Principles for Acquisition of Images Image resolution is best in the axial plane, intermediate in the lateral or azimuthal plane, and lowest in the plane of elevation; this information should be used to decide how best to examine individual structures of interest Insonation should be performed orthogonal to the plane of the structure of interest Meticulous attention should be paid to the quality of 2DE images Adjacent structures that are of clinical relevance should be included The pediatric probe should be used whenever possible The width of the scanning sector should be narrowed and the depth of the image should be optimized Gain and compression must be adjusted to minimize false dropout, typically due to an undergained image, or noise within the cardiac chamber, which is typically due to an overgained image Either overgained or undergained images may impede visualization (Fig 20.4, optimized gain; Video 20.5, optimized; Video 20.6, overgained; and Video 20.7, undergained) To ensure that full volume acquisitions are free of artifact, careful review of multiplanar images in orthogonal views is recommended.10 FIG 20.4 The free walls of the right heart chambers have been cropped away to obtain this live three-dimensional echocardiography demonstration of a large membranous ventricular septal defect (dashed lines) in a patient with double-outlet right ventricle and pulmonary atresia The papillary muscle of the conus (also known as the medial papillary muscle [MPM] or the papillary muscle of Lancisi) is seen attaching between the limbs of the septomarginal trabeculation (SMT) (septal band) and, in effect, dividing the ventricular septal defect into an anterosuperior component and a posteroinferior component The settings for gain and compression in this image have been optimized in order to minimize intracavitary noise, while maintaining adequate gain to be able to visualize details of the chordal structure and papillary muscles of the tricuspid valve The accompanying videos (Videos 20.6 and 20.7) demonstrate the result of suboptimal settings for gain and compression RA, Right atrium Display and Orientation of ThreeDimensional Echocardiography Images Three modes for the display and presentation of 3DE are currently available Volume-rendered images lend themselves to virtual dissections, enabling the operator to “crop” the heart in multiple sections to view the areas of interest from the perspective that is desired Surface-rendered images present a cast of the internal surfaces of chambers; these serve as the basis for quantifying ventricular function Multiplanar reformatting provides orthogonal and adjustable views of the 3DE dataset in a so-called quad screen that has four images These consist of three rendered 2DE views and the 3DE acquisition This type of display provides unique 2DE planes that are not available using conventional 2DE devices It enhances the accuracy of measurements such as diameters and areas, and helps with understanding complex anatomy Prior published recommendations for the display of 3DE described the display of cropped images using the three orthogonal planes (right/left, superior/inferior, and anterior/posterior) as they pertain to the heart itself, rather than to the entire body; these guidelines specifically excluded congenital heart disease.11,12 The joint European-American consensus document on pediatric 3DE recommends an anatomically correct orientation for image display The heart is projected in the same orientation as in a person standing upright Structures that are positioned superiorly in the body are displayed uppermost on the screen, and the diaphragmatic surface of the heart is lowermost This approach is consistent with other tomographic imaging modalities such as magnetic resonance imaging (MRI) and computed tomography.13 When applied to 3DE, this approach results in en face views of the septums or valves; these can be rotated either clockwise or counterclockwise to achieve the anatomically correct orientation Examples of the application of this approach to the atrial septum are demonstrated in Fig 20.5 and Video 20.8 ... body; these guidelines specifically excluded congenital heart disease.11,12 The joint European-American consensus document on pediatric 3DE recommends an anatomically correct orientation for image display The heart is projected in the