubular junction, and AV can be visualized proximally and the probe can be advanced cephalad keeping the aorta in LAX Imaging of the aorta should further extend toward the aortic arch with visualization of the innominate, left common carotid, and left subclavian artery origins ROLE OF EPIAORTIC ULTRASONOGRAPHY IN AORTIC PATHOLOGY Aortic Atherosclerosis A primary advantage of EAU examination is grading and quantification of aortic atherosclerosis It is an important Fig 30.4: Short-axis view of ascending aorta showing right lateral (RL), left lateral (LL), anterior (A), and posterior (P) walls (RPA: Right pulmonary artery; SVC: Superior vena cava) tool to quantify the degree of plaque formation within the aorta.10 Moreover, the degree of atherosclerosis has been shown to predict the incidence of postoperative renal dysfunction, long-term neurological outcome, and mortality.11 Intraoperative aortic manipulation like cannulation or cross clamping can also be guided by ultrasonography to the plaque-free sites.12 In a survey, EAU of the ascending aorta increased from 45.3% in 2002 to 89.4% in 2009 and aortic cross clamp use decreased from 97.7% of cases to 72.7%.13 Grading of atherosclerosis is done by various authors depending upon the size and site of atheroma or presence of any mobile component Some institutions follow their own protocols for the grading of atheroma Katz et al.14 introduced the grading system based on TEE on a fivepoint scale with outcome as stroke • Grade I: Normal to mild intimal thickening • Grade II: Severe intimal thickening without protruding atheroma • Grade III: Atheroma protruding ≤ mm into lumen • Grade IV: Atheroma protruding ≥ mm into lumen • Grade V: Any thickness with a mobile component or components Nohara et al.15 also studied the plaque density of aortic atheroma in coronary artery bypass grafting and the incidence of stroke They suggested that a computer analysis of aortic atheromatous plaque was useful in patients who had a high risk of postoperative stroke or embolism and helped in decreasing its incidence • Grade I: Normal or thickening of the intima extending < mm into the aortic lumen Chapter 30: Epiaortic Ultrasonography 641 important for DeBekay type II dissection, which is usually missed in the region of distal ascending aorta and aortic arch.17 Role of Three-Dimensional Epiaortic Ultrasonography Fig 30.6: Short-axis view of aorta showing plaque height • Grade II: Smooth-surfaced plaques and thickening of the intima extending >3 mm into the aortic lumen • Grade III: Marked irregularity of the intimal surface and thickening of the intima extending >3 mm into the aortic lumen • Grade IV: Plaque with a mobile element In summary, whatever grading system is used, chances of neurological injury increase with a plaque height/ thickness > mm, presence of mobile components, or an ascending aortic location of plaque.16 Comprehensive EAU examination should include an evaluation of each of the following measurements for each of the SAX segments of ascending aorta and arch.3 • Maximal plaque height/thickness (Fig 30.6) • Location of the maximal plaque within the ascending aorta • Presence of mobile components The extent of atheroma burden should be assessed as: • Plaque area: Circumferential area of maximal plaque obtained by planimetry • Plaque area to aortic area ratio: Aortic diameter should also be noted to quantify atheroma burden as a ratio of plaque area to aortic area • Multiple plaques: Measurements should be repeated as necessary Aortic Dissection Epiaortic ultrasonography scanning is a valuable tool for detection of aortic dissection as well as the detection of diastolic collapse of the true lumen It is particularly 3D allows two basic imaging modes—a live 3D mode and a full volume mode Full volume mode: It acquires a larger image by gating the ultrasound acquisition to the heart beat, using eight cardiac cycles; the probe itself must remain motionless during the acquisition phase Live 3D mode: The images are displayed live, allowing the probe to be manipulated, but limiting the size of the interrogated area Live 3D is useful in identifying and localizing the position of plaque within the aorta and directs aortic cross clamping and cannulation Following this, the full volume mode can be used to evaluate the proposed sites completely and ensure no plaque was missed during the live scanning process ADVANTAGES OF THREE-DIMENSIONS OVER TWO-DIMENSIONS IN EPIAORTIC ULTRASONOGRAPHY18 • 3D imaging demonstrates the full extent of the plaque • Relative distribution of plaque within the aorta and diffusely dispersed plaques are assessed • The inclusion of discernible landmarks within the aorta (sinotubular junction, AV) makes it easier to evaluate the relative position of the plaques CONCLUSION Epiaortic scanning is an important intraoperative diag nostic tool that acts as an adjuvant to TEE to detect the atheroma burden Its use is associated with a change in treatment strategies by 4.1% that includes a change in the technique for inducing cardiac arrest during CPB in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting in 0.6%, avoidance of aortic cross clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, and avoidance of aortic cannulation in 0.2%.19 It can be performed rapidly and may reduce neurological complications associated with aortic manipulation 642 Section 2: Echocardiography/Ultrasound Examination and Training REFERENCES Konstadt SN, Reich DL, Quintana C, Levy M The ascending aorta: how much does transesophageal echocardiography see? Anesth Analg 1994;78(2):240–4 Dávila-Román VG, Murphy SF, Nickerson NJ, Kouchoukos NT, Schechtman KB, Barzilai B Atherosclerosis of the ascending aorta is an independent predictor of longterm neurologic events and mortality J Am Coll Cardiol 1999;33(5):1308–16 Glas KE, Swaminathan M, Reeves ST, et al Council for Intraoperative Echocardiography of the American Society of Echocardiography; Society of Cardiovascular Anesthesiologists Guidelines for the performance of a comprehensive intraoperative epiaortic ultrasono graphic examination: recommendations of the American Society of Echocardiography and the Society of Cardio vascular Anesthesiologists; endorsed by the Society of Thoracic Surgeons J Am Soc Echocardiogr 2007;20(11): 1227–35 Bucerius J, Gummert JF, Borger MA, et al Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients Ann Thorac Surg 2003;75(2):472–8 Cleveland JC Jr, Shroyer AL, Chen AY, Peterson E, Grover FL Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity Ann Thorac Surg 2001;72(4):1282–8; discussion 1288 Roach GW, Kanchuger M, Mangano CM, et al Adverse cere bral outcomes after coronary bypass surgery Multicenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators N Engl J Med 1996;335(25):1857–63 John R, Choudhri AF, Weinberg AD, et al Multicenter review of preoperative risk factors for stroke after coronary artery bypass grafting Ann Thorac Surg 2000;69(1):30–5; discussion 35 Marshall WG Jr, Barzilai B, Kouchoukos NT, Saffitz J Intraoperative ultrasonic imaging of the ascending aorta Ann Thorac Surg 1989;48(3):339–44 Hangler HB, Nagele G, Danzmayr M, et al Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting J Thorac Cardiovasc Surg 2003;126(2):391–400 10 Ribakove GH, Katz ES, Galloway AC, et al Surgical impli cations of transesophageal echocardiography to grade the atheromatous aortic arch Ann Thorac Surg 1992;53(5): 758–63 11 Royse AG, Royse CF, Ajani AE, et al Reduced neuropsycho logical dysfunction using epiaortic echocardiography and the exclusive Y graft Ann Thorac Surg 2000;69(5):1431–8 12 Trehan N, Mishra M, Dhole S, Mishra A, Karlekar A, Kohli VM Significantly reduced incidence of stroke during coro nary artery bypass grafting using transesophageal echocar diography Eur J Cardiothorac Surg 1997;11(2):234–42 13 Daniel WT 3rd, Kilgo P, Puskas JD, et al Trends in aortic clamp use during coronary artery bypass surgery: Effect of aortic clamping strategies on neurologic outcomes J Thorac Cardiovasc Surg 2013 Mar 8;pii:S0022-5223(13) 00171-2 doi:10.1016/j.jtcvs.2013.02.021 [Epub ahead of print] 14 Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography J Am Coll Cardiol 1992;20(1):70–7 15 Nohara H, Shida T, Mukohara N, Obo H, Higami T Ultrasonic plaque density of aortic atheroma and stroke in patients undergoing on-pump coronary bypass surgery Ann Thorac Cardiovasc Surg 2004;10(4):235–40 16 van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta J Am Coll Cardiol 2001;38(1):131–5 17 Demertzis S, Casso G, Torre T, Siclari F Direct epiaortic ultrasound scanning for the rapid confirmation of intraoperative aortic dissection Interact Cardiovasc Thorac Surg 2008;7(4):725–6 18 Bainbridge DT, Murkin JM, Menkis A, Kiaii B The use of 3D epiaortic scanning to enhance evaluation of atherosclerotic plaque in the ascending aorta: a case series Heart Surg Forum 2004;7(6):E636–E638 19 Rosenberger P, Shernan SK, Löffler M, et al The influence of epiaortic ultrasonography on intraoperative surgical management in 6051 cardiac surgical patients Ann Thorac Surg 2008;85(2):548–53 CHAPTER 31 Intracardiac Echocardiography Krishnaswamy Chandrasekaran, Donald Hagler, James Seward Snapshot Equipment and the Catheters Imaging SpecificaƟons Intracardiac Echocardiography: Clinical ApplicaƟons INTRODUCTION Intracardiac echocardiography (ICE) is an extension of ultrasound imaging in cardiology Advances in the transducer, computer, and catheter technologies have permitted miniaturizing ultrasound crystal, embedding the electronics into a small catheter, which permits high-resolution echo-Doppler ultrasound images and physiological features of the intra- and extra-cardiothoracic structures In order to gainfully use ICE, an in-depth knowledge of cardiothoracic anatomy and physiology is essential ICE is invasive, which mandates a novel support environment The cardiovascular community has also successively transitioned ICE technologies to other subspecialties (e.g electrophysiologists, surgical subspecialties, interventional cardiologists, pediatric cardiologists, and others) who have recognized the invaluable assistance provided by in-body ultrasound morphology and physiology A second invasive ultrasound technology is intravascular ultrasonography (IVUS), which typically uses higher frequency transducers to image intravascular and adjacent anatomy IVUS is most commonly used to Intracardiac Echocardiography During Electrophysiology (EP) IntervenƟon Intracardiac Echocardiography During Structural IntervenƟon visualize structural details of the coronary artery as well as peripheral vessels This technology usually does not have the diverse Doppler imaging attributes of ICE EQUIPMENT AND THE CATHETERS There are two basic imaging systems for ICE and IVUS Mechanical system with rotating ultrasound transducer(s) or an array of piezoelectric elements at the tip of the catheter are used clinically Mechanical System A typical device uses mechanical ultrasound transducertipped catheter along with the imaging console, (e.g Cardiovascular Imaging Systems Inc, Fremont, CA, USA; Boston Scientific Corp, San Jose, CA, USA) This catheter can be used for both intravascular and intracardiac imaging A 9-MHz single element transducer incorporated in an 8F catheter is used for ICE In this system, the piezoelectric crystal rotates at 1,800 rpm in the radial dimension perpendicular to the catheter shaft This provides crosssectional 360° tomographic images perpendicular to the catheter The depth of view is about cm 644 Section 2: Echocardiography/Ultrasound Examination and Training Table 31.1: AcuNav Ultrasound Catheter Specifications Size (F) Length (cm) 10 90 110 Phased Array Ultrasound System A typical device uses 64 miniaturized ultrasound crystals in a longitudinal array at the tip of the catheter (e.g Sequoia ultrasound system [Acuson Corporation], which is currently part of Siemens Medical Solutions, USA; AcuNav Diagnostic Ultrasound Catheter (Fig 31.1A), Acuson Corporation, Mountain View, CA, USA) Types of catheters and imaging platforms are shown in Table 31.1 IMAGING SPECIFICATIONS ICE catheter provides high resolution images similar to transesophageal long-axis two-dimensional images Vector wide-view imaging format for wider anatomical information Sequoia system two-dimensional (2D) imaging frequencies: 10.0 MHz, 8.5 MHz, 7.5 MHz, and 5.5 MHz Cypress system image frequencies: 7.0 MHz and 6.0 MHz CV70 system 2D imaging frequencies: 9.0 MHz, 7.0 MHz, and 5.0 MHz Aspen system 2D imaging frequencies: 8.5 MHz, 7.0 MHz, and 5.0 MHz The imaging sector is 90° and parallel to the long axis of the catheter and the penetration depth is approximately 15 cm The frequency of the phased array transducer can be changed from 5.5 to 10 MHz Hence, high resolution imaging of both near-field and far-field structures can be done by using the frequency according to the depth of the structure that is being imaged Furthermore, the catheter can be steered in anterior–posterior and left–right, each in a direction of 160° by using a mechanism on the handle of the catheter (Figs 31.1A to C) The transducer-catheter can be advanced up and down, rotated laterally along its long axis providing innumerable 2D sector images Although this can be obtained within in any cardiac chamber, generally imaging is performed from the right atrium (RA), right ventricle (RV), and at times from within the coronary sinus This system also provides Doppler color flow imaging and hemodynamics Advantages and Limitations of the Mechanical Versus Phased Array Ultrasound Catheters for Intracardiac Echocardiography Mechanical ultrasound catheter imaging system is less expensive than phased array catheter imaging system The tomographic cross-sectional images are not as easy to comprehend for the cardiologist who is more accustomed to tomographic anatomy The lack of multifrequency capability limits the depth of imaging Furthermore, lack of color flow imaging and Doppler limits clinical utility INTRACARDIAC ECHOCARDIOGRAPHY: CLINICAL APPLICATIONS ICE technology is commonly used by the pediatric, interventional cardiologist and electrophysiologists The ICE is used to assess the morphology of a lesion, suitability of the lesion for intervention and guidance during intervention, and to assess the efficacy of the intervention Hence, the imaging views are tailored for the specific intervention However, basic cardiovascular views are nicely described by Earing et al.1 INTRACARDIAC ECHOCARDIOGRAPHY DURING ELECTROPHYSIOLOGY (EP) INTERVENTION Atrial Septal Puncture ICE provides high frequency excellent realtime imaging of the atrial septum The major focus is on the morphology of the fossa ovalis and the surrounding limbus (Figs 31.2A to D) Imaging View The catheter is advanced into the RA with the tip of the catheter straight and the face of the transducer facing the left side This can be recognized by gently rotating the catheter clockwise along its long axis if the catheter was facing anteriorly looking at right atrial appendage or by counterclockwise rotation if it was facing the posterior wall of the RA One can obtain a family of images demonstrating the relationship of the inferior vena cava (IVC), superior vena cava (SVC), fossa ovalis, coronary sinus, crista terminalis, right atrial appendage, and Eustachian ridge/ valve One may need to flex or extend the tip of the catheter to refine the image; usually this is not needed unless the Chapter 31: Intracardiac Echocardiography 645 A B C Figs 31.1A to C: (A) Diagnostic ultrasound catheter (AcuNav) placed adjacent to a pediatric transesophageal echocardiography probe shows the relatively small size of the 10F catheter (B) Close-up of the 3.3 mm diameter catheter tip (arrows) shows the longitudinally oriented crystal array (palette) (C) Overhead view of the four-way tip maneuverability of the diagnostic catheter Source: With permission from Mayo Proceedings RA is enlarged Typically, the image needed for atrial septal puncture is similar to bicaval view obtained by transesophageal echocardiography (TEE) This can be obtained by keeping the catheter in the middle of the RA rotating clockwise or counterclockwise until the SVC, fossa ovalis membrane, and IVC are well seen During the atrial septal puncture,2 the tip of the trans-septal needle tenting of the fossa ovalis toward the left atrium (LA) should be seen to avoid complications (Fig 31.3) Pulmonary Vein Isolation for Atrial Fibrillation (AF) Ablation ICE provides excellent imaging of the pulmonary veins (Fig 31.4), permitting recognition of the number of veins and their entrance, whether they enter the LA via separate ostium or via a common ostium.3,4 Imaging View Left atrium and pulmonary veins can be imaged with the catheter tip straight in the body of the RA and facing inter atrial