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This review focused on right ventricular (RV) three-dimensional echocardiography (3DE) and discussed the following agenda. First, we summarized the clinical RV anatomy and function-related RV3DE use followed by the explanations about 3DSTE image acquisition, including pitfall. Next, we reviewed the reliability and feasibility of RV volume and RV ejection fraction measurements during the last decade. Besides, we described the techniques that might overcome the dropout images at RV anterior and out tract including the current limitations. Finally, speckle tracking echocardiography by RV3DE and novel RV shape assessment were reviewed. This review will help you get comprehensive information on the current status and future perspectives of RV3DE.

Echocardiography is a key evaluation tool for the diagnosis, prognosis, and guidance of interventional management of numerous cardiovascular conditions, including ischaemia, heart failure, and structural heart diseases. Recent technological advancements have also seen the exploration of artificial intelligence, intracardiac vortex imaging, and three-dimensional printing in echocardiography. With cardiovascular diseases increasing in prevalence worldwide, it is important for clinicians including general practitioners to have updated knowledge of appropriate use of echocardiography. As such, this article reviews the current literature and summarises the latest developments and the general clinical usage of echocardiography., Competing Interests: APW Lee receives speaker honorarium and research grant from Philips Healthcare.

Since its introduction >15 years ago, the use of spatial and temporal image correlation (STIC) technology has contributed substantially to fetal echocardiography. Moreover, significant advances have occurred in 3- and 4-dimensional (3D/4D) echocardiography over the past several years including the matrix probe along with advances in gray scale and color Doppler post processing, resulting in improved display of ultrasound images. In this article, we provide examples to show these recent developments including the use of color Doppler with STIC in the glass-body mode and the matrix probe thus enabling the demonstration of cardiac anomalies of the 4-chamber-view and great arteries. The use of the matrix probe allows the examination of cardiac structures in 2 orthogonal planes simultaneously, which can help in display of anatomy side by side (Biplane mode). In addition, the rapid image reconstruction of the matrix probe allows for the display of live 4D and the rapid acquisition of a STIC volume. The display of multiplanar images of the heart in 3D/4D has also been used to automate the display of ultrasound images, resulting in standardization of the image display and thus minimizing the operation dependency of the ultrasound examination. Future addition of image recognition software can also provide assistance in image review., (© 2019 S. Karger AG, Basel.)

Background: The Heartmate 3 (HM3) is a Conformiteé Européenne mark-approved left ventricular (LV) assist device (LVAD) with fully magnetically levitated rotor and features consisting of a wide range operational speeds, wide flow paths, and artificial pulse. We performed a hemodynamic-echocardiographic speed optimization evaluation in HM3-implanted patients to achieve optimal LV- and right ventricular (RV) shape., Methods and Results: Sixteen HM3 patients underwent pump speed ramp tests with right heart catheterization. Three-dimensional echocardiographic (3DE) LV and RV datasets (Philips) were acquired, and volumetric (Tomtec) and shape (custom software) analyses were performed (LV: sphericity, conicity; RV: septal and free-wall curvatures). Data were recorded at up to 13 speed settings. Speed changes were in 100-rpm steps, starting at 4600 rpm and ramping up to 6200 rpm. 3DE was feasible in 50% of the patients. Mean original speed was 5306 ± 148 rpm. LV end-diastolic (ED) diameter (-0.15 ± 0.09 cm/100 rpm) and volumes (ED: 269 ± 109 mL to 175 ± 90 mL; end-systolic [ES]: 234 ± 111 mL to 146 ± 81 mL) progressively decreased as the shape became less spherical and more conical; RV volumes initially remained stable, but at higher speeds increased (ED: from 148 ± 64 mL to 181 ± 92 mL; ES: 113 ± 63 mL to 130 ± 69 mL). On average, the RV septum became less convex (bulging toward the LV) at the highest speeds., Conclusions: LV and RV shape changes were noted in HM3-supported patients. Although a LV volumetric decrease and shape improvement was consistently noted, RV volumes grew in response to increase in speed above a certain point. A next concern would be whether understanding of morphologic and function changes in LV and RV during LVAD speed change assessed with the use of 3DE helps to optimize LVAD speed settings and improve clinical outcomes., (Copyright © 2018. Published by Elsevier Inc.)

