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doi:10.1016/j.jacc.2006.07.0472006;48;2053-2069; originally published online Oct 31, 2006;J. Am. Coll. Cardiol.

SahnRoberto M. Lang, Victor Mor-Avi, Lissa Sugeng, Petra S. Nieman, and David J.

DimensionThree-Dimensional Echocardiography: The Benefits of the Additional

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FOCUS ISSUE: CARDIAC IMAGING State-of-the-Art Paper

Three-Dimensional Echocardiography

Three-Dimensional EchocardiographyThe Benefits of the Additional DimensionRoberto M. Lang, MD,* Victor Mor-Avi, PHD,* Lissa Sugeng, MD,* Petra S. Nieman, MD,David J. Sahn, MD

Chicago, Illinois; and Portland, Oregon

Over the past 3 decades, echocardiography has become a major diagnostic tool in the arsenalof clinical cardiology for real-time imaging of cardiac dynamics. More and more, cardiolo-gists decisions are based on images created from ultrasound wave reflections. From the timeultrasound imaging technology provided the first insight into the human heart, our diagnosticcapabilities have increased exponentially as a result of our growing knowledge and developingtechnology. One of the most significant developments of the last decades was the introductionof 3-dimensional (3D) imaging and its evolution from slow and labor-intense off-linereconstruction to real-time volumetric imaging. While continuing its meteoric rise instigatedby constant technological refinements and continuing increase in computing power, this toolis guaranteed to be integrated in routine clinical practice. The major proven advantage of thistechnique is the improvement in the accuracy of the echocardiographic evaluation of cardiacchamber volumes, which is achieved by eliminating the need for geometric modeling and theerrors caused by foreshortened views. Another benefit of 3D imaging is the realistic andunique comprehensive views of cardiac valves and congenital abnormalities. In addition, 3Dimaging is extremely useful in the intraoperative and postoperative settings because it allowsimmediate feedback on the effectiveness of surgical interventions. In this article, we review thepublished reports that have provided the scientific basis for the clinical use of 3D ultrasoundimaging of the heart and discuss its potential future applications. (J Am Coll Cardiol 2006;48:205369) 2006 by the American College of Cardiology Foundation

Significant advances in ultrasound, such as the transitionfrom M-mode to 2-dimensional (2D) imaging, coupledwith the addition of pulsed- and continuous-wave Dopplerand color flow, have established echocardiography as one ofthe most clinically used diagnostic tools in daily cardiologypractice. Although 2D echocardiography has impacted ourability to diagnose valvular and ischemic heart disease, theconcept of 3-dimensional (3D) imaging has been envisionedby numerous investigators as a natural evolution of thistechnology. Initial efforts used echocardiography-gated 2Dacquisition techniques based on freehand imaging frommultiple acoustic windows or a single acoustic window,necessitating spatial tracking using a spark gap method ormagnetic locators (17). This methodology resulted inwire-frame or surface-rendered reconstructions of the ven-tricular chambers, from which accurate calculations ofventricular volumes (35,79), mass (912), and ejection

fraction (EF) (35,79) could be obtained. In addition,this approach provided a more in-depth understanding ofthe saddle shape of the mitral valve apparatus and thusredefined our diagnostic criteria for mitral valve prolapse(13). Continued efforts led to sequential data acquisition,gated to echocardiography and respiration using either arotational, fan-like, or parallel approach. From either atransthoracic or transesophageal fixed acoustic window,2D images collected at smaller increments enabledvolume-rendered 3D reconstructions of ventricular orvalvular structures with more anatomical detail and spa-tial relationships in complex congenital heart disease, not

seen with previous 3D images (1416). Visualization ofcolor flow jets in 3 dimensions was also achieved usingthis technique (17,18).

Although it became readily apparent that 3D echocardi-ography provides more accurate and reliable measurementsof chamber size and function and improved delineation ofvalvular and congenital abnormalities, the complex acquisi-tion and lengthy data analysis have limited the use of 3Dechocardiography in daily clinical practice. To overcomethese limitations, investigators and manufacturers teamed todevelop faster imaging strategies coupled with on-linerendering, which could be used for quantification of cham-

ber size and function. One of the first attempts at volumetricimaging used a sparse array matrix transducer (2.5 or 3.5

From the Cardiac Imaging Center, Departments of Medicine and Radiology,University of Chicago, Chicago, Illinois; and the Cardiac Fluid Dynamics andImaging Laboratory, Oregon Health and Science University, Portland, Oregon. Dr.Lang has received research and equipment grants and honoraria for the speakersbureau from Philips; Dr. Mor-Avi received a research grant from Philips; Dr. Sugengreceived honoraria for the speakers bureau from Philips; Dr. Sahn is a consultant toGeneral Electric Healthcare and Philips Medical Systems and received a researchpartnership grant from the National Institutes of Health with a subcontract with

General Electric.Manuscript received May 10, 2006; revised manuscript received July 6, 2006,accepted July 10, 2006.

