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BACKGROUND: Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded into three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality. METHODS: We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into Study (n=122 patients with 3D images) and Validation (n=162) cohorts. VC was measured in both the right ventricular (RV) inflow and apical-4 chamber views and averaged. For the Study cohort, tricuspid annular (TA), RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain (Epsilon Imaging), and RV volumes (TomTec) were measured from 2D and 3D datasets, respectively. A K-partition algorithm was used in the Study cohort to derive a mortality-related cutoff VC value, above which TR was termed “massive”. The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the Validation cohort using Kaplan-Meier survival analysis. RESULTS: In the Study cohort, VC>0.92 cm (”massive” TR) was optimally associated with worse survival. TA and RV size were larger in the Massive group (p

Increased vascular stiffness is known to be an independent predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). The effects of sacubitril–valsartan on vascular structure and function have not been systematically studied in this patient population. We hypothesized that aortic distensibility (AD) and fractional area change (AFAC), as assessed by 2D transthoracic echocardiography (TTE), would improve over time in HFrEF patients on sacubitril–valsartan therapy, due to the vasodilatory properties of the medication. We prospectively studied 30 patients with HFrEF (25 < EF < 40%) on optimal guideline-directed medical therapy who were subsequently started on sacubitril–valsartan. Patients underwent serial 2D TTE imaging at baseline, 3 and 6 months following therapy initiation. Ascending aortic diameters were measured 3 cm above the aortic valve in the parasternal long-axis view and used to calculate AD and AFAC, two markers of vascular compliance. For reference, we also measured AD and AFAC in 30 healthy, age and gender-matched controls at a single time point. Normal controls had significantly higher values of AD and AFAC than HFrEF patients at baseline (AD: 4.0 ± 1.1 vs. 2.2 ± 0.9 c m(2)dyne(−1)10(−3), p < 0.0001 and AFAC: 18.8 ± 3.7% vs. 10.3 ± 4.3%, p < 0.0001). In HFrEF patients on sacubitril–valsartan, both indices of aortic compliance progressively improved towards normal from baseline to 6 months: AD from 2.2 ± 0.9 to 3.6 ± 1.5 cm(2)dyne(−1)10(−3) (p < 0.0001) and AFAC from 10.3 ± 4.3 to 13.7 ± 4.1% (p < 0.0001). In conclusion, AD and AFAC are decreased in patients with HFrEF and gradually improve with sacubitril–valsartan treatment. The echocardiographic markers used in this study may become a useful tool to assess the effectiveness of sacubitril–valsartan therapy in HFrEF patients.

Tricuspid annular (TA) size, assessed by 2D transthoracic echocardiography (TTE), has a well-established prognostic value in patients undergoing mitral valve surgery, with TA dilatation triggering simultaneous tricuspid annuloplasty. While TA dilatation is common in patients with dilated atria secondary to atrial fibrillation, little is known about the mechanisms of TA dilatation in patients with sinus rhythm (SR). This study aimed to identify echocardiographic parameters most closely related to the TA size as a potential tool for identification of patients prone to developing TA enlargement. 120 patients with SR underwent clinically indicated TTE, including 30 patients with normal hearts and 90 patients diagnosed with at least one right heart abnormality, defined as: right ventricular (RV) or right atrial (RA) dilatation, ≥ moderate tricuspid regurgitation (TR) and elevated systolic pulmonary artery pressure (sPAP). RA and RV end-diastolic and end-systolic volumes (EDV, ESV) and function were measured using commercial 3D software (TomTec). 3D RV long and short axes were used as surrogate indices of RV shape. Degrees of TR and sPAP were estimated by 2D TTE. 3D TA sizing was performed at end-diastole using 3D custom software. Linear regression analysis was used to identify variables best correlated with TA size, followed by multivariate analysis to identify independent associations. The highest correlations were found between TA area and: RA ESV (r = 0.73; p

Three-dimensional echocardiography (3DE) allows accurate and reproducible measurements of right ventricular (RV) size and function. However, widespread implementation of 3DE in routine clinical practice is limited because the existing software packages are relatively time-consuming and skill demanding. The aim of this study was to test the accuracy and reproducibility of new machine learning- (ML-) based, fully automated software for three-dimensional quantification of RV size and function.Fifty-six unselected patients with a wide range of RV size and function and image quality, referred for clinically indicated cardiac magnetic resonance (CMR) imaging, underwent a transthoracic 3DE exam on the same day. End-systolic and end-diastolic RV volumes (ESV, EDV) and ejection fraction (EF) were measured using the ML-based algorithm and compared with CMR reference values using Bland-Altman and linear regression analyses.RV function quantification by echocardiography was feasible in all patients. The automatic approach was accurate in 32% patients with analysis time of 15 ± 1 seconds and 100% reproducible. Endocardial contour editing was necessary after the automated postprocessing in the remaining 68% patients, prolonging analysis time to 114 ± 71 seconds. With these minimal adjustments, RV volumes and EF measurements were accurate in comparison with CMR reference (biases: EDV, -25.6 ± 21.1 mL; ESV, -7.4 ± 16 mL; EF, -3.3% ± 5.2%) and showed excellent reproducibility reflected by coefficients of variation7% and intraclass correlations ≥0.95 for all measurements.The new ML-based 3DE algorithm provided accurate and completely reproducible RV volume and EF measurements in one-third of unselected patients without any boundary editing. In the remaining patients, quick minimal editing resulted in reasonably accurate measurements with excellent reproducibility. This approach provides a promising solution for fast three-dimensional quantification of RV size and function.