Background: Right heart failure remains a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. Multiple 2D echocardiography derived parameters are associated with right ventricular failure (RV failure), but none of them has been proven to be a reliable predictor to date. We hypothesized that novel 3D-echocardiography (3DE) based parameters are associated with RV failure and predict long term outcome in patients undergoing LVAD implantation., Methods: This single-center study retrospectively enrolled 26 patients undergoing continuous-flow LVAD implantation. RV failure was defined as prolonged inotropic support for >14 days after LVAD implantation or consecutive implantation of a right ventricular assist device. Based on transesophageal 3DE datasets acquired prior to surgery right ventricular size, ejection fraction and longitudinal strains were calculated., Results: The overall RV failure rate was 19.2%. Patients suffering from RV failure had a significantly impaired 3D-right ventricular ejection fraction (3D-RVEF; 28 ± 2% vs. 19 ± 3%, p = 0.0145) and 3D derived RV free wall longitudinal strain (3D-RV-fws; -13.2 ± 0.97% vs. -6.4 ± 1.98%; p = 0.0056) when compared to patients without RV failure. ROC analysis for 3D-RV-fws (AUC 0.914) and 3D-RVEF (AUC 0.876) showed high discriminative capabilities in regard to detection of RV failure. Kaplan-Meier analysis showed an improved long-term survival of patients with a 3D-RV-fws <-11.9%., Conclusions: 3D-echocardiography derived RV ejection fraction and RV free wall strain are associated with right ventricular failure and long term outcome in patients undergoing LVAD implantation. These parameters have the potential to be future predictors for right heart failure in LVAD surgery., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The ongoing refinements in 3-dimensional (3D) echocardiography technology continue to expand the scope of this imaging modality in clinical cardiology by offering new features that stem from the ability to image the heart in its complete dimensionality. Over the years, countless publications have described these benefits and tested new frontiers where 3D echocardiographic imaging seemed to offer promising ways to improve patients' care. These include improved techniques for chamber quantification and novel ways to visualize cardiac valves, including 3D printing, virtual reality, and holography. The aims of this review article are to focus on the most important developments in the field in the recent years, discuss the current utility of 3D echocardiography, and highlight several interesting future directions., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Our aim is to investigate the acute intraoperative effects of the NeoChord repair procedure on mitral valve (MV) annular geometry and LV function and the impact of these changes on MR at 1-year follow-up., Background: Recently transapical off-pump mitral valve repair with NeoChord implantation has been demonstrated to be safe and effective in patients with degenerative mitral regurgitation (DMR)., Methods: We retrospectively analyzed baseline and early postoperative 3-dimensional transesophageal echocardiography of 66 patients who underwent NeoChord repair for isolated posterior leaflet MV disease using semiautomatic off-line analysis software., Results: We observed a significant acute reduction of indexed LV end diastolic volume (Δ% = 14, p < .001), LV ejection fraction (Δ = 5.7%, p = .002), indexed left atrial volume (Δ = 14.7%, p = .045), and pulmonary artery pressure (Δ = 2.1%, p = .026). Among MV geometric parameters, we observed a significant reduction of MV antero-posterior diameter (Δ = 7%, p < .001), sphericity index (Δ = 8%, p < .001), annulus circumference (Δ = 0.9%, p = .021), and annulus area (Δ = 2.7%, p = .018). At 1-year, 53 patients (85.5%) presented MR ≤ mild, while 9 patients (14.5%) had MR ≥ moderate. Reduction of AP diameter (OR = 0.14, CI -3.83; 0.08, p < .001), annulus circumference (OR = 0.27, CI -2.98; 0.37, p = .005), MV area (OR = 0.39, CI -2.46; 0.61, p = .04), aorto-mitral angle (OR = 0.38, CI -2.49; 0.54, p = .002) and iEDV (OR = 0.44, CI -2.44; 0.81, p = .001) were independent protective factors against recurrence of MR greater than mild at 1-year follow-up., Conclusions: Transapical NeoChord repair produces important acute intraoperative changes in MV anatomy in DMR patients. The acute changes observed were associated with procedure durability at 1-year FU., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The status of intrinsic left ventricular (LV) contractility in patients with isolated rheumatic mitral stenosis (MS) has been debated. The acute changes in loading conditions after percutaneous mitral valvuloplasty (PMV) may affect LV performance. We aimed to examine the acute effects of PMV on LV function and identify factors associated with LV ejection fraction (LVEF) changes, and determinants of long-term events following the procedure., Methods: One hundred and forty-two patients who underwent PMV for symptomatic rheumatic MS (valve area of 0.99±0.3cm 2 ) were prospectively enrolled. LV volumes and LVEF were measured by three-dimensional (3D) echocardiography. Long-term outcome was a composite endpoint of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, and stroke., Results: The mean age was 42.3±12.1years, and 125 patients were women (88%). After PMV, LVEF increased significantly (51.4 vs 56.5%, p<0.001), primary due to a significant increase in LV end-diastolic volume (65.8mL vs 67.9mL, p=0.002), and resultant increase in the stroke volume (33.9mL vs 39.6mL, p<0.001). Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. During a mean follow-up period of 30.8months, 28 adverse clinical events were observed. Postprocedural mitral regurgitation, MV area, and mean gradient were independent predictors of composite endpoints., Conclusions: In patients with rheumatic MS, PMV resulted in a significant improvement in LV end-diastolic volume, stroke volume and consequently increased in LVEF. Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. The predictors of long-term adverse events following PMV were post-procedural variables, including mitral regurgitation, valve area, and mean gradient., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Traditional methods of describing and classifying congenital mitral valve malformations (CMVMs) often lack specificity and scientificity. Thus, documentation is incomplete, especially in terms of ultrasound findings., Methods: Data were collected from 436 patients (mean age, 36.6±26.8years; male 47.9%), each subjected to echocardiographic evaluation of CMVM. Valvar characteristics were studied and analyzed via a four-tiered echocardiographic analysis (FTEA) approach: (1) supravalvular region and annulus, (2) valvar leaflets and commissures, (3) chordae tendineae, and (4) papillary muscles. A clinical random ultrasonic reading controlled trial was designed to the compare conventional diagnostic method and FTEA in patients with CMVMs., Results: From a total of 246,507 echocardiograms, CMVMs were methodically investigated in 436 (0.18%) patients. Of these, 16 (3.7%) had multi-level malformations; and in 133 (30.5%), CVCMs were associated with other cardiac defects. Using a FTEA approach, involvement was distributed as follows: (1) supravalvular region and annulus (n=7 [1.6%]; excessive supravalvular tissue, 3; abnormal annulus, 4 [overriding, 1; shifted, 2; bridging/cord-like accessory tissue, 1]); (2) valvar leaflets and commissures (n=421 [96.3%]; lengthy or excessive, 210; underdeveloped, 35; contracture,12; atretic, 3; anomalously connected, 1; loose or billowy, 63; clefts, 57; dual orifice, 5; localized bulging, 6; accessory tissue element, 4; fibrotic, 18; fused leaflet cusps, 3; abnormal commissures, 4 [fused, 1; clefts, 3]); (3) chordae tendineae (n=14 [3.2%]; confined to single papillary muscle, 4; excessive, 2; thickened and fused, 2; shortened, 2; fibrotic, 2; accessory tissue element, 1; straddling, 1); and (4) papillary muscles (n=13 [3.0%]; absent, 2; single, 5; asymmetric, 2; abnormally located, 3; fibrotic, 1). According to the report comparing one by one each section among the inexperienced (groups A and B) and experienced (group C) groups out of 100 patients with CMVMs, group A of the inexperienced group using the conventional diagnostic method had a score of 76±12, while group B of the inexperienced group using the FTEA method had a score of 85±11; group B scored significantly higher than group A (all P<0.05)., Conclusions: Detailed incremental FTEA method in a systematic manner clearly defines malformations of the MV apparatus, ensuring more accurate diagnostic imaging. The results of clinical randomized controlled trials confirm that FTEA diagnostic accuracy was higher than conventional methods in CMVMs., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: In the last decades, interventional cardiology has received fast and wide implementation as an effective alternative treatment to surgery for several congenital and acquired diseases. In this scenario, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, as well as anatomical and functional assessment., Methods: In this review article, we present recent innovations in medical imaging for structural heart disease and coronary artery disease, emphasizing the progress achieved in the field of multimodality imaging and the solutions proposed to some as-yet unresolved technical problems for safe and effective procedural performance., Results: Intra-procedural guidance can be facilitated by established multimodality cardiac imaging such as transesophageal 2D and 3D echocardiography and by novel techniques as echo-fluoroscopy overlay and 3D modeling/printing. Computed tomography and magnetic resonance imaging are particularly helpful for preprocedural morphology assessment and device sizing., Conclusion: Successful planning, performance, and aftercare of interventions depend heavily on accurate imaging for both structural heart disease and coronary artery disease., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Advances in ultrasound, computer, and electronics technology have permitted three-dimensional echocardiography (3DE) to become a clinically viable imaging modality, with significant impact on patient diagnosis, management, and outcome. Thanks to the inception of a fully sampled matrix transducer for transthoracic and transesophageal probes, 3DE now offers much faster and easier data acquisition, immediate display of anatomy, and the possibility of online quantitative analysis of cardiac chambers and heart valves. The clinical use of transthoracic 3DE has been primarily focused, albeit not exclusively, on the assessment of cardiac chamber volumes and function. Transesophageal 3DE has been applied mostly for assessing heart valve anatomy and function. The advantages of using 3DE to measure cardiac chamber volumes derive from the lack of geometric assumptions about their shape and the avoidance of the apical view foreshortening, which are the main shortcomings of volume calculations from two-dimensional echocardiographic views. Moreover, 3DE offers a unique realistic en face display of heart valves, congenital defects, and surrounding structures allowing a better appreciation of the dynamic functional anatomy of cardiac abnormalities in vivo. Offline quantitation of 3DE data sets has made significant contributions to our mechanistic understanding of normal and diseased heart valves, as well as of their alterations induced by surgical or interventional procedures. As reparative cardiac surgery and transcatheter procedures become more and more popular for treating structural heart disease, transesophageal 3DE has expanded its role as the premier technique for procedure planning, intra-procedural guidance, as well as for checking device function and potential complications after the procedure.