Journal of the American College of Cardiology Vol. 48, No. 10, 2006 2006 by the American College of Cardiology Foundation ISSN 0735-1097/06/$32.00Published by Elsevier Inc. doi:10.1016/j.jacc.2006.07.047

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MHz) containing 256 elements that were activated nonsi-multaneously to generate a 60 60 pyramidal volumewithin a single heartbeat. Images were displayed in 2orthogonal (B-scan) and 2 to 3 parallel short-axis planes(19,20). This approach was advantageous for stress testing(21,22) and also resulted in accurate left ventricular (LV)volumes and EF (2325). Although the sparse array trans-ducer was capable of generating on-line different cut-planes

from a 3D volume, it was unable to display in real-timerendered 3D images. In addition, poor image quality, largetransducer footprint, and the lack of portability hamperedthe use of this system.

Significant advances in ultrasound, electronic, and com-puter technology have thrust the field forward toward thedevelopment of a fully sampled matrix array transducer andon-line 3D display of rendered images (Fig. 1), as well assoftware for postprocessing and quantification. The ease ofdata acquisition, the ability to image the entire heart nearlyin real time, as well as the ability to focus on a specificstructure in a single beat have brought 3D echocardiography

closer to routine clinical use (Fig. 2). Within several years ofits inception, real-time 3D technology has sparked newendeavors in research and opened a glimpse into the futureof echocardiography.

CLINICAL APPLICATIONS

Since the early 1990s, the usefulness of 3D echocardiogra-phy has been shown in several areas, including: 1) directevaluation of cardiac chamber volumes without the need forgeometric modeling and without the detrimental effects of

foreshortened views (2641); 2) unique noninvasive realis-tic views of cardiac valves (13,4258)and congenital abnor-malities (5971), extremely helpful for showing a variety ofpathologies (72)and assessing the effectiveness of surgical orpercutaneous transcatheter interventions (63,7382); 3) di-rect 3D assessment of regional LV wall motion aimed atobjective detection of ischemic heart disease at rest (37,8386)and during stress testing (21,87), as well as quantifica-tion of systolic asynchrony to guide ventricular resynchro-nization therapy (8892); 4) 3D color Doppler imagingwith volumetric quantification of regurgitant lesions(18,67,93,94), shunts (95), and cardiac output (96,97); and

5) volumetric imaging and quantification of myocardialperfusion (98102). In some instances, the scientific evi-dence seems strong enough to endorse the use of 3Dechocardiography as a new standard in the clinical assess-ment of the heart (40,103106).Chamber quantification. One of the main reasons forrequesting an echocardiogram in routine clinical practice isthe assessment of global and regional LV function. To date,this assessment is predominantly performed using visualinterpretation or eye-balling of dynamic ultrasound im-ages of the beating heart, which requires adequate trainingand experience to accurately estimate LVEF and evaluate

wall motion. However, the limitations of this subjectiveinterpretation have been long recognized, and consequentlythe use of quantitative techniques has been recommended.Thus, multiple methods of measuring LV size and function

Figure 1. The transition from 2-dimensional (2D) to 3-dimensional (3D) imaging. Although 2D imaging is based on scanning a single cross-sectional planeof the heart at a time (left), 3D imaging scans a pyramidal volume (right). RT3D real-time 3D echocardiography.

Abbreviations and Acronyms

2D 2-dimensional3D 3-dimensionalEF ejection fractionLV left ventricle/ventricularMRI magnetic resonance imaging

TEE transesophageal echocardiography

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have been developed, validated, and refined for bothM-mode and 2D B-mode images, and subsequently forreconstructed 3D images and more recently for volumetricreal-time 3D data sets. The relative inaccuracy of the1-dimensional and 2D echocardiographic approaches has

been attributed to the need for geometric modeling of theventricle. The missing dimensions have also been consis-tently referred to as the main source of the relatively wideintermeasurement variability of the echocardiographic esti-mates of ventricular size and function. In addition, thefrequently encountered limitations in endocardial visualiza-tion, particularly in the apical-lateral segments of the LV,are commonly compensated for by tilting the transducer.This maneuver generally improves endocardial visualization,but at the same time generates oblique or foreshortenedviews of the ventricle, resulting in even less accurate andreproducible measurements. In this regard, the biggest

advantage of 3D echocardiography is the lack of dependence

on geometric modeling and image plane positioning, whichtheoretically should result in accurate chamber quantifica-tion (Fig. 3).

