(BQ) Part 1 book Comprehensive textbook of echocardiography presents the following contents: History and basics (history of echocardiography, basics of ultrasound, basics of 3D ultrasound,...), echocardiography/ultrasound examination and training (M-mode examination, the complete transthoracic echocardiography, nonstandard echocardiographic examination,...).
Vol Comprehensive Textbook of Echocardiography Vol Comprehensive Textbook of Echocardiography Editor Navin C Nanda MD Distinguished Professor of Medicine and Cardiovascular Disease and Director, Heart Station/Echocardiography Laboratories University of Alabama at Birmingham and the University of Alabama Health Services Foundation The Kirklin Clinic, Birmingham, Alabama, USA President, International Society of Cardiovascular Ultrasound Under the Aegis of The International Society of Cardiovascular Ultrasound and The Indian Academy of Echocardiography ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi London Philadelphia Panama đ Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: 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any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners The publisher is not associated with any product or vendor mentioned in this book Medical knowledge and practice change constantly This book is designed to provide accurate, authoritative information about the subject matter in question However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications It is the responsibility of the practitioner to take all appropriate safety precautions Neither the publisher nor the author(s)/ editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book This book is sold on the understanding that the publisher is not engaged in providing professional medical services If such advice or services are required, the services of a competent medical professional should be sought Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com Comprehensive Textbook of Echocardiography (Vol 1) First Edition: 2014 ISBN 978-93-5090-634-7 Printed at: Dedicated to My late parents Balwant Rai Nanda MD and Mrs Maya Vati Nanda My wife Kanta Nanda MD Our children Nitin Nanda, Anita Nanda Wasan MD and Anil Nanda MD Their spouses Sanjeev Wasan MD and Seema Tailor Nanda, and our grandchildren Vinay and Rajesh Wasan, and Nayna and Ria Nanda Contributors Masood Ahmad M D FRCP (C) FACP FACC FAHA FASE Division of Cardiology Department of Internal Medicine University of Texas Medical Branch Galveston Texas, USA Dheeraj Arora DNB PDCC MNAMS Institute of Critical Care and Anesthesia Medanta The Medicity Gurgaon, Haryana, India Mohammad Al-Admawi MD King Faisal Specialist Hospital and Research Center Heart Center Riyadh, Saudi Arabia Bader Almahdi MD Manreet Basra MBBS Monodeep Biswas MBBS MD Professor of Medicine University at Buffalo School of Medicine and Biological Sciences New York, USA Division of Cardiology Geisinger-Community Medical Center, and The Wright Center for Graduate Medical Education Scranton, Pennsylvania, USA Charles E Beale MD Department of Medicine Division of Cardiovascular Diseases Stony Brook University Medical Center Stony Brook, New York, USA Roy Beigel MD The Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA The Leviev Heart Center Sheba Medical Center, Affiliated to the Sackler School of Medicine Tel Aviv University, Tel Aviv, Israel Steven Bleich MD Department of Medicine Division of Internal Medicine University of Alabama at Birmingham Birmingham, Alabama, USA O Julian Booker MD Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Eduardo Bossone MD PhD FCCP FESC FACC Echocardiography and Vascular Lab Assistant Professor of Medicine New York University School of Medicine New York, New York, USA Via Principe Amedeo Lauro (AV), Italy Heart Department, University of Salerno, “Scuola Medica Salernitana” Salerno, Italy Department of Cardiac Surgery IRCCS Policlinico San Donato, Milan, Italy Division of Cardiology Department of Medicine University of Texas Medical Branch Galveston, Texas, USA Kunal Bhagatwala MBBS Luis Bowen MD Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Department of Medicine University of Alabama at Birmingham Birmingham, Alabama, USA Neeraj Awasthy FNB Aditya Bharadwaj MD Gerald Buckberg MD Department of Cardiology Loma Linda University and VA Medical Centers Loma Linda, California, USA Department of Cardiothoracic Surgery David Geffen School of Medicine University of California-Los Angeles Los Angeles, California, USA Heart Center, St Christopher’s Hospital for Children and Section of Cardiology Department of Pediatrics, Drexel University College of Medicine Philadelphia, Pennsylvania, USA Aarti H Bhat MBBS Michael J Campbell MD Assistant Professor Division of Pediatric Cardiology Seattle Children’s Hospital and University of Washington Seattle, Washington, USA Department of Pediatrics Division of Pediatric Cardiology Duke University Medical Center Durham, North Carolina, USA Piers Barker MD Nicole Bhave MD FRCP FACC Department of Pediatrics Division of Pediatric Cardiology Duke University Medical Center Durham, North Carolina, USA University Health Network Toronto General Hospital University of Toronto Toronto, Ontario, Canada Professor Emeritus Division of Cardiology UC-Irvine School of Medicine Irvine, California, USA King Faisal Specialist Hospital and Research Center Heart Center Riyadh, Saudi Arabia Ahmed Almomani MBBS Fortis Escorts Heart Institute New Delhi, India Rula Balluz MD MPH Ricardo Benenstein MD Premindra PAN Chandraratna MD viii Comprehensive Textbook of Echocardiography Leon H Charney Michele D’ Alto MD PhD Daniel Forsha MD Division of Cardiology New York University Medical Center New York, New York, USA Department of Cardiology Second University of Naples: Monaldi Hospital, Naples, Italy Department of Pediatrics Division of Pediatric Cardiology Duke University Medical Center Durham, North Carolina, USA Farooq A Chaudhry M D FACP FACC David Daly MD FASE FAHA Professor of Medicine Director, Echocardiography Laboratories Associate Director, Mount Sinai Heart Network, Icahn School of Medicine at Mount Sinai, Zena and Michael A Wiener Cardiovascular Institute and Marie-Josée and Henry R Kravis Center for Cardiovascular Health New York, New York, USA Preeti Chaurasia MD Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama Reema Chugh MD FACC Consultant in Cardiology/Specialist in Adult Congenital Heart Disease and Heart Disease in Pregnancy Kaiser Permanente Medical Center Panorama City, California, USA Krishnaswamy Chandrasekaran MD Mayo Clinic, Scottsdale, Arizona, USA Rochester, Minnesota, USA Michael Chen MD University of Washington Seattle, Washington DC, USA HK Chopra