septum Left pulmonary veins are easily imaged by gently rotating the catheter clockwise If the LA is enlarged, then the catheter tip may require flexion or extension to look at the left pulmonary veins Right pulmonary veins, on the other hand, require catheter manipulation to image their entrance into the LA Since the right pulmonary veins are adjoining the SVC, they can be imaged from the SVC, SVC–RA junction, or from the high RA In the SVC and SVC–RA junction, the catheter must be slightly flexed to look down Generally, the superior limbus of the fossa ovalis is seen adjoining the entrance of the pulmonary vein from this position Very rarely they can be imaged from the lower RA with the catheter extended looking up at the SVC and superior limbus region 646 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 31.2A to D: (A) IVC-RA junction with the Eustachian valve (arrow); (B) SVC-RA junction with crista terminales (arrow); (C) RA wall (arrow) and (D) Atrial septum with superior (SFL) and inferior fatty limbus (IFL) Fig 31.3: Note the tenting (arrow head) of the atrial septum during trans-septal puncture (left) and the color Doppler demonstrating right to left shunt after the septostomy Fig 31.4: Color flow Doppler of the left inferior (LIPV) and superior (LSPV) Pulmonary veins (left) and pulsed wave Doppler of the LIPV (right) Chapter 31: Intracardiac Echocardiography During ablation, ICE provides realtime monitoring of adequate contact of the ablation catheter with atrial wall, and delivery of radio frequency (RF) energy results in cavitation seen as bubbles on the ICE5 and lesion development as there is a change in the tissue texture (Figs 31.5A and B) ICE monitoring during ablation avoids unnecessary slippage of the catheter into the pulmonary and also recognize proper tissue contact This prevents over use of the energy and unnecessary complications RF Ablation at Other Locations Right Ventricular Outflow Tract Tachycardia ICE has demonstrated structural abnormalities such as focal muscle tissue underneath the anterior pulmonary valve cusp or ridge in the right ventricular outflow tract (RVOT) that may be responsible for the ventricular tachycardia (VT).6 Imaging the RVOT can be achieved either from the RA or from the RV From the RA, the catheter should be flexed and rotated clockwise until the RVOT is well seen To image from the RV, catheter has to be flexed to enter the RV; once in the RV, the catheter should be flexed more and rotated counterclockwise facing upward until the RVOT and the pulmonary valve is well seen (Figs 31.6A and B) The extreme flexion and navigation from one chamber to the other needs fluoroscopic monitoring 647 fluoroscopy; however, they can easily be verified and monitored by ICE during ablation (Figs 31.7A to D) In this situation, the LMCA and the aortic root can be imaged from the mid-RA with the catheter flexed, looking down, and rotated clockwise until the aortic root and the LMCA ostium are well seen Ventricular Tachycardia from Left Ventricle ICE can allow recognition of anatomical substrate as well as guide mapping and ablation catheter location in the left ventricle (LV).8 It avoids unnecessary catheter entrapment in the mitral apparatus and potential complication ICE can also confirm tissue contact of the ablation catheter and monitor lesion development ICE catheter has to be advanced into the RV apex This can be achieved either by flexion or extension Once in the RV, if the anterior wall of the RV is seen rotating gently, clockwise will bring interventricular septum and the LV in view, or if the posterior wall of the RV is seen, then gentle counterclockwise rotation will bring the septum and LV in view Fine refinement of the catheter position is needed to locate the mapping and ablation catheter It is also used for monitoring and guiding ablation of VT foci from the epicardial surface (Figs 31.8A to D) VT Foci from the Great Vessels Intracardiac Echocardiography During EP Procedures VT foci arising from the adnexa of left main coronary artery ostium (LMCA) from the cusps of the aortic valve7 are difficult to assess for their closeness to LMCA from The usefulness of ICE in EP procedures has been well recognized during trans-septal puncture,2 pulmonary vein isolation,3,4 and other complex RF ablative procedures A B Figs 31.5A and B: Radio frequency (RF) ablation catheter in the left inferior pulmonary vein (A) and microbubbles and tissue changes during ablation (B) 648 Section 2: Echocardiography/Ultrasound Examination and Training to monitor ablation and lesion development,5–8 and to avoid complications The fluoroscopic time as well as complications rates have decreased One of the primary applications of ICE imaging to be rapidly adopted into clinical practice was for guidance of device closure of atrial septal defects, such as secundum atrial septal defect (ASD) or patent foramen ovale (PFO) Transcatheter placement of closure devices for ASD or PFO is facilitated by ICE guidance in the cardiac catheterization laboratory Intracardiac images provide superior imaging of the atrial septum (see Figs 31.2 and 31.3) Assessment of the defect(s) and relationship to the surrounding cardiac structures is critical to a successful deployment of the closure device and is facilitated by the ICE Documentation of normal pulmonary venous return to the LA (Fig 31.9) is an important aspect of ASD closure and is easily accomplished by ICE.1,9,10,11 A B INTRACARDIAC ECHOCARDIOGRAPHY DURING STRUCTURAL INTERVENTION Patent Foramen Ovale/Atrial Septal Defect Closure Figs 31.6A and B: (A) Intracardiac ultrasound image showing the close relationship between the pulmonary valve and the aortic valve close to the ostium of the left main coronary artery This image was obtained by placing the intracardiac ultrasound probe in the right ventricle and the probe directed upward to view the pulmonary artery aorta relationship; (B) Intracardiac ultrasound image showing the cross-sectional view of the aortic valve with the ablation catheter in the left coronary cusp (LCC) His indicates His catheter; ABL: Ablation catheter (AO: Aortic valve; LMCA: Left main coronary artery ostium; PA: Pulmonary artery; PV: Pulmonary valve) Source: Reproduced with permission from AHA Circ Arrhythmia Electrophysiol 2009;2:316–26 A Figs 31.7A and B B Chapter 31: Intracardiac Echocardiography C 649 D Figs 31.7A to D: Intracardiac echocardiography (ICE) images of the ablation catheter at the level of the aortic valve (A and B) and pulmonary valve (C and D) (A) Shows the catheter between the left and noncoronary cusps of the aortic valve; (B) Shows a longitudinal section of the aortic valve in which the catheter is in the right coronary cusp with the left coronary cusp inferior; (C) Shows the catheter above the pulmonary valve targeting This image shows the proximity of this site to those that are above the aortic valve; (D) Shows the catheter just below the pulmonary valve (ABL: Ablation catheter; LA: Left atrium; LV: Left ventricle; MV: Mitral valve; PV: Pulmonary valve) Source: Reproduced with permission from Circ Arrhythmia Electrophysiol 2008;1:30–38 A B C D Figs 31.8A to D: (A) Intracardiac echocardiography (ICE) image with increased echogenicity in epicardium (white arrows) identified on the posterolateral wall Pericardium is noted by the red arrow; (B) Left ventricle (LV) endocardial voltage map with normal voltage; (C) LV epicardial voltage map with area of low voltage on the posterolateral wall; (D) Late potentials identified on LV epicardium (fractionated, split, and isolated) Source: Reproduced with permission from Circ Arrhythm Electrophysiol 2011;4:667–73 650 Section 2: Echocardiography/Ultrasound Examination and Training Fig 31.9: Intracardiac echocardiography (ICE) in the right atrium (RA) demonstrating the patent foramen ovale (PFO; arrow) on the left and the color flow demonstrating a left to right shunt (arrow) on the right Source: Reproduced with permission from Mayo proceedings Long-axis and short-axis views aid in dimensional analysis of the septal defect and allow very accurate measurement of both static diameter, and, more importantly, balloon-stretched diameter (typically used to select the appropriate device size) when compared to fluoroscopy.9,10 Spatial relationships of devices in relationship to surrounding cardiac structures are better visualized by ICE compared to TEE (Fig 31.10) During deployment and subsequent delivery of an occlusion device, there is no shadowing of the right atrial disc of the device by the left atrial disc when ICE guidance is utilized Therefore, ICE imaging provides superior visualization of septal rims in relationship to device position before final deployment is accomplished, reducing the risk of device embolization In contrast, when TEE is used for evaluation of device placement, significant acoustic shadowing from the left atrial disc may preclude adequate imaging of each disc and its relationship to the atrial septum, increasing the time needed for imaging prior to delivery of the device in an optimal position Balloon sizing is performed and monitored with ICE and fluoroscopy Usually, the best images for clear measurement of balloon size were obtained with the long-axis view of the atrial septum Multiple views of the inflated balloon and atrial septum with color flow imaging were obtained to show complete defect occlusion and to exclude other associated atrial defects By fluoroscopy, the balloon size was obtained in both the anterior and lateral imaging planes Once deployed but before release, the device was again imaged with ICE in both the long- and short-axis planes Fig 31.10: Intracardiac echocardiography (ICE) catheter in the right atrium (RA) demonstrating moderate shunt (arrow) across the atrial septal defect in the long-axis view of the atrial septum (top left) and the Amplatzer atrial septal defect (ASD) closure device across the defect seen in the short-axis view just behind the aortic root (top right) Color flow Doppler demonstrating the device (arrows) and the residual central trivial shunt in the longaxis view Source: Reproduced with permission from Mayo proceedings to determine appropriate device positioning in the atrial septum, to exclude the presence of additional defects, and to ensure that the device did not interfere with the surrounding structures (Fig 31.10) Ventricular Septal Defect Closure Transcatheter closure of muscular ventricular septal defect (VSD) congenital or postmyocardial infarction is now possible.11,12 In a patient with postmyocardial infarction VSD, TEE imaging may not be tolerated by the more clinically compromised patient ICE is an additional imaging modality that can be used to aid visualization of cardiac structures during defect sizing, delivery, and deployment of a septal closure device Monitoring of tricuspid valve regurgitation is facilitated by ICE during such procedures In order to visualize the VSD properly, manipulation of the ICE catheter through the right atrioventricular valve orifice into the right-sided ventricle may be needed as described above and seen in Figure 31.11 Periprosthetic Valve In patients who had undergone valve replacement for both acquired heart disease and congenital heart disease, perivalvular leak is a reported phenomenon Chapter 31: Intracardiac Echocardiography 651 Fig 31.11: Intracardiac echocardiography (ICE) image obtained from within a right-sided morphological left ventricle (LV) in a young man with congenitally corrected transposition of the great arteries Image on the left demonstrates an iatrogenic ventricular septal defect (VSD) observed (arrow) near the inlet ventricular septum (VS) Color flow imaging on the right demonstrates a large left-to-right shunt originating in the morphological right ventricle (RV) A prosthetic atrioventricular valve is observed near the left atrium (LA) (A: Anterior; S: Superior) Source: Reproduced with permission from Mayo proceedings Fig 31.12: Intracardiac echocardiography (ICE) image from the right atrium (RA) in a patient with a left ventricular (LV) to RA shunt following mitral valve (MV) replacement The image on the left demonstrates the crux of the heart and the entrance (arrow) of the fistula in the RA Color flow image on the right demonstrates a moderate shunt from LV to RA (L: Left; LA: Left atrium; S: Superior Often, acoustic shadowing by the mechanical valve precludes adequate echo imaging from one side of the valve Depending on the intracardiac anatomy, both ICE and TEE may be needed to facilitate evaluation of such defects for location, proximity to the mechanical valve, and size of the defect.13 In addition, during deployment of closure devices, assurance of valve function during and after device placement is critical Evaluation of leaflet mobility is important, and the device must not interfere with normal valve function Continuous monitoring during device deployment, positioning, and delivery is easily accomplished by ICE (Fig 31.12) Judicious use of TEE may be needed to fully evaluate some patients during closure of perivalvular leak but can then be minimized to facilitate patient comfort during supine imaging with the additional use of ICE imaging plane toward the pulmonary outflow tract, one can obtain excellent images of the conduit and Melody valve implant Imaging can demonstrate the competency of the valve and exclude residual paravalvular leaks From within the RA, similar views and assessment of the Melody valve implanted in a previous tissue valve implant can be obtained Melody Valve ICE imaging has been described to assess the function of percutaneously implanted “Melody valves” both in the pulmonary and in the tricuspid position By placing the catheter within the RV and directing the catheter tip Extracardiac Use of the Intracardiac Echocardiography Probe The intracardiac echo probe has also been used for transesophageal imaging in small infants during congenital cardiac surgery.14 The small size of this probe facilitates its placement in children < 3.0 kg In these small infants, standard biplane pediatric TEE probe cannot be advanced into the esophagus due to the patient’s small size High quality 2D and Doppler images are obtained by the use of ICE (Figs 31.13A and B) The major disadvantage of the ICE probe is that it is monoplane Longitudinal imaging is effective; however, the crux of the heart and the inlet ventricular septum are not adequately visualized 652 Section 2: Echocardiography/Ultrasound Examination and Training A B Figs 31.13A and B: (A) Demonstrates a transesophageal echocardiography (TEE) image with the intracardiac echocardiography (ICE) catheter obtained in a small infant with critical discrete coarctation (arrow) of the aorta (Ao); (B) Shows the color flow image demonstrating aliased flow through the obstruction with a 4-m/s velocity recorded with continuous wave Doppler Source: Reproduced with permission from Mayo proceedings Advantages and Limitations of Intracardiac Echocardiography During Interventional Procedures Limitations ICE compliments fluoroscopy during percutaneous intervention, by providing anatomical details of the structure intervened as well as guiding the mainpulation of catheters and guide wires whose spatial location at times are difficult to locate by fluoroscopy Advantages of Intracardiac Echocardiography Use of ICE for trans-septal puncture and locating the catheter position has significantly reduced the radiation The need for general anesthesia for TEE and associated patient discomfort is less with the use of ICE Furthermore, this allows communication with the patient during the procedure With the use of ICE, there is no need to invade the sterile field, which may be needed with the use of TTE for structural assessment ICE provides real time information about the catheter position, device details, recognizes complications such as development of thrombus on the catheter, pericardial effusion, etc The size of the catheters is relatively large and as such vascular injuries are a potential problem Phased array catheter is expensive when used only one time Reuse has received limited attention The single-plane imaging requires extreme catheter manipulation that has the potential for complications Three-dimensional (3D) ICE is currently under clinical investigation No standard imaging planes Three-Dimensional Intracardiac Echocardiography Imaging Three- and four-dimensional ICE imaging is now commercially available with the Siemens SC2000 platform The 3D ICE probe currently is only available in the 10F size but also has the same functionality as the 2D catheter The hub of the catheter connecting to the imaging console is different (Figs 31.14A and B) The four-dimensional (4D) images provide realtime 20° 3D images With similar catheter positioning as described with the 2D