International Journal of Cardiology xxx (2014) xxx–xxx

IJCA-18096; No of Pages 2

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International Journal of Cardiology

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