MD Moolchand City Hospital New Delhi, India Department of Medicine University of Alabama at Birmingham Birmingham, Alabama, USA Hisham Dokainish M D FRCPC Associate Professor of Medicine McMaster University Director of Echocardiography and Medical Diagnostic Units Hamilton Health Sciences Hamilton, Ontario, Canada Maximiliano German Amado Escañuela MD Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Bahaa M Fadel MD King Faisal Specialist Hospital and Research Center Heart Center Riyadh, Saudi Arabia Naveen Garg MBBS Dip Cardiology Fellow, Noninvasive Cardiac Lab Indraprastha Apollo Hospitals New Delhi, India Luna Gargani MD Institute of Clinical Physiology National Research Council Pisa, Italy Eleonora Gashi DO MPhil Robert P Gatewood Jr MD FACC Division of Cardiology Fondazione Cardiocentro Ticino Lugano, Switzerland Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Honorary Consultant Imperial and King's Colleges, London, UK University of Illinois Hospital & Health Science System Jesse Brown VA Medical Center Chicago, Illinois, USA Francesco Faletra MD Francesco Ferrara MD David Cosgrove MD Leon J Frazin MD Fellow, Division of Cardiology Allegheny General Hospital Pittsburgh, Pennsylvania, USA Heart Department, University of Salerno “Scuola Medica Salernitana” Salerno, Italy Department of Internal Medicine and Cardiovascular Sciences University “Federico II” of Naples Naples, Italy Director, Division of Clinical Cardiology Program Director, Cardiovascular Fellowship, Lenox Hill Hospital New York, USA Department of Cardiology Loma Linda University and VA Medical Centers, Loma Linda California, USA Senior Cardiology Fellow Lenox Hill Hospital Non-Invasive Cardiology New York, New York, USA Abid Ali Fakhri MD Cecil Coghlan MD Neil L Coplan MD FACC Gary P Foster MD Brandon Fornwalt MD PhD Assistant Professor of Pediatrics Department of Pediatrics University of Kentucky Lexington, Kentucky, USA Chief of Cardiac Services Kaleida Heath; Clinical Associate Professor of Medicine University at Buffalo School of Medicine and Biological Sciences Buffalo Cardiology and Pulmonary Associates, Main Street Williamsville New York, USA Shuping Ge MD FAAP FACC FASE Chief, Section of Cardiology St Christopher’s Hospital for Children Associate Professor of Pediatrics Drexel University College of Medicine Philadelphia, Pennsylvania, USA Acting Chair, Pediatric Cardiology Deborah Heart and Lung Center Browns Mills, New Jersey, USA Contributors ix Gopal Ghimire MD DM MRCP Donald Hagler MD Rachel Hughes-Doichev MD FASE Division of Cardiovascular Diseases University of Alabama at Birmingham Birmingham, Alabama, USA Mayo Clinic Rochester, Minnesota, USA Temple University School of Medicine Pittsburgh, Pennsylvania, USA Stephanie El-Hajj MD Arzu Ilercil MD Nina Ghosh MD Department of Internal Medicine Louisiana State University Health Sciences Center Baton Rouge, Louisiana, USA Associate Professor of Medicine Department of Cardiovascular Sciences University of South Florida Tampa, Florida, USA Kamran Haleem MD Trevor Jenkins MD Division of Cardiovascular Medicine Brigham and Women’s Hospital Harvard Medical School Francis Street Boston, Massachusetts, USA Edward Gill MD Professor of Medicine and Cardiology, University of Washington Seattle, Washington DC, USA Rohit Gokhale MBBS University at Buffalo Buffalo, New York, USA Aasha S Gopal MS MD FACC FAHA FASE Associate Professor of Medicine Stony Brook University Stony Brook, New York, USA Director, Advanced Echocardiography St Francis Hospital, Washington Blvd Roslyn, New York, USA Willem Gorissen Clinical Market Manager Toshiba Medical Systems Europe Zoetermeer, The Netherlands Luis Gruberg MD FACC Department of Medicine Division of Cardiovascular Diseases Stony Brook University Medical Center Stony Brook, New York, USA Rakesh Gupta MD JROP Healthcare New Delhi, India Fadi G Hage MD Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Section of Cardiology, Birmingham Veteran’s, Administration Medical Center Birmingham, Alabama, USA Yale University New Haven, Connecticut, USA Dan G Halpern MD St Luke’s-Roosevelt Hospital Center Columbia University, College of Physicians and Surgeons New York, New York, USA Rachel Harris MD MPH Morehouse School of Medicine Section of Cardiology Assistant Professor Echo Lab Co-Director Grady Memorial Hospital Atlanta, Georgia, USA Christine Henri MD Department of Cardiology Heart Valve Disease Clinic CHU Sart Tilman, University of Liège, Belgium Julien IE Hoffman MD Department of Pediatrics University of California San Francisco, California, USA Brian D Hoit MD Director of Echocardiography Harrington Heart & Vascular Center University Hospitals of Cleveland Texas, USA Steven J Horn MD FACC FASE FASNC SUNY Buffalo Buffalo, New York, USA Ming Chon Hsiung MD Cardiologist Cheng Hsin General Hospital Taipei, Taiwan Harrington Heart and Vascular Institute University Hospital Case Medical Center, Cleveland Ohio, USA Madhavi Kadiyala MD Saint Francis Hospital, Roslyn New York, USA Arshad Kamel MD Department of Medicine University of Alabama at Huntsville Huntsville, Alabama, USA Abdallah Kamouh MD University of Buffalo Buffalo, New York, USA Poonam Malhotra Kapoor MD All India Institute of Medical Sciences New Delhi, India Kanwal K Kapur MD DM Cardiology, Sr Consultant and Chief Noninvasive Cardiology Indraprastha Apollo Hospitals New Delhi, India Department of Noninvasive Cardiology Indraprastha Apollo Hospitals New Delhi, India Nidhi M Karia MBBS Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham, Alabama, USA Jarosław D Kasprzak MD Chair and Department of Cardiology Biegański Hospital Medical University of Lodz Lodz, Poland 500 Section 2: Echocardiography/Ultrasound Examination and Training A B C D Figs 25.15A to D: Transpharyngeal ultrasound detection of carotid body paraganglioma (A) The arrowheads show an encapsulated mass; (B to C) The tumor mass (arrowheads) surrounds the distal right common carotid artery (CA) Color Doppler-guided pulsed Doppler interrogation of CA (inset in C) demonstrates a high maximum systolic velocity of 1.5 m/s and a high maximum diastolic velocity of 1.0 m/s suggestive of tumor compression; (D) Tumor vascularity is well seen Note that the Nyquist limit has been reduced to cm/s (IJV: Internal jugular vein) Source: Reproduced with permission from Khanna D, Cheng PH, Nanda NC, et al Transpharyngeal ultrasound detection of carotid body paraganglioma Echocardiography 2004;21:299–301 A Figs 25.16A and B B Chapter 25: Upper Transesophageal and Transpharyngeal Examination C Figs 25.16A to C: Transesophageal echocardiographic identification of left vertebral artery (LVA) origin stenosis (A) The LVA is narrowed at