Transoesophageal echocardiography (TOE) is used in the perioperative arena to monitor patients during life-threatening emergencies, cardiac and high-risk non-cardiac surgeries. It provides qualitative and quantitative information on valvular and ventricular functions, and dynamic cardiac anatomy can be displayed with a physiological perspective. This technology has evolved from two-dimensional (2D) to the ready availability of real-time three-dimensional (RT-3D) imaging in the operating rooms. Enhanced spatial and temporal resolutions with 3D imaging have most significantly impacted the quality of intraoperative surgical valve repair and replacement decisions. Additionally, 3D imaging has facilitated the advent of minimally invasive and percutaneous interventions for structural heart disease. Information derived from TEE is routinely used to evaluate a patient's suitability for an intervention, provide guidance during the intervention and eventually comment on the quality and success of the procedure. Expertise in perioperative TEE is an integral component of a cardiac anaesthesiologist's skill sets. With structural heart disease interventions becoming more minimally invasive, the intraoperative guidance provided by TEE will continue to be a critical component of these procedures. With improving computational and processing power, the expectations from TEE will continue to be incremental in the perioperative arena., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Left ventricular mechanical dyssynchrony is an important prognostic factor for patients with symptomatic systolic heart failure and has emerged as a therapeutic target for cardiac resynchronization therapy (CRT). However, approximately one-third of patients fail to improve after CRT based on current guideline recommendations and electrocardiographic criteria. Two-dimensional echocardiography and tissue Doppler-based techniques have shown variable results in assessment of left ventricular (LV) dyssynchrony and have limited value in clinical practice. Three-dimensional echocardiography (3DE) is an appealing novel imaging modality that has been recently used in quantitative evaluation of global and regional LV function. There is accumulating evidence that 3DE measurement of LV systolic dyssynchrony index may potentially play a role in predicting the short- and long-term response to CRT and further improve patient selection for CRT. New developments in 3DE speckle tracking technique and strain analysis may further improve the accuracy of LV mechanical dyssynchrony assessment in this population. In addition, recent studies suggest that mechanical dyssynchrony is present in patients with LV hypertrophy and diastolic heart failure. Three-dimensional echocardiographic assessment of dyssynchrony may aid in diagnosis and in predicting long-term outcome in these patients. We will summarize current understanding of 3DE techniques and parameters in assessment of LV mechanical dyssynchrony in the population of patients with systolic heart failure, LV hypertrophy, and diastolic heart failure. A number of the novel 3DE techniques described in this review are early in their stage of development, and they will continue to evolve and need further testing in large multicenter studies., (© 2015, Wiley Periodicals, Inc.)

