Editor's Note: The following are related resources.

1. Qin JX, Jones M, Shiota T, et al. Validation of real-time three-dimensional echocardiography for quantifying left ventricular volumes in the presence of a left ventricular aneurysm: in vitro and in vivo studies. J Am Coll Cardiol 2000;36:900-7.
2. Saito K, Okura H, Watanabe N, et al. Influence of chronic tethering of the mitral valve on mitral leaflet size and coaptation in functional mitral regurgitation. JACC Cardiovasc Imaging 2012;5:337-45 .

Current Status of Clinical Utility of 3D Echocardiography

Since the introduction of real-time (or live) 3-dimensional (3D) echocardiography in the late 90th, dramatic progress of this technology has enabled real-time 3D observation of structure and function of the heart. Real-time 3D echocardiography principally allows dynamic 3-dimensional visualization and quantification of the region of interest. Currently, real-time 3D echocardiography systems with matrix array transducers are widely used not only for clinical research but in clinical practice as an informative imaging modality, and applied for evaluations of heart chamber volume, global or regional left ventricular (LV) function and wall motion including mechanical synchronicity, 3D structures of heart valve apparatus (Figure 1), and complex congenital anomalies.^1-3 Finding a useful method for the evaluation of LV mechanical dyssynchrony to accurately identify responders to cardiac resynchronization therapy (CRT) has been challenging for echocardiography. Real-time 3D transthoracic echocardiography (TTE) provides a potential approach to this task. Standard deviation of the regional volume time curves (SDI:SD index) of 17 segments acquired by real-time 3D TTE may be a useful measure to predict responses to CRT.⁴ The entire LV volume data can be acquired in 1 heart beat by using the latest real-time 3D echocardiography technology, which made this method applicable to wide range of patients including those with atrial fibrillation. Analyses of mitral valve structure and regurgitant color Doppler jets by real-time 3D echocardiography may change a standard for evaluation of the severity of mitral regurgitation in the near future. Estimations of mitral effective regurgitant orifice area and regurgitant volume based on the 3D data set were more accurate than 2D echocardiographic assessment, and may have comparable accuracy with evaluation by cardiac magnetic resonance (CMR).⁵ Real-time 3D transesophageal echocardiography (TEE) has been revealing precise mechanisms of the development and exacerbation of heart valve diseases. Based on the analysis by 3D TEE, Otani, et al. showed that LV dilatation caused by the primary mitral valve prolapse with regurgitation led to mitral leaflet tethering with papillary muscle displacement. These morphological changes in LV and mitral valve apparatus may synergistically exacerbate valve leakage in patients with degenerative mitral regurgitation.⁶ Real-time 3D TEE is applied for pre-operative evaluation and intra-operative monitoring during heart valve surgery and for guiding catheter ablation,^7,8 and is also contributing to the progress of new transcatheter procedures such as atrial septal closure, mitral valve repair, and aortic valve implantation.^9-11 Analysis of procedural effects in patients undergoing percutaneous mitral valve edge-to-edge repair (PMVR) is complex and 2-dimensional (2D) echocardiography techniques to define mitral regurgitation severity are not validated for post procedural double-orifice mitral valve. In these patients, the unique visualization of the mitral valve by 3D-TEE allows better understanding of the morphological and functional changes induced by PMVR.¹² It is certainly also the case that 3D-TEE enables better visualization and understanding of the morphology of congenital double-orifice mitral valve.¹³ Transcatheter aortic valve implantation is a more established and rapidly spreading procedure than PMVR. Real-time 3D TEE can yield higher precision in the measurement of aortic annulus diameter to determine prosthesis size than 2D TEE, and more effectively predict post-procedural paravalvular aortic regurgitation.^14,15 Thus, pre-operative as well as intra-operative imaging by 3D TEE is becoming an integral part of TAVI.