its origin from the left subclavian artery (LSA) Color Doppler-directed continuous wave Doppler interrogation demonstrates a high peak systolic velocity of m/s and a high peak diastolic velocity of 0.8 to 1.0 m/s (inset, above the baseline), indicative of significant stenosis Systolic velocity in the LSA at the LVA origin also is high, measuring m/s (inset, below the baseline); (B) A long segment of the precervical portion of the LVA is shown The arrowhead points to aliasing of color Doppler flow signals at its origin due to stenosis; (C) Left vertebral vein (VV) is shown Color Dopplerguided pulsed wave Doppler interrogation (inset) shows continuous flow signals throughout the cardiac cycle typical of venous flow Source: Reproduced with permission from Aaluri S, Miller AP, Nanda NC, et al Transesophageal echocardiographic detection of left vertebral artery origin stenosis Echocardiography 2002;19(8):695–7 A B C D Figs 25.17A to D 501 502 Section 2: Echocardiography/Ultrasound Examination and Training E Figs 25.17A to E: Transesophageal echocardiographic identification of bilateral vertebral artery ostial stenosis (A and B) The arrow points to stenosis at origin of the left vertebral artery (LVA) that arises from the left subclavian artery (LSA) Color Doppler-guided continuous wave Doppler interrogation of the LVA demonstrates high peak systolic and peak end-diastolic velocities of 3.8 and 1.7 m/s, respectively, indicative of severe ostial stenosis (bottom left inset in A) The bottom right inset in A demonstrates normal flow velocities obtained from the LSA The inset in B reveals normal flow velocities from the more distal precervical LVA segment; (C) The arrow points to stenosis at the origin of right vertebral artery (RVA), which arises from right subclavian artery (RSA) Color Doppler-guided continuous wave Doppler interrogation of the RVA demonstrates high peak systolic and peak end-diastolic velocities of 3.7 m/s and approximately 1.2 m/s, respectively, indicative of severe ostial stenosis (inset in C); (D and E) Vertebral artery angiogram FA: Flow acceleration) Source: Reproduced with permission from Ahmed S, Nekkanti R, Nanda NC, Gomez CR Transesophageal echocardiographic identification of bilateral vertebral artery ostial stenosis Echocardiography 2003;20(4):395–8 (Movie clip 25.17) A B C D Figs 25.18A to D Chapter 25: Upper Transesophageal and Transpharyngeal Examination E F G H 503 Figs 25.18A to H: Transesophageal echocardiographic (TEE) identification of left subclavian artery stenosis with steal phenomenon (A) Arrow demonstrates long stenotic segment of the left subclavian artery (LSA) shortly after its origin from the aorta; (B to D) Arrowheads denote large atherosclerotic plaque as cause of stenosis; (E) Color Doppler-guided continuous wave interrogation of the stenotic segment shows a high peak velocity of 3.5 m/s (equivalent to a gradient of 49 mm Hg), indicative of severe stenosis; (F) Normalization of flow velocity in LSA distal to the stenosis; (G and H) Reversal of flow is noted in the left vertebral artery (VA), consistent with steal phenomenon (LCC: Left common carotid artery; R: Artifactual reverberations) Source: Reproduced with permission from Mukhtar OM, Miller AP, Nanda NC, et al Transesophageal echocardiographic identification of left subclavian artery stenosis with steal phenomenon Echocardiography 2000;17:197–200 (Movie clip 25.18) flow of 3.5 m/s, peak gradient of 49 mm Hg) Color and pulsed Doppler revealed reversal of flow in the LVA as well as normalization of flow distal to the stenosis consistent with steal phenomenon TEE is often used in the diagnosis of aortic dissection and possible associated aortic regurgitation Examination of the aortic arch branches and extension of the dissection into the branches can be evaluated Katz et al.19 describe the visualization of the intimal flap extending into the left common carotid artery in a patient with neurological symptoms and into the left subclavian artery in a patient with reduced left upper extremity pulses Also, upper esophageal and TPU may complement other TEE findings in the diagnosis of torrential aortic regurgitation especially when the Doppler color flow signal is not well visualized in the left ventricular outflow tract during diastole.12 Figures 25.19A to F (probe in the upper esophagus) show pan-diastolic backflow in left subclavian artery and LVA while Figures 25.20A and B (probe in the pharynx) demonstrate pan-diastolic backflow in the left common 504 Section 2: Echocardiography/Ultrasound Examination and Training carotid artery as well as the left internal carotid artery in a case of torrential aortic regurgitation due to a type I aortic dissection.12 The major disadvantage to TPU is that the gag reflex is often triggered dislodging the probe and making careful examination of the vasculature difficult This can usually be avoided by providing sufficient topical anesthesia at the beginning of the examination and repeating it when necessary later, and by making very slow and careful movements of the probe Older patients generally have diminished gag reflex and therefore, may not require repeat anesthesia Examination is also dependent on the subject’s anatomy as well as her/his cooperation and ability to avoid head movements, tongue movements, and swallowing Another disadvantage is that the success of the procedure, as well as the interpretation of images, is highly operator-dependant and like other procedures has a learning curve.1,2,8,9 Upper esophageal and TPU done toward the end of TEE as a minimally invasive technique can be rewarding and may add a lot of pertinent information to the examination It allows for the inspection of and identification of the aortic arch and its branches as well as the neck vessels TPU can be used to accurately diagnose carotid bulb and internal carotid artery stenosis, left subclavian stenosis, and subclavian steal phenomenon; and to evaluate the patency of the left internal mammary graft to left anterior descending artery20 as well as the patency of internal carotid stents It also allows for imaging of distal extracranial segments of the vertebral artery and perivascular tumors Three-dimensional (3D) TPU imaging and reconstruction of the LVA, left common, internal, and external carotid A B C D Figs 25.19A to D Chapter 25: Upper Transesophageal and Transpharyngeal Examination E 505 F Figs 25.19A to F: Transesophageal and transpharyngeal ultrasound demonstration of reversed pan-diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation due to aortic dissection Probe in the upper esophagus (A and B) Arrows point to the dissection flap protruding into the left ventricular