Background: Treatment-related cardiac death is the primary, noncancer cause of mortality in adult survivors of childhood malignancies. Early detection of cardiac dysfunction may identify a high-risk subset of survivors for early intervention., Objectives: This study sought to determine the prevalence of cardiac dysfunction in adult survivors of childhood malignancies., Methods: Echocardiographic assessment included 3-dimensional (3D) left ventricular ejection fraction (LVEF), global longitudinal and circumferential myocardial strain, and diastolic function, graded per American Society of Echocardiography guidelines in 1,820 adult (median age 31 years; range: 18 to 65 years) survivors of childhood cancer (median time from diagnosis 23 years; range: 10 to 48 years) exposed to anthracycline chemotherapy (n = 1,050), chest-directed radiotherapy (n = 306), or both (n = 464)., Results: Only 5.8% of survivors had abnormal 3D LVEFs (<50%). However, 32.1% of survivors with normal 3D LVEFs had evidence of cardiac dysfunction by global longitudinal strain (28%), American Society of Echocardiography-graded diastolic assessment (8.7%), or both. Abnormal global longitudinal strain was associated with chest-directed radiotherapy at 1 to 19.9 Gy (rate ratio [RR]: 1.38; 95% confidence interval [CI]: 1.14 to 1.66), 20 to 29.9 Gy (RR: 1.65; 95% CI: 1.31 to 2.08), and >30 Gy (RR: 2.39; 95% CI: 1.79 to 3.18) and anthracycline dose > 300 mg/m(2) (RR: 1.72; 95% CI: 1.31 to 2.26). Survivors with metabolic syndrome were twice as likely to have abnormal global longitudinal strain (RR: 1.94; 95% CI: 1.66 to 2.28) and abnormal diastolic function (RR: 1.68; 95% CI: 1.39 to 2.03) but not abnormal 3D LVEFs (RR: 1.07; 95% CI: 0.74 to 1.53)., Conclusions: Abnormal global longitudinal strain and diastolic function are more prevalent than reduced 3D LVEF and are associated with treatment exposure. They may identify a subset of survivors at higher risk for poor clinical cardiac outcomes who may benefit from early medical intervention., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

As interventional procedures in structural heart diseases are coming of age, there is a significant lag in the periinterventional imaging development for these procedures to become safe, expedient, accurate, and well tolerated by this patient population. Currently, transesophageal echocardiography (TEE), including real-time three-dimensional (RT-3D), has been used for monitoring and guidance for these procedures. Accurate identification of the pathology, its anatomy, and its relationship with the adjoining structures along with spatial resolution is of paramount importance for wire and catheter placement, device deployment, evaluation of the results, and any potential complications. Two-dimensional intracardiac echocardiography (ICE) has been used extensively for a variety of interventional procedures that undergo conscious sedation of monitored anesthesia. RT-3D ICE has recently become available; we describe our initial experience with this new imaging technology.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited progressive cardiomyopathy, clinically characterized by ventricular arrhythmias and increased risk of sudden cardiac death. Echocardiography has a role in the diagnosis and prognosis of ARVD/C. However, in the current era of magnetic resonance imaging (MRI), the role of echocardiography in ARVD/C patients and family member screening is subject to debate. Relatively novel echocardiographic techniques, such as three-dimensional right ventricular (3D-RV) imaging and tissue deformation imaging, may improve the diagnostic and prognostic performance of echocardiography in these patients. 3D-RV imaging provides more insights on RV anatomy and global function compared to conventional echocardiography. Subtle RV regional wall motion abnormalities, and mechanical dyssynchrony, are accurately measured by tissue deformation imaging. Several studies suggest an incremental value of novel echocardiographic parameters in addition to conventional measurements. Moreover, new parameters indicating subtle RV dysfunction, and mechanical dyssynchrony, are of predictive value and could help in risk stratification of ARVD/C patients. New robust parameters, derived from 3D-RV echocardiography and RV tissue deformation imaging, in combination with established conventional parameters, suggest that there is a current and future role for echocardiography in ARVD/C supplementing MRI.