Nevertheless, almost all studies that have directly com-pared the accuracy of 3D measurements of LV volumes and

EF have shown the superiority of the 3D approach over the2D methodology, which was shown to consistently under-estimate LV volumes. This superiority was shown in bothaccuracy and reproducibility when compared against inde-pendent reference techniques, such as radionuclide ventricu-lography or magnetic resonance imaging (MRI)(3,4,12,21,30,34,35,40,107110). These improvementshave been shown irrespective of the 3D acquisition strategyused. Although in earlier 3D studies, quantification of LVsize and function relied on tedious, manual, or at bestsemiautomated tracing of endocardial boundaries in multi-ple planes, today it is based on near fully automated

frame-by-frame detection of the 3D endocardial surface

Figure 2. Different modes of data acquisition using the matrix-array transducer. These include narrow-angled scan (left), zoom mode (middle), andwide-angled scan (right). Reproduced, with permission, from Sugeng et al.(32).

Figure 3. Dynamic analysis of real-time 3-dimensional data. Biplanar display(left)can be used to detect left ventricular (LV) endocardial surface at eachtime point(middle), which allows the calculation of LV volume over time throughout the cardiac cycle (right).

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from real-time 3D data sets. Recently, a similar approachwas implemented in commercial imaging systems, is rapidlygaining widespread popularity because of its accuracy andease of use (111), and is poised to become part of themainstream assessment of LV function.

Another clinically important variable that is frequentlyassessed by echocardiography is LV mass. Measurement ofLV mass relies not only on endocardial but also on epicar-dial visualization, which is known to be even more chal-lenging because of the difficulties in identifying the epicar-dial border. This difficulty is in addition to the limitationspreviously discussed for the measurements of LV volumes,

such as inaccurate modeling and foreshortening. Again, theuse of 3D images seems to have overcome these limitations,

as several studies have reported significant improvements inthe accuracy and reproducibility of 3D estimates of LV masscompared with their traditional M-mode and 2D counter-parts(10,11,106,112115)(Fig. 4).

Similar results confirming improved accuracy and repro-ducibility of the 3D approach were reported by investigators

who compared 2D and 3D echocardiographic measure-ments of left and right atrial volumes against an indepen-dent gold standard (3,39,116,117). These findings may haveimportant clinical implications on the diagnosis and man-agement of patients with atrial fibrillation, diastolic dys-function, and acute myocardial infarction.

Because of its complex geometrical crescent shape, theestimation of right ventricular volumes based on geometricmodeling from 2D images has been extremely challenging.Thus, not surprisingly, the intrinsic ability of 3D imaging todirectly measure right ventricular volumes without the needfor geometrical modeling has resulted in significant im-provements in accuracy and reproducibility compared withpreviously used 2D techniques (26,31,118120).

Diagnosis of regional wall motion abnormalities in echo-cardiographic studies is routinely performed by visuallyintegrating regional endocardial motion and wall thickness.The reproducibility of this interpretation is limited becauseof its subjective nature, which is also extremely dependenton the experience of the reader. This is of particular concernin patients with suboptimal image quality that impedesendocardial visualization. Not only may endocardial seg-ments that are poorly visualized be incorrectly interpreted as

having abnormal wall motion, but also discrete areas ofhypokinesis may be missed because they are simply notvisualized in the standard imaging planes. It is not uncom-mon for an echocardiographer performing the test toslightly change transducer orientation to better see aspecific myocardial segment. Such maneuvers can make amyocardial segment look like an area of hypokinesis, oralternatively, can make an apparent wall motion abnormalitydisappear, and thus affect the diagnostic accuracy of the test.In this regard, volumetric imaging is different because the3D data set contains the complete dynamic information onLV chamber contraction and filling.

Importantly, such data sets are acquired virtually instan-taneously, and any 2D view can be obtained from themsimply by cropping out or peeling off the rest of theinformation. In addition, the function of any ventricularwall can be objectively assessed by measuring a variety ofwall motion parameters (37)(Fig. 5). For these reasons, 3Ddata sets are extremely appealing for the evaluation ofregional LV function. Real-time 3D imaging has beenrecently used during dobutamine stress testing and found tobe feasible and useful for the detection of stress-inducedwall motion abnormalities (121) (Fig. 6). Several otherstudies have explored the potential of quantitative evalua-

tion of regional LV function based on segmental analysis ofthe dynamic 3D endocardial surface (37,8386). The use of

Figure 4. Effects of volumetric imaging on the accuracy of left ventricular(LV) mass measurements. End-diastolic apical 4- (A4C) and 2-chamber(A2C) views of the LV obtained in a patient using conventional2-dimensional (2D) imaging (top)and anatomically correct apical 4- and2-chamber cut planes selected from a real-time 3-dimensional (3D) dataset obtained in the same subject(middle). Manually traced endocardial andepicardial boundaries used to calculate LV mass are shown on the images.