outflow tract in diastole The arrowheads point to the aortic valve leaflets held in the fully opened position and prevented from closure; (C) The arrows point to two parts of the dissection flap, which gives an erroneous impression of a second aortic valve just distal to the normal aortic valve (arrowheads) located in the usual position The asterisk shows the origin and the proximal portion of the right coronary artery; (D) The arrowhead points to turbulent flow signals occupying the whole of the proximal left ventricular outflow tract in diastole indicative of torrential aortic regurgitation; (E and F) Color Doppler-guided continuous wave Doppler examination of the left subclavian (SA, E) and left vertebral arteries (VA, F) demonstrates pan-diastolic backflow (arrowhead in the inset) in both vessels The arrows in the inset in F point to less dense and less prominent Doppler signals and these represent artifacts due to a mirroring phenomenon (AO: Aorta; LA: Left atrium; RV: Right ventricle) Source: Reproduced with permission from Khanna D, Sinha A, Nanda NC, et al Transesophageal and transpharyngeal ultrasound demonstration of reversed diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation Echocardiography 2004;21:349–53 A B Figs 25.20A and B: Transesophageal and transpharyngeal ultrasound demonstration of reversed diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation due to aortic dissection (A and B) Probe in the left pharynx Color Doppler-guided continuous wave Doppler examination of the left common carotid artery (CA, A) near the carotid bulb, and color Doppler-guided pulsed wave Doppler examination of the proximal left internal carotid artery (ICA, B) demonstrates pan-diastolic backflow in both neck vessels (arrowhead in both insets) Source: Reproduced with permission from Khanna D, Sinha A, Nanda NC, et al Transesophageal and transpharyngeal ultrasound demonstration of reversed diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation Echocardiography 2004;21:349–53 506 Section 2: Echocardiography/Ultrasound Examination and Training arteries has been described and now that real-time live 3D TEE is clinically available, this modality may offer added information to TPU examination.21,22 REFERENCES Khanna D, Nanda N, Cheng P, et al Examination of the aortic arch branches and neck vessels using upper transesophageal and Transpharyngeal approaches Anesth Analog 2004;98,SCA 1–134 Nanda N (2006) Chapter 11: Transpharyngeal ultrasound In: Nanda N, Domanski N, editors (2004) Atlas of Transesophageal Echocardiography Lippincott Williams & Wilkins, pp 557–70 Zoghbi GJ, Nanda NC, Baweja G Transesophageal and transpharyngeal echocardiographic detection of the extracranial segments of the left vertebral artery Am J Geriatr Cardiol 2003;12(2):113–6 Nanda NC, Thakur AC, Thakur D, et al Transesophageal Echocardiographic Examination of Left Subclavian Artery Branches Echocardiography 1999;16(3):271–7 Nanda NC, Miller AP, Nekkanti R, et al Transpharyngeal echocardiographic imaging of the right and left carotid arteries Echocardiography 2001;18(8):711–6 Agrawal G, LaMotte LC, Nanda NC, et al Identification of the Aortic Arch Branches Using Transesophageal Echocardiography Echocardiography 1997;14(5):461–6 LaMotte LC, Nanda NC, Thakur AC, et al Transesophageal Echocardiographic Identification of Neck Veins: Value of Contrast Echocardiography Echocardiography 1998;15(3): 259–68 Nanda NC, Gomez CR, Narayan VK, et al Transpharyngeal Echocardiographic Diagnosis of Carotid Bulb and Left Internal Carotid Artery Stenosis Echocardiography 1999; 16(7, Pt 1):671–4 Howard JH, Dod HS, Nanda NC, et al Images in geriatric cardiology: transpharyngeal ultrasound evaluation of internal carotid artery stent in an octogenarian Am J Geriatr Cardiol 2003;12(6):375–6 10 Khanna D, Cheng PH, Nanda NC, et al Transpharyngeal ultrasound detection of carotid body paraganglioma Echocardiography 2004;21(3):299–301 11 Mukhtar OM, Miller AP, Nanda NC, et al Transesophageal echocardiographic identification of left subclavian artery stenosis with steal phenomenon Echocardiography 2000;17(2):197–200 12 Khanna D, Sinha A, Nanda NC, et al Transesophageal and transpharyngeal ultrasound demonstration of reversed diastolic flow in aortic arch branches and neck vessels in severe aortic regurgitation Echocardiography 2004; 21(4):349–53 13 Trattnig S, Hübsch P, Schuster H, et al Color-coded Doppler imaging of normal vertebral arteries Stroke 1990; 21(8):1222–5 14 Ries S, Steinke W, Devuyst G, et al Power Doppler imaging and color Doppler flow imaging for the evaluation of normal and pathological vertebral arteries J Neuroimaging 1998; 8(2):71–4 15 Aaluri S, Miller AP, Nanda NC, et al Transesophageal echocardiographic detection of left vertebral artery origin stenosis Echocardiography 2002;19(8):695–7 16 Ahmed S, Nekkanti R, Nanda NC, et al Transesophageal echocardiographic identification of bilateral vertebral artery ostial stenosis Echocardiography 2003;20(4):395–8 17 Thomassen L, Aarli JA Subclavian steal phenomenon Clinical and hemodynamic aspects Acta Neurol Scand 1994;90(4):241–4 18 Berni A, Tromba L, Cavaiola S, et al Classification of the subclavian steal syndrome with transcranial Doppler J Cardiovasc Surg (Torino) 1997;38(2):141–5 19 Katz ES, Konecky N, Tunick PA, et al Visualization and identification of the left common carotid and left subclavian arteries: a transesophageal echocardiographic approach J Am Soc Echocardiogr 1996;9(1):58–61 20 Nanda NC, Nekkanti R, Melendez A, et al Transesophageal two-dimensional echocardiographic demonstration of the innominate artery and its branches Am J Geriatr Cardiol 2001;10(6):368–70 21 Miller AP, Aaluri SR, Mukhtar OM, et al Three-dimensional color Doppler transpharyngeal echocardiographic reconstruction of the left common, internal, and external carotid arteries Echocardiography 2002;19(3):223–5 22 Ansingkar KG, Nanda NC, Nekkanti R, et al Transesophageal three-dimensional color Doppler echocardiographic reconstruction of the left vertebral artery Echocardiography 2001;18(7):623–5 CHAPTER 26 How to Perform a Three-Dimensional Transesophageal Echocardiogram Elisa Zaragoza-Macias, Michael Chen, Edward Gill Snapshot ¾¾ Three-Dimensional Transesophageal Technology ¾¾ Performing 3D TEE Evaluation INTRODUCTION Three-dimensional transesophageal echocardiography (3D TEE) has improved diagnostic accuracy compared to the standard two-dimensional transesophageal echocardiography (2D TEE) and has revolutionized interventional cardiology interventions for structural heart disease With the aid of 3D TEE, procedures like deployment of vascular plugs into paravalvular prosthetic leaks are now possible