Introduction: In functional mitral regurgitation (FMR), effective regurgitant orifice area (EROA) displays a dynamic pattern. The impact of dynamic changes of annulus dysfunction and leaflets tenting on phasic EROA was explored with real-time three-dimensional transesophageal echocardiography (RT3D-TEE)., Methods: RT3D-TEE was performed in 52 FMR patients and 30 controls. Mitral annulus dimensions and leaflets tenting were measured throughout systole (TomTec, Germany). Phasic EROA was measured by proximal isovelocity surface area (PISA) method., Results: Mitral annulus had the minimal area and an oval shape with saddle configuration during early systole in controls, which enlarged and became round and flattened towards mid and late systole (P<0.05). In contrast, annulus in FMR was significantly larger, rounder and flatter (P<0.001), which further dilated and became more flattened at late systole (P<0.05 vs control). Leaflet tenting height in FMR decreased in mid systole and remains unchanged towards late systole. The leaflet tenting volume peaked at early and late systole with a mid-systolic trough in both FMR and controls. But tenting volume of patients with FMR was significantly larger than that of controls (all P<0.001 vs control in whole systole). Further analysis demonstrated that early tenting volume (β value=0.053, P<0.05) was a predictor of early EROA, whereas late tenting volume (β value=0.031, P<0.05) and late annular displacement velocity were predictors of late EROA., Conclusions: The early and late peak EROAs of FMR was primarily contributed by tenting volume at early systole and late systole respectively. These findings would be of value to consider in interventions aimed at reducing the severity of FMR., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Congenital heart disease is the commonest congenital anomaly. It is much more common than chromosomal malformations and spinal defects. Its estimated incidence is about 4-13 per 1000 live births. Congenital heart disease is a significant cause of fetal mortality and morbidity. Antenatal diagnosis of congenital heart disease is extremely difficult and requires extensive training and expertise. The detection rate of congenital heart disease is very variable and it ranged from 35 to 86% in most studies. In the light of the above, the introduction of the new 3D/4D based spatio-temporal Image Correlation (STIC) is highly welcomed to improve antenatal detection of congenital heart disease. STIC is an automated device incorporated into the ultrasound probe and has the capacity to perform slow sweep to acquire a single 3-dimensional (3D) volume. This acquired volume is composed of a great number of 2-dimension (2D) frames. This volume can be analyzed and reanalyzed as required to demonstrate all the required cardiac views. It also provides the examiner with the ability to review all images in a looped cine sequence. This technology has the ability to improve our ability to examine the fetal heart in the acquired volume and decrease examination time. Using this technique you can share the information and consult colleagues both at your clinical sitting or remotely using the internet.

Echocardiography has evolved over the past 45 years from a simple M-mode tracing to an array of technologies that include two-dimensional imaging, pulsed and continuous wave spectral Doppler, color flow and tissue Doppler, and transesophageal echocardiography. Together, these modalities provide a comprehensive anatomic and functional evaluation of cardiac chambers and valves, pericardium, and ascending and descending aorta. The switch from analog to digital signal processing revolutionized the field of ultrasound, resulting in improved image resolution, smaller instrumentation that allows bedside evaluation and diagnosis of patients, and digital image storage for more accurate quantification and comparison with previous studies. It also opened the door for new advances such as harmonic imaging, automated border detection and quantification, 3-dimensional imaging, and speckle tracking. This article offers an overview of some newer developments in echocardiography and their promising applications.

Assessment of ischemic mitral regurgitation( IMR) severity is important to stratify patients' management. Because IMR is influenced by loading condition seriously, it is difficult to evaluate severity of IMR in clinically stable condition at rest. Exercise stress echocardiography is useful tool to assess "true" severity of IMR. Recently, mitral valve plasty( undersized annuloplasty) creates a new problem, which is called "functional mitral stenosis". Exercise stress echocardiography also reveals this hemodynamics. Recent 3-dimensional (3D) echocardiography enables an intuitive understanding a valve anatomy by surgeon's view, and a more detailed quantitative evaluation. The 3D echocardiography can contribute to exact valve area calculation and can evaluate the forms of the valve ring which had difficulty in evaluation by 2D echocardiography. The treatment of structural heart disease with catheter has been introduced, and therefore the importance of the 3D echocardiography increases in this field. In this review, we describe the role of stress echocardiography on the assessment of IMR and the current status of 3D echocardiography.