The LV long-axis dimension was measured on such images in 19 patients(bottom). Note the increase in the length of the LV in both apical views,as assessed by the 3D technique in most patients (large circles and error

barsrepresent mean SD, *p 0.05). Reproduced, with permission, fromMor-Avi et al. (114).





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this methodology in clinical practice requires further studiesto be performed in larger groups of patients.

A clinically useful byproduct of the 3D quantificationof regional LV wall motion is the ability to quantify thetemporal aspects of regional endocardial systolic contrac-tion, which have been used for objective serial diagnosisof LV systolic asynchrony as a guide for resynchroniza-tion therapy (90,91), despite the relatively low temporalresolution of real-time 3D imaging. The standard devi-ation of the regional ejection times (interval between theR wave and peak systolic endocardial motion) has beenused as an index of myocardial synchrony. This approachhas been used to assess the short- and long-term benefitsof biventricular pacing (Fig. 7). A recent study has shown

a direct relationship between overall LV performance andsynchronicity (92). In this study, this approach has also

been shown to be useful for identifying patients withsevere heart failure and asynchronous LV contraction

who could theoretically benefit from resynchronizationtherapy but would not be considered candidates based ontheir QRS duration (92). Also, real-time 3D intracardiacimaging has been successfully used to guide the position-ing of pacing catheters during interventional electrophys-iology (89).

Recently, it has become feasible to perform multiplanarsimultaneous tissue Doppler-based strain rate imaging usinga matrix array transducer (Fig. 8). The clinical benefits ofthis approach versus the existing single plane strain andstrain rate imaging have yet to be determined.Contrast-enhanced 3D echocardiography. The ability of

conventional contrast-enhanced echocardiographic imag-ing to provide accurate information on the extent and

Figure 5. Volumetric analysis of regional left ventricular (LV) function. Example of LV endocardial surface detected from a 3-dimensional (3D) data setat 3 different phases of the cardiac cycle, superimposed on a cross-sectional long-axis plane (top left). Schematic representation of the 3D segmentationmodel: A2C, A3C, and A4C apical 2-, 3-, and 4-chamber planes, respectively; Ao central point of the aortic annulus; MV central point of themitral valve(top right).Shaded areais an example of an LV endocardial surface segment representing the midseptal (m-sp) wall. Below are examples ofregional volume and wall motion time curves and regional shortening fraction (RSF) in 6 apical segments, obtained in a normal subject (left)and a patient

with coronary artery disease (CAD)(right)and hypokinesis in the lateral wall (arrow). Ant anterior; asp anteroseptal; inf inferior; lat lateral;%RR percent of electrocardiogram RR-interval; pst posterior; sp septal.





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severity of either wall motion or perfusion abnormalities

is also limited by its 2D nature. Despite the obviousappeal of the 3D imaging in this context, its use inhumans has not been explored until recently. This isbecause this approach relied on off-line reconstructionfrom multiple planes, significantly complicating volumet-ric assessment of LV function. The feasibility of applying

volumetric analysis to contrast-enhanced real-time 3D

data sets obtained in patients with suboptimal imagequality was recently tested. This approach allows quan-tification of global (122) as well as regional (123) LVfunction when used with selective dual triggering at endsystole and end diastole to reduce the destructive effectsof ultrasound on contrast microbubbles (Fig. 9).

Figure 6. Off-line viewing of real-time 3-dimensional data obtained during dobutamine stress test. These data sets can be used to extract multiple short-axisviews at different levels of the left ventricle(left). Example of such views extracted from data sets obtained at rest and during peak dobutamine stress (right).

Figure 7. Assessment of the improvement in synchrony of left ventricular (LV) contraction with pacing. Regional volume time curves (left) obtained ina patient with LV dyssynchrony without (top)and with(bottom)biventricular pacing. Endocardial surfaces reconstructed from each data set are shown

with segmentation and color coding according to regional time to end ejection(middle)along with the bulls-eye representation of the same data(right).Note the changes in colors with pacing reflecting the effects of resynchronization therapy in this parametric display. Ant anterior; Ant-Sept anteroseptal; EF ejection fraction; Inf inferior; Lat lateral; Post posterior; Sept septal.





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Before the development of real-time 3D imaging, assess-ment of myocardial perfusion had to remain limited toeither visualization of perfusion defects (98) or at bestquantification of their size (99,100). Quantification of tissueblood flow would require repeated contrast maneuvers, suchas bolus injections, which are necessary to assess flowdynamics for each imaging plane, rendering this methodol-

ogy clinically inapplicable. In contrast, real-time 3D echo-cardiography offers an opportunity for online volumetricimaging of the entire heart during a single contrast-enhancement maneuver. The feasibility of volumetric per-fusion imaging was recently tested (101,102)in conjunctionwith a new technique for volumetric quantitative analysis ofmyocardial perfusion from contrast-enhanced real-time 3Dechocardiography data sets (102)(Fig. 10).