while there is enhanced safety for other procedures, such as trans-septal puncture Furthermore, there has been an improvement in the visualization of anatomical structures that has aided interventional cardiologists and surgeons for their presurgical or preprocedural planning In this chapter, we discuss in detail the general approach for performing 3D TEE THREE-DIMENSIONAL TRANSESOPHAGEAL TECHNOLOGY Similar to 2D technology, image acquisition for 3D relies on the piezoelectric elements inside the ultrasound probe These elements act as both the source and detectors for ultrasound waves In the case of 3D TEE, the ultrasound probe has many more piezoelectric elements (about ¾¾ Specific Uses of 3D TEE ¾¾ Guidelines and Final Recommendations 2,500–3,000) arranged in an array that will process more ultrasound waves and lines improving image resolution.1 A 3D TEE probe scans about 4,016 lines 25 times per second, compared to 128 at 45 times per second with a standard 2D TEE probe These independent elements steer electronically to acquire images in volumes of pixels or “voxels.” These voxels can be subtracted by cropping images, thus, achieving views of anatomical structures from angles previously not seen by 2D echocardiography and all the while visualizing a volume rather than a slice The benefits of 3D imaging technology lie in the ability to see the third plane, the plane of elevation, and hence enable visualization of an entire volume of data and perform volumetric analysis without 2D assumptions This allows visualization of the cardiac valves and chambers in their entirety Visualizing “volumes of data” would be worthless if 3D imaging did not include the capability of cropping and rotating the obtained images With these functions, we are able to have improved visualization of the anatomical structure of interest Other added benefits inherent to the 3D transducer include obtaining simul taneous orthogonal 2D views with biplane or “X-plane” mode, assessment of regional dyssynchrony, and segme ntal wall motion evaluation.2 508 Section 2: Echocardiography/Ultrasound Examination and Training PERFORMING 3D TEE EVALUATION Preprocedural Planning 3D TEE technique is unchanged compared to a 2D TEE examination (see chapter 24) First, there should be an appro priate indication for performing an exam that warrants the very small risk (0.18%) of complications that include oropharyngeal injury, esophageal or gastric perforation, aspiration, hypoxia, arrhythmias, and the intrinsic risk of administering moderate sedation.3 Some specific indications to use 3D TEE can be found in Table 26.1 Absolute contraindications for performing a TEE examination include the presence of esophageal pathology such as stricture, esophageal diverticulum, tumor, varices, and recent esophageal or gastric surgery Other relative contraindications include atlanto-axial joint disease, severe cervical arthritis, coagulopathy, thromobocytopenia, esophagitis, and peptic ulcer disease.4 The preprocedural steps include instructing the patient not to eat or drink for hours, obtaining prior to the test/exam an informed consent explaining the risks and benefits of the procedure, applying a local anesthetic agent like Lidocaine to the posterior pharynx, and administering moderate sedation with appropriate monitoring of vital signs Transesophageal echo probes capable of obtaining 3D images include those produced by Philips and General Electric so the operators and sonographers should verify that the appropriate matching equipment is available Probe insertion into the esophagus is performed with the same technique as with 2D TEE The tip of the 3D TEE transducer is slightly (1 mm) wider than the corresponding 2D transducer Image Acquisition The exam starts with a standard 2D evaluation; during this initial 2D exam, the X-plane or biplane imaging can be used to obtain two simultaneous views with the same probe position and angle This biplane method can reduce scanning time and thus patient discomfort and side effects Once an anatomical structure is seen in 2D, the operator can switch modes to 3D The available 3D imaging modalities are summarized in Table 26.2 and include: Real time (RT) 3D: This modality allows live visuali zation of a narrow sector image Image optimization is performed at the time of image acquisition and thus it does not require postprocessing It is useful for a rapidly obtained screening view for evaluating valve structure and function, mobile structures, or when procedures are performed such as delivering a vascular device or “plug,” crossing interatrial septum, balloon valvuloplasty or Amplatzer device deployment Zoom view: When performing RT3D, the zoom or focused sector view can be used to enlarge a specific cardiac structure This modality will decrease the spatial and temporal resolution of images This and the full-volume views tend to be the ones used for “working” during interventional procedures Table 26.1: Current Indications to Use 3D TEE Indication Benefits of 3D TEE Assessment of LV volume and ejection fraction Eliminates geometric assumptions and provides more accuracy and reproducibility of volumes and EF Mitral valve • • • • Aortic valve • Guidance of transcatheter valve implantation • Measurement of aortic valve stenosis and regurgitation Tricuspid valve • Evaluation of function and structure of the valve Left atrial appendage • Differentiate from thrombus and other structures • Determination of size of left atrial appendage for device closure Interatrial septum • Evaluation of the septum for size, number, and location of septal defects Accurate evaluation of the anatomy and function of each of the leaflet components En face visualization from the LV and LA perspectives Accurate measurement of annular size Guidance of interventional procedures (3D: Three-dimensional; EF: Ejection fraction; LA: Left atrium; LV: Left ventricle) Chapter 26: How to Perform a Three-Dimensional Transesophageal Echocardiogram Table 26.2: Imaging Modalities Available in Three-Dimensional Echocardiography Real time or “live” Live zoomed view Full volume Full volume with color Multiplane or “X-plane” Full volume: In this modality, images are obtained with the largest sector and provides the best spatial and temporal resolution with frame rates up to 35 Hz Recording of a full volume allows for postprocessing including cropping This mode captures sequential gated beats and thus acquisition takes longer than the live 3D mode Full volume can be used for determination of cardiac chamber volume, dimension, dyssynchrony, and for the assessment of spatial relationships Simultaneous biplane mode (X-plane): With this modality, two simultaneous 2D images