Background The prevalence of isolated cleft mitral valve (MV; no concomitant congenital heart disease or degenerative MV disease) with significant mitral regurgitation (MR) diagnosed using two-dimensional echocardiography (2DE) has been reported to be very low. Three-dimensional echocardiography (3DE) has enabled a more comprehensive visualization of the MV and detailed understanding of the mechanisms of MR and can potentially reveal isolated cleft MV that is not recognized with 2DE. The aim of this study was to determine, using 3DE, the prevalence, location, and associated MV annular and left ventricular characteristics of isolated cleft MV, in the absence of associated congenital heart disease, in patients with significant MR. Methods A total of 1,092 patients with unexplained moderate or greater MR on two-dimensional transthoracic echocardiography who were referred for three-dimensional transesophageal echocardiography between 2005 and 2017 (n = 626) were retrospectively studied. Left ventricular dimensions and function were determined, and quantitative MR assessment and three-dimensional analysis of the MV annulus was performed. Results Twenty-one patients (prevalence 3.3%) were diagnosed with isolated cleft MV using three-dimensional transesophageal echocardiography but not 2DE. The majority of these patients (n = 16) were noted to have anterior cleft MVs, with most located in the mid-A1 (n = 10) or mid-A3 (n = 5) scallops. Posterior clefts were less common (n = 5) and occurred at the site of the natural scallop indentations (three between P1 and P2 and two between P2 and P3). Among patients with either anterior or posterior MV cleft, there were no differences in left ventricular ejection fraction or three-dimensional MV geometry (annular distance, height, circumference, and area). There was a trend toward worse MR severity in patients with anterior cleft MV. Conclusions In patients with otherwise unexplained significant MR referred for transesophageal echocardiography, 3DE uncovered a considerably higher prevalence of isolated cleft MV than previously reported by 2DE, with the majority located in the anterior MV. Although the annular geometry was similar between patients with anterior and posterior cleft MVs, a trend toward more severe MR in anterior clefts may reflect underlying abnormalities in the embryologic development of the anterior MV leaflet. Evaluation of MV pathology is improved by 3DE, which should be used routinely in the setting significant MR.

Objectives This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value. Background Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape. Methods We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, in whom good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression. Results Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk. Conclusions GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain ( r =0.70; P =0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; P =0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; P =0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index ( P =0.02), increasing mean arterial pressures ( P =0.02), and decreasing E′ values ( P =0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.

Background Three-dimensional (3D) echocardiography directly assesses right ventricular (RV) volumes without geometric assumptions, despite the complex shape of the right ventricle, and accordingly is more accurate and reproducible than the two-dimensional methodology, which is able to measure only surrogate parameters of RV function. Volumetric analysis has been hampered by frequent inability to clearly visualize RV endocardium, especially the RV free wall, in 3D echocardiographic images. The aim of this study was to test the hypothesis that RV contrast enhancement during 3D echocardiographic imaging would improve the accuracy of RV volume and function analysis. Methods Thirty patients with a wide range of RV size and function and image quality underwent transthoracic 3D echocardiography with and without contrast enhancement and cardiovascular magnetic resonance imaging on the same day. RV end-diastolic and end-systolic volumes and ejection fraction were measured from contrast-enhanced and nonenhanced 3D echocardiographic images and compared with cardiovascular magnetic resonance reference values using linear regression and Bland-Altman analyses. Blinded repeated measurements were performed to assess measurement variability. Results RV contrast enhancement was feasible in all patients. RV volumes obtained both with and without contrast enhancement correlated highly with cardiovascular magnetic resonance (end-diastolic volume, r = 0.90 and r = 0.92; end-systolic volume, r = 0.92 and r = 0.94, respectively), but the correlation for ejection fraction was better with contrast ( r = 0.87 vs r = 0.70). Biases were smaller with contrast for all three parameters (end-diastolic volume, −16 ± 23 vs −36 ± 25 mL; end-systolic volume, −10 ± 16 vs −23 ± 18 mL; ejection fraction, −0.7 ± 5.5% vs −2.7 ± 8.1% of the mean measured values), reflecting improved accuracy. Also, measurement reproducibility was improved by contrast enhancement. Conclusions Contrast enhancement improves the visualization of RV endocardial borders, resulting in more accurate and reproducible 3D echocardiographic measurements of RV size and function. This approach may be particularly useful in patients with suboptimal image quality.

Objective\ud\udStatistical shape modelling (SSM) has established as a powerful method for segmenting the left ventricle in cardiac magnetic resonance (CMR) images However, applying them to segment the right ventricle (RV) is not straightforward because of the complex structure of this chamber. Our aim was to develop a new inter-modality SSM-based approach to detect the RV endocardium in CMR data.\udMethods\ud\udReal-time transthoracic 3D echocardiographic (3DE) images of 219 retrospective patients were used to populate a large database containing 4347 3D RV surfaces and train a model. The initial position, orientation and scale of the model in the CMR stack were semi-automatically derived. The detection process consisted in iteratively deforming the model to match endocardial borders in each CMR plane until convergence was reached. Clinical values obtained with the presented SSM method were compared with gold-standard (GS) corresponding parameters.\udResults\ud\udCMR images of 50 patients with different pathologies were used to test the proposed segmentation method. Average processing time was 2 min (including manual initialization) per patient. High correlations (r2 > 0.76) and not significant bias (Bland-Altman analysis) were observed when evaluating clinical parameters. Quantitative analysis showed high values of Dice coefficient (0.87 ± 0.03), acceptable Hausdorff distance (9.35 ± 1.51 mm) and small point-to-surface distance (1.91 ± 0.26 mm). Conclusion\ud\udA novel SSM-based approach to segment the RV endocardium in CMR scans by using a model trained on 3DE-derived RV endocardial surfaces, was proposed. This inter-modality technique proved to be rapid when segmenting the RV endocardium with an accurate anatomical delineation, in particular in apical and basal regions.