images, 3D images of the atrial septum, atrioventricular valves, and semilunar valves can be obtained A large recurrent ASD is better demonstrated with 3D ICE imaging as noted in Figures 31.15A to D Chapter 31: Intracardiac Echocardiography A 653 B Figs 31.14A and B: AcuNav 8F two-dimensional (2D) intracardiac echocardiography (ICE) and 10F three-dimensional (3D) ICE catheters (A) and the magnified view of the electronic connections of the hub (B) demonstrates the difference between 2D and 3D catheters A B C D Figs 31.15A to D: Two-dimensional (2D) sector image short-axis view of a secundum atrial septal defect (ASD) obtained from the threedimensional (3D) intracardiac echocardiography (ICE) catheter with the corresponding 3D view (A) Note the slightly rotated view of the 3D image demonstrating the spatial relations of the ASD (arrow) in Figure B; (C) Demonstrates the 3D image of the ASD (arrow) from the left atrium (LA) perspective, and (D) represents the ASD closure device in the same perspective 654 Section 2: Echocardiography/Ultrasound Examination and Training REFERENCES Earing MG, Cabalka AK, Seward JB, et al Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale Mayo Clin Proc 2004;79(1):24–34 Szili-Torok T, Kimman G, Theuns D, et al Transseptal left heart catheterisation guided by intracardiac echocardiography Heart 2001;86(5):E11 Verma A, Marrouche NF, Natale A Pulmonary vein antrum isolation: intracardiac echocardiography-guided technique J Cardiovasc Electrophysiol 2004;15(11): 1335–40 KhaykinY, Marrouche NF, Saliba W, et al Pulmonary vein antrum isolation for treatment of atrial fibrillation in patients with valvular heart disease or prior open heart surgery Heart Rhythm 2004;1:4 Wood MA, Shaffer KM, Ellenbogen AL, et al Microbubbles during radiofrequency catheter ablation: composition and formation Heart Rhythm 2005;2(4): 397–403 Tabatabaei N, Asirvatham SJ Supravalvular arrhythmia: identifying and ablating the substrate Circ Arrhythm Electrophysiol 2009;2(3):316–26 Srivathsan KS, Bunch TJ, Asirvatham SJ, et al Mechanisms and utility of discrete great arterial potentials in the ablation of outflow tract ventricular arrhythmias Circ Arrhythm Electrophysiol 2008;1(1):30–8 Bala R, Ren JF, Hutchinson MD, et al Assessing epicardial substrate using intracardiac echocardiography during VT ablation Circ Arrhythm Electrophysiol 2011;4(5):667–73 Khositseth A, Cabalka AK, Sweeney JP, et al Transcatheter Amplatzer device closure of atrial septal defect and patent foramen ovale in patients with presumed paradoxical embolism Mayo Clin Proc 2004;79(1):35–41 10 Hijazi Z, Wang Z, Cao Q, et al Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography Catheter Cardiovasc Interv 2001;52(2): 194–9 11 Jongbloed MR, Schalij MJ, Zeppenfeld K, et al Clinical applications of intracardiac echocardiography in interventional procedures Heart 2005;91(7):981–90 12 Holzer R, Balzer D, Amin Z, et al Transcatheter closure of postinfarction ventricular septal defects using the new Amplatzer muscular VSD occluder: Results of a U.S Registry Catheter Cardiovasc Interv 2004;61(2):196–201 13 Cabalka AK, Hagler DJ, Mookadam F, et al Percutaneous closure of left ventricular-to-right atrial fistula after prosthetic mitral valve rereplacement using the Amplatzer duct occluder Catheter Cardiovasc Interv 2005;64(4): 522–7 14 Bruce CJ, O’Leary P, Hagler DJ, et al Miniaturized transesophageal echocardiography in newborn infants J Am Soc Echocardiogr 2002;15(8):791–7 CHAPTER 32 Intravascular Ultrasound Imaging Sachin Logani, Charles E Beale, Luis Gruberg, Smadar Kort Snapshot ¾¾ Principles of Ultrasound Technology ¾¾ Image Acquisition ¾¾ Intravascular Ultrasound Examination ¾¾ Image Interpretation INTRODUCTION Intravascular ultrasound (IVUS) is an invasive imaging modality based on the principles of ultrasound that can be used in conjunction with coronary angiography to further assist the interventional cardiologist in decision making, especially in patients with complicated coronary anatomy This chapter discusses the principles of this technology, image acquisition and interpretation, the role of IVUS in clinical practice, and future direction PRINCIPLES OF ULTRASOUND TECHNOLOGY An understanding of image acquisition using IVUS requires an understanding of the fundamental principles of ultrasound wave transmission A detailed discussion of this topic is beyond the scope of this chapter However, a brief review is provided here Moving ultrasound waves used for imaging cardiac structures have a frequency of > 20,000 cycles/s, making them undetectable to the human ear.1 The velocity at which sound travels through the human soft tissue remains essentially constant at 1,540 m/s Transducers are involved in the conversion of electrical energy into ultrasound waves and vice versa Emission of an ultrasound wave is followed by a generated impulse traveling away from the transducer As it travels, the ultrasound impulse may encounter an ¾¾ Utility of Intravascular Ultrasound in Clinical Practice ¾¾ Safety Considerations ¾¾ Future Perspectives interface between two different types of tissues, causing it to be partially reflected and partially transmitted The degree of reflection depends on the impedance of the tissues The passage of an impulse through the tissue interface leads to a decrease in its energy Thus, only a small proportion of the emitted impulse returns to the transducer The transducer converts the received signal into electrical energy, which is then amplified by an image processing system and converted into a graphic Resolution is defined as the ability to discriminate two closely placed objects Thus, two objects that are closer than the resolution of the device cannot be reliably discerned on ultrasound Image quality is described by spatial resolution as well as contrast resolution Spatial resolution is the ability to display, as separate images, two objects that are very close to each other Contrast resolution is the ability to display, as distinct images, areas that differ in density by a small amount IMAGE ACQUISITION An IVUS catheter consists of a miniaturized transducer and a console responsible for image reconstruction Monorail rapid exchange IVUS catheters have an outer diameter ranging between 2.6 and 3.5 Fr These catheters can be advanced to the coronaries through a 6-Fr guide catheter Currently, two different types of IVUS transducers are available in the United States: Mechanically rotating 656 Section 2: Echocardiography/Ultrasound Examination and Training Table 32.1: Overview and Comparison between Mechanical IVUS and Phased-Array Transducers Mechanical Transducers Phased-Array Transducers Uses a single transducer firing an ultrasound beam as it rotates Uses multiple transducers fixed in an annular array sequentially firing Requires larger caliber catheters Can be used with smaller caliber catheters Rigid structure requires the use of guide wires to pass the aortic bifurcation, more difficult to pass through torturous vessels Increased flexibility allows for accessibility in smaller tortuous vessels and passage through aortic bifurcation Increased difficulty/technical skill to use in conjunction with other interventional devices Relative ease of compatibility with other interventional devices Presence of drive cable and moving parts can lead to nonuniform rotational distortion Nonuniform rotational distortion is not present due to arrangement of multiple transducers Decreased cost when compared to phased-array transducers Increased cost when compared to mechanical IVUS transducer transducer (mechanical IVUS system) and electronically switched multielement array system (solid-state design IVUS system; Table 32.1) Mechanical systems have a single transducer rotating at 1,800 rpm driven by a flexible drive cable By sending and receiving pulses of ultrasound signals, the rotating transducer provides 256 individual radial scans for each image Appropriate image creation requires the absence of air bubbles in the IVUS sheath Conversely, in the electronic transducer system, multiple transducer elements (as many as 64 in currently available systems) are arranged in an annular array These phased array transducers are activated in sequence in order to generate an image These systems allow the image to be manipulated, thereby enabling optimal focus at various ranges of depths Additionally, Doppler effect may be used to provide coloration while depicting blood flow Table 32.1 provides a comparison between mechanical and phased array transducers Most currently available IVUS systems include an imaging console equipped with the necessary hardware and software, a monitor, and recording devices for digital recording of obtained images Artifacts on IVUS images can lead to misinterpretation Therefore, prompt detection and correction of artifacts is crucial for obtaining high-quality images The ringdown artifact is manifested as disorganization of the image closest to the face of the transducer or the catheter surface These artifacts are more commonly seen with the electronic array systems than with mechanical systems, and they usually appear as bright haloes surrounding the catheter Optimal transducer design and digital subtraction may minimize the ring-down effect Another type of artifact is nonuniform rotational distortion (NURD) that is only seen with mechanical IVUS imaging systems NURD results from asymmetric friction along the drive-shaft mechanism, leading to a lag during rotation This in turn results in geometric distortion of the image, which affects circumferential resolution NURD may lead to, for example, inaccurate cross-sectional measurements of an implanted stent Because of the lack of a mechanical rotational component in the phase-array IVUS, NURD does not occur INTRAVASCULAR ULTRASOUND EXAMINATION IVUS is an invasive procedure performed in the cardio vascular catheterization laboratory The IVUS is intro duced into the coronary artery that is to be imaged over a guide wire The patient must be treated with an anticoagulant (usually unfractionated heparin) prior to guide wire insertion To avoid catheter-induced spasm, intracoronary nitroglycerin (200 µg) is administered prior to the introduction of the catheter The IVUS catheter is advanced over the guide wire until it has reached a point beyond the lesion to be imaged Then, the transducer tip is pulled back through the target lesion by either a mechanical device or manually This maneuver creates a series of tomographic, cross-sectional images of the coronary artery A pullback device is usually utilized to provide a steady pullback speed at 0.5 or mm/s IVUS probes are handled similarly to over-thewire percutaneous transluminal coronary angioplasty catheters The position of the guiding catheter must be stable in order to provide support for large profile IVUS catheters The tip of the guide wire must be positioned distal in the target vessel Care must be taken not to advance the IVUS catheter over the floppy end of the guide wire in order to avoid catheter prolapse When imaging aorto-ostial lesions in the left main coronary artery, it is important to disengage the guiding catheter from the ostium before pullback If this is not Chapter 32: Intravascular Ultrasound Imaging done, the true aorto-ostial lumen may be masked or covered by the guiding catheter, and this may hamper the detection of significant ostial lesions To prevent damage to the vessel wall, the IVUS catheter should not be advanced to the smaller distal coronary branches In addition, caution must be exercised when crossing recently deployed stents in order to avoid disruption of the fragile stent struts As briefly mentioned earlier, IVUS catheters may be manipulated either by the motorized approach or manually Regardless of the method selected, target imaging should include a length of at least 10 mm of the distal vessel, the lesion site, and the entire proximal segment of the vessel back to the aorta A major advantage of motorized pullback is that it allows steady and stable catheter withdrawal, thereby providing uniform images and accurate measurement of the length of the segment that is being evaluated Manual transducer pullback needs to be performed slowly It allows the operator to concentrate on specific regions that may be of greater interest, as the transducer motion can be paused at the desired location(s) However, a disadvantage of manual pullback is that the process is uneven, which could adversely affect image uniformity Once images have been obtained, they may be viewed as individual cross-sectional images or as a video sequence Through computerized image reconstruction, a series of IVUS images can be made to depict the longit udinal appearance of the artery IMAGE INTERPRETATION Coronary angiography is currently regarded as the primary modality used to assess coronary artery anatomy and morphology However, since IVUS provides crosssectional images of the coronary vessel, it also enables depiction of vessel anatomy and identification of the lumen, plaque, and vessel wall Proper interpretation of IVUS images plays a key role in the use of this invaluable imaging modality for assessing lesion severity and guiding complex percutaneous coronary interventions (PCIs) In order to interpret IVUS images, two key structures must be identified: the vessel lumen and the vessel wall.2 A specific echogenic pattern known as “speckle” is created by flowing blood within the coronary artery It is visible as fine echoes moving in swirling patterns Blood speckle is invaluable in image interpretation since it allows distinct identification of the lumen and vessel wall Changes in acoustic 657 impedance are observed as ultrasound waves reflect on coronary artery wall tissue The first of such changes is observed at the border of the blood and arterial intima The second change occurs at the external elastic membrane (EEM) located at the media-adventitia border (Fig 32.1A) Although coronary angiography is the primary mode of imaging of the coronary arteries and the basis for PCI, given the two-dimensional nature of the images obtained by coronary angiography, there are certain limitations with regard to lesion observation The degree of luminal stenosis can only be assessed by comparing a lesion with a “normal” coronary artery segment Furthermore, it cannot provide information regarding plaque type or burden.3 Conversely, the two-dimensional, tomographic nature of IVUS can better evaluate atherosclerotic disease severity, plaque morphology and composition, progression or regression of coronary disease, and cardiac allograft vasculopathy (CAV).4,5 A low echogenicity signal is observed in soft lipid-rich lesions on IVUS (Fig 32.1B) The term “soft” in this case refers to low echo density and not the specific structural characteristics of the plaque.6 Such soft plaques are often seen in high-risk patients and represent potentially unstable lesions Echo dense (“hard”) plaques have a high fibrous tissue content and show intermediate echogenicity (Fig 32.1C).7 The greater the fibrous content of the plaque, the higher its echo density Most coronary artery lesions are mixed plaques whose components have varying echogenic properties Calcium deposits within lesions appear as bright echoes (Fig 32.1D) Calcium prevents the penetration of ultrasound waves, resulting in acoustic shadowing, as clearly depicted in Figure 32.1D Extensive calcification usually indicates plaque stability whereas microcalcifications within lipid-rich lesions may indicate plaque vulnerability.8 Features associated with increased risk of rupture include thin-cap fibroatheromas, a large plaque burden, and a small lumen area.9 Intraluminal thrombus may be identified on IVUS as a layered, lobulated, or pedunculated mass in the arterial lumen However, we need to be cautious because such thrombi are often echolucent and may be confused with a lipidrich “soft” plaque A more detailed analysis of plaque composition is achieved by IVUS with virtual histology (IVUS-VH) This technique is based on advanced radiofrequency analysis of reflected ultrasound signals in a frequency domain analysis, and displays a reconstructed color-coded tissue map of plaque composition superimposed on cross-sectional images of the coronary artery obtained by grayscale IVUS.10 Images obtained using IVUS-VH are depicted in Movie clip 32.1 658 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 32.1A to D: (A) The elastic membrane is labeled as EM and is demarcated by small arrows outlined in red; (B) Soft plaque (SP) enclosed by a dotted red outline; (C) Dense or fibrous plaque (FP) outline by a blue line; (D) A calcium deposit is demarcated by a arrow outline in white, seen to the left is a dark area, known as the acoustic shadow or calcium shadow (CS) Neointimal tissue growth within