will be obtained The two simultaneous images can be rotated 30 to 150° from each other This modality is very useful when different planes of cardiac structures are examined Some examples of its use include excluding left atrial appendage clot or when evaluating the mitral valve By using X-plane, one can reduce the total time required for an evaluation or view images at angles that would be harder to obtain on a standard 2D study A 509 New technology allows the visualization of biplane “real time” 3D images Figures 26.1A and B is an example of multiple anatomical structures that can be visualized with biplane mode The left atrial appendage and the interatrial septum are two structures that are particularly well visualized by biplane imaging Full-volume and live 3D color flow: This modality is used to assess valvular regurgitation It requires obtaining a gated full volume in newer software renditions on live mode This modality allows assessment of vena contracta, proximal isovelocity surface area (PISA), and mechanism of the regurgitation Imaging Sequence The protocols for performing a 3D TEE vary from center to center, and each operator will develop his or her own imaging sequence Some operators start with a comprehensive 2D exam and then proceed to 3D However, now that 3D imaging acquisition is faster, the flow of an examination improves if the operator moves from 2D to 3D The main sequences when obtaining 3D images include: first obtain a 2D image, and then proceed to live 3D that will provide an “overall” 3D view Subsequently, the operator can proceed with live zoom images of specific structures and then obtain a full volume clip with and without color X-plane mode is usually incorporated at the time of 2D scanning to obtain simultaneous orthogonal views B Figs 26.1A and B: (A) Biplane (X-plane) image of left atrial appendage Arrows show opening of left atrial appendage (left) and point at a pectinate muscle within the left atrial appendage (right); (B) Biplane (X-plane) view of the aortic valve Short-axis view on the left and LVOT or longitudinal view on the right (AO: Aorta; AoV: Aortic valve; LA: Left atrium; LV: Left ventricle; LVOT: Left ventricular outflow tract; RA: Right atrium; RV: Right ventricle 510 Section 2: Echocardiography/Ultrasound Examination and Training Table 26.3: Proposed 3D TEE Protocol Structure Views 3D Modality Left ventricle Mid-esophageal 0–120° Live 3D to optimize gain settings and for assessment of masses or thrombus Right ventricle Mid-esophageal 0–120° with probe tilted to center the right ventricle Full volume with postprocessing will provide ejection fraction, volume, segmental wall motion, and dyssynchrony Mitral valve Mid-esophageal 0–120° X-plane for simultaneous 2D views Live 3D zoomed mode for structure evaluation Full volume with postprocessing for reconstruction of the mitral valve and full-volume color 3D Aortic valve Mid-esophageal at 120° for long-axis view Mid-esophageal at 60° for short-axis view Live 3D zoomed mode for structure Full volume with and without color Pulmonic valve High esophageal at 90° Mid-esophageal at 120° Live 3D zoomed mode for structure Full volume with and without color Tricuspid valve Mid-esophageal at 0–30° Live 3D zoomed mode for structure Full volume with and without color Interatrial septum Mid-esophageal at 0° with the probe rotated to the interatrial septum Live 3D and full volume Left atrial appendage Mid-esophageal at 90° with focus in the appendage X-plane for simultaneous 2D views Live 3D and full volume (2D: Two-dimensional; 3D: Three-dimensional; TEE: Transesophageal echocardiography) Source: Modified from American Society of Echocardiography (reference number 2) Table 26.3 is a proposed imaging protocol for 3D TEE A standard sequence might include 3D images of the interatrial septum, the left atrial appendage, the aortic valve, and the mitral valve Improving Image, Tips, and Pitfalls Image optimization can transpire both at the time of scanning and also to improve the previously obtained images by postprocessing full-volume images Prior to obtaining 3D images, the settings of the 2D image should be optimized; operators should remember that poor 2D images lead to poor 3D images The main setting one can modify when obtaining 3D images include: • Gain: If gain is set too low, it leads to dropout and if it is too high, the image resolution decreases, covering up or “masking” structures and leading to poor visuali zation of structures or loss of 3D perspective • Compression: Compression utilizes a mathematical technique that reduces the amount of data stored optimizing storage efficiency Compression is often described as “softening” the image Depending on the compression algorithm, the goal is to keep more wavelet coefficients in the anatomical structure of interest and compress the information of the background area • Smoothing: Smoothing is a “mask-based” processing that uses neighboring pixels to generate a modified value for that pixel In 3D because of the array conformation of the transducer, there will be unwanted noise Smoothing can be modified to improve image quality by applying filter and reduce unwanted blurring (noise or speckling) • Cropping and rotation: These are among the most useful tools of 3D imaging When cropping and rotating images, the operator should try to recreate the viewing perspective of surgeons If images are cropped during the exam and saved after cropping, they cannot be reconstructed; thus, it is recommended to saves images in full volume during the exam for postprocessing reconstruction • Color: Several colors are available to improve image visualization Other important aspects for optimizing 3D images include: (a) echocardiogram (ECG) lead capture which minimizes stitch artifacts while obtaining full-volume images If one ECG lead does not provide adequate triggering, using other leads or repositioning of the leads should be attempted (b) Spatial resolution can improve by increasing the number of scan lines per volume or acquiring a full volume; this will be at the expense of longer time of acquisition (c) To decrease acquisition time, the image size can be decreased Chapter 26: How to Perform a Three-Dimensional Transesophageal Echocardiogram Proper Display of 3D TEE Images Table 26.4 summarizes the recommended 3D image orientation and rotation to present final 3D images.2 With 3D technology, orientation and display of images is important since images can be cropped and rotated in any direction or plane Consistency of the image orientation will allow others proper interpretation of the obtained images Figures 26.2A to D show the recommended way to display cardiac structures Very