Objectives The goal of this study was to test the feasibility and accuracy of an automated algorithm that simultaneously quantifies 3-dimensional (3D) transthoracic echocardiography (TTE)-derived left atrial (LA) and left ventricular (LV) volumes and left ventricular ejection fraction (LVEF). Conventional manual 3D TTE tracings and cardiac magnetic resonance (CMR) images were used as a reference for comparison. Background Cardiac chamber quantification from 3D TTE is superior to 2D TTE measurements. However, integration of 3D quantification into clinical practice has been limited by time-consuming workflow and the need for 3D expertise. A novel automated software was developed that provides LV and LA volumetric quantification from 3D TTE datasets that reflect real-life manual 3-dimensional echocardiography measurements and values comparable to CMR. Methods A total of 159 patients were studied in 2 separate protocols. In protocol 1, 94 patients underwent 3D TTE imaging (EPIQ, iE33, X5-1, Philips Healthcare, Andover, Massachusetts) covering the left atrium and left ventricle. LA and LV volumes and LVEF were obtained using the automated software (HeartModel, Philips Healthcare) with and without contour correction, and compared with the averaged manual 3D volumetric measurements from 3 readers. In protocol 2, automated measurements from 65 patients were compared with a CMR reference. The Pearson correlation coefficient, Bland-Altman analysis, and paired Student t tests were used to assess inter-technique agreement. Results Correlations between the automated and manual 3D TTE measurements were strong (r = 0.87 to 0.96). LVEF was underestimated and automated LV end-diastolic, LV end-systolic, and LA volumes were overestimated compared with manual measurements. Agreement between the automated analysis and CMR was also strong (r = 0.84 to 0.95). Test–retest variability was low. Conclusions Automated simultaneous quantification of LA and LV volumes and LVEF is feasible and requires minimal 3D software analysis training. The automated measurements are not only comparable to manual measurements but also to CMR. This technique is highly reproducible and timesaving, and it therefore promises to facilitate the integration of 3D TTE-based left-heart chamber quantification into clinical practice.

International audience; We evaluate in this paper different strategies for the construction of a statistical shape model (SSM) of the left ventricle (LV) to be used for segmentation in cardiac magnetic resonance (CMR) images. From a large database of LV surfaces obtained throughout the cardiac cycle from 3D echocardiographic (3DE) LV images, different LV shape models were built by varying the considered phase in the cardiac cycle and the registration procedure employed for surface alignment. Principal component analysis was computed to describe the statistical variability of the SSMs, which were then deformed by applying an active shape model (ASM) approach to segment the LV endocardium in CMR images of 45 patients. Segmentation performance was evaluated by comparing LV volumes derived by ASM segmentation with different SSMs and those obtained by manual tracing, considered as a reference. A high correlation (r2 > 0.92) was found in all cases, with better results when using the SSM models comprising more than one frame of the cardiac cycle.

Severely reduced left ventricular (LV) ejection fraction (EF) derived from 2D echocardiographic (2DE) images is associated with increased mortality and used to guide therapeutic choices. Global longitudinal strain (GLS) is more sensitive than LVEF to detect abnormal LV function, and accordingly may help identify patients with mildly-to-moderately reduced LVEF who are at a similarly high cardiovascular (CV) risk. We hypothesized that 3D echocardiographic (3DE) measurements of EF and GLS, which are more reliable and reproducible, may have even better predictive value than the 2DE indices, and compared their ability to identify such patients. We retrospectively studied 104 inpatients with 2DE-derived LVEF of 30-50% who underwent transthoracic echocardiography during 2006-2010 period, had good quality images, and were followed-up through 2016. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Kaplan-Meier survival curves were generated for two subgroups defined by the median of each parameter as the cutoff. Of the 104 patients, 32 died of CV related causes. Cox regression revealed that 3D GLS was the only variable associated with CV mortality. Kaplan-Meier curves showed that 2D LVEF, 2D GLS and 3D EF were unable to differentiate patients at higher CV mortality risk, but 3D GLS was the only parameter to do so. Because 3D GLS is able to identify patients with mildly-to-moderately reduced LVEF who are at higher CV mortality risk, its incorporation into clinical decisions may improve survival of those who would benefit from therapeutic interventions not indicated according to the current guidelines.

Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects.Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements.Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e' significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume.In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.

Preservation of native left ventricular (LV) function in patients supported with LV assist device (LVAD) may be beneficial to attain optimal hemodynamics and enhance potential recovery. Currently, LVAD speed optimization is based on hemodynamic parameters, without considering residual native LV function. We hypothesized that alternatively, LV rotational mechanics can be quantified by 3D echocardiography (3DE), and may help preserve native LV function while optimizing LVAD speed. The goal of this study was to test the feasibility of quantifying the effects of LVAD implantation on LV rotational mechanics and to determine whether conventional speed optimization maximally preserves native LV function. We studied 55 patients with LVADs, who underwent 3DE imaging and quantitative analysis of LV twist. Thirty patients were studied before and after LVAD implantation. The remaining 25 patients were studied during hemodynamic ramp studies. The pump speed at which LV twist was maximal was compared with the hemodynamics-based optimal speed. LV twist decreased following LVAD implantation from 4.2 ± 2.7 to 2.3 ± 1.9° (P

Aims In functional mitral regurgitation (FMR), increased leaflet area has been described as a remodelling compensatory mechanism. We hypothesized that chordae tendineae elongation would also occur as part of this remodelling. In this study, the lengths of primary chords and measurements of mitral leaflets and annulus were compared with varying degrees of mitral regurgitation (MR). Methods and results We studied 58 patients who underwent three-dimensional (3D) transoesophageal echocardiography, including 38 with FMR and 20 with normal mitral valves (NL). The FMR group was divided into two subgroups according to two-dimensional vena contracta width (VCW). Three-dimensional datasets from transgastric or mid-oesophageal approach were used to measure primary chordal length, coaptation length, inter-papillary muscle distances, and quantitative 3D measurements of the annulus and leaflets. Leaflet surface area was increased and coaptation length was decreased in FMR compared with NL. While no difference in other 3D measurement of annulus/leaflets was noted between the FMR subgroups, averaged chordal length was shorter in patients with more severe FMR. Chords of the anterior leaflet in FMR with larger VCW were shorter compared with both NL and FMR with smaller VCW. In contrast, the chords of the posterior leaflet were longer in FMR with smaller VCW compared with the other two groups. Conclusion Our results suggest the posterior leaflet chords possibly remodel by elongating and contribute to reduced MR and that in a subgroup of FMR patients, the primary chords may remodel by shortening, resulting in augmented MR. This information could be useful in choosing strategy for FMR correction. [10.1093/ehjci/jew029][1] [1]: /lookup/doi/10.1093/ehjci/jew029

