The role of 3D echocardiography in the assessment of valvular heart disease

Points to remember

• 3D echocardiography is an emerging modality with a diverse array of clinical applications, including assessment of valvular heart disease.
• Intraoperative transesophageal echocardiography during mitral valve surgery provides views of the mitral valve either from the left atrial perspective (surgeon's view) or from the left ventricular perspective.
• 3D echocardiography can be helpful in identifying whether pacemaker or intracardiac defibrillator leads contribute to tricuspid regurgitation.

Three-dimensional (3D) echocardiography is one of several emerging modalities to define cardiac anatomy and function. Although still in evolution, 3D echocardiography can complement current 2D echocardiographic techniques in the assessment of valvular heart disease.

3D planimetry for mitral stenosis with cut planes identified

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3D planimetry for mitral stenosis showing mitral valve area trace

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In a way not possible with 2D echocardiography, 3D echocardiography can allow images to be viewed at different angles that improve the visualization of cardiac structures. Image resolution remains a concern for transthoracic 3D imaging, but the recent development of 3D transesophageal echocardiography (TEE), either real-time or reconstructed, has made image resolution less of an issue.

Development of 3D echocardiography has made vast contributions to the understanding of mitral valve function. Although in the majority of patients with mitral stenosis, comprehensive 2D and Doppler echocardiography is sufficient; several clinical trials have demonstrated that 3D echocardiographic mitral valve planimetry can provide better correlation with an invasively determined mitral valve area.

With the advent of real-time 3D TEE, rapidly obtainable views of the mitral valve, either from the left atrial perspective (surgeon's view) or from the left ventricular perspective, are now possible with intraoperative TEE during mitral valve surgery.

Flail mitral valve posterior leaflet (middle scallop, P2)

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Long-axis 2D TEE view of aortic valve perforation

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Aortic valve perforation seen using 3D TEE

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Mayo Clinic cardiologists have demonstrated the incremental value of 3D TEE in the recognition of mitral valve surgical pathology during operative repair. This benefit is especially true with respect to mitral valve anterior leaflet pathology and with commissural disease. Although 2D TEE remains an excellent method for the assessment of mitral valve disease, 3D TEE allows for a more rapid assessment of surgical pathology and can increase diagnostic confidence.

Cardiologists at Mayo Clinic were among the first to report on the superiority of 2D TEE over transthoracic echocardiography for the diagnosis of complications of endocarditis. 3D TEE may also be useful in this setting by allowing for better visualization of leaflet perforations as well as a clearer description of adjacent cardiac structures.

Finally, 3D echocardiography can help identify whether pacemaker or intracardiac defibrillator leads are contributing to tricuspid regurgitation, something that can be difficult to do using 2D echocardiography. Ongoing investigations will also clarify whether 3D color Doppler imaging provides further clarification of regurgitant severity and whether 3D imaging can be of value during interventional procedures.

3D echocardiography is an emerging modality with a diverse array of clinical applications, including assessment of valvular heart disease. It complements current 2D echocardiographic techniques and its use continues to evolve as technologic advances are developed.