Recent Advances in RT3D TEE Imaging There have been three particularly notable advances in RT3D TEE imaging with the latest software release that have addressed significant limitations that were particularly troublesome when performing interventional echo procedures These are the release of RT3D color Table 26.4: Display recommendations when performing 3D TEE Structure Display recommendations Left ventricle Short-axis view or apical four chamber view Right ventricle Four chamber view or short-axis view at the level of the aortic valve with the left atrium at 12 o’clock position Interatrial septum When viewed from the left atrium orient the right upper pulmonary vein at o’clock When viewed from the right atrium position the superior vena cava at 11 o’clock Left atrial appendage Present the left atrial appendage en-face with the pulmonary veins located superiorly or longitudinally Source: Addapted from Lang RM AEA/ASE recommendations for image acquisition and display using three-dimensional echocardiography J Am Soc Echocardigr 2012;25(1):3-46 (reference number 2) A1 A2 B C Figs 26.2A to C 511 512 Section 2: Echocardiography/Ultrasound Examination and Training ovalis Once the needle is positioned in the fossa ovalis, the operator then can rotate planes to the left atrial perspective to assess the needle puncture into the left atrium Another technique involves performing X-plane with orthogonal views such that the aorta is also seen and puncture into the aorta is avoided Mitral Prosthesis Paravalvular Leak Closure D Figs 26.2A to D: (A) Aortic valve display in short-axis view by 3D TEE Right coronary cusp at 11:00 as described in text Aortic valve closed on left and open on right; (B) Proper display of the mitral valve Aortic valve is displayed at 12:00 in the surgeon’s view (AV) Mitral valve is posterior (MV); (C) Interatrial septum viewed from the left atrial side Fossa ovalis shown by arrow (AV) as is right atrium; (D) Interatrial septum seen from the right atrial side Note catheter, SVC, and fossa ovalis are cath, SVC, fossa ovalis, respectively (AoV: Aortic Valve; MV: Mitral valve) for all of the different 3D modalities including “live 3D,” full-volume 3D, and 3D zoom SPECIFIC USES OF 3D TEE The utility of 3D TEE is now widely recognized Some of the specific uses of 3D TEE include: guidance of paravalvular leak closure device, intra-atrial septal puncture, and dyssynchrony assessment Transseptal Puncture There are multiple catheter-based procedures (including electrophysiologic ablation procedures and mitral valve percutaneous procedures) that require access from the right atrium to the left atrium via trans-septal puncture With 3D, the interatrial septum can be imaged from both the left atrial and right atrial sides, and with biplane mode, it is possible to visualize the interatrial septum and the aortic root simultaneously thus improving the safety of this procedure.5,6 When assisting a trans-septal puncture, the echocardi ographer should obtain images of the septum either in the four-chamber or bicaval view The image should then be rotated such that the interatrial septum is seen from the right atrial perspective; this will help identify the fossa 3D TEE allows excellent view of prosthetic valve and assessment of the number, shape, size, and precise location(s) of paravalvular leaks New procedures for deploying vascular plugs in this paravalvular leaks cannot be performed without the assistance of 3D TEE 3D TEE will assist in the canalization of the paravalvular leak with the catheter and correct deployment of the plug.7–9 Echocardiographic assistance will require the operator to visualize the mitral valve from the left atrial perspective New 3D software allows color in live images; this will improve visualization of the paravalvular leak and correct location of the catheter/plug Figures 26.3A and B show an example of mitral paravalvular plugs seen with 3D TEE Detection of Left Atrial Appendage Clot 3D TEE allows the visualization of the entire volume of the left atrial appendage (LAA) in RT, cropping through multiple transverse levels and longitudinal planes, and visualizing multiple 2D planes simultaneously with the “X-plane” mode The benefits of 3D TEE include increased certainty in ruling out LAA clot, better definition of LAA geometry, and differentiation of normal structures from thrombus.10 Catheter-Based Left Atrial Appendage Closure Catheter-based LAA closure is performed in patients who are not candidates for anticoagulation 3D TEE helps assess proper sizing of the device and RT assistance during the procedure 3D TEE compared to 2D TEE has better correlation to CT measurements of the LAA orifice (r = 0.9 vs 0.72), and measurements are more accurate than 2D imaging.11 Transcatheter Aortic Valve Replacement Precise aortic valve annulus measurements and morphology description are needed when selecting the Chapter 26: How to Perform a Three-Dimensional Transesophageal Echocardiogram A 513 B Figs 26.3A and B: (A) Area of paravalvular defect (arrow); (B) Paravalvular defect after closure Vascular plug (arrow) (AoV: Aortic valve; MVR: Mitral valve replacement) appropriate valve size when performing transcatheter aortic valve replacement (TAVR) 3D TEE measurements correlate well with those obtained with CT.12 In addition, 3D TEE allows the measurement of the aortic annulus to left main ostial distance that is important to avoid the risk of occluding the ostium of the left main with the implanted valve Annular-ostial distance cannot be obtained by 2D because of the left main coronary artery position, whereas feasibility of imaging the annular-ostial distance by 3D TEE is high.13 Finally, 3D TEE can help guide adequate positioning of the valve across the annulus and assess the new prosthetic valve function for the presence of regurgitation In summary, the advantages of 3D TEE compared to 2D TEE in TAVR cases are: (a) improved accuracy of the measurements and shape of the aortic annulus, (b) feasibility and accuracy of measurement of the distance between the annulus and the left main coronary artery ostium, (c) improved visualization of “en face” seating of the percutaneous valve to guide the procedure, and (d) visualizing the valve leaflets and the tissue surrounding the prosthetic annulus to observe the postimplantation results.9 septal defects, and guidance of percutaneous closure When performing percutaneous closure of ASD, 3D TEE allows for visualization of (a) the appropriate site of crossing of the catheters from the right atrium through the ASD into the left atrium (especially with multifenestrated ASDs), (b) the release of the disc into the left atrium, (c) release of the disc on the