Aims Right ventricular (RV) remodelling involves changes in size, function, and shape. Although three-dimensional echocardiography (3DE) allows imaging of RV morphology, regional RV shape analysis has not been evaluated using 3DE. We developed a technique to quantify RV shape and tested its ability to differentiate normal from pressure overloaded right ventricles. Methods Transthoracic 3DE RV images were acquired in 54 subjects, including 39 patients with pulmonary artery hypertension (PAH) and 15 normal controls (NL). 3D RV surfaces were reconstructed (TomTec) at end-diastole and end-systole (ED, ES) and processed using custom software to calculate mean curvature of the inflow and outflow tracts (RVIT, RVOT), apex, and body (both divided into free wall and septum). Methods and Results Septal segments (apical and body) in NLs were characterized by concavity (curvature 0) in ES. In PAH, however, the septum remained convex, bulging into the left ventricle throughout the cardiac cycle. In keeping with the ‘bellows-like’ action of RV contraction in the NL group, the body free wall transitioned from a convex surface at ED to a more flattened surface at ES, while the apex free wall progressed from a less convex surface at ED to a more convex surface at ES. In contrast, in PAH, both RV free-wall segments (apical and body) remained equally convex throughout the cardiac cycle. Conclusions Curvature analysis using 3D echocardiography allows quantitative evaluation of RV remodelling, which could be used to track differential changes in regional RV shape, as a way to assess disease progression or regression.

This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value.Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape.We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, who had good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression.Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk.GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.

Background Although 3D echocardiography (3DE) allows accurate and reproducible quantification of cardiac chambers, it has not been integrated into clinical practice because it relies on manual input, which interferes with workflow. A recently developed automated adaptive analytics algorithm for simultaneous quantification of left ventricular and atrial (LV, LA) volumes was found to be accurate and reproducible in patients with good images. We sought to prospectively test its feasibility and accuracy in consecutive patients in relationship with image quality and reader experience. Methods Three hundred consecutive patients underwent 3DE. Image quality was graded as poor, adequate, or good. Images were analyzed by an expert echocardiographer to obtain LV volumes and ejection fraction (EF) and LA volume using the automated analysis (HeartModel, Philips, Andover, MA) with and without editing the endocardial boundaries and using conventional manual tracing (QLAB, Philips, Andover, MA) blinded to the automated measurements as a reference. In a subgroup of 100 patients, automated analysis was repeated by two readers without 3DE experience. Results Automated analysis failed in 31/300 patients (10%). Patients with poor image quality ( n = 72, 24%) showed suboptimal agreement with the reference technique, especially for LVEF. Importantly, patients with adequate ( n = 89, 30%) and good ( n = 108, 36%) images showed small biases and excellent correlations without border corrections, which were further improved with editing. In contrast, border corrections by inexperienced readers did not improve the agreement with reference values. Conclusions Automated 3DE analysis allows accurate quantification of left-heart size and function in 66% of consecutive patients, while in the remaining patients, its performance is limited/unreliable due to image quality. Border corrections require 3DE experience to improve the accuracy of the automated measurements. In patients with sufficient image quality, this automated approach has the potential to overcome the workflow limitations of the 3D analysis in clinical practice.

This study examined cardiac remodeling and functional changes induced by 5 days of head-down (−6°) bed rest (HDBR) and the effectiveness of short-arm centrifugation (SAC) in preventing them in males. Twelve healthy men (mean age: 33 ± 7) were enrolled in a crossover design study (BR-AG1, European Space Agency), including one sedentary (CTRL) and two daily SAC countermeasures (SAC1, 30 min continuously; SAC2, 30 min intermittently) groups. Measurements included plasma and blood volume and left ventricular (LV) and atrial (LA) dimensions by transthoracic echocardiography (2- and 3-dimensional) and Doppler inflows. Results showed that 5 days of HDBR had a major impact on both the geometry and cardiac function in males. LV mass and volume decreased by 16 and 14%, respectively; LA volume was reduced by 36%; Doppler flow and tissue Doppler velocities were reduced during early filling by 18 and 12%, respectively; and aortic flow velocity time integral was decreased by 18% with a 3% shortening of LV ejection time. These modifications were presumably due to decreased physiological loading and dehydration, resulting in reduced plasma and blood volume. All these changes were fully reversed 3 days after termination of HDBR. Moreover, SAC was not able to counteract these changes, either when applied continuously or intermittently.

Background Right ventricular (RV) strain is a potentially useful prognostic marker in patients with pulmonary arterial hypertension (PAH). However, published reports regarding the accuracy of two-dimensional echocardiography (2DE)-derived RV strain against an independent reference in this patient population are limited. The aims of this study were: (1) to study the relationship between 2DE RV longitudinal strain and cardiovascular magnetic resonance (CMR)-derived RV ejection fraction (RVEF) in patients with PAH; (2) to compare 2DE-derived and CMR-derived RV longitudinal strain in these patients; and (3) to determine the reproducibility of these measurements. Methods Thirty patients with PAH underwent 2DE and CMR imaging within a 2-hour time period. 2DE RV longitudinal strain was measured from a focused RV apical four-chamber view using speckle tracking software. CMR RV longitudinal strain was measured from short-axis slices acquired using fast-strain-encoded sequence. Global peak systolic RV longitudinal strain was calculated for both 2DE and CMR. Results RV longitudinal strain using 2DE software correlated well with CMR-derived RVEF (R = 0.69, P = 0.0006). There was moderate agreement when comparing 2DE to CMR RV longitudinal strain (R = 0.74, P = 0.0002; bias −1%, limits of agreement −9 to 7%). Inter-observer variability and intra-observer variability for RV longitudinal strain were lower for 2DE than CMR. Conclusions RV longitudinal strain by 2DE provides a good alternative for CMR-derived RVEF in patients with PAH. The moderate agreement in strain measurements between 2DE and CMR suggests that further software improvements are needed before these measurements can be used interchangeably in clinical practice.