stented segments may lead to the development of in-stent restenosis, which could be identified by IVUS Early in-stent restenosis shows low echogenicity, while late in-stent restenosis appears more echogenic IVUS can also be used to identify and assess the severity of coronary artery dissections A dissection involving the coronary artery may be intimal, medial, or adventitial Flow limiting coronary artery dissections following PCI are associated with increased frequency of long-term adverse cardiac events.11 Chapter 32: Intravascular Ultrasound Imaging A 659 B Figs 32.2A and B: (A) Coronary angiography showing the aneurysm at the center of a black circle; (B) Intravascular ultrasound (IVUS) imaging showing an aneurysm of a coronary artery Additionally, IVUS can identify other PCI-related compli cations that may be missed by angiography, including intramural hematomas, aneurysms, and pseudoaneurysms as shown in Figures 32.2A and B UTILITY OF INTRAVASCULAR ULTRASOUND IN CLINICAL PRACTICE Although coronary angiography remains the primary imaging modality for defining coronary anatomy and for guiding interventions, the increasingly complex nature of interventions has highlighted its limitations as an imaging modality Limited resolution and the two-dimensional nature of the images obtained hamper its ability to depict the severity of intermediate lesions accurately In addition, angiography provides no information regarding plaque composition, which may be useful for prognosis and treatment.12,13 IVUS provides an accurate assessment of plaque burden and its components Various other clinical utilities of IVUS are listed in Table 32.2 However, the use of IVUS in clinical practice remains limited This has been attributed to an increase in cost, procedure time, and radiation exposure The widespread use of IVUS is also limited by operator experience During PCI, IVUS is a useful supplemental modality that helps plan an interventional strategy and optimize stent deployment, overcoming some of the shortcomings of coronary angio graphy A recent meta-analysis by Parise and collea gues showed that IVUS-guided PCI is associated with a significant reduction in restenosis and target vessel revascularization with similar mortality and myocardial infarction rates.14 IVUS-guided PCI is of critical importance during intervention of unprotected left main coronary artery lesions The dire consequences of a poorly deployed stent in the left main coronary artery was demonstrated in the MAIN-COMPARE trial that showed a significant reduction in mortality rates in patients who underwent IVUS-guided PCI.15 IVUS is especially useful in assessing diffusely diseased segments.16 A minimum lumen area (MLA) < mm2 on IVUS indicates significant coronary stenosis.17 This information provided by IVUS may be combined with coronary artery physiologic data to facilitate clinical decisions in the cardiac catheterization laboratory A Doppler-tipped guide wire, which permits measurement of translesional pressure gradient can be used to calculate the fractional flow reserve which is derived from the ratio of distal coronary pressure to aortic pressure at maximum hyperemia (induced by adenosine) During diagnostic angiography, coronary flow reserve can replace out-oflaboratory stress testing for single lesion assessment.18,19 660 Section 2: Echocardiography/Ultrasound Examination and Training Table 32.2: Clinical Utility of Intravascular Ultrasound (IVUS) Identification of plaque composition, allowing for identification and possible differentiation of stable opposed to high-risk unstable plaque Accurate identification of lesion size, length, eccentricity, and significance, thereby enabling improvement in interventional planning in complex lesions Improvement in stent outcomes by identifying balloon under expansion, stent and edge malapposition, therefore leading to decreased thrombosis Improved identification of indeterminate lesions Can be used to monitor progression or regression of plaque accumulation Identification of coronary structural abnormalities such as dissections, aneurysm, or hematomas Fig 32.3: The struts of the stent are indicated by the arrows outlined in white The area of poor stent apposition is demarcated by three blue arrows IVUS also provides important prognostic information for lesions in the left main coronary artery.20 Further, it plays a role in the assessment and treatment of lesions in previously stented coronary artery segments.21 A study reported that information regarding plaque composition and morphology provided by IVUS may change therapy in up to 40% of lesions.22 The histologic characteristics of the target lesion may need to be considered in order to select the most appropriate treatment strategy While angiography can identify calcium in a lesion in only 15% cases, IVUS can so in 85% cases23 and therefore, for optimal treatment, a calcified lesion may require high-pressure balloon inflations or plaque modification strategies (cutting balloon or rotational atherectomy) prior to stenting In addition to calcification, other lesion characteristics assessed by IVUS that may change the strategy include the presence of arterial remodeling, dissections, and thrombus After stent deployment, the stent must be properly expanded with all struts apposed to the wall of the vessel in order to allow adequate blood flow (Fig 32.3) IVUS may improve stenting outcomes by ensuring proper stent expansion and apposition and thereby minimizing the risk of stent thrombosis.24,25 Routine use of IVUS during stent implantation is not the standard of care at most centers, but it may prove useful in complex cases involving high-risk patients in order to ensure proper stent expansion Thereby, the risk of thrombosis and in-stent restenosis and the need for repeat revascularization can be reduced, as aforementioned, for unprotected left main artery intervention.26–28 Coronary angiography is not an effective tool for assessing atherosclerosis progression or regression IVUS is better able to quantify the extent of disease and atheroma volume, which may be useful in measuring the effectiveness of antiatherosclerotic agents such as statins.29 CAV is a unique and accelerated form of atherosclerosis and is the leading cause of morbidity and mortality following heart transplantation, but it is often silent, making it difficult to diagnose It usually affects the large epicardial vessels and also the microcirculation leading to a significant reduction in coronary blood flow Coronary angiography is unable to recognize the disease in 20% of patients and has a negative predictive value of 50% Conversely, IVUS has shown to be more sensitive than angiography and is currently recommended for heart transplant recipients for early detection of CAV.30 In addition to its utility in the detection and treatment of coronary artery disease, IVUS has also been proven useful in detecting lesions within saphenous vein grafts.31 Chapter 32: Intravascular Ultrasound Imaging SAFETY CONSIDERATIONS The safety of IVUS is well documented by numerous randomized studies and years of experience The most commonly encountered complication is focal coronary artery spasm, occurring in up to 3% of cases However, such spasms are rapidly reversible with intracoronary nitroglycerin The rate of other complications related to IVUS, including coronary artery dissection, perforation, intramural hematoma, vessel thrombosis, and fracture of the IVUS catheter was reported to be low, at 0.4%.32 FUTURE PERSPECTIVES As mentioned previously, grayscale IVUS enables the operator to obtain a tomographic high-resolution visual ization of the vessel Grayscale IVUS, however, is limited in its ability to determine plaque composition Plaque analysis can be accomplished with the use of IVUS-VH or high frequency IVUS, which can provide advanced images of atherosclerotic tissue composition Information regarding plaque composition may allow early identi fication of plaques vulnerable to rupture Even more recent advances in IVUS technology include acquisition of computational images of IVUS in three dimensions, known as three-dimensional (3D) IVUS However, at the present time, 3D IVUS remains primarily a research tool and is not routinely utilized in clinical setting at most centers Forward-looking intravascular ultrasound (FL-IVUS) utilizes a special catheter that emits ultrasound waves distally from the catheter tip Given its ability to visualize the vessel in a forward-looking configuration, FL-IVUS holds particular promise in percutaneous revascularization of chronic total occlusions Although, chronic total occlusions are frequently encountered in clinical practice, they are rarely revascularized due to the complexity of the case and the risk of complications such as vessel dissection, perforation, guide wire injury, embolization, myocardial infarction, and even death.33 Also, the success rate has never been excellent because of the inability to re-enter the true vessel lumen The enhanced visualization provided by FL-IVUS can be used for crossing chronic total occlusions while minimizing risk of vessel dissection by maintaining the catheter and the guide wire in the true lumen Such advances in IVUS technology have ensured that IVUS will continue to play an integral role in our understanding and management of coronary artery disease in the future 661 REFERENCES Nishimura RA, Edwards WD, Warnes CA, et al Intravascular ultrasound imaging: in vitro validation and pathologic correlation J Am Coll Cardiol 1990;16(1):145–54 Schoenhagen P Atherosclerosis imaging with intravascular ultrasound Validating acquisition and measurement tools to assure meaningful results Int J Cardiovasc Imaging 2006;22(5):615–8 Mintz GS, Nissen SE, Anderson WD, et al American College of Cardiology Clinical Expert Consensus Document on Standards for Acquisition, Measurement and Reporting of Intravascular Ultrasound Studies (IVUS) A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents J Am Coll Cardiol 2001; 37(5):1478–92 Berry C, L’Allier PL, Grégoire J, et al Comparison of intra vascular ultrasound and quantitative coronary angiography for the assessment of coronary artery disease progression Circulation 2007;115(14):1851–7 Kawasaki M, Bouma BE, Bressner J, et al Diagnostic accuracy of optical coherence tomography and integrated backscatter intravascular ultrasound images for tissue characterization of human coronary plaques J Am Coll Cardiol 2006;48(1):81–8 Palmer ND, Northridge D, Lessells A, et al In vitro analysis of coronary atheromatous lesions by intravascular ultrasound; reproducibility and histological correlation of lesion morphology Eur Heart J 1999;20(23): 1701–6 Potkin BN, Bartorelli AL, Gessert JM, et al Coronary artery imaging with intravascular high-frequency ultrasound Circulation 1990;81(5):1575–85 Ehara S, Kobayashi Y, Yoshiyama M, et al Spotty calcifi cation typifies the culprit plaque in patients with acute myocardial infarction: an intravascular ultrasound study Circulation 2004;110(22):3424–9 Stone GW, Maehara A, Mintz GS The reality of vulnerable plaque detection JACC Cardiovasc Imaging 2011;4(8): 902–4 10 Nair A, Kuban BD, Tuzcu EM, et al Coronary plaque classification with intravascular ultrasound radiofrequency data analysis Circulation 2002; 106(17):2200–6 11 Maluenda G, Lemesle G, Ben-Dor I, et al Impact of intravascular ultrasound guidance in patients with acute myocardial infarction undergoing percutaneous coronary intervention Catheter Cardiovasc Interv 2010;75(1):86–92 12 Kotani J, Mintz GS, Castagna MT, et al Usefulness of preprocedural coronary lesion morphology as assessed by intravascular ultrasound in predicting Thrombolysis In Myocardial Infarction frame count after percutaneous coronary intervention in patients with Q-wave acute myocardial infarction Am J Cardiol 2003;91(7):870–2 13 Hausmann D, Erbel R, Alibelli-Chemarin MJ, et al The safety of intracoronary ultrasound A multicenter survey of 2207 examinations Circulation 1995;91(3):623–30 662 Section 2: Echocardiography/Ultrasound Examination and Training 14 Parise H, Maehara A, Stone GW, et al Meta-analysis of randomized studies comparing intravascular ultrasound versus angiographic guidance of percutaneous coronary intervention in pre-drug-eluting stent era Am J Cardiol 2011;107(3):374–82 15 Park SJ, Kim YH, Park DW, et al.; MAIN-COMPARE Investigators Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis Circ Cardiovasc Interv 2009;2(3):167–77 16 Jensen LO, Thayssen P, Mintz GS, et al Comparison of intravascular ultrasound and angiographic assessment of coronary reference segment size in patients with type diabetes mellitus Am J Cardiol 2008;101(5):590–5 17 Nishioka T, Amanullah AM, Luo H, et al Clinical validation of intravascular ultrasound imaging for assessment of coronary stenosis severity: comparison with stress myo cardial perfusion imaging J Am Coll Cardiol 1999; 33(7):1870–8 18 Miller DD, Donohue TJ, Younis LT, et al Correlation of pharmacological 99mTc-sestamibi myocardial perfusion imaging with poststenotic coronary flow reserve in patients with angiographically intermediate coronary artery stenoses Circulation 1994;89(5):2150–60 19 Joye JD, Schulman DS, Lasorda D, et al Intracoronary Doppler guide wire versus stress single-photon emission computed tomographic thallium-201 imaging in assess ment of intermediate coronary stenoses J Am Coll Cardiol 1994;24(4):940–7 20 Abizaid AS, Mintz GS, Abizaid A, et al One-year follow-up after intravascular ultrasound assessment of moderate left main coronary artery disease in patients with ambiguous angiograms J Am Coll Cardiol 1999;34(3):707–15 21 Prati F, Pawlowski T, Sommariva L, et al Intravascular ultrasound and quantitative coronary angiography assessment of late in-stent restenosis: in vivo human correlation and methodological implications Catheter Cardiovasc Interv 2002;57(2):155–60 22 Mintz GS, Pichard AD, Kovach JA, et al Impact of preintervention intravascular ultrasound imaging on transcatheter treatment strategies in coronary artery disease Am J Cardiol 1994;73(7):423–30 23 St Goar FG, Pinto FJ, Alderman EL, et al Intravascular ultrasound imaging of angiographically normal coronary arteries: an in vivo comparison with quantitative angio graphy J Am Coll Cardiol 1991;18(4):952–8 24 Ziada KM, Tuzcu EM, De Franco AC, et al Intravascular ultrasound assessment of the prevalence and causes of angiographic “haziness” following high-pressure coronary stenting Am J Cardiol 1997;80(2):116–21 25 Gil RJ, Pawlowski T, Dudek D, et al.; Investigators of Direct Stenting vs Optimal Angioplasty Trial (DIPOL) Comparison of angiographically guided direct stenting technique with direct stenting and optimal balloon angioplasty guided with intravascular ultrasound The multicenter, randomized trial results Am Heart J 2007;154(4):669–75 26 Bourantas CV, Naka KK, Garg S, et al Clinical indications for intravascular ultrasound imaging Echocardiography 2010;27(10):1282–90 27 Roy P, Waksman R Intravascular ultrasound guidance in drug-eluting stent deployment Minerva Cardioangiol 2008;56(1):67–77 28 Weissman NJ, Koglin J, Cox DA, et al Polymer-based paclitaxel-eluting stents reduce in-stent neointimal tissue proliferation: a serial volumetric intravascular ultrasound analysis from the TAXUS-IV trial J Am Coll Cardiol 2005;45(8):1201–5 29 Nissen SE Application of intravascular ultrasound to characterize coronary artery disease and assess the progression or regression of atherosclerosis Am J Cardiol 2002;89(4A):24B–31B 30 Logani S, Saltzman HE, Kurnik P, et al Clinical utility of intravascular ultrasound in the assessment of coronary allograft vasculopathy: a review J Interv Cardiol 2011; 24(1):9–14 31 Jain SP, Roubin GS, Nanda NC, et al Intravascular ultra sound imaging of saphenous vein graft stenosis Am J Cardiol 1992;69(1):133–6 32 Pinto FJ, St Goar FG, Gao SZ, et al Immediate and oneyear safety of intracoronary ultrasonic imaging Evaluation with serial quantitative angiography Circulation 1993;88 (4 Pt 1):1709–14 33 Srinivas VS, Brooks MM, Detre KM, et al Contemporary percutaneous coronary intervention versus balloon angioplasty for multivessel coronary artery disease: a comparison of the National Heart, Lung and Blood Institute Dynamic Registry and the Bypass Angioplasty Revascularization Investigation (BARI) study Circulation 2002;106(13):1627–33 CHAPTER 33 Peripheral Vascular Ultrasound Ricardo Benenstein, Muhamed Saric Snapshot Ultrasound Diagnosis of CaroƟd Artery Diseases INTRODUCTION Atherosclerosis is a systemic disease of the medium and large arteries It affects not only the coronaries—the main focus of cardiologists—but also aorta, carotids, and other major peripheral vessels It is a dynamic disease that makes prevention and treatment a highly complex process, and it is the leading cause