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Today’s 3D Echocardiography Approaches of 3D Echocardiography Alexandra Garcia, RCS, RVS Oregon Institute of Technology This Photo by Unknown Author is licensed under CC BY-SA-NC Approaches of 3D Echocardiography Echocardiography History of 3D imaging Today’s use of 3D imaging The latest advances in 3D imaging Conclusion References This Photo by Unknown Author is licensed under CC BY Echocardiography “Echocardiography is the most clinically used diagnostic imaging modality in cardiac practice today, and with good reason. In addition to its noninvasive nature and time- and cost-efficiency, its bedside availability in the clinic, emergency ward and operating room is a major advantage. Furthermore, its uncomplicated use in children, pregnant women, and those with implanted pacemakers or defibrillators has set it apart from other closely competing imaging modalities, such as cardiovascular computed tomography (CT) and magnetic resonance imaging (MRI). (Heart J, 2009)” History of 3D Echocardiography The first 3D scan of the heart was developed by Dekker in 1974. “With that technique, the patient was scanned using a transducer that was connected to a mechanical arm that fed quadrant data to a computer mainframe. Read More: https://www.ajronline.org/doi/full/10.2214/AJR.04.0857.” 3D reconstruction was the first technique and it required reconstruction of 2D into 3D image. It’s limitations such as complex labor-intensive, time-consuming acquisition and offline reconstruction, limited by artifacts and poor image quality. In the early 1990s, Von Ramm developed the ‘real-time’ 3D with less limitations but still limited by poor image quality and data volume, (too large to store and transfer). Then in 2002 a user-friendly version of a matrix array transducer capable of real-time 3D imaging together with software which allows rapid slicing and quantification of 3DE data sets was released. Another improvement was made in 2007 by Philips Medical Systems called “Live 3D”. The incorporation of real-time 3D imaging into TEE transducer. Live 3D greatly enhanced the image quality while increasing computer processing power and hard drive capacity. (Heart J, 2009) History of 3D Echocardiography “Only 2 decades ago, real-time 3-dimensional (3D) ultrasound imaging of the beating heart seemed like a futuristic idea with many hurdles to overcome to become a mainstream imaging modality. (Lang, Addetia, Narang, Mor-Avi, 2018).” Today’s use of 3D Imaging Volume measurements “Current live 3D imaging routinely performs imaging in a narrow angle, a 3D volume sector that cannot span the entire heart; cardiac gating is used only in the sense that frames are captured throughout the cardiac cycle, the same as with 2D imaging. A full-volume acquisition requires cardiac gating to acquire four cardiac cycles and then reconstruct them into an entire cardiac volume. Gating is an important part of this acquisition for aligning similar frames for each of the four cycles. The four cardiac cycles are then volume rendered with some interpolation required between each cycle. This approach is, of course, subject to the limitations of patient and transducer movement, but because only four cycles are acquired, it is less of a limitation.” Read More: https://www.ajronline.org/doi/full/10.2214/AJR.04.0857 (AJR, 2006) Today’s use of 3D Imaging Ejection fraction “The clinical significance of quantitative analysis of ventricular volume and mass is well known for many cardiovascular diseases and their accurate and reliable measurement is therefore essential. While 2DE quantification techniques have limitations such as the need for geometric modelling and foreshortened views, these are absent in 3DE assessment of ventricular size and function. This theoretical advantage is validated in practice by numerous studies showing superiority of 3 DE over 2 DE in both accuracy and reproducibility of LV volumes and EF measurements when compared against the gold standard MRI. Similar results were reported for quantification of LV mass. An important additional value of 3DE is the potential to evaluate regional LV function based on segmental analysis of the 3D endocardial borders during the cardiac cycle. The ability of 3DE to quantify segmental timing of endocardial systolic contraction, and thus detect and quantify LV intraventricular dyssynchrony, seems useful in predicting which patients will respond to cardiac resynchronization therapy (CRT), although further studies are warranted. (Heart J, 2009).” (Am Heart J, 1999) (J Am Coll Cardiol, 2007) (Am J Cardiol, 2008) Today’s use of 3D Imaging Visualization of septal defects “Whereas 2D echocardiography is useful for identifying membranes in patients with atrial septal defects or ventricular septal defects, 3D echocardiography can measure diameters of the defects or of closure devices after placement using en face views from both the left and right sides (Figs. 18A). Defect sites, fenestrations, membranes, and particularly relationships to surrounding structures and tissues are theoretic advantages of 3D echocardiography, all of which may influence management options, particularly in the era of minimal-access surgery and percutaneous catheter closure.” Read More: https://www.ajronline.org/doi/full/10.2214/AJR.04.0857 Today’s use of 3D Imaging Valve evaluation “2DE has always been the standard for evaluation of regurgitant or stenotic heart valves. However, the advantages of 3DE offering depth as an additional dimension and enabling unlimited view angles are of considerable value in the diagnosis and management of valvular heart disease. From its initial use, 3DE has been critical in providing new insights on the mitral apparatus and the pathophysiology of mitral stenosis and egurgitation.7,33-35 Moreover, mitral valve area measurements by 3 DE have shown lower intraobserver and interobserver