Background Three-dimensional echocardiographic (3DE) analysis provides better measurements of left ventricular (LV) volumes, ejection fraction, myocardial deformation, and dyssynchrony. Many studies have shown that this technique has high intrainstitutional reproducibility. However, interinstitutional reproducibility is low, limiting its adoption. The aim of this study was to determine if standardization of training could reduce the interinstitutional variability in 3DE data analysis. Methods In total, 50 full-volume, transthoracic 3DE data sets of the left ventricle were analyzed by two readers. Measurements obtained included LV volumes, ejection fraction, global longitudinal strain, and two dyssynchrony indices. The cases represented a wide spectrum of ejection fraction. After initial analysis of 21 studies, readers formally met to standardize their analytic approach on six additional cases. Five months after the intervention, 23 new cases were analyzed. Paired t tests were performed to identify systematic institutional differences in measurements. Interinstitutional variability was quantified using intraclass correlation coefficients and variability. Results Before the intervention, there was a systematic bias in LV volumes, which was eliminated after intervention. Intraclass correlation coefficients showed that the intervention improved agreement in measurements of LV volumes, strain, and dyssynchrony between the two centers and decreased variability. Conclusions A simple intervention to standardize analysis can reduce interinstitutional variability of measurements obtained from 3DE analysis. This intervention is needed before the use of 3DE measurement in multicenter trials and to increase the reproducibility of such measurements in routine clinical practice.

with the advent of real-time 3-dimensional transesophageal echocardiography (3d tee), rapid creation of high-quality, true-to-life images of mitral valve anatomy and pathology has become possible in the vast majority of patients ([1][1]). In addition to common mitral valve lesions, such as

Aims Although recommended by current guidelines, adoption of three-dimensional echocardiographic (3DE) chamber quantification in clinical practice has lagged because of time-consuming analysis. We recently validated an automated algorithm that measures left atrial (LA) and left ventricular (LV) volumes and ejection fraction (EF). This study aimed to determine the accuracy and reproducibility of these measurements in a multicentre setting. Methods and results 180 patients underwent 3DE imaging (Philips) at six sites. Images were analysed using automated HeartModel (HM) software with endocardial border correction when necessary and by manual tracing. Measurements were performed by each site and by the Core Laboratory (CL) as the reference. Inter-technique comparisons included HM measurements by the sites against manual tracing by CL, and showed strong correlations (r-values: LVEDV: 0.97, LVESV: 0.97, LVEF: 0.88, LAV: 0.96), with the automated technique slightly underestimating LV volumes (biases: LVEDV: -14 ± 20 ml, LVESV: -6 ± 20 ml), LVEF (-2 ± 7%) and LAV (-9 ± 10 ml). Intra-technique comparisons included HM measurements by the sites against CL, with and without corrections. Corrections were unnecessary or minimal in most patients, and improved the measurements only modestly. Comparisons without corrections showed perfect agreement for all parameters. With corrections, correlations were better (r-values: LVEDV: 0.99, LVESV: 0.99, LVEF: 0.94, LAV: 0.99) and biases (LVEDV: -8 ± 12 ml, LVESV: -6 ± 12 ml, LVEF: 1 ± 5%, LAV: -10 ± 6 ml) smaller than in inter-technique comparison. All automated measurements with corrections were more reproducible than manual measurements. Conclusion Automated 3DE analysis of left-heart chambers is an accurate alternative to conventional manual methodology, which yields almost the same values across laboratories and is more reproducible. This technique may contribute towards full integration of 3DE quantification into clinical routine.

Objectives We studied in a multicenter setting the accuracy and reproducibility of 3-dimensional echocardiography (3DE)–derived measurements of left atrial volume (LAV) using new, dedicated volumetric software, side by side with 2-dimensional echocardiography (2DE), using cardiac magnetic resonance (CMR) imaging as a reference. Background Increased LAV is associated with adverse cardiovascular outcomes. Although LAV measurements are routinely performed using 2DE, this methodology is limited because it is view dependent and relies on geometric assumptions regarding left atrial shape. Real-time 3DE is free of these limitations and accordingly is an attractive alternative for the evaluation of LAV. However, few studies have validated 3DE-derived LAV measurements against an accepted independent reference standard, such as CMR imaging. Methods We studied 92 patients with a wide range of LAV who underwent CMR (1.5-T) and echocardiographic imaging on the same day. Images were analyzed to obtain maximal and minimal LAV: CMR images using standard commercial tools, 2DE images using a biplane area-length technique, and 3DE images using Tomtec LA Function software. Intertechnique comparisons included linear regression and Bland-Altman analyses. Reproducibility of all 3 techniques was assessed by calculating the percentage of absolute differences in blinded repeated measurements. Kappa statistics were used to compare 2DE and 3DE classification of normal/enlarged against the CMR reference. Results 3DE-derived LAV values showed higher correlation with CMR than 2DE measurements (r = 0.93 vs. r = 0.74 for maximal LAV; r = 0.88 vs. r = 0.82 for minimal LAV). Although 2DE underestimated maximal LAV by 31 ± 25 ml and minimal LAV by 16 ± 32 ml, 3DE resulted in a minimal bias of −1 ± 14 ml for maximal LAV and 0 ± 21 ml for minimal LAV. Interobserver and intraobserver variability of 2DE and 3DE measurements of maximal LAV were similar (7% to 12%) and approximately 2 times higher than CMR (4% to 5%). 3DE classified enlarged atria more accurately than 2DE (kappa: 0.88 vs. 0.71). Conclusions Compared with CMR reference, 3DE-derived LAV measurements are more accurate than 2DE-based analysis, resulting in fewer patients with undetected atrial enlargement.

Objectives To determine the accuracy of calcium-containing rings measurements imaged by three-dimensional echocardiography (3DE), multi-slice CT (MSCT) and cardiac magnetic resonance (CMR) under ideal conditions against the true ring dimensions. To compare the accuracy of aortic annulus (AoA) measurements in ex vivo human hearts using 3DE, MSCT and CMR. To determine the accuracy of AoA measurements in an in vivo human model. Design 3DE, MSCT and CMR imaging were performed on 30 calcium-containing rings and 28 explanted human hearts. Additionally, 15 human subjects with clinical indication for MSCT underwent 3DE. Two experts in each modality measured the images. Main outcome measures Bias and intraclass correlation coefficient for accuracy of imaging measurements when compared with actual ring dimensions. Bias, intraclass correlation coefficient and variability were obtained: (1) when comparing explanted human heart AoA measurements from the two remaining imaging modalities with the most accurate one as determined from the ring measurements and (2) in in vivo human AoA measurements. Analysis was repeated on explanted heart subgroups divided by aortic valve Agatston score. Results Against the known ring dimensions, CMR had the highest accuracy and the lowest variability. MSCT measurements had high accuracy but wider variability and 3DE had the lowest accuracy with the largest variability. When 3DE and MSCT were compared with CMR, 3DE underestimated and MSCT overestimated AoA dimensions, but inter-measurement variability of 3DE and MSCT were similar. When divided by Agatston score, both 3DE and MSCT measurements were larger and showed greater variability with increasing calcium burden. The in vivo study showed that the correlation between 3DE and MSCT measurements was high; however, 3DE measurements were smaller than those measured with MSCT. Conclusions In the in vitro model, CMR measurements were the most accurate for assessing the actual dimensions suggesting that further investigations on its role in AoA measurement in TAVR are needed. However from the in vivo model, MSCT and 3DE are reasonable alternatives with the understanding that they can slightly overestimate and underestimate annular dimensions, respectively.