The future uses of contrast enhancement for endocardialsurface delineation and volumetric myocardial perfusionimaging and quantification will be determined in largertrials, which will also require expanded software capabilities.Valvular heart disease. Most studies using 3D echocardi-ography have focused on the evaluation of the mitral valve.These studies have played a crucial role in describing and

quantifying the geometry of the mitral annulus, leafletsurface, tethering distances, and tenting volumes. Thesestudies have also defined and quantified the relationshipbetween the mitral apparatus and the position of thepapillary muscles, thus providing insight into the patho-physiology of mitral regurgitation.

Initially, 3D visualization of the mitral valve used awire-frame display, which was instrumental in describingthe saddle shape of the mitral annulus and redefining thediagnostic criteria for mitral valve prolapse (13). A variety ofmitral valve abnormalities have been shown by 3D recon-structions using gated transesophageal echocardiography(TEE) acquisition and volume-rendered display (124). Therecent development of a fully sampled matrix array trans-ducer has enabled real-time volumetric imaging of themitral valve from the transthoracic approach (125)(Fig. 11,top). The feasibility of this approach has been recentlydemonstrated in a study that showed that the mitral valvecould be adequately reconstructed in 70% of consecutivepatients (125). The anterior mitral valve leaflet was morereadily visualized compared with the posterior leaflet, prob-ably because of its larger size. The mitral leaflets, commis-sures, and mitral valve orifice were also easily viewed. Of

note, this study found that the posterior leaflet is bestvisualized from the parasternal window, whereas the ante-

Figure 8. Simultaneous multiplanar strain rate imaging. Matrix-array technology allows quantitative assessment of strain rate in multiple myocardialsegments by analysis of tissue Doppler data obtained from the apical approach.

Figure 9. Real-time 3-dimensional (3D) visualization of myocardial perfu-sion. Contrast-enhanced 3D data set obtained in a patient with severe discreteleft anterior descending artery stenosis (left). A region in the interventricular

septum shows lack of contrast enhancement, indicating a perfusion defect thatwas supported by abnormal wall motion. This defect was visible in multiplecross-sections(right), allowing easy estimation of its extent.





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rior mitral leaflet was equally well seen from either the

parasternal or the apical window.The utility of real-time 3D echocardiography in the

evaluation of mitral stenosis and accuracy of mitral valvearea measurements has been established by multiple studies(46,51,57,126130). The main advantage of 3D echocardi-ography is the ability to achieve a perpendicular en-face cutplane of the mitral valve orifice, enabling accurate mitralvalve area measurements. These measurements have been

found more accurate when performed from the ventricular

orientation. When compared with traditional 2D andDoppler measurements, such as 2D planimetry, pressurehalf-time, and flow convergence, 3D echocardiography bestagreed with mitral orifice area calculations derived using theGorlin formula during cardiac catheterization (51,57,129).Importantly, the 3D measurements had the additionaladvantage of having lower intraobserver and interobservervariability (51,57,129). The ease of acquisition and on-line

Figure 10. Volume rendering of the mitral valve obtained from real-time 3-dimensional data. The data set on the left was obtained in a patient with aperforated anterior mitral leaflet, which was confirmed by an intraoperative image (right). Reproduced, with permission, from Schwalm et al. J Am SocEchocardiogr 2004;17:91922.

Figure 11. Real-time volumetric imaging and analysis of the mitral valve. (Top)Baseline image before mitral balloon valvuloplasty(A) shows a restrictedmitral valve opening with bicommissural fusion. After valvuloplasty, splitting of the medial commissure and posterior leaflet tear can be seen (B).(Bottom)

Example of 3-dimensional reconstruction of the mitral annulus (C)and leaflets(D)obtained in a patient with dilated cardiomyopathy, showing the saddleshape of the annulus and increased leaflet tenting volume. IVS interventricular septum; LA left atrium; LV left ventricle; M medial; P posterior; RV right ventricle.





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review of real-time 3D echocardiography facilitates imme-diate assessment of the mitral valve commissural splitting,stretching, or tearing after percutaneous balloon mitralvalvuloplasty (PBMV) in the cardiac catheterization labo-ratory. Immediately after PBMV, changes in left atrial andventricular compliance together with irregularities of the

mitral valve orifice limit the utility of the pressure half-timemethod and 2D planimetry. The high accuracy and repro-ducibility of 3D echocardiography before and after PBMVcompared with the pressure half-time method and 2Dechocardiography have been shown in a recent article (130).