variability compared with 2 DE quantification measurements.36 Although most studies were performed with TEE, evaluation of the mitral valve from a TTE approach was made possible with the development of the fully sampled matrix array transducer, yielding adequate reconstruction of the mitral valve in 70% of consecutive patients.37 Over time the merit of 3DE in evaluating the mitral valve has led to a turning point, where many at present believe 3 DE should be considered the new clinical standard for the assessment of mitral valve pathology.38,39 The arrival of the live 3D TEE probe and the encouraging first experiences with it only affirm these beliefs (figure 5).40 (Heart J, 2009).” (Heart J, 2009) Today’s use of 3D Imaging Contrast-enhanced three-dimensional echocardiography “Contrast enhancement can be recommended in patients with poor acoustic windows to improve endocardial border visualization. Application of 3DE contrast enhancement for quantification of LV volumes and function has not only proven to be feasible, but also to be more accurate compared with non-contrast-enhanced 2DE or 3DE.30 Similar results were found for contrast-enhanced 3D dobutamine stress echocardiography.29,31 Finally, contrast-enhanced 3DE allows rapid quantitative assessment of myocardial perfusion due to the benefit of capturing every conceivable imaging plane in a 3D dataset during a single contrast injection.32 (Heart J, 2009).” Latest Advances of 3D Imaging Tricuspid valve “There is an emerging interest to develop transcatheter therapies that treat TV disease, especially because significant secondary TR is increasingly recognized as a major source of morbidity and mortality. Given the complex geometry of the right ventricle and the TV, a combination of TTE and TEE imaging is required to evaluate the TV comprehensively before intervention. Similar to the evaluation of the MV, 3DE lends itself to the understanding TV disorders through cropping of the dataset and thereby allowing for visualization of the TV from multiple points of view. This is especially relevant because there is an interest in applying edge-to-edge repair systems in the patients with significant TR. Careful identification of the TV leaflets with 3DE is key (and challenging). More-over, novel devices that aim to correct severe TR by reducing TV annular dilation (through effective bicuspidalization of the TV) or suturing the TV annulus also rely on 3DE for correct device placement and delivery. Similarly, TV replacements with percutaneous valves will also require 3DE guidance. As further percutaneous solutions to correct TR emerge, echocardiographers will increasingly rely on the combination of 2DE and 3DE to aid in device insertion. (Lang, Addetia, Narang, Mor-Avi, 2018).” Latest Advances of 3D Imaging Virtual reality “Virtual reality has been an important part of the computer gaming industry for more than a decade, but only recently has this technology been incorporated into cardiac imaging. While historically using CT or magnetic resonance datasets, it is now possible to create virtual reality models of cardiac structures using 3DE (Figure 14). Although current 3DE relies on using shadowing and volume or surface rendering to give the appearance of a 3D structure on a flat monitor, virtual reality allows for true 3D visualization of datasets by using special headsets (Online Video 9). These computer-generated 3D virtual reality environments allow the user to interact with, explore, and manipulate a cardiac model from any desired direction or spatial orientation (Figure 15),including visualization and measurements of the epicardial and endocardial surface of the heart, the chambers, valves (Figure 16), and arterial or venous system. (Langet al. JACC: CARDIOVASCULAR IMAGING, VOL. 11, NO. 12, 20183-Dimensional Echocardiography Update DECEMBER 2018:1854–781874).” Latest Advances of 3D Imaging Holography “Although holography, like virtual reality, also made its debut in the entertainment industry, translating this technology to cardiology and medical practice seems promising. Similar to virtual reality, holography offers the promise of being able to understand complex anatomy and pathology in a 3Dformat. Rather than wearing special headsets, specialized projectors create a 3D“floating”model of the heart. Alternatively, holographic glasses can also be worn to project images acquired from 3DE. The user can interact with the model, including cropping or rotating the image to visualize desired structures. The benefits of holography are similar to those of virtual reality and include enhanced education, communication, and its potential use for procedural planning.(Lang, Addetia, Narang, Mor-Avi, 2018).” Conclusion “Significant advances in three-dimensional echocardiography have made this modality a powerful diagnostic tool in the cardiology clinic. It can provide accurate and reliable measurements of chamber size and function, including the quantification of left ventricular mechanical dyssynchrony to guide patient selection for cardiac resynchron-isation therapy. Furthermore, three-dimensional echocardiography offers novel views and comprehensive anatomic definition of valvular and congenital abnormalities, improving diagnosis and preoperative planning.” (Heart J, 2009) References Kleijn, S. A., & Kamp, O. (2009). Clinical application of three-dimensional echocardiography: past, present and future. Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation, 17(1), 18–24. Live 3D Echocardiography: A Replacement for Traditional 2D Echocardiography? Robin C. Houck, Jason E. Cooke, and Edward A. Gill American Journal of Roentgenology 2006 187:4, 1092-1106. Roberto M. Lang, Karima Addetia, Akhil Narang, Victor Mor-Avi, 3-Dimensional Echocardiography: Latest Developments and Future Directions, JACC: Cardiovascular Imaging, Volume 11, Issue 12, 2018, Pages 1854-1878, ISSN 1936-878X.