Currently, no real-time three-dimensional echocardiographic (RT3DE) indices are recommended by the official guidelines for the assessment of diastolic dysfunction (DD). We hypothesized that recent developments in RT3DE imaging technology that allow dynamic quantification of both left ventricular (LV) volume and 3D myocardial deformation, could be utilized to objectively assess DD. Transthoracic RT3DE datasets were acquired (Philips iE33, X5 transducer, frame rate 19 ± 4) in 76 subjects, including 20 normal controls (NL), 16 mild DD, 20 moderate DD and 20 severe DD (grade 1, 2 and 3, respectively, using ASE guideline). Images were analyzed using prototype software (TomTec) that performs 3D speckle tracking to generate time curves of LV volume and segmental myocardial strain. Indices of diastolic LV function were calculated: volume at 25, 50 and 75 % of filling duration (FD) in percent of end-diastolic volume (volume index, LVVi), and rapid filling volume (RFV) fraction. Temporal indices included: FD in % of RR, and rapid filling duration (RFD) in % of FD. Additionally, longitudinal, radial and circumferential strains at 25, 50 and 75 % of FD were calculated. Inter-groups differences were tested using ANOVA. LVVi and RFV fraction showed a biphasic pattern with the severity of DD characterized by an initial decrease (grade 1), a pseudo-normalization (grade 2), and then an increase above normal (grade 3). FD progressively decreased with severity of DD. RFD was significantly increased in all 3 groups compared to NL. After normalization by peak systolic values, all three strain components showed a linear pattern with the severity of DD, suggesting potential clinical usefulness. This is the first study to show that current RT3DE technology allows combined quantitative analysis of LV volume and 3D myocardial strain, which is sensitive enough to demonstrate differences in myocardial relaxation in patients with different degrees of DD.

Background: Sickle cell disease (SCD) is a hemoglobinopathy that affects one in 500 African Americans. Although it is well established that patients with SCD have left ventricular (LV) diastolic dysfunction, it is not clear whether they have subtle LV systolic dysfunction despite preserved ejection fraction (EF). We used three-dimensional speckle tracking echocardiography (3DSTE) to assess changes in both systolic and diastolic LV function in SCD. Methods: Transthoracic real time 3D images were obtained (Philips iE33) in 56 subjects, including 28 stable outpatients with SCD (age 33 ± 7 years) and 28 normal controls (age 35 ± 9 years). 3DSTE was performed using prototype software (4DLV Analysis, TomTec) to obtain LV volume and deformation time curves, from which indices of systolic and diastolic LV function were calculated. Results: In SCD patients, 3DSTE-derived LV filling parameters were significantly different from normal controls, reflecting an increase in both rapid and atrial filling volumes and prolonged active relaxation, depicted by a decrease in filling volume fractions at fixed times and an increase in rapid filling duration. Global LV systolic function was not only preserved but increased compared to controls, as reflected by significantly increased global longitudinal strain. Importantly, twist angle and torsion as well as radial and circumferential components of 3D strain were similar in both groups. Conclusions: 3DSTE was able to confirm diastolic dysfunction, as expected in some patients with SCD. However, 3DSTE strain analysis did not reveal any changes in LV systolic function. These findings provide novel insight into the pathophysiology of the cardiovascular complications of SCD.

Significant advances in 3-dimensional echocardiography (3DE) technology have ushered its use into clinical practice. The recent advent of real-time 3DE using matrix array transthoracic and transesophageal transducers has resulted in improved image spatial resolution, and therefore, enhanced visualization of the pathomorphological features of the cardiac valves compared with previously used sparse array transducers. It has enabled an unparalleled real-time visualization of valves and subvalvular anatomic features from a single volume acquisition without the need for offline reconstruction. On-cart or offline post-processing using commercially available and custom 3-dimensional analysis software allows the quantification of multiple parameters, such as orifice area, prolapse height and volume in mitral valve disease, area of the left ventricular outflow tract, and tricuspid annular geometry. In this review, we discuss the incremental role of 3DE in evaluating valvular anatomic features, volumetric quantification, pre-surgical planning, intraprocedural guidance, and post-procedural assessment of valvular heart disease.

Background: Assessment of right ventricular (RV) function is difficult due to the complex shape of this chamber. Tricuspid annular plane systolic excursion (TAPSE) measured with M-mode echocardiography is frequently used as an index of RV function. However, its accuracy may be limited by ultrasound beam misalignment. We hypothesized that two-dimensional (2D) speckle tracking echocardiography (STE) could provide more accurate estimates of RV function. Accordingly, STE was used to quantify tricuspid annular displacement (TAD), from which RV longitudinal shortening fraction (LSF) was calculated. These STE derived indices were compared side-by-side with M-mode TAPSE measurements against cardiac magnetic resonance (CMR) derived RV ejection fraction (EF). Methods: Echocardiography (Philips iE33, four-chamber view) and CMR (Siemens, 1.5 T) were performed on the same day in 63 patients with a wide range of RV EF (23–70% by CMR). TAPSE was measured using M-mode echocardiography. TAD and RV LSF were obtained using STE analysis (QLAB CMQ, Philips). TAPSE, TAD and RV LSF values were compared with RV EF obtained from CMR short axis stacks. Results: STE analysis required