Comparison With Other Imaging Modalities

The significance of 3D echocardiography should be assessed via comparisons with other imaging modalities. As the representative 3 modalities for 3D cardiac imaging, real-time 3D echocardiography, CMR and multidetector-row computed tomography (MDCT) have been most compared in quantitative volumetric analysis and global LV functional analysis. Multimodality comparisons repeatedly showed small but consistent overestimation by MDCT, small underestimation by real-time 3D echocardiography, and acceptably high correlation of both measurements with CMR reference in quantitative volumetric analysis, although considerably wider margins of error might be found in 3D echocardiography measurement.^16,17 Diagnostic accuracy of regional LV function seems comparable among the 3 modalities, whereas higher agreement of MDCT rather than 3D echocardiography with CMR reference was recently reported in the assessment of global LV function.¹⁸ When each imaging modality is utilized in clinical practice, not only imaging ability itself but user-friendliness is also an important factor to be considered. Comparison of real-time 3D TTE and TEE with 2 other 3D imaging modalities, CMR and MDCT, are summarized in Table 1. Because there is not the best modality in all parameters for 3D cardiac imaging, we should select the best modality for each case, each purpose, and each clinical setting. At present, 3D echocardiography may be the most investigated and utilized among these modalities for 3D cardiac imaging, as suggested by the number of manuscripts in PubMed retrieved by "name of the modality" and "3-dimensional cardiac imaging" as keywords: echocardiography=295, magnetic resonance=224, computed tomography=193 (accessed October 12, 2012).

We recently reported the results of structural analysis of mitral apparatus in patients with ischemic mitral regurgitation by MDCT with use of an original software (Figure 2).¹⁹ Three-dimensional analysis based on MDCT data set revealed that symmetric leaflet tethering was predominant even in patients with ischemic mitral regurgitation, and asymmetric apical displacement of papillary muscle tips led to asymmetric leaflet tethering in patients with ischemic mitral regurgitation. Although we should always consider the issue of radiation in MDCT, radiation dosage has been decreasing by many efforts, and the accuracy and objectivity of MDCT imaging analyses may also be promising.