The evaluation of ventricular function is a core component of 2-dimensional echocardiography (2DE). Given the known limitations of 2DE, a more accurate assessment of ventricular function has long been desired. Three-dimensional echocardiography (3DE) holds promise to fulfill this role while still maintaining the same benefits of low cost, portability, and efficiency of 2DE. Although 3DE has been investigated for over 30 years, the technology has seen little use in the modern clinical echocardiography lab. Although the benefit provided by the additional dimension of 2DE over M-Mode was immediately apparent, the clinical advantages of 3DE over 2DE have been difficult to appreciate. Several reasons for the lack of adoption include the learning curve, concerns about workflow, skepticism about clinical validity, and perceptions that the technology is too unrefined. Nonetheless, the past 2 decades have seen tremendous technical improvements in the field and a wealth of clinically applicable research. In particular, 3DE now has an established role in evaluating left ventricular systolic function. This review highlights the clinical relevancy of 3DE in evaluating ventricular function in terms of the history, relevant data, advantages, and the limitations of current generation 3DE.

In this article, we review a number of topics that we believe reflect new and exciting aspects of fetal echocardiography. These new advances include early fetal cardiovascular imaging around 14 weeks, the utility of three/four dimensional imaging technology for the fetus, and finally the utility of fetal echocardiography for antenatal and perinatal care of congenital heart diseases to improve and optimize outcome. Finally, we briefly discussed future directions in fetal cardiac intervention., (© 2013, Wiley Periodicals, Inc.)

There have been major technological advances in echocardiography over the past decade. New and robust measures of myocardial function, both systolic and diastolic, have been identified and extensively evaluated. Some of the new measures such as annular velocities by tissue Doppler imaging have become an integral part of the echocardiographic examination, and other measures such as strain and strain rate have yet to be widely adopted. Three-dimensional (3D) echocardiography has evolved greatly since its introduction in the 1980s. Currently, its main clinical application is the perioperative assessment of the mitral valve. Though 3D echocardiography provides superior quantification of cardiac chamber size, its adoption has been limited by the lack of robust automated data analysis software with smooth integration of analysis packages into clinical workstations and suboptimal temporal and spatial resolution. With advancement in electronics and miniaturization, these limitations can be overcome. The history of contrast echocardiography is long and arduous. Use of a microbubble contrast for left ventricular opacification has become commonplace in most echocardiographic laboratories, but the routine use of microbubble contrast for myocardial perfusion will require standardization of the procedure and/or development of new contrast agents. The applications of 3D and microbubble contrast are also under active evaluation in vascular ultrasound. This review summarizes the current and future applications of these exciting developments in echocardiography and vascular ultrasound., (Copyright © 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Real-time 3D echocardiography is one of the most important developments in the field of non-invasive cardiac imaging within the last years. To investigate whether this new technology can be considered as a standard method the current guidelines and recommendations were reviewed. In the field of left ventricular function assessment, evaluation of mitral valve pathologies and peri-interventional monitoring of percutaneous valve repair procedures 3D echocardiography plays a major role. For other clinical applications, such as right heart assessment, congenital heart disease and stress echocardiography, a high potential is seen but evidence is currently too weak for general recommendations. However, in the near future no echo laboratory will be working without 3D modalities.

Two-dimensional speckle tracking echocardiography (2D STE) is a novel technique of cardiac imaging for quantifying complex cardiac motion based on frame-to-frame tracking of ultrasonic speckles in gray scale 2D images. Two-dimensional STE is a relatively angle independent technology that can measure global and regional strain, strain rate, displacement, and velocity in longitudinal, radial, and circumferential directions. It can also quantify rotational movements such as rotation, twist, and torsion of the myocardium. Two-dimensional STE has been validated against hemodynamics, tissue Doppler, tagged magnetic resonance imaging, and sonomicrometry studies. Two-dimensional STE has been found clinically useful in the assessment of cardiac systolic and diastolic function as well as providing new insights in deciphering cardiac physiology and mechanics in cardiomyopathies, and identifying early subclinical changes in various pathologies. A large number of studies have evaluated the role of 2D STE in predicting response to cardiac resynchronization therapy in patients with severe heart failure. However, the clinical utility of 2D STE in the above mentioned conditions remains controversial because of conflicting reports from different studies. Emerging areas of application include prediction of rejection in heart transplant patients, early detection of cardiotoxicity in patients receiving chemotherapy for cancer, and effect of intracoronary injection of bone marrow stem cells on left ventricular function in patients with acute myocardial infarction. The emerging technique of three-dimensional STE may further extend its clinical usefulness., (© 2013, Wiley Periodicals, Inc.)

Speckle-tracking echocardiography (STE) is an advanced echocardiographic technique that allows a novel approach to the assessment of cardiac physiology through the study of myocardial mechanics. In its three-dimensional (3D) modality, it overcomes the drawbacks inherent to other echocardiographic techniques, namely two-dimensional echocardiography and tissue Doppler imaging. Several research studies and software improvements have led 3D-STE to become a promising tool for accurate evaluation of global and regional cardiac function. This article addresses the image acquisition, analytical methods, and parameters of myocardial mechanics that could be derived from 3D-STE. This systematic guidance may help to establish its usefulness in the global and regional evaluation of cardiac function, and to facilitate its clinical application., (© 2012, Wiley Periodicals, Inc.)