Background Accurate segmental mitral valve (MV) analysis is essential for surgical planning. Although real-time three-dimensional (3D) transesophageal echocardiography has improved the ability to visualize the MV, accurate localization of MV pathology from 3D transesophageal echocardiographic images still remains experience dependent. Three-dimensional parametric maps of the MV obtained from these images further simplify the visualization of MV anatomy. The aims of this study were to examine whether 3D parametric maps of the MV could improve the diagnostic accuracy in localizing pathology and to determine their usefulness for readers with different levels of training. Methods Five novice (American Society of Echocardiography [ASE] level 2), three intermediate-level (ASE level 3; 500 MV cases) readers interpreted MV segmental anatomy in 50 patients (30 with degenerative MV disease, 20 with normal MVs). All readers reviewed two-dimensional and 3D transesophageal echocardiographic and 3D parametric maps at sequential weekly sessions. The results were compared with surgical findings. Results Expert readers were the most accurate irrespective of image type. Novice readers were the least accurate and commonly misinterpreted P2 and P3 scallops. Their accuracy was highest when interpreting 3D parametric maps (from 87% with two-dimensional transesophageal echocardiography to 92%). Intermediate readers' accuracy fell between the other two groups irrespective of image type and showed no change with the use of parametric maps. Conclusions This is the first study to show that the interpretation of 3D parametric maps improves the accuracy of localization of MV pathology by novice readers. Therefore, parametric maps should be used routinely by less experienced readers during the assessment of degenerative MV disease.

Over the past few decades, transesophageal echocardiography (TEE) has evolved from one-dimensional imaging using a probe with a single-crystal, M-mode transducer to two-dimensional imagingwith phased-array transducers and now three-dimensional (3D) imaging with matrix array transducers. Current 3D imaging probes are vastly superior to the earlier technique of using multi-plane TEE imaging to reconstruct 3D images. While these earlier techniques enabled improved visualization of valvular anatomy, acquisition of images was tedious and time-consuming and extensive post-processing was required to generate images. As well, image quality was poor and frequently affected by artifact limiting its use for research purposes. Recent advancements in real-time three-dimensional (RT3D) TEE have propelled 3D TEE imaging into clinical practice from the research realm. With the development of the matrix array TEE probe real-time acquisition and on-line display of 3D TEE images are now easy to acquire and there is no need for either sequential multi-plane acquisition or off-line reconstruction. These images have enabled the visualization of valvular anatomy from unique orientations with improved spatial relationships not previously seen with 2D echocardiography. In particular, RT3D TEE has allowed improved visualization and assessment of prosthetic valves. In this editorial, we will discuss the use of RT3D TEE in the assessment of prosthetic valves, their associated complications such as prosthetic valve endocarditis and paravalvular regurgitation as well as limitations and future uses of RT3D TEE.

A comprehensive evaluation of patients with mitral valve disease must include an echocardiographic examination of the mitral valve apparatus and resultant hemodynamic changes due to mitral pathology. Three-dimensional echocardiography has impacted on the diagnosis of mitral valve prolapse but has mostly existed in a research realm. After decades of development, three-dimensional echocardiography is now easily performed and readily incorporated in the assessment of mitral valve disease in daily clinical practice. Unique anatomic views of the mitral valve, accurate quantitative assessment of the mitral valve orifice area, and delineation of segmental prolapse are several advantages of three-dimensional echocardiography. Moreover, there is a wealth of data that can be derived from a three-dimensional volume, enabling more detailed analysis of mitral valve apparatus and valve annular dynamics. This review highlights current applications of three-dimensional echocardiography in the routine evaluation of mitral valve disease.

Background Left ventricular (LV) ejection fraction (EF) by transthoracic two-dimensional echocardiography is time-intensive and highly dependent on image quality. Mitral annular displacement (MAD) qualitatively correlates with EF and can be measured in patients with poor image quality and dropout. The authors hypothesized that speckle-tracking echocardiography (STE)–derived MAD could quantify EF accurately and tested this hypothesis using cardiac magnetic resonance (CMR) as a reference. Methods One hundred eighteen patients undergoing clinical transthoracic echocardiography were screened, and 110 whose mitral annuli was sufficiently well-defined irrespective of LV endocardial visualization underwent CMR within 6 days (85 of 110 in 1 day). Reference CMR EF values were obtained using standard methodology. STE was used to track annular motion throughout the cardiac cycle in the apical 2-chamber and 4-chamber views. To establish the relationship between MAD and CMR EF and to obtain a formula to estimate EF from MAD, regression analysis was performed in a study group of 60 patients with a wide range of EFs. This formula was then used in an independent test group of 50 patients by comparing estimated MAD EF against CMR EF values using Pearson's correlation and Bland-Altman analyses. Results In the study group, STE MAD correlated highly with CMR EF and resulted in a formula relating MAD to EF. In the test group, estimated EF correlated well with CMR EF (4-chamber, R 2 = 0.64; 2-chamber, R 2 = 0.55), with near-zero bias and acceptable limits of agreement. Intraobserver and interobserver variability were between 5.8% and 12.7%. Conclusions STE MAD is a clinically useful tool for quick, easy, robust, and accurate estimates of EF irrespective of LV endocardial definition.

Accurate preoperative determination of defect location and size is important for successful transcatheter closure of atrial septal defects (ASD). Real-time 3D transesophageal echocardiography (3DTEE) has the potential to delineate the shape of ASD in 3D space. Full volume and 3D zoom datasets by 3DTEE were acquired in 17 ASD patients. Using quantitative software, maximal/minimal diameter, defect area and residual rim length were measured and compared to the standard 2D measurements. Real-time 3DTEE allowed delineation of the en-face view of the ASDs. The defect typically had an oval shape, and its size changed dynamically, having its minimal size at end-diastole and maximal at end-systole. A good correlation was noted between the maximal defect area by 3DTEE and 2DTEE (r = 0.93, p