---

References

1. Qin JX, Jones M, Shiota T, et al. Validation of real-time three-dimensional echocardiography for quantifying left ventricular volumes in the presence of a left ventricular aneurysm: in vitro and in vivo studies. J Am Coll Cardiol 2000;36:900-7.
2. Saito K, Okura H, Watanabe N, et al. Influence of chronic tethering of the mitral valve on mitral leaflet size and coaptation in functional mitral regurgitation. JACC Cardiovasc Imaging 2012;5:337-45.
3. Baker GH, Shirali G, Ringewald JM, Hsia TY, Bandisode V. Usefulness of live three-dimensional transesophageal echocardiography in a congenital heart disease center. Am J Cardiol 2009;103:1025-8.
4. Tani T, Sumida T, Tanabe K, Ehara N, Yamaguchi K, Kawai J, Yagi T, Morioka S, Fujiwara H, Okada Y, Kita T, Furukawa Y. Left ventricular systolic dyssynchrony index by three-dimensional echocardiography in patients with decreased left ventricular function: comparison with tissue Doppler echocardiography. Echocardiography 2012;29:346-52.
5. Shanks M, Siebelink HM, Delgado V, van de Veire NR, Ng AC, Sieders A, Schuijf JD, Lamb HJ, Ajmone Marsan N, Westenberg JJ, Kroft LJ, de Roos A, Bax JJ. Quantitative assessment of mitral regurgitation: comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging. Circ Cardiovasc Imaging 2010;3:694-700.
6. Otani K, Takeuchi M, Kaku K, Haruki N, Yoshitani H, Eto M, Tamura M, Okazaki M, Abe H, Fujino Y, Nishimura Y, Levine RA, Otsuji Y. 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:S214-21.
7. Wei J, Hsiung MC, Tsai SK, Ou CH, Chang CY, Chang YC, Lee KC, Sue SH, Chou YP. The routine use of live three-dimensional transesophageal echocardiography in mitral valve surgery: clinical experience. Eur J Echocardiogr 2010;11:14-8.
8. Regoli F, Faletra FF, Nucifora G, Pasotti E, Moccetti T, Klersy C, Auricchio A. Feasibility and acute efficacy of radiofrequency ablation of cavotricuspid isthmus-dependent atrial flutter guided by real-time 3D TEE. JACC Cardiovasc Imaging 2011;4:716-26.
9. 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;2:1238-42.
10. Altiok E, Becker M, Hamada S, Grabskaya E, Reith S, Marx N, Hoffmann R. Real-time 3D TEE allows optimized guidance of percutaneous edge-to-edge repair of the mitral valve. JACC Cardiovasc Imaging 2010;3:1196-8.
11. Berry C, Oukerraj L, Asgar A, Lamarche Y, Marcheix B, Denault AY, Laborde JC, Cartier R, Ducharme A, Bonan R, Basmadjian AJ. Role of transesophageal echocardiography in percutaneous aortic valve replacement with the CoreValve Revalving system. Echocardiography 2008;25:840-8.
12. Altiok E, Hamada S, Brehmer K, Kuhr K, Reith S, Becker M, Schröder J, Almalla M, Lehmacher W, Marx N, Hoffmann R. Analysis of Procedural Effects of Percutaneous Edge-to-Edge Mitral Valve Repair by 2D and 3D Echocardiography. Circ Cardiovasc Imaging 2012;5:748-55.
13. Tani T, Kim K, Fujii Y, Komori S, Okada Y, Kita T, Furukawa Y. Mitral valve repair for double-orifice mitral valve with flail leaflet: the usefulness of real-time three-dimensional transesophageal echocardiography. Ann Thorac Surg 2012;93:e97-8.
14. Husser O, Rauch S, Endemann DH, Resch M, Nunez J, Bodi V, Hilker M, Schmid C, Riegger GA, Luchner A, Hengstenberg C. Impact of three-dimensional transesophageal echocardiography on prosthesis sizing for transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2012;80:956-63.
15. Gripari P, Ewe SH, Fusini L, Muratori M, Ng AC, Cefalù C, Delgado V, Schalij MJ, Bax JJ, Marsan NA, Tamborini G, Pepi M. Intraoperative 2D and 3D transoesophageal echocardiographic predictors of aortic regurgitation after transcatheter aortic valve implantation. Heart 2012;98:1229-36.
16. Sugeng L, Mor-Avi V, Weinert L, Niel J, Ebner C, Steringer-Mascherbauer R, Schmidt F, Galuschky C, Schummers G, Lang RM, Nesser HJ. Quantitative assessment of left ventricular size and function: side-by-side comparison of real-time three-dimensional echocardiography and computed tomography with magnetic resonance reference. Circulation 2006;114:654-61.
17. Sugeng L, Mor-Avi V, Weinert L, Niel J, Ebner C, Steringer-Mascherbauer R, Bartolles R, Baumann R, Schummers G, Lang RM, Nesser HJ. Multimodality comparison of quantitative volumetric analysis of the right ventricle. JACC Cardiovasc Imaging 2010;3:10-8.
18. Greupner J, Zimmermann E, Grohmann A, Dübel HP, Althoff TF, Borges AC, Rutsch W, Schlattmann P, Hamm B, Dewey M. Head-to-head comparison of left ventricular function assessment with 64-row computed tomography, biplane left cineventriculography, and both 2- and 3-dimensional transthoracic echocardiography: comparison with magnetic resonance imaging as the reference standard. J Am Coll Cardiol 2012;59:1897-907.
19. Kim K, Kaji S, An Y, Yoshitani H, Takeuchi M, Levine RA, Otsuji Y, Furukawa Y. Mechanism of asymmetric leaflet tethering in ischemic mitral regurgitation: 3D analysis with multislice CT. JACC Cardiovasc Imaging 2012;5:230-2.

Keywords: Cardiac Resynchronization Therapy, Cardiac Volume, Echocardiography, Three-Dimensional, Echocardiography, Heart Valves, Ventricular Function, Left

< Back to Listings