Recent technologic advances in 3-dimensional (3D) echocardiography, using parallel processing to scan a pyramidal volume, have allowed for a superior ability to describe valvular anatomy using both transthoracic and transesophageal echocardiography. Although still in evolution and at an early phase of adaptation with respect to its clinical application, 3D echocardiography has emerged as an important clinical tool in the assessment of valvular heart disease. Three-dimensional echocardiography provides unique perspectives of valvular structures by presenting "en face" views of valvular structures, allowing for a better understanding of the topographical aspects of pathology, and a refined definition of the spatial relationships of intracardiac structures. Three-dimensional echocardiography makes available indices not described by 2D echocardiography and has been demonstrated to be superior to 2D echocardiography in a variety of valvular disease scenarios. The information gained from 3D echocardiography has especially made an impact in guiding clinical decisions in the evaluation of mitral valve (MV) disease. The decision of early surgery in degenerative MV disease is based on the suitability of repair, and the suitability of repair is generally based on echocardiography. The superior understanding of MV anatomy afforded by 3D echocardiography has been shown to be quite valuable in this setting. This review will describe the contemporary use of 3D echocardiography in the assessment of valvular heart disease, including MV, aortic, tricuspid, and prosthetic valve abnormalities. This article illustrates how 3D echocardiography can complement current echocardiography techniques in the management of valvular heart disease.

Complex intracardiac anatomy and spatial relationships are inherent to congenital heart defects (CHDs). Recognition of the limitations of two-dimensional echocardiography has stimulated clinical interest in three-dimensional imaging. The current review examines contemporary studies in the following areas where three-dimensional echocardiography has provided additive value in CHD: (1) visualization of morphology, (2) quantitation of chamber sizes and ventricular function, and (3) image-guided interventions., (© 2012, Wiley Periodicals, Inc.)

The role of two-dimensional stress echocardiography (2D-SE) is well established for diagnosis and prognosis of patients with known or suspected coronary artery disease. 2D-SE has its limitations as multiple views of the left ventricle (LV) must be obtained within 90 seconds of peak stress from more than window to completely visualize all LV segments. 2D-SE is operator-dependent and requires advanced skills to match the same myocardial segments during stress. LV foreshortening is a frequently encountered problem in 2D-SE that may result in false negative studies. Real time three-dimensional SE (RT-3D-SE) can overcome many limitations of 2D-SE. In 3D-SE, overall wall motion of the entire LV is assessed simultaneously in different planes. 3D images can be displayed in multiplane or multislice views for ease of comparison with greater accuracy and interobserver agreement when compared to 2D. 3D-SE is quantitative, provides rapid image acquisition, requires lower level of operator skills, and avoids LV foreshortening by correct alignment of imaging planes. 3D-SE is easily applied during pharmacologic stress and is feasible during exercise-induced stress. Despite these advantages, 3D has lower temporal and spatial resolution than 2D and requires longer analysis time. With advances in transducer technology, smaller matrix footprints, and automated softwares, 3D full LV volume image acquisition can be obtained with a single beat that is less prone to artifacts. We will discuss the current application of RT-3D-SE, highlight the pros and cons of 3D-SE over conventional 2D-SE, and review major studies on 3D-SE and future implications., (© 2012, Wiley Periodicals, Inc.)

The use of three-dimensional echocardiography (3DE) during electrophysiology (EP) procedures is the end product of years of growth in two diverse cardiology subspecialties; namely, advanced cardiac imaging and the EP. During the past decade, progress in both fields has resulted in many important advances that have culminated in their union for a new area of growth and development. Imaging advances have provided the cardiovascular specialist with enhanced cardiac volume and function data, and more recently, 3DE capabilities with improved spatial and temporal resolution providing unprecedented spatial relationships. This latter development is valued by EP specialists in need of hitherto never required anatomic knowledge as they press forward with extraordinary expansion in their capabilities. It makes sense that by combining these two rapidly growing subspecialties, future capabilities in patient care may be achieved that would otherwise not be possible. This paper discusses the value of 3DE during EP procedures and offers the readers insight into this novel multispecialty hybrid arena. Using this model as a template, it is likely that the readers may identify other areas within their practices where periprocedural advanced imaging may afford significant dividends in patient outcomes., (2011, Wiley Periodicals, Inc)

Left atrial appendage (LAA) has unique anatomical and physiological properties, which make it a common site for thrombus formation in many cardiovascular and systemic diseases. Assessment of LAA for thrombus thus becomes important in many clinical situations and two-dimensional transesophageal echocardiography (2D TEE), which allows excellent quality images of LAA because of its close proximity to esophagus is routinely used for this purpose. However, it is a semiinvasive procedure, requires more time and involves some degree of patient discomfort. With some training and experience, two-dimensional transthoracic echocardiography (2D TTE) can visualize LAA in most patients with good acoustic windows. A disadvantage of both 2D TTE and 2D TEE is that they provide only a thin slice or section of cardiac structures at any given time limiting their utility in comprehensively assessing the LAA for thrombus. On the other hand, live/real time three-dimensional (3D) TTE overcomes this limitation of both 2D TTE and 2D TEE because of its ability to encompass whole of the LAA in three-dimensions in the acquired data set, which can then be cropped and sectioned systematically at any desired angulation to more definitively look for clot. 3D TTE is also useful in differentiating a clot from pectinate muscles in the LAA, which can mimic a thrombus resulting in patient mismanagement. In addition, 3D TTE is helpful in sectioning a clot for lysis, which has implications in clot resolution. We reviewed the existing literature comparing the relative advantages and disadvantages of 3D TTE versus 2D TEE and found that in patients with good acoustic windows 3D TTE had similar efficacy for detecting LAA thrombus., (2011, Wiley Periodicals, Inc)