Objectives This study sought to establish normal values for real-time 3-dimensional echocardiography (RT3DE)–derived left ventricular (LV) dyssynchrony index (LVDI) and determine its age dependency, and to compare dyssynchrony in patients with normal LV function and patients with dilated cardiomyopathy (DCM), with and without left bundle branch block (LBBB). Background Cardiac resynchronization therapy is known to be ineffective in one-third of patients with heart failure, highlighting the need for alternative techniques to assess LV dyssynchrony. Methods Datasets from RT3DE were analyzed to calculate LVDI using 16- and 17-segment models. First, 135 normal subjects were studied to establish LVDI abnormality threshold (mean + 2 SD) and to study the relationship with age. Then, 3 groups of patients (N = 16 each: DCM with and without LBBB, normal LV function with LBBB) were compared with 50 age-matched normal control subjects. Results In normal subjects, the 16-segment model resulted in a lower LVDI abnormality threshold than the 17-segment model (4.0% vs. 4.5%). In patients with normal LV function, LVDI was significantly lower than in those with DCM, irrespective of LBBB. Although LBBB resulted in a nearly 2-fold increase in LVDI in patients with normal LV function, its effects were nonsignificant in DCM. All patients with DCM and ejection fraction Conclusions Normal values established in this study resulted in indiscriminate diagnosis of abnormal dyssynchrony in all patients with reduced LV function. The value of RT3DE-derived LVDI in the evaluation of dyssynchrony in patients with reduced LV function needs to be critically reassessed because of the inability to accurately detect end-ejection in low-amplitude regional volume curves. Alternative indices of dyssynchrony need to be developed to address this limitation.

Background The aim of this study was to determine the feasibility and accuracy of a new real-time 3-dimensional (RT3D) matrix-array transesophageal echocardiographic probe for the determination of left atrial appendage (LAA) geometry. Methods Sixty-six consecutive patients (mean age, 53 ± 17 years) referred for 2-dimensional (2D) transesophageal echocardiography (TEE) underwent additional RT3D TEE. The feasibility of RT3D TEE for LAA geometry was studied in the first 37 patients, and 2D and RT3D transesophageal echocardiographic quantification of the LAA were compared in the subsequent 29 patients. The LAA orifice diameter and depth were measured using biplane 2D TEE, and LAA orifice area was calculated as an ellipse. LAA orifice area and depth were measured in 3D and correlated to 2D measurement and were also correlated to 64-slice cardiac computed tomography (CT) in 8 patients. Results All 66 patients underwent RT3D matrix-array TEE without complication. In the feasibility study, the LAA was well visualized in 95%. In the quantitation study, 2D TEE underestimated LAA orifice area compared with 3D imaging (3.1 ± 1.3 vs 4.2 ± 2.2 cm 2 ; r = 0.55). LAA depth by 2D and 3D imaging were well correlated (3.7 ± 0.7 vs 3.4 ± 0.7 cm; r = 0.77). LAA orifice area on CT was well correlated with area on 3D TEE ( r = 0.98) but not with area 2D TEE ( r = 0.13). Bland-Altman analysis demonstrated that 2D TEE systematically underestimated LAA orifice area compared with 3D TEE (mean bias, −1.0 cm 2 , with wide limits of agreement [−4.6 to 2.6 cm 2] . In the 8 patients who underwent both 3D TEE and CT, the mean bias was 0.15 cm 2 , with narrow limits of agreement (−0.50 to 0.20 cm 2 ). Conclusions RT3D TEE for the visualization and quantitative analysis of LAA orifice area is feasible and correlates well with 64-slice cardiac CT.

Objectives Our study goals were to evaluate the 3-dimensional matrix array transesophageal echocardiographic (3D-MTEE) probe by assessing the image quality of native valves and other intracardiac structures. Background Because 3-dimensional transesophageal echocardiography with gated rotational acquisition is not used routinely as the result of artifacts, lengthy acquisition, and processing, a 3D-MTEE probe was developed (Philips Medical Systems, Andover, Massachusetts). Methods In 211 patients, 3D-MTEE zoom images of the mitral valve (MV), aortic valve, tricuspid valve, interatrial septum, and left atrial appendage were obtained, followed by a left ventricular wide-angled acquisition. Images were reviewed and graded off-line (Xcelera with QLAB software, Philips Medical Systems). Results Excellent visualization of the MV (85% to 91% for all scallops of both MV leaflets), interatrial septum (84%), left atrial appendage (86%), and left ventricle (77%) was observed. Native aortic and tricuspid valves were optimally visualized only in 18% and 11% of patients, respectively. Conclusions The use of 3D-MTEE imaging, which is feasible in most patients, provides superb imaging of native MVs, which makes this modality an excellent choice for MV surgical planning and guidance of percutaneous interventions. Optimal aortic and tricuspid valve imaging will depend on further technological developments. Fast acquisition and immediate online display will facilitate wider acceptance and routine use in clinical practice.

Objectives: We sought to study: 1) the accuracy and reproducibility of real-time 3-dimensional echocardiographic (RT3DE) analysis of left ventricular (LV) volumes in a multicenter setting, 2) interinstitutional differences in relationship with the investigators' specific experience, and 3) potential sources of volume underestimation. Background: Reproducibility and accuracy of RT3DE evaluation of LV volumes has not been validated in multicenter studies, and LV volumes have been reported to be underestimated compared to cardiac magnetic resonance (CMR) standard. Methods: A total of 92 patients with a wide range of ejection fractions underwent CMR and RT3DE imaging at 4 different institutions. Images were analyzed to obtain LV end-systolic volume (ESV) and end-diastolic volume (EDV). Reproducibility was assessed using repeated analyses. The investigation of potential sources of error included: phantom imaging, intermodality analysis-related differences, and differences in LV boundary identification, such as inclusion of endocardial trabeculae and mitral valve plane in the LV volume. Results: The RT3DE-derived LV volumes correlated highly with CMR values (EDV: r = 0.91; ESV: r = 0.93), but were 26% and 29% lower consistently across institutions, with the magnitude of the bias being inversely related to the level of experience. The RT3DE measurements were less reproducible (4% to 13%) than CMR measurements (4% to 7%). Minimal changes in endocardial surface position (1 mm) resulted in significant differences in measured volumes (11%). Exclusion of trabeculae and mitral valve plane from the CMR reference eliminated the intermodality bias. Conclusions: The RT3DE-derived LV volumes are underestimated in most patients because RT3DE imaging cannot differentiate between the myocardium and trabeculae. To minimize this difference, tracing the endocardium to include trabeculae in the LV cavity is recommended. With the understanding of these intermodality differences, RT3DE quantification of LV volume is a reliable tool that provides clinically useful information.