of cardiovascular morbidity and mortality worldwide Physicians who fashion themselves as providers of health care to people with cardiac illnesses, frequently encounter patients who may have sought their expertise for treatment of ischemic heart disease but whose lives are also affected by peripheral vascular disease Thus, there is an increasing trend for these practitioners—who, if board-certified, are deemed experts in “cardiovascular diseases”—to be more involved in the vascular medicine component of their subspecialty The rapid growth in percutaneous peripheral vascular interventions has contributed to this trend With the fast pace of noninvasive imaging technology, there has been burgeoning interest among cardiologists, and particularly echocardiographers, in performing vascular ultrasound studies, in an attempt to refine both risk stratification and the need for more aggressive preventive strategies.1,2 Furthermore, there is a growing desire among cardiology trainees to acquire more experience in vascular medicine and vascular imaging Ultrasound Diagnosis of Femoral Access ComplicaƟons modalities The effort to strengthen the understanding of vascular diseases among cardiologists is reflected in a recent joint statement by the Society for Cardiovascular Angiography and Interventions and the Society of Vascular Medicine: “The essentials of vascular medicine should be taught to all cardiology fellows Vascular medicine training should be integrated into the fellowship program and include the evaluation and management of vascular diseases, exposure to noninvasive diagnostic modalities, angiography, and peripheral catheter-based interventions.”3 In our experience at the New York University Langone Medical Center’s Noninvasive Cardiology Laboratory, two areas of vascular ultrasound use have fostered particular interest among clinical and interventional cardiologists— the assessment of the extracranial cerebrovascular circulation and the evaluation of complications of femoral access during percutaneous interventions Both topics will be discussed in detail in this chapter ULTRASOUND DIAGNOSIS OF CAROTID ARTERY DISEASES Introduction In the United States, stroke ranks as the third leading cause of death, after ischemic heart disease and cancer, and is the 664 Section 2: Echocardiography/Ultrasound Examination and Training leading cause of permanent disability Every year, there are >700,000 new stroke cases in the United States, resulting in >150,000 deaths The economic burden imposed on society, estimated to be more than $58 billion in direct and indirect costs annually, is enormous Carotid artery occlusive disease accounts for 15–20% of the ischemic strokes, of which three quarters involve the anterior carotid circulation and the remaining quarter the posterior vertebrobasilar system Because most of these cerebrovascular accidents, resulting in significant morbidity and mortality, occur without any warning sign, attention has turned to the detection and management of asymptomatic carotid stenosis, the prevalence of which is on the rise.4 The overall prevalence of asymptomatic carotid artery disease (defined as >50% luminal reduction by duplex ultrasound) varies considerably In the general population, it is between 2% and 8% But among patients with known coronary artery disease, the prevalence is reported to be 11–26% It is even higher in patients with recognized peripheral vascular disease.5 The risk of stroke is highly dependent on the degree of carotid stenosis and the presence of symptoms Landmarkrandomized multicenter trials have determined that the combination of carotid endarterectomy (CEA) and best medical therapy significantly reduces the risk of stroke in symptomatic patients with ≥70% carotid artery stenosis, as well as in asymptomatic patients with ≥60% carotid stenosis.6–8 At the same time, AbuRahma et al have shown that the heterogeneity of the plaque is more closely related to symptoms than the degree of stenosis, and they have suggested that plaque characteristics be considered when selecting patients for CEA, particularly in asymptomatic carotid disease.9 The principal role of carotid duplex ultrasound examination is the detection of stenosis in the internal carotid artery (ICA) But, because of studies demonstrating the prognostic significance of plaque morphology, characterizing plaque by analyzing the gray-scale appearance of the arterial wall, with particular attention to the ultrasonic features of the plaque in the carotid bulb, has important implications At the same time, the fact that no diagnostic method has been proven to predict which asymptomatic plaques will lead to cardiovascular events makes carotid duplex ultrasound a fertile ground for research in patients with cardiovascular disease.10 This chapter will emphasize fundamental aspects of the carotid ultrasound examination, including cerebrovascular anatomy and physiology, scanning protocol, intima-media thickness (IMT) and plaque characterization, criteria for grading stenosis of native arteries, and standards for follow-up evaluation of vessels after endarterectomy and stenting It should be noted that the accuracy of carotid duplex studies depends on the technical skills of the sonographer, on consistent adherence to the examination protocol, and on the experience of the physician interpreting them Cerebrovascular Anatomy Thorough knowledge of the anatomy of the cervical arteries, including vessel origin and trajectory, branches, and main collateral pathways, is paramount to understanding cerebrovascular hemodynamics, particularly when there is significant stenosis or total occlusion of one the carotid and/or vertebral arteries (VAs) What follows is a basic overview of the cervical arteries and the complex intracranial connections between the anterior and posterior circulations through the Willis circle and main collateral pathways Four vessels supply the brain: two internal carotid arteries, which provide circulation to the anterior cerebrum; and two VAs, which provide circulation to the posterior brain Distally, both circulations join at the base of the brain forming an arterial loop known as the Circle of Willis The presence of significant flow abnormalities of the origin of the carotid or subclavian arteries (SAs) will have great impact on the Doppler spectrum and direction of the flow in the cervical arteries Therefore, knowledge of the anatomy and ultrasound interrogation techniques of the aortic arch vessels is necessary to ensure complete assessment and understanding of the duplex findings Aortic Arch The aortic arch is approximately 4–5 cm long and 2.5–3.0 cm in diameter Morphologically, the aortic arch is classified as one of three types, based on its relationship to the innominate artery This assessment, however, is more important to the interventionalist than to the vascular technologist performing ultrasound examination.11 In type I aortic arch, all three great vessels originate in the same horizontal plane as the outer curvature of the aortic arch In the type II aortic arch, the innominate artery originates between the horizontal planes of the outer and inner curvatures of the arch Chapter 33: Peripheral Vascular Ultrasound Fig 33.1: Types of aortic arch Type I aortic arch—all three great vessels originate in the same horizontal plane as the outer curvature of the aortic arch Type II aortic arch—the innominate artery originates between the horizontal planes of the outer and inner curvatures of the arch Type III aortic arch—the innominate artery originates below the horizontal plane of the inner curvature of the arch Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU) In the type III aortic arch, the innominate artery originates below the horizontal plane of the inner curvature of the arch (Fig 33.1) The arch gives rise to three great vessels From right to left, the first branch is the innominate or brachiocephalic artery, which in turn branches into the right SA and the right common carotid artery (CCA) In approximately 70% of the population, the second branch is the left CCA, and the last branch is the left SA (Figs 33.2A to C) The remaining 30% of the population exhibit any of the several anatomical variations, which may lead to difficulty in the identification of a stenotic vessel.12 The most common variant, seen in nearly 15% of the population, is the so-called bovine arch in which the innominate artery and the left CCA share a common origin Anecdotally, the term bovine arch is a misnomer, as this type of branching is actually exceedingly rare or perhaps nonexistent among cattle (a true bovine aortic arch has no similarity to any of the common human aortic arch variations: the aortic arch branching pattern found in cattle has a single brachiocephalic trunk arising from the aortic arch, which ultimately splits into the bilateral SAs and a bicarotid trunk)12 (Figs 33.3A and B) The second most common variant, seen in approximately 10% of the population, involves the left 665 CCA originating directly from the innominate artery at a distance of 1–2.5 cm from the aortic arch (this variant is similar to the common origin variant, except that the left CCA originates more distally from the innominate artery, rather than as part of a common trunk).12 A much less common aortic arch anomaly is a left aortic arch with an aberrant right SA that arises from the arch distally, near the origin of the left SA, and crosses in the posterior mediastinum, usually behind the esophagus, on its way to the right upper extremity (0.5–2.0% of the aortic arch anomalies) When an aneurysmal dilatation of the proximal portion of the aberrant right SA is present, the pouch-like aneurysmal dilatation is called a diverticulum of Kommerell A similar aneurysm can be seen with an aberrant left SA associated with a right aortic arch.13 More rare aortic arch anomalies are beyond the scope of this chapter The innominate or brachiocephalic artery is the first and largest aortic arch branch It originates near the midline and travels superiorly and slightly posteriorly toward the right supraclavicular fossa (from where it is best interrogated by Doppler ultrasound) It divides, about 4–5 cm after its origin and just above the right sternoclavicular junction, into the right SA and the right CCA The left CCA is the second branch of the aortic arch It too originates within the thorax immediately after the innominate artery, running anteriorly toward the left side of the neck Its origin can be evaluated from either the suprasternal notch or the left supraclavicular fossa The left SA is the last arch branch; it originates laterally and posteriorly to the left common carotid, and ascends through the thoracic outlet Its origin is usually interrogated from the left supraclavicular fossa Anterior Circulation Both CCAs ascend straight through the neck behind the sternocleidomastoid muscles, usually posterior and medial to the internal jugular veins But their trajectories can become quite tortuous with age and long-standing hypertension The CCAs are 6–8 mm in diameter Generally speaking, they not give rise to branches proximal to the bifurcation; but it is not uncommon to see the superior or inferior thyroid arteries arise from the CCA near the origin of the external carotid arteries The CCA bifurcates into the ICA and the external carotid artery (ECA) at the level of C4 to C5 in approximately 50% of patients In 10% of patients, this bifurcation is lower in the 666 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 33.2A to C: Branches of the aortic arch (A) Three-dimensional (3D) volume rendering computed tomography angiography (CTA) demonstrates the normal origin of the great vessels From right to left: the innominate artery, which in turn branches into the right subclavian and common carotid arteries, the left CCA, and the left subclavian artery This common variant is present in approximately 70% of the population; (B and C) Magnetic resonance angiography images demonstrate the origin of the great vessels from an anterolateral view (B) and from an anterior view (C) (CCA: Common carotid artery; INN art: Innominate artery; Subcl: Subclavian artery; Vert: Vertebral artery) A B Figs 33.3A and B: “Bovine Arch.” (A) Demonstrates the most common configuration of the aortic arch; (B) The innominate artery and the left common carotid artery share a common origin This variant is present in 15% of the population and is so-called “Bovine Arch” This term in fact is a misnomer, as this type of branching is actually extremely rare among cattle Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU) neck (lowest seen at T1–T2), and in about 40% of patients, the bifurcation is higher (highest seen at C1–C2).14,15 This variance presents a diagnostic challenge for the vascular technologist performing duplex interrogation of the ICA (Figs 33.4A to C) The ECA originates at the bifurcation and supplies blood flow to neck, face, scalp, maxilla, and thyroid It courses superiorly and anteriorly, and gives off a highly variable number of branches before it divides into the maxillary artery and superficial temporal artery Both terminal vessels are important as collateral pathways, providing known pre-Willisian extracranial–intracranial anastomoses between the ECA and ICA (discussed later in this chapter) The ICA runs cranially, posterior and lateral to the ECA, and supplies blood to the anterior cerebral hemispheres as well as the ipsilateral eye Chapter 33: Peripheral Vascular Ultrasound A B 667 C Figs 33.4A to C: Right side vessels (A) This three-dimensional (3D) volume rendering computed tomography angiography (CTA) demonstrate the relationship of the CCA and the vertebral artery on the right side The common carotid runs anteriorly behind the sternocleidomastoid muscle, until it bifurcates into the internal and external carotid arteries The vertebral artery runs posterior and lateral to the common carotid and ascends in the neck within the transverse foramens of the cervical vertebrae C6 to C2 The right subclavian artery originates from the innominate artery bifurcation and runs behind the clavicle bone toward the arm Indicated with a “star” is the left carotid system 3D reconstruction courtesy of NYU Langone Medical Center Radiology Lab; (B) Diagram showing the origin and relationship of the anterior and posterior circulations; (C) 3D volume rendering CTA of the CCA and bifurcation The proximal ICA presents its bulbous, fusiform dilatation known as the “carotid bulb” (CCA: Common carotid artery; ECA: External carotid artery; ICA: Internal carotid artery; INN: Innominate artery; SCM: Sternocleidomastoid muscle) Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU) Typically, the ICA is larger than the external, and its proximal portion has a fusiform dilatation known as the “carotid bulb” because of its particular shape (Figs 33.5A to C) The carotid bulb begins at the level of the CCA bifurcation and extends 1.5–2 cm into the ICA measuring approximately 7–9 mm in its larger diameter This structure, known also as the carotid sinus, is heavily innervated, and contains baroreceptors involved in arterial blood flow regulation In the posterior aspect of the carotid bulb, there is a small cluster of chemoreceptors known as the carotid body, which is responsible for sensing changes in pH, temperature, partial pressure of O2, and CO2 The carotid bulb is the most common site of atheroma formation in the cervical segment of the ICA The atherosclerotic disease process, as well as revascularization techniques (either surgical or endovascular), may affect the regulatory functions of the carotid bulb Distal to the bulb, the ICA is generally straight and measures 4–6 mm in diameter This vessel turns medially before entering the carotid canal in the petrous bone The mid and distal cervical segments of the ICA tend to have only mild curvatures, but it is not uncommon for the ICA to undergo some elongation and to become tortuous with aging or in the presence of hypertension Three morphological variants may be present:15,16 • Loops are described as “S” or “C” shaped elongations or curved arteries • Coils are pronounced, redundant “S” shaped curves (or complete circle of the vessel) Loops and coils are thought to be congenital variations They are usually bilateral and not cause symptoms unless exaggerated by aging or aggravated by atherosclerotic disease • Kinks are sharp angulations of the artery, usually causing some degree of luminal narrowing, but rarely producing hemodynamically significant stenosis Aging, atherosclerosis, and hypertension are considered predisposing factors (Figs 33.6 and 33.7 and Movie clip 33.1) The ICA enters the carotid canal in the temporal bone without giving off any branches in its cervical extracranial 668 Section 2: Echocardiography/Ultrasound