Ebook Comprehensive textbook of echocardiography (Volume 1): Part 2

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 2 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 8 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 5 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 8 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 8 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
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. Little SH. Three-dimensional echocardiography to quantify
mitral valve regurgitation. Curr Opin Cardiol. 2012;27(5):
477–84.
9. 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 do 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 0 (normal) to 4 (severely
abnormal). A normal MV, thus, has a score of 0. 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 5 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