Cardiac imaging continues to reveal new anatomical and functional insights into heart disease. In echocardiography, both transesophageal and transthoracic three-dimensional imaging have been fully developed and optimized, and the value of the techniques that have increased our understanding of cardiac mechanics and ventricular function is well established. At the same time, the healthcare industry has released new devices onto the market which, although they are easier to use, have limitations that restrict their use for routine assessment. Tomography's diagnostic and prognostic value in coronary artery disease continues to increase while radiation exposure becomes progressively lower. With cardiac magnetic resonance imaging, myocardial injury and recovery in ischemic heart disease and following acute coronary syndrome can be monitored in exquisite detail. The emergence of new combined tomographic and gamma camera techniques, exclusively developed for nuclear cardiology, have improved the quality of investigations and reduced radiation exposure. The hybrid or fusion images produced by combining different techniques, such as nuclear cardiology techniques and tomography, promise an exciting future., (Copyright © 2012 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Chemotherapy-induced cardiotoxicity has become a significant public health issue. Left ventricular ejection fraction is routinely used to monitor cardiotoxicity but fails to detect subtle alterations in cardiac function. Improvements in the measurement of left ventricular ejection fraction, physical or pharmacologic stressors, and novel cardiac functional indices may be useful in the detection of cardiotoxicity. The improvements in the detection and therapy of cancer have led to the emergence of chemotherapy-induced cardiotoxicity. New echocardiographic techniques may be useful in the detection of patients undergoing chemotherapy treatments who could benefit from alternative cancer treatments, therefore decreasing the incidence of cardiotoxicity., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Gastric decompression with an orogastric tube after anesthetic induction does not appear to enhance image quality for routine cases. The insertion of a transesophageal echocardiographic (TEE) probe can cause significant upper-airway trauma, which can be minimized with rigid laryngoscopy. Limited TEE imaging without transgastric views appears to be safe and clinically adequate in patients with advanced liver disease and esophageal varices. Although esophagogastric perforation because of transesophageal echocardiography is rare, the risk is significantly higher with advanced age and female sex. The echocardiographic assessment of right ventricular function and left ventricular diastolic function can improve the prediction of atrial arrhythmias after elective lung resection. Furthermore, asymptomatic left ventricular systolic or diastolic dysfunction is an independent predictor of cardiovascular mortality and morbidity after open vascular surgery. Advances in 3D echocardiography have shown that hypertrophic cardiomyopathy frequently is associated with changes in the mitral valve complex that predispose to left ventricular outflow tract obstruction. Furthermore, 3D imaging of the mitral apparatus has highlighted the importance of the annular saddle shape and the anatomic variability in ischemic mitral regurgitation. Education in perioperative echocardiography is experiencing high demand that can be satisfied partially with simulators and Internet-based educational activities. These modalities will aid in the dissemination of echocardiography through perioperative practice., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Volumetric determinations by cardiac magnetic resonance imaging after tetralogy of Fallot repair may more accurately assess significant right ventricular dilation and pulmonary regurgitation to guide timing of pulmonary valve replacement. Recent guidelines by the American and European Societies of Echocardiography have summarized the clinical approach to valvular stenosis. They emphasize aortic stenosis given its high incidence and assessment confounders such as left ventricular function, aortic regurgitation, systemic hypertension, and mitral regurgitation. The applications of 3-dimensional echocardiography have reached transcatheter procedures such as atrial septal closure, mitral valve repair, and aortic valve replacement. It also provides detailed assessment of the mitral valve, cardiac chambers, and can guide pediatric aortic valve repair. The timing of surgery in mitral regurgitation remains controversial, especially when it is asymptomatic with normal left ventricular function. Recent data emphasize the outcome advantage of mitral valve repair in asymptomatic mitral regurgitation when the effective regurgitant orifice area is >40 mm(2). Transesophageal echocardiography is an established gold standard in the assessment of endocarditis. Multislice computed tomographic imaging has facilitated simultaneous detailed assessment of the cardiac valves and coronary arteries. Recent comparison has shown that these 2 imaging modalities are equivalent and complementary. Tricuspid valve regurgitation associated with mitral disease is common and important. At the time of mitral surgery, moderate or greater tricuspid regurgitation should be corrected, preferably by rigid annuloplasty. Recent evidence also supports tricuspid annuloplasty for an annular diameter >35 mm regardless of regurgitation severity. Although repair is preferred, tricuspid replacement also has acceptable outcomes., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)