Examination and Training A B C Figs 33.5A to C: Left side vessels (A) The left common carotid and left subclavian have independent origin in the aortic arch Threedimensional (3D) reconstruction courtesy of NYU Langone Medical Center Radiology Lab; (B) Diagram shows the origin and relationship of the anterior and posterior circulations; (C) 3D volume rendering computed tomography angiography (CTA) of the CCA and bifurcation The carotid bulb is evident in this view (CCA: Common carotid artery; ECA: External carotid artery; ICA: Internal carotid artery) Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU) and the middle cerebral artery, which are part of the Circle of Willis Posterior Circulation Fig 33.6: Morphological variants of internal carotid artery (ICA) elongation and tortuosity Diagram demonstrates the three most common types of curvatures and tortuosity of the ICA Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU) segment The ophthalmic artery and the posterior communicating artery are the main intracranial branches of the ICA Both constitute critical collateral pathways in the setting of significant stenosis or total occlusion of the cervical ICA After a short segment known as the supraclinoid ICA, the artery divides into the anterior cerebral artery The VAs arise from the posterosuperior aspect of the SAs, and they ascend in the neck within the transverse foramens of the cervical vertebrae C6 to C2—producing a characteristic imaging during color duplex interrogation— before entering the cranium through the foramen magnum VAs are frequently asymmetric In 50% of cases the left VA is larger and dominant, in 25% the right VA is larger, and in the remaining 25% they are codominant In a small fraction of patients, one of the vessels is hypoplastic or even absent.17 The basilar artery is a short vessel formed by the convergence of the intracranial segments of both VAs, at the base of the medulla oblongata, and which then courses the median groove of the pons The posterior inferior cerebellar arteries and the anterior inferior cerebellar arteries—branches of the vertebral and basilar arteries, respectively—provide blood flow to the lower medulla, pons, lower cerebellum, and fourth ventricle Chapter 33: Peripheral Vascular Ultrasound 669 B A C Figs 33.7A to C: Left ICA loop (A) Magnetic resonance angiography of the left carotid system demonstrate an “S” loop of the mid-distal ICA (within the yellow dotted circle); (B) Color duplex ultrasound image of the mid-distal ICA “S” loop of the left, obtained with a curvilinear C6-2 MHz transducer array This large footprint transducer provides a large field of view of the neck Movie clip 33.1 corresponds to this panel; (C) Corresponding computed tomography angiography (CTA) image of the “S” loop in the same orientation as the ultrasound image The black dotted arrow indicates a moderate stenosis in the carotid bulb (ECA: External carotid artery; IA: Innominate artery; ICA: Internal carotid artery; LCCA: Left common carotid artery; LSA: Left subclavian artery) Ultimately, the basilar artery bifurcates into the posterior cerebral arteries, which supply blood to the brain stem, superior cerebellum, and cerebral cortex The anterior and posterior circulations are interconnected at the base of the brain via the posterior communicating arteries, each of which connect its ipsilateral ICA with its ipsilateral posterior cerebral artery17,18 (Figs 33.8A and B) Collateral Pathways With advanced atherosclerosis, the capacity of the cerebral circulation to distribute flow becomes increasingly compromised However, whether neurological deficits appear depends partly on how well-developed the builtin reserve cerebral collateral circulation is The ability of the collateral pathways to supply blood depends not only on the age of the patient but also on the speed of the arterial occlusion This is because atherosclerotic disease may involve collateral pathways in older individuals; or the collateral vessels may not adapt fast enough in the case of sudden occlusions, such as those resulting from embolism.19 Several routes for collateral circulation have been described: The major intracranial collateral pathway of the brain is the “Circle of Willis.” Thomas Willis (1621–75) is credited with the first description of this structure—a large interarterial connection between the anterior and posterior circulations Several possible configurations of the Circle of Willis have been described in the human anatomy, and a complete ring is found in 1.5 mm as measured from the media–adventitia interface to the intima–lumen interface.”23 Plaques should be evaluated with high-resolution gray-scale images without color flow mapping Both longitudinal and transverse views are required to completely assess a plaque’s size and extension It is important to determine the location, size and extent of the plaque, as well as its thickness, echogenicity, and texture The degree of luminal narrowing produced by a plaque’s encroachment should also be assessed.36 Plaques may progress from small intraluminal protrusions lacking any significant hemodynamic effects to high degree stenosis or total occlusion of the vessel Larger carotid plaque size is associated with a higher risk of stroke and major adverse cardiovascular events In a 5-year prospective study of 1,600 patients, Spence et al found an adjusted relative risk of 2.9 for a combined stroke and acute coronary event end point in patients with large carotid plaque area.37 Based on ultrasonographic and histological correlations, plaques that are classified as echogenic have increased calcified and fibrous tissue; and those that are echolucent have higher lipid content, increased macrophage density, and a thin fibrous cap Studies have shown that the presence of echolucent (hypoechoic) plaques is highly predictive of stroke and cardiovascular events.37–39 In fact, the more echolucent a plaque appears on ultrasound, the more likely the patient will sustain a TIA or stroke in the future Surface irregularities and intraplaque hemorrhage are characteristics of complicated plaques While intraplaque hemorrhage is a marker of plaque inflammation and instability, its role as an independent predictor of future ischemic events is not well established35 (Figs 33.16A to D and Movie clips 33.6 and 33.7) Calcification is very common in carotid plaques Calcification provides the plaque with structural stability, making it less likely to rupture, and cause symptoms than a noncalcified plaque would be.40 Gray-scale images not reliably identify plaque ulceration But focal depression associated with irregularities in the plaque’s surface may suggest the presence of an ulcerated plaque, and color Doppler may help to demonstrate the ulceration (Figs 33.17A to F) The ultrasonic plaque classification used most frequently today is based on the Gray-Weale criteria Modified by Geroulakos in 1993, is known as the “Geroulakos classification”:41 Type 1: Uniformly echolucent plaque, with or without a visible thin fibrous cap Chapter 33: Peripheral Vascular Ultrasound A B C D 679 Figs 33.16A to D: Intraplaque hemorrhage and protruding plaque (A and B) Duplex ultrasound shows a small, nonobstructing echolucent plaque in the carotid bulb, with an anechoic area within (yellow arrow), very suggestive of intraplaque hemorrhage There is no hemodynamic disturbance of the blood flow as demonstrated by the absence of color flow acceleration and the presence of normal physiological turbulence Movie clip 33.6 corresponds to this panel; (C and D) Duplex ultrasound shows a heterogeneous, irregular protruding plaque in the carotid bulb in a patient admitted for recurrent transient ischemic attacks Note in Movie clip 33.7 the mobile component of this plaque Type 2: Predominantly echolucent plaque, < 50% of which contains echogenic areas Type 3: Predominantly echogenic plaque, < 50% of which contains echolucent areas Type 4: Uniformly echogenic plaque Type 5: Unclassified plaque in which heavy calcification and acoustic shadows precludes adequate visualization (Figs 33.18A to F) Ultrasound examination and plaque characterization are highly subjective The use of disparate gain, filter, and compression settings by different operators may result in poor reproducibility B-mode image normalization by computer-assisted measurements of plaque echodensity has helped to overcome this problem For the most part, this innovation remains a research tool used in the identification of vulnerable plaques and in large studies of carotid stenting But the software is expected to become commercially available for duplex scanners in the near future Grading Carotid Stenosis: How much is Severe? Internal Carotid Artery Stenosis The criteria for defining a hemodynamically significant ICA stenosis by duplex ultrasound have been debated for decades Digital angiography is still considered the 680 Section 2: Echocardiography/Ultrasound Examination and Training A B C D E F Figs 33.17A to F: Ulcerated plaque (A and B) The gray-scale and color flow images demonstrate a heterogeneous plaque in the posterior wall of the carotid bulb with a focal depression suggestive of ulceration (short red arrow) The color flow imaging shows helps to demonstrate the ulceration The Doppler interrogation in (C) demonstrates normal velocities There is no hemodynamically significant stenosis associated with this plaque; (D) The gray-scale and color flow images show a large, predominantly echolucent plaque in the posterior wall of the carotid bulb, with a deep depression and interruption of the fibrous cap (white long arrow) The color flow fills the cavity in (E), and shows evidence of flow disturbance characterized by a flow convergence (“pisa” flow) in the distal segment of the bulb; (F) demonstrates significant increase in systolic and diastolic velocities, consistent with moderate degree of stenosis Chapter 33: Peripheral Vascular Ultrasound A B C D E F 681 Figs 33.18A to F: The Geroulakos classification (A) Normal carotid bifurcation and carotid bulb free of disease; (B) Type 1: Uniformly echolucent plaque, with or without visible thin fibrous cap (C) Type 2: Predominantly echolucent plaque, 4.0 > 100 50%–69% ≥ 70% to near occlusion Near occlusion High, low, or undetec able Visible Variable Variable Total occlusion Undetectable Visible, no detectable lumen N/A N/A (CCA: Common carotid artery; EDV: End-diastolic velocity; ICA: Internal carotid artery; PSV: Peak systolic velocity; ICA/CCA PSV ratio: Internal carotid artery to common carotid artery peak systolic velocity ratio) A 70% include ICA/CCA PSV ratio > and ICA EDV > 100 cm/s While the EDV threshold value is very suggestive of lesions > 70%, this parameter is not very sensitive because EDV varies with the heart rate and other systemic factors (Figs 33.23A to E and Movie clips 33.10 to 33.13) As the degree of luminal narrowing increases, the increase in the intrastenotic flow velocity becomes the most important direct criterion for diagnosing a flowlimiting lesion The ICA/CCA ratio and the EDV velocity increase as well However, as the lesion progresses in severity, the resistance through the tight stenosis greatly affects the blood flow, causing a paradoxical low flow velocity (“string sign”) This corresponds to the critical Grade III–IV stenosis in the Spencer’s curve, wherein significant decreases in the flow velocity and blood flow volume occur with >80% diameter stenosis (or more than 95% in cross-sectional area stenosis).48 In cases of near occlusion of the ICA, the diagnostic velocity parameters may not apply, and velocities may be high, low, or undetectable This diagnosis is therefore established primarily by demonstrating a markedly narrowed lumen with color or power Doppler ultrasound Total occlusion of the ICA should be suspected when there is no detectable patent lumen on grayscale ultrasound and no flow with spectral, power, or color Doppler modalities MRA, CTA, or conventional angiography may be used for confirmation in this setting Validation of the 2003 Carotid Duplex SRU Consensus Criteria During a 3-year period, AbuRahma et al analyzed 376 carotid arteries, for which both duplex examinations and digital angiography were available Duplex scans were interpreted in accordance with the 2003 SRU Consensus Criteria for carotid artery stenosis, and arteriographic evaluations were performed using the NASCET method The study found that the consensus criteria had a sensitivity (Sn) of 93%, a specificity (Sp) of 68%, and an overall accuracy (OA) of 85% for detecting an angiographic stenosis in the range of 50–69% The authors concluded that the consensus criteria for diagnosing 50–69% stenosis could be significantly improved by using an ICA PSV of 140–230 cm/s (instead of 125–230 cm/s), which would have provided a Sn of 94%, a Sp of 92%, and an OA of 92% The consensus criteria performed well for stenosis ≥ 70%, with a Sn of 99%, a Sp of 86%, and an OA of Chapter 33: Peripheral Vascular Ultrasound A B C D 685 Figs 33.20A to D: Carotid bulb plaque with 70% stenosis (A) There is a large, heavily calcified plaque in the posterior wall of the carotid bulb, right at the origin of the ICA Movie clips 33.10 and 33.11 demonstrate significant luminal reduction and high aliasing flow during both systole and diastole, indicating high velocities at the stenosis during the entire cardiac cycle There is also evident poststenotic turbulent flow Movie clip 33.12 is a transverse view of the carotid bulb showing similar the heavily calcified plaque and the high velocity flow across the residual lumen; (B) The Power Angio mode enhances the flow across the stenosis and in the remaining ICA, which matches exactly to the three-dimensional computed tomography angiography (3D CTA) reconstruction shown in Figure E Movie clip 33.13 corresponds to this figure (C and D) The duplex study exhibits a peak systolic velocity in the distal CCA of 85 cm/s, and a peak systolic velocity in the ICA of 410 cm/s The carotid artery/common carotid artery (ICA/ CCA) ratio is 4.8 (>4.0), and the end diastolic velocity in the ICA is 105 cm/s This data is consistent with severe >70% stenosis in the carotid bulb (CCA: Common carotid artery; ECA: External carotid artery; EDV: End-diastolic velocity; ICA: Internal carotid artery; PSV: Peak systolic velocity) contralateral high-grade carotid stenosis or occlusion, and this overestimation appears to be proportional to the severity of the contralateral disease.53,54 The increased velocities may be a consequence of increased collateral flow that is thought to represent a compensatory mechanism in the ipsilateral carotid system aimed at maintaining a stable cerebral circulation via the Circle of Willis.54–56 This phenomenon must be considered when applying established duplex velocity criteria to an ICA stenosis, as high velocities may be misconstrued as reflecting a higher degree of stenosis than is actually the case Assessment after Carotid Artery Endarterectomy and Stenting The traditional standard of care in treating cervical carotid artery occlusive disease has been CEA, a procedure initially described in the 1950s by Scott, DeBakey, and Cooley In 1991, landmark NASCET demonstrated a reduction in stroke and death rates at years from 26% to 9% after endarterectomy Since then, several other studies have suggested the superiority of the surgical approach to medical therapy for stenosis > 70% In the 1980s, angioplasty was pioneered for cervical carotid artery disease treatment, and the subsequent introduction of stent technology advanced nonsurgical interventional management of carotid artery disease At present, there are two randomized clinical trials and six registries evaluating the safety and efficacy of carotid artery stenting (CAS).57 Recently, the CREST trial showed that stenting and endarterectomy result in similar rates of the primary composite outcome (stroke, myocardial Chapter 33: Peripheral Vascular Ultrasound 689 C A B D Figs 33.24A to D: Occlusion of the ICA (A) The color duplex image of the right carotid bifurcation demonstrates a large heterogeneous plaque filling the entire carotid bulb There is no flow across the ICA, which is occluded Movie clips 33.14 and 33.15 correspond to this figure; (B) Shows two cross-sectional views of the bifurcation demonstrating patency of the ECA, and the occlusion of the ICA (white arrows); (C) The ECA has increased compensatory flow velocity (“internalization of the ECA”) The temporal tap helps to confirm its identity and patency The yellow arrows indicate the fluctuations in the baseline tracing of the ECA; (D) The brain computed tomography angiography (CTA) in this patient shows total or near total occlusion of the right ICA A diminutive segment of the right middle cerebral artery (black arrow) is filled via Circle of Willis