Characterization of the mitral valve apparatus using 3Dechocardiography (Fig. 11,bottom) has shed new light onthe pathophysiology of mitral regurgitation in patients withnonischemic and ischemic cardiomyopathy. It has beenshown that functional mitral regurgitation is associated withannular dilatation and reduced cyclic variations in annularshape and area (52). Further investigations showed differ-

ences in patients with ischemic mitral regurgitation com-pared with normal subjects in mitral annular shape withincreased intercommissural and anteroposterior diametersand increased leaflet tenting, indicating chordal tethering(28,47,58,131). Also, patients with anterior wall myocardialinfarction have flattened mitral annulus, which is morepronounced than with posterior myocardial infarction (132).Three-dimensional echocardiography has also been used toevaluate the differences in the shape and dynamics of 2 typesof mitral rings: although the Duran ring seemed nonplanarand showed changes in annular area throughout the cardiaccycle, the Carpentier ring was planar and did not effectively

change its area (133).Although the additional information provided by 3D

imaging may aid in surgical planning and design of futuremitral prostheses and rings, it has been recognized thatchanges in mitral annular deformation may not be the solecause of ischemic mitral regurgance (MR). Several studieshave reported that MR caused by ischemia occurs inconjunction with remodeling of the ischemic region, leadingto LV dilatation with subsequent papillary muscle displace-ment (134,135). This results in increased chordal tetheringand leaflet tenting, which in turn leads to mitral regurgita-tion caused by decreased leaflet apposition. Interestingly, an

animal 3D echocardiographic study showed that MR re-solved after plication of the infarct region (135). Hence, theinsights provided by 3D echocardiography have shown thatthe presence of MR in patients with dilated or ischemiccardiomyopathy is a disease of the remodeled myocardiumrather than being caused by a true valvular abnormality.

Compared with the mitral valve, the collective experiencein visualizing aortic valve disease is limited. Most of theaortic valve imaging has been performed using gated 3Da cquis i tion fr om the t r a nse sop ha ge a l a p pr oa ch(43,48,55,94,136141). The challenges with the 3D imag-ing of the aortic valve are related to the fact that aortic

leaflets are thinner and frequently present with heavycalcification, both resulting in drop-out artifacts. Neverthe-

less, it was found that adequate to excellent reconstructionof the aortic valve is feasible in over 80% of patients, morefrequently in native than in prosthetic valves (142). Similarto mitral stenosis, in patients with aortic stenosis, TEE-based planimetry of the aortic valve is more accurate with3D than 2D imaging (48). Three-dimensional echocardi-

ography also results in improved visualization and thus moreaccurate diagnosis of bicuspid aortic valves, valvular vegeta-tion, prosthetic aortic valve leaks, and subaortic pathology.However, the additional information that 3D echocardiog-raphy may offer in this context remains to be determined infuture studies.

The utility of 3D echocardiography in the evaluation oftricuspid valve disease has not been explored in depth.There have been numerous case reports describing tricuspidabnormalities such as tricuspid stenosis, cleft tricuspid valve,and a flail tricuspid leaflet (143147). Initial observationsmade in the pediatric population, pertaining to the tricuspid

annulus and its dynamic interaction with the mitral valveannulus, were that during systole, the area of the tricuspidannulus decreased more in lateral diameter compared withthe mitral annulus, and that the tricuspid annulus retainedits shape more than the mitral annulus throughout systole(148). Characterization of the tricuspid annulus and leafletsin patients with rheumatic heart disease with mitral stenosisand severe tricuspid regurgitation was performed usinggated 3D TEE, which showed thickened leaflets withrestricted motion, together with annular dilatation (149).Volumetric color Doppler imaging. Three-dimensionalcolor flow imaging did not come to fruition until gated TEE

methods and computer software allowed reconstruction of3D color flow jets superimposed on the reconstructed grayscale data (Fig. 12). With the ability to combine 3D colorflow with gray scale information, it became possible todetect the origin and direction of jets, to measure regurgi-tant orifice areas, and to improve the delineation of valvularleaks, paravalvular leaks, and multiple jets (18,94,150,151).

Initially, reconstructive 3D methods have been used toobtain 3D measurements of stroke volume using Dopplervelocities perpendicular to the outflow or inflow tracts(152,153). With this approach, the surface projection al-lowed removal of the known limitation of Doppler imaging

(i.e., its angle dependency). Although acquisition timeswere still long, the time required for reconstruction wassignificantly shortened. Multiple studies have been pub-lished on the accuracy of this method by several investiga-tors (154,155). Multiplanar TEE 3D color flow imaging,however, has many drawbacks because of the long timerequired for data acquisition, which may result in temporaland spatial misregistration. Another disadvantage is theextended time required for analysis, which has limited theclinical utility of this methodology.