right atrial side by switching planes, and (d) the apposition of the two discs Finally, one can assess for residual shunting and its precise location.14–16 • Ventricular septal defects: 3D TEE can accurately determine the number, anatomical location of ventri cular septal defects, and guide percutaneous closure of defects if indicated or provide accurate information for surgical planning.14 Congenital Heart Disease Mitral Stenosis and Balloon Valvotomy 3D TEE allows better anatomical spatial relationship of congenital defects and guides surgeons and interventional cardiologist in performing procedures; • Atrial septal defects (ASDs): 3D TEE allows for the evaluation of the size, shape, location, rims of the Estimations of the mitral valve area are more accurate when obtained with 3D TEE because cropping permits multilevel planimetry and assurance that the valve area estimate is truly being determined at the level of the tips of the valve leaflets Degree of commissural fusion is Mitral Valve Assessment Excellent visualization of the mitral valve is achieved with 3D TEE The technique allows for RT or live imaging and then postprocessing reconstruction of the valve, improved accuracy for defining the mechanism and site(s) of regurgitation This information is useful for surgeons in their presurgical planning and feasibility of repair.17 514 Section 2: Echocardiography/Ultrasound Examination and Training better seen by en face 3D TEE, and when doing balloon valvotomy, the balloon position can be guided with 3D TEE.18–20 Left Ventricular Function and Assessment of Dyssynchrony Software packages such as QLab (Philips Medical System) and TomTec allow the reconstruction and assessment of three-dimensional left ventricular volume, systolic function, regional wall motion abnormalities, and the assessment of dyssynchrony Specific software use is beyond the scope of this chapter, and but operators should become familiar in obtaining and processing this information GUIDELINES AND FINAL RECOMMENDATIONS Technology for 3D TEE will continue to evolve, and new imaging modalities and improved probes will become available Operators and echocardiographers have a steep learning curve that requires performing several studies and learning to display and optimize images REFERENCES Salgo IS Three-dimensional echocardiographic technology Cardiol Clin 2007;25(2):231–9 Lang RM, Badano LP, Tsang W, et al American Society of Echocardiography; European Association of Echocardiography EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography J Am Soc Echocardiogr 2012;25(1):3–46 Daniel WG, Erbel R, Kasper W, et al Safety of transesophageal echocardiography A multicenter survey of 10,419 examinations Circulation 1991;83(3):817–21 Hilberath JN, Oakes DA, Shernan SK, et al Safety of transesophageal echocardiography J Am Soc Echocardiogr 2010;23(11):1115–27; quiz 1220 Faletra FF, Nucifora G, Ho SY Imaging the atrial septum using real-time three-dimensional transesophageal echocardiography: technical tips, normal anatomy, and its role in transseptal puncture J Am Soc Echocardiogr 2011;24(6):593–9 Chierchia GB, Capulzini L, de Asmundis C, et al First experience with real-time three-dimensional transoesophageal echocardiography-guided transseptal in patients undergoing atrial fibrillation ablation Europace 2008;10(11): 1325–8 Biner S, Kar S, Siegel RJ, Rafique A, Shiota T Value of color Doppler three-dimensional transesophageal echocardiography in the percutaneous closure of mitral prosthesis paravalvular leak Am J Cardiol 2010;105(7): 984–9 García-Fernández MA, Cortés M, García-Robles JA, et al Utility of real-time three-dimensional transesophageal echocardiography in evaluating the success of percutaneous transcatheter closure of mitral paravalvular leaks J Am Soc Echocardiogr 2010;23(1):26–32 Zamorano JL, Badano LP, Bruce C, et al EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart disease J Am Soc Echocardiogr 2011;24(9):937–65 10 Latcu DG, Rinaldi JP, Saoudi N Real-time three-dimensional transoesophageal echocardiography for diagnosis of left atrial appendage thrombus Eur J Echocardiogr 2009;10 (5):711–12 11 Nucifora G, Faletra FF, Regoli F, et al Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure Circ Cardiovasc Imaging 2011;4(5):514–23 12 Altiok E, Koos R, Schröder J, et al Comparison of twodimensional and three-dimensional imaging techniques for measurement of aortic annulus diameters before transcatheter aortic valve implantation Heart 2011;97(19): 1578–84 13 Tamborini G, Fusini L, Gripari P, et al Feasibility and accuracy of 3DTEE versus CT for the evaluation of aortic valve annulus to left main ostium distance before transcatheter aortic valve implantation JACC Cardiovasc Imaging 2012;5(6):579–88 14 Perk G, Lang RM, Garcia-Fernandez MA, et al Use of real time three-dimensional transesophageal echocardiography in intracardiac catheter based interventions J Am Soc Echocardiogr 2009;22(8):865–82 15 Taniguchi M, Akagi T, Watanabe N, et al Application of realtime three-dimensional transesophageal echocardiography using a matrix array probe for transcatheter closure of atrial septal defect J Am Soc Echocardiogr 2009;22(10): 1114–20 16 Lodato JA, Cao QL, Weinert L, et al Feasibility of real-time three-dimensional transoesophageal echocardiography for guidance of percutaneous atrial septal defect closure Eur J Echocardiogr 2009;10(4):543–8 17 Chandra S, Salgo IS, Sugeng L, et al Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair Circ Cardiovasc Imaging 2011;4(1): 24–32 18 Gill EA, Kim MS, Carroll JD 3D TEE for evaluation of commissural opening before and during percutaneous mitral commissurotomy JACC Cardiovasc Imaging 2009;2(8):1034–5; author reply 1035 19 Schlosshan D, Aggarwal G, Mathur G, et al Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis JACC Cardiovasc Imaging 2011;4(6):580–8 20 Zamorano J, Perez de Isla L, Sugeng L, et al Non-invasive assessment of mitral valve area during percutaneous balloon mitral valvuloplasty: role of real-time 3D echocardiography Eur Heart J 2004;25(23):2086–91 ... Tracking 11 41 Hemodynamics 11 43 Other Imaging Modalities 11 44 11 34 xxx Comprehensive Textbook of Echocardiography 54 Three-Dimensional Echocardiographic Assessment of LV and RV Function 11 49 Aasha... Function 11 77 State -of- the-Art 11 80 Composite of State -of- the-Art Reports 11 81 Novel Mechanical and Timing Interdependence between Torsion and Untwisting 11 84 The Normal Heart 11 85 The Septum 11 94... Perspective 11 9 • Underlying Concept 11 9 11 9 Contents xxi • Color M-Mode 12 0 • Advantages and Disadvantages of M-Mode 12 0 • Use of M-Mode 12 1 The Complete Transthoracic Echocardiography 13 2 Rachel