collaterals, and the right anterior cerebral artery (blue arrow) is filled via the anterior communicating artery The left middle cerebral artery (yellow arrow) is of normal caliber (ECA: External carotid artery; ICA: Internal carotid artery) infarction, and death) among men and women with either symptomatic or asymptomatic carotid stenosis.58 Duplex ultrasound is a reliable tool for surveillance post carotid artery endarterectomy and CAS , and criteria have been established for follow-up of both interventions However, the timing and frequency of postintervention studies remains controversial Several published reports have shown that most cases of restenosis occur within the first years after CEA, and recommend an initial survey months after surgery.59–61 Following CEA, the intima-media layer at the surgical site is not seen An “intimal step” at the proximal end is often seen, followed by bright reflectors in the anterior wall, which arise from the arteriotomy closure sutures Persistent flow disturbances and high velocities are usually the result of residual plaque and stenosis, which may be attributable to technically inadequate surgery that may have been prevented with placement of a synthetic or vein patch Restenosis at the surgical site within the first year is usually due to neointimal proliferation (overgrowth of smooth muscle and fibrous tissue in place of the striped intima-media following carotid intervention) In contrast, recurrence seen years after CEA is usually due to the uninterrupted process of atherosclerosis Duplex ultrasonography is the standard technique for surveillance after CEA In 2011, AbuRahma reported follow-up in 200 patients who had undergone CEA 690 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 33.25A to D: Carotid stenting (A) Severe left ICA stenosis confirmed by CT angiography The white arrow indicated the large plaque in the carotid bulb with small residual lumen Movie clips 33.16 and 33.17 correspond to this figure; (B) Spectral velocity analysis shows the increased peak systolic and end-diastolic velocities in the ICA, with a carotid artery/common carotid artery (ICA/CCA) ratio of 4.8, consistent with severe >70% stenosis in the left carotid bulb; (C) The patient underwent angiography and carotid stenting with adequate lumen postintervention Movie clip 33.18 shows the significant lesion in the left carotid bulb, and Movie clip 33.19 exhibits adequate residual lumen after stent deployment (ICA: Internal carotid artery); (D) The color duplex ultrasound post intervention shows the stent (white arrows) with normalization of the vessel lumen and velocities with patching during a recent 2-year period PSVs, EDV, and ICA/CCA ratios were correlated with angiography (ICA PSVs of ≥ 130 cm/s underwent carotid CTA and/or conventional carotid arteriograms to confirm the presence of post-CEA stenosis) The findings were:62 • An ICA PSV > 213 cm/s optimally detected restenosis ≥ 50% with a Sn of 99%, Sp of 100%, and OA of 99% An ICA EDV > 60 cm/s had a Sn, Sp, and OA of 93, 97, and 93%, respectively for detecting ≥ 50% restenosis A PSV ICA/CCA ratio > 2.3 optimally detected restenosis of ≥ 50% • An ICA PSV > 274 cm/s was optimal for identifying ≥ 80% restenosis with a Sn of 100%, Sp of 91%, and OA of 100% An ICA EDV > 94 cm/s had a Sn, Sp, and OA of 98, 100, and 98%, respectively for detecting ≥ 80% restenosis A PSV ICA/CCA ratio > 3.4 was best for identifying restenosis ≥ 80% It must be noted that the placement of a stent in a carotid artery alters the mechanical properties of the vessel, producing higher velocities in the absence of residual stenosis or technical error Because the reduced Chapter 33: Peripheral Vascular Ultrasound compliance of a stented carotid artery may produce falsely elevated velocities relative to the native nonstented carotid artery, established ultrasound criteria for ICA stenosis are not appropriate for assessing restenosis after CAS.63 The incidence of carotid restenosis may vary widely depending on the definition of restenosis and the method used to calculate the degree of stenosis While several groups have proposed restenosis criteria, to date there is no consensus regarding what constitutes significant restenosis AbuRahma et al have confirmed the need for revised velocity criteria in stented carotid arteries They reported on 144 patients who had undergone CAS as part of clinical trials Follow-up consisted of carotid duplex ultrasound immediately after and month after stenting, as well as every months thereafter Patients whose ICA PSVs were > 130 cm/s underwent carotid computed tomography (CT) or angiography to corroborate the presence of stenosis In this study, the PSVs, EDVs, and ICA/CCA ratios were recorded, and ROC analysis was used to determine the optimal velocity criteria for the diagnosis of angiographic in-stent restenosis of ≥30%, ≥50%, and ≥80%.64 • To detect a stenosis of at least 30%, an ICA PSV of > 154 cm/s was optimal with a Sn of 99%, Sp of 89%, and OA of 96% An ICA EDV of 42 cm/s had a Sn, Sp, and OA of 86, 62, and 80%, respectively An ICA/CCA ratio of 1.5 was optimal • To identify a stenosis > 50%, an ICA PSV of >224 cm/s was optimal with a Sn of 99%, Sp of 90%, and OA of 98% An ICA EDV of 88 cm/s had Sn, Sp, and OA of 96, 100, and 96%, respectively An ICA/CCA ratio of 3.5 was optimal • To diagnose a >80% stenosis, an ICA PSV of > 325 cm/s was optimal with a Sn of 100%, Sp of 99%, and OA of 99% An ICA EDV of 119 cm/s had Sn, Sp, and OA of 99, 100, and 99%, respectively An ICA/CCA ratio of 4.5 was optimal For all strata, the PSV of the stented artery was a better predictor of in-stent restenosis than the end-diastolic velocity or ICA/CCA ratio In 2008, Lal et al reported similar findings after reviewing 255 CAS procedures Available for analysis were 189 pairs of duplex ultrasound and either carotid angiography (29) or CT angiogram (99), during a median follow up of 4.6 years post-stenting.65 691 Residual stenosis after CAS was defined as ≥ 20% luminal reduction, the presence of in-stent restenosis was defined as ≥ 50% luminal reduction, and hemodynamically significant high-grade in-stent restenosis was defined as ≥80% luminal reduction ROC analysis demonstrated the following optimal threshold criteria: • For residual stenosis > 20%, PSV > 150 cm/s, and ICA/ CCA ratio > 2.2; • For in-stent restenosis > 50%, PSV > 220 cm/s, and ICA/CCA ratio > 2.7; and, • For in-stent restenosis > 80%, PSV 340 cm/s, and ICA/ CCA ratio > 4.2 While both types of studies have limitations, these criteria are guidelines that may suggest the need for additional imaging when in-stent restenosis is suspected With the exponential rise in carotid stenting, intrastent restenosis is expected to become increasingly prevalent, and these patients will require close monitoring and ultrasound follow-up Until new standardized duplex ultrasound criteria for CAS are established, follow-up velocities must be compared with earlier results after stenting Persistent or recurrent elevation of PSVs may indicate progressive in-stent carotid restenosis and should warrant further investigation and appropriate clinical management.64,65 Furthermore, because variants in the observed velocities may result from biomechanic alterations in the stented artery, it is possible that future modifications in stent composition and design may result in different velocity profiles Whether or not these changes will be important enough to merit further revisions in the velocity criteria thresholds remains unknown65 (Figs 33.26A to D and Movie clips 33.16 to 33.19) Assessment of the Vertebral Arteries The VAs provide approximately 20% of the total cerebral blood flow, and the vertebrobasilar system is not an uncommon site for acute ischemic events However, the understanding of the mechanism of ischemia in the posterior circulation is less developed and there are fewer studies validating the diagnostic criteria for significant vertebrobasilar lesions than there are confirming the diagnostic criteria for carotid disease.66 Nonetheless, Doppler interrogation of the proximal SAs and the extracranial portion of the VAs are integral parts of the cervical artery duplex ultrasound study and not infrequently a source of interesting hemodynamic findings 692 A Section 2: Echocardiography/Ultrasound Examination and Training B C D Figs 33.26A to D: Vertebral artery and subclavian stenosis (A) Normal vertebral artery spectral Doppler waveform: sharp systolic upstroke followed by forward diastolic flow There is no evidence for significant stenosis in the proximal subclavian artery (or innominate artery in the right side); (B) Latent or partial subclavian steal The vertebral Doppler waveform shows an early, rapid deceleration or “systolic dip” (yellow arrow), followed by a second more rounded diastolic forward flow (white arrow) This corresponds to a moderate degree of subclavian artery stenosis; (C) Bidirectional “to-and-fro” flow in the vertebral artery is seen with higher degree of stenosis in the ipsilateral subclavian artery There is systolic reversal of flow in the vertebral artery (yellow arrow), followed by antegrade diastolic flow (white arrow); (D) Complete retrograde flow in the vertebral artery is seen with complete occlusion or near-occlusion of the ipsilateral subclavian artery As mentioned earlier, the VAs are frequently asymmetric In 50% of patients the left VA is dominant, in 25% the right VA is larger, and in the remaining 25% the two vessels are codominant Examination should be performed in multiple planes, to accurately demonstrate patency and direction of the flow Almost all atherosclerotic stenosis of the VA occurs at its origin, making it crucial to follow the artery lower in the neck A PSV > 100 cm/s usually suggests a ≥50% stenosis High-grade stenosis is diagnosed when there is a marked increase in PSV of >150 cm/s Since there is wide variation in flow volume across these vessels, and velocities through the VAs are affected by differences in caliber (some vessels even being hypoplastic), the diagnosis of stenosis may be challenging This is often of limited clinical impact since collateralization from the spinal arteries and contralateral VA tend to protect against posterior circulation ischemic insult.67 Of greater hemodynamic significance is the presence of subclavian steal syndrome—flow reversal in one of the VAs in the setting of significant stenosis or occlusion of the ipsilateral proximal SA With significant stenosis in the SA, the pressure in the arm distal to the stenosis becomes lower than the pressure in the vertebral system During systole, flow proceeds retrograde in the VA into the distal SA In diastole, the gradient across the lesion is low and the pressure in the distal SA increases Antegrade flow in the VA follows, producing a characteristic bidirectional Doppler waveform.20 Symptoms suggesting transient posterior circulation ischemia may be occur, but the subclavian steal phenomenon seldom leads to cerebrovascular events.66 The severity of the subclavian steal syndrome varies with the degree of the occlusive process in the SA and the relative role of the VA in supplying collateral flow to the arm Several waveforms have been described indicating different grades of subclavian steal:20,67–69 • A latent or partial subclavian steal is characterized by antegrade flow with an early systolic “dip” in the vertebral Doppler waveform, followed by a second more rounded systolic peak, and subsequent forward diastolic flow This so-called “bunny rabbit waveform” (because of its resemblance to the profile of a rabbit) generally corresponds to a SA of ≥50% stenosis A high velocity jet created by the proximal ipsilateral Chapter 33: Peripheral Vascular Ultrasound SA lesion, leads to a pressure drop in the VA, and the resulting transient siphoning of flow from the contralateral VA, producing this sharp deceleration after the first systolic upstroke A “retrograde” dip in midsystole indicates a more severe stenosis in the SA • With higher degrees of SA stenosis, there is greater deceleration of flow in the VA This produces a characteristic bidirectional “to-and-fro” flow, with initial retrograde systolic flow toward the arm, and subsequent antegrade diastolic flow toward the brain The alternating Doppler signal indicates a high-grade ipsilateral SA stenosis • Complete retrograde flow in the VA is seen when there is complete occlusion or near-occlusion of the ipsilateral proximal SA (Figs 33.26A to D) Subclavian steal syndrome can be caused by a lesion in either SA It is important to note, however, that on in the right side, when there is a significant stenosis or nearocclusion in the innominate artery, a “parvus and tardus” Doppler waveform (diminished amplitude and rounding of the systolic peak with delayed or prolonged systolic acceleration) will be seen in the right CCA as well The flow in the ipsilateral VA will exhibit either bidirectional or the parvus and tardus characteristics, depending on the state of the contralateral VA A significant stenosis in the origin of the left CCA will result in a dampened monophasic waveform in the cervical segment of the vessel, with a typical parvus and tardus spectral display Any of the above findings during examination of the cervical arteries warrants thorough Doppler interrogation of the aortic arch vessels as described earlier in this chapter In our experience, sonographers skilled in both adult echocardiography and vascular studies are better equipped to understand the significance of these hemodynamic riddles and to perform a more comprehensive examination of the entire supra-aortic circulation (Figs 33.27A to D) Cardiac Pathology and Carotid Ultrasound Findings During a routine carotid duplex study, atypical flow patterns not related to peripheral vascular disease may be encountered Although, as echocardiographers, we have a thorough knowledge and understanding of cardiac disease entities, their hemodynamic alterations to flow in 693 the cervical arteries may lead to faulty interpretation of the peripheral arterial studies, if the association between the two is not established during the examination • Aortic stenosis: The flow pattern of a normal carotid artery usually has a fast upstroke with rapid acceleration time, a prominent dicrotic notch, and a diastolic wave Mild to moderate aortic stenosis is unlikely to affect the carotid and subclavian velocity profiles In patients with severe aortic stenosis, however, increased acceleration time, decreased peak velocity, delayed upstroke, and rounded waveforms may occur in the common carotid and SAs When disease is not present in the cervical arteries, the presence of “parvus and tardus” changes in the cervical arteries should alert the examiner to the possibility of aortic stenosis The velocity profile of the internal carotid arteries does not seem to be affected.70 • Aortic insufficiency: Retrograde diastolic flow has been described in the ascending, descending, and abdominal aorta in patients with severe aortic regurgitation Diastolic reversal of flow is always an abnormal finding in the carotid arteries, and it has been reported in patients with severe aortic insufficiency and with patent ductus arteriosus The vessels most likely to exhibit diastolic reversal of flow are the proximal SAs, and to some extent, the common and external carotid arteries, presumably because they supply vascular beds with high resistance In contrast, the ICA flow is directed to a low resistance bed, and while it may show decreased antegrade diastolic flow, it is unlikely to exhibit diastolic reversal of flow The presence of a “bisferiens pulse” (two distinct systolic peaks) in the CCAs may also suggest significant aortic regurgitation However, a similar Doppler pattern may be seen in the carotid arteries of patients with hypertrophic obstructive cardiomyopathy and significant left ventricular outflow tract gradients.71 • Intra-aortic balloon pump: An IABP will limit the Doppler evaluation of the carotid arteries As the balloon inflates and deflates with each cardiac cycle (1:1 setting), it creates a second, typically higher peak that coincides with diastolic balloon counterpulsation The disruption of blood flow by the balloon, thus precludes the use of standard velocities and waveforms in the assessment of carotid stenosis22,72 (Figs 33.28A to D) • Left Ventricular Assist Device (LVAD): LVADs are increasingly being implanted for heart failure 694 Section 2: Echocardiography/Ultrasound Examination and Training A C B D Figs 33.27A to D: Subclavian steal syndrome This is part of the study performed in a 72-year-old man, referred for a transthoracic echocardiogram, to assess the degree of aortic stenosis after a significant murmur was heard during routine examination The twodimensional (2D), color flow, and Doppler evaluation of the aortic valve did not reveal significant pathology (A) During color flow and Doppler interrogation of the aortic arch and great vessels, high velocity flow is found in the innominate artery; (B) The sonographer then proceeds to evaluate the right side cervical arteries During a transverse scan of the neck, the CCA and the vertebral artery exhibit opposite flow direction (CCA in red and vertebral artery in blue) during systole Indicated by the yellow arrows there is evidence for systolic reversal of flow in the right vertebral artery (bidirectional “to-and-fro” flow), consistent with subclavian steal syndrome; (C) The right CCA and the distal right subclavian artery exhibit characteristic “parvus and tardus” spectral Doppler tracings, which in fact strongly suggests the location of the lesion in the innominate artery (the innominate artery divides into the right common carotid and right subclavian arteries); (D) Magnetic resonance angiography of the aortic arch and great vessels confirm the presence of a severe stenosis in the innominate artery (yellow arrow) (CCA: Common carotid artery) Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU refractory to medical therapy—as bridges to myocardial recovery, or cardiac transplantation, or as destination therapy for patients who are not candidates for heart transplant The HeartMate II is the device most frequently used in our institution Doppler waveforms in the carotid and VAs resemble “parvus and tardus” flow, being characterized by monophasic flow with dampened PSV, round-shaped systolic peak, and prolonged acceleration.73 The marked alteration in waveform morphology and velocities created by the device renders the diagnosis of stenosis impossible by velocity criteria Sonographers should, therefore, emphasize the gray-scale features to elucidate the presence of carotid disease ULTRASOUND DIAGNOSIS OF FEMORAL ACCESS COMPLICATIONS In the last decade, medicine has witnessed an exponential growth in percutaneous coronary, peripheral arterial, and now structural heart disease interventions, as well as cardiac electrophysiology procedures The common femoral artery and vein continue to be the preferred and most commonly used access sites for the performance of these techniques Although the use of arterial closure devices has increased the safety of vascular cannulation, femoral access-site complications remain a major cause of morbidity, patient discomfort, and prolonged length of hospital stay Chapter 33: Peripheral Vascular Ultrasound 695 A B C D Figs 33.28A to D: Cardiac pathology and carotid Doppler findings (A) In the absence of significant disease in the cervical arteries, the finding of “parvus and tardus” Doppler waveforms in several vascular territories in the neck suggests the possibility of severe aortic stenosis as cause of the altered tracings Note the significant delay and round shape of the systolic upstroke, and the prolonged deceleration; (B) Patient with severe aortic regurgitation exhibits diastolic reversal of flow in the descending thoracic aorta and in the subclavian artery (white arrows) The common carotid artery may show cessation of the forward diastolic flow (as shown in this particular case in [B]) or reversal of flow; (C) Spectral Doppler tracing in a patient with an intra-aortic balloon pump After the initial systolic upstroke (white arrow), there is a second, typically higher peak (red arrow) that coincides with diastolic balloon counterpulsation There is a third, short, retrograde waveform, which coincides with balloon deflation (dotted arrow) A simultaneous electrocardiogram tracing helps to correlate events and differentiate from premature atrial or ventricular activity (D) Duplex ultrasound has become the “gold standard” and first-line diagnostic imaging modality to assess for vascular access-site complications, particularly those using the femoral approach It is important that physicians caring for patients returning from the catheterization laboratory be able to recognize the presentation and ultrasonographic features of the most common postprocedural complications, and be mindful of the different treatment options The overall incidence of vascular access-site complications ranges broadly from 0.7% to 9% This wide variation is related to whether the procedures are purely diagnostic or include therapeutic interventions Prolonged interventions, the use of larger sheath size, and the aggressive use of antiplatelets agents and anticoagulants, make hemostasis more difficult to achieve, and result in an increased incidence in complications at the puncture site.74 696 Section 2: Echocardiography/Ultrasound Examination and Training Vascular complications can be divided into:75 • Minor complications: – Minor bleeding – Ecchymosis – Stable small hematomas • Major complications: – Pseudoaneurysm – Arteriovenous (AV) fistulas – Large hematomas requiring transfusion – Retroperitoneal hematoma – Arterial dissection – Infection – Thrombosis – Limb ischemia Several patient and procedure-related risk factors may contribute to the development of complications at the femoral access site.75–77 • Patient-related risk factors: – Older age – Female gender – Obesity or low body weight – Peripheral vascular disease – Hypertension – Chronic renal failure – Low platelet count • Procedure-related risk factors: – High puncture site (above the inguinal ligament) – Low puncture site (below common femoral bifurcation) – Through-and-through puncture/multiple punctures – Prior catheterizations at the same site – Large sheath size – Concomitant venous sheath – Prolonged procedure time – Long indwelling sheath time – Use of antiplatelet therapy (ASA, clopidogrel, GPIIb/IIIa, etc.) – Use of anticoagulants – Inadequate postprocedure compression to achieve hemostasis – Premature ambulation Bleeding and hematoma are the most common complications of the transfemoral approach They may occur during the intervention because of failed puncture of the artery, during sheath removal, or subacutely hours after the procedure.77 Ecchymosis and small hematoma are common They are often superficial, originate from the anterior aspect of the vessel, and generally resolve spontaneously over a few weeks as the blood degrades and by-products are reabsorbed However, persistent uncontrolled bleeding can lead to large hematomas with significant swelling and discomfort in the femoral region, and may take several weeks or months to resolve (Figs 33.29A to C and Movie clips 33.20–33.23) Large hematomas can cause compression of the femoral or iliac veins leading to lower extremity edema or even deep venous thrombosis, and femoral nerve compression may result in muscle weakness Bleeding from a high arterial puncture above the inguinal ligament or a deep puncture after posterior transfixion of the artery may have catastrophic consequences if overlooked Retroperitoneal bleeding is a life-threatening complication that has been reported to occur in 0.12–0.44% of percutaneous interventions,78 and should be suspected in any postcatheterization patient who develops ipsilateral flank, abdominal or back pain, profound hypotension, or a drop in hematocrit without a clear source The retroperitoneal space can accommodate an enormous amount of blood before local signs become manifest or hemodynamic deterioration occurs.75,76 A pseudoaneurysm is a collection of blood and thrombus encapsulated by the adjacent soft tissue that remains connected to the artery by way of a neck created by the needle track The reported incidence of pseudoaneurysm is 0.5–1.5% after diagnostic catheterizations and 2.1–6% following interventional procedures It has been found to be as high as 7.7% when duplex examinations are routinely performed after all procedures.79–82 Pseudoaneurysm usually originates at the site of femoral access and is associated with punctures below the bifurcation of the common femoral artery, difficult hemostasis due to lack of bony structures beneath the superficial and profunda arteries, and inadequate compression The clinical presentation is usually that of an enlarging painful mass in the groin area surrounded by extensive ecchymosis On examination, there is typically a palpable, tender, pulsatile mass, with or without a systolic bruit, but the presenting signs vary The presence of a palpable ‘thrill” or auscultation of a continuous bruit over the groin should raise concern for coexistent AV fistula.83 Any clinical suspicion warrants further investigation with ultrasound Color duplex ultrasound is considered the modality of choice to establish the diagnosis of femoral pseudoaneurysm and is nearly 100% accurate The Sn of Chapter 33: Peripheral Vascular Ultrasound 697 B A C Figs 33.29A to C: (A) Hematoma after femoral artery access; (B and C) These large field of view images from a C6-2 MHz curvilinear transducer demonstrate normal superficial femoral artery and vein, with no connection to the hematoma (no residual tract) The hematoma is completely thrombosed Movie clips 33.20 and 33.21 demonstrate normal common femoral artery and vein, with no evidence of AV fistula Movie clips 33.22 and 33.23 demonstrate normal superficial femoral artery and vein in longitudinal and transverse scan, with no visible tract connecting with the thrombosed hematoma Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU duplex ultrasound to identify pseudoaneurysm is 94% with a Sp of 97%.84 Typically, the patient is placed supine with the ipsilateral leg externally rotated to better expose the groin area A 5–7 MHz linear array transducer may be used, but extensive soft tissue edema may limit resolution A curved array probe with lower frequency is therefore preferable to improve penetration and create a larger field of view.85 As with any other vascular structure, both longitudinal and transverse views of the external iliac and femoral arteries and veins should be obtained We recommend starting exploration high in the external iliac territory and moving downward toward the proximal superficial and profunda femoral artery and veins Adequate spectral Doppler samples of both arteries and veins should be obtained Even when the presumptive diagnosis is pseudoaneurysm, the coexistence of other complications must be excluded The characteristic features of a pseudoaneurysm by duplex ultrasonography are best described as three main structures:83,85 The false aneurysm sac—an irregular, occasionally multilobulated, vascularized cavity that usually measures 3–6 cm (but is sometimes larger), containing a swirling pattern of flow The location of the cavity and presence of thrombus should be noted, and the size measured in at least two dimensions It is not uncommon for more than one or two interconnected chambers to be seen The neck—an irregular, cylindrical tract that connects the cavity with the artery A pathognomonic feature exhibited by the neck, when interrogated with pulsed wave Doppler, is a “to-and-fro” flow This characteristic spectral Doppler pattern reflects the changes within the cardiac cycle: In systole, the pressure in the artery is higher than the pressure in the sac, directing the flow toward the false aneurysm cavity In diastole, the pressure in the sac is 698 Section 2: Echocardiography/Ultrasound Examination and Training B A C D Figs 33.30A to D: Pseudoaneurysm after femoral artery access (A) Duplex ultrasound with Power Angio show the three components of a pseudoaneurysm, (S) the aneurysmal sac, (N) the neck or needle tract, and (A) the feeding artery; (B) Shows the aneurysmal sac with typical swirling of flow Movie clips 33.24 and 33.25 correspond to this figure; (C) These gray-scale and color flow images show an irregular tract that constitutes the neck of the pseudoaneurysm and (D) demonstrates the characteristic “to-and-fro” flow during Doppler interrogation: in systole, the pressure in the artery is higher than the pressure in the sac; therefore, the flow is toward the aneurysmal sac During diastole, the flow is directed backward toward the artery Movie clips 33.26 and 33.27 demonstrate the typical “to-and-fro” flow through an irregular neck created by the needle tract Courtesy: Illustration created by Melissa LoPresti and Robert Spencer, NYU higher than the pressure in the feeding artery, so the flow empties from the cavity The identification of such a high pulsatility tract makes the diagnosis of pseudoaneurysm a certainty It is essential to record the length and the width of the neck, since both have therapeutic implications.86 The feeding artery—usually the common femoral or superficial femoral artery The disruption of all three layers of the artery happens more often in the anterior aspect of the vessel, but is not uncommon in cases of posterior transfixion of the artery for the tract to have a deeper trajectory In such cases, the diagnosis of pseudoaneurysm may become more challenging Careful attention should be paid to the depth of the field of view, so deep tracts and cavities are not overlooked In cases in which access was difficult and multiple puncture attempts were required, more than one tract may be found (Figs 33.30A to D and Movie clips 33.24 to 33.27) Small pseudoaneurysms (3 cm or less) in asymptomatic patients can be followed up with serial ultrasound examinations, as they usually spontaneously close within few weeks Toursarkissian et al followed up 286 lesions including 196 pseudoaneurysms, 81 AV fistulae, and combined lesions They reported spontaneous closure of the pseudoaneurysm in 86% of the patients who were selected for conservative management.87 Several other small studies have shown similar results In the literature, there are no specific duplex ultrasound findings described other than size < cm, as valid predictor of spontaneous resolution Larger pseudoaneurysms (> cm or expanding hematomas), combined lesions, or patients who are symptomatic or require chronic anticoagulation should be managed with a different strategy Chapter 33: Peripheral Vascular Ultrasound In 1991, Fellmeth et al described the use of ultrasoundguided compression—a nonsurgical approach for those patients who are not eligible to be managed conservatively.88 The technique consists of the manual compression of the pseudoaneurysm by a physician or an experienced sonographer under direct ultrasound visualization It is recommended the use of a MHz curvilinear probe, which provides a wide and deep field of view, and facilitates the task of exerting continuous pressure Pressure to the cavity and the neck of the pseudoaneurysm should be applied for about 10–15 minute intervals, until the “to-and-fro” flow is completely stopped Careful attention should be paid to ensure adequate flow in the femoral artery while preventing flow into the pseudoaneurysm; however, some degree of compression of the artery may be unavoidable After completion of the first interval, the pressure is slowly released and blood flow into the lesion is reassessed If there is persistent flow through the neck, the same procedure may be repeated once or twice until thrombosis of the neck and pseudoaneurysm is accomplished or it exceeds a discretionary failure time In general, patients should be given analgesia or sedation before procedure to minimize the discomfort created by exerting pressure in the affected groin area.83,85,86 The success rate for ultrasound-guided compression ranges from 60% to 90%, but in patients who are on anticoagulation therapy, complete resolution can be achieved only in 30–75% of the cases.89,90 The most important predictors of successful treatment are the size of the pseudoaneurysm, and the length and width of the neck Larger aneurysm sacs, and short and wide tracts have the least rate of success A major disadvantage of ultrasound-guided compression is the time to achieve obliteration It has been reported in compression times exceeding hour81 (Figs 33.31A and B) Another technique—ultrasound-guided thrombin injection—is a safe alternative to ultrasound-guided compression therapy, and it has been used frequently since first described by Cope and Zeit in 1986.91 A 0.1–0.3 mL saline dilution of 1000 U/mL bovine thrombin is slowly injected into the pseudoaneurysmal sac under direct ultrasound visualization Thrombosis of the pseudoaneurysm cavity is achieved, usually, within 5–10 seconds after injection Complete obliteration of the sac should be confirmed by color-flow Doppler, as well as patency of the femoral artery and vein In general, an interventionalist or a vascular surgeon performs this 699 procedure It is very important to position the needle tip just inside the sac, and as far as technically possible away from the neck, to avoid forcing thrombin into the tract and therefore into the femoral artery.83 Embolization to the femoral artery following thrombin injection has been reported in