Volumetric color flow imaging has overcome some ofthese limitations and proved useful for estimating regurgi-

tant volumes, stroke volumes, and cardiac output, togetherwith the delineation of valve regurgitation in pediatric





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populations (17,156159). It has recently been shown that3D color Doppler imaging can provide accurate measure-ments of flow in the great vessels and ventricles (Fig. 13) bysampling the entire cross-sectional flow profile through theventricular outflow tract, thus allowing the calculation ofvalvular flow volume, regurgitant volume, fraction, andorifice area (160). Although 3D Doppler laminar flowmeasures were originally developed using reconstructive 3D,real-time color Doppler volumes are much less time consum-ing; they reduce respiratory artifacts and allow immediatereview without lengthy reconstruction (155). This approach

was initially validated in an in vitro setup and in open-chestanimals (96,161), and more recently in humans (97).

However, there are several issues that continue hamper-ing the daily use of 3D color flow imaging, including: 1)reliance on acquisition of multiple cardiac cycles that mayresult in stitch artifacts because of the patients inability tomaintain a breath hold over 7 to 10 beats; 2) limited sectorangle that may not allow complete visualization of eccentricjets; and 3) compromised visualization of 3D gray-scaleinformation when acquired simultaneously with the color.Single-beat acquisition with wider sector and improvedresolution as well as online quantification tools are the issues

that need to be addressed for 3D color flow imaging tobecome clinically useful.

Surgical or transcatheter interventions. There has beeninterest in intraoperative application of 3D imaging as wellas intraprocedural guidance of transcatheter interventions inthe catheterization laboratory (162,163). Also, in the elec-trophysiology laboratory, electroanatomical mapping usingelectromagnetic sensor localization has become widelyadopted for complicated procedures (164,165). Intraopera-tive real-time 3D imaging has mostly been performed fromthe epicardial surface using narrow-angled acquisition,which only allows the visualization of a relatively thin sliceof the heart. One disadvantage of epicardial imaging is the

difficulty in maintaining acoustic coupling between thetransducer and the beating heart. In addition, the use ofwide-angled acquisition in this context is limited because itrequires cropping of the data set to visualize the structure ofinterest and thus does not provide easy and immediate visualfeedback to the surgeon. Despite these difficulties, severalgroups have used real-time 3D imaging of the beating heartduring on-pump procedures to visualize suture closure ofatrial septal defects in animal models (166168).Perinatology and fetal heart. Dynamic 3D echocardiog-raphy originally developed for the radiology and perinatol-ogy market also has been used for cardiac imaging in the

fetus and sometimes in newborns. A curved ultrasound arraywith a motorized handle can develop 3D images of the fetus

Figure 12. Color flow volume rendering. These data were obtained in a patient with mitral stenosis depicting a 3-dimensional (3D) mitral regurgitant (MR)jet in systole(A). Both regurgitant jet and left atrium (LA) could be manually traced to estimate the MR and LA volume, displayed as a surface-renderedimages superimposed on the 3D image (B and C). The vena contracta (arrows)of the regurgitant jet is shown in two orthogonal views (D and E). Thelevel of the vena contracta is visualized along with the gray-scale information (F).





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in a wide or narrow field with a rapid mechanical sweep fastenough to stop the heart, therefore avoiding motion arti-facts. For resolving heart motion, the mechanical sweep canbe either fast (15 or 30 frames/s, covering a narrow field ofview over the fetal chest) or slow with realignment sweepingacross the field with high line density. Then the temporalintegration is computed, realigning frames that are matchedto the phases of the cardiac cycle by correlating the positionof the major interfaces, especially on technically good

images when the fetus does not move or the mother is notbreathing. These provide dynamic sequences at 16 to 18frames per cycle that are measurable for cardiac volumeswith acceptable accuracy (169,170)(Fig. 14).

This method will gradually be replaced by smaller,larger-aperture matrix technology that requires a higherfrequency than is currently available on real-time adultcardiac 3D systems. The original work in this type ofrealignment (171,172) was followed by other methods of

Figure 13. Real-time 3-dimensional color Doppler stroke volume computation. Dynamic analysis of Doppler velocities in the left ventricular outflow tract(LVOT) throughout the cardiac cycle allows accurate quantification of left ventricular stroke volume. AV aortic valve.

Figure 14. Real-time 3-dimensional (3D) fetal echocardiography. (A) A 3D image obtained in a 23-week fetus with tetralogy of Fallot and absentpulmonary valve showing a small pulmonary annulus with no valve tissue and a dilated main pulmonary artery. (B) Spatio-temporal image correlationslow-sweep image of ventricular filling in a normal 21-week fetus.





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achieving cardiac gating for fetal wide-field views, in-clude navigator-type gating of the image data itself, orusing a separate waveform derived, for instance, from anumbilical arterial trace.Congenital heart disease. Although it is known thatcomplex anatomy can be more easily understood by 3Dnavigation, most studies to date have applied this technol-

ogy to relatively simple congenital diagnostic questions,such as atrioventricular valvular structure and atrioventric-ular canal en-face views of atrial and ventricular septaldefects for sizing (173175). The concept was also put forththat with the real-time 3D imaging, the entire examinationmight be completed rapidly using a small number ofwide-angled acquisitions, thus avoiding the need for pedi-atric and infant sedation. Nonetheless, excellent renderingsof intraventricular anatomical abnormalities, congenitalheart valvular disease, and aortic arch and vascular abnor-malities have been published (176,177).

Although in adult patients most attention has been

focused on the 3D quantification of the LV volumes andmass, in congenital heart disease the key focus has been onserial assessment of right ventricular volume. Surgical plan-ning and postoperative status of many patients with con-genital heart disease rests with accurate direct quantificationof right ventricular function. Most published outcomesstudies have involved MRI quantifications of right ventric-ular volume and EFs, but many MRI studies have used anoversimplified approach that does not fully image the inflowand outflow tracts. Accordingly, a more sophisticated mul-tiplanar approach incorporating RV inflow and outflowcomponents for volume and mass quantification has been

described for both MRI and ultrasound applications(168,178)(Fig. 15).

FUTURE DIRECTIONS

Future advances in transducer and computer technology willallow wider angle acquisition and color flow imaging to becompleted in a single cardiac cycle, which will shorten dataacquisition time and eliminate stitching artifacts. The trans-

ducers will have a smaller footprint and weight with higherspatial and temporal resolution. In addition, transducerscapable of 2D imaging only will be gradually phased out andreplaced by new probes that will be versatile in theircapability of imaging in different modes, including 2D, 3D,and color and tissue Doppler. With these multitaskingtransducers, it may be possible to significantly reduce thenumber of steps required to complete an echocardiographicexamination, and thus reduce the time required for the test.For example, the standard 2D views could theoretically beobtained from a single volumetric data set and used fordiagnostic purposes, assuming that both spatial and tempo-

ral resolution are sufficiently high. Significant improvementsfrom the current state of the art are needed in the temporalresolution as well as in the spatial resolution in the far field.We also anticipate that the quantification of all cardiacchambers, including flow dynamics, will be performed onthe imaging system in an increasingly automated fashion,thus gradually eliminating the need for off-line analysis.This is of crucial importance, in particular in the interven-tional settings of the catheterization laboratory and theoperating room, where immediate visual and quantitativefeedback is important. For the purposes of interpretationand storage, it is vital that the 3D data sets are incorporated

into digital information systems with full rendering andquantification capabilities.

CONCLUSIONS

In summary, in the coming years, we anticipate thatreal-time 3D imaging will continue to be integrated into theroutine echocardiographic examination. Presently there issufficient evidence to prove that 3D imaging is superior tothe traditional 2D techniques and should be routinely usedin 2 clinical scenarios: 1) quantification of LV volume, EF,and mass; and 2) quantification of the mitral valve area in

mitral stenosis. Future clinical applications of this technol-ogy are likely to include stress testing with real-timevolumetric or simultaneous multiplane imaging from asingle transducer position. Volumetric assessment of ven-tricular asynchrony will be used as an additional tool toguide resynchronization therapy. Also, miniaturization ofthe matrix-array transducer technology will enable both theacquisition of real-time 3D transesophageal images and thedevelopment of small-footprint probes suited for pediatrictransthoracic and fetal imaging.

Reprint requests and correspondence: Dr. Roberto M. Lang,

University of Chicago MC5084, 5841 South Maryland Avenue,Chicago, Illinois 60637. E-mail: [email protected].

Figure 15. Real-time 3-dimensional imaging of the right ventricle. Sub-

costal data set shows both inlet and outflow components of the rightventricle required for accurate right ventricular volume determination. MB moderator band; OS INF os infundibulum or opening of the right

ventricular outflow tract; LV left ventricle;. PV pulmonary valve; TV tricuspid valve.





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doi:10.1016/j.jacc.2006.07.047

2006;48;2053-2069; originally published online Oct 31, 2006;J. Am. Coll. Cardiol.Sahn

Roberto M. Lang, Victor Mor-Avi, Lissa Sugeng, Petra S. Nieman, and David J.Dimension

Three-Dimensional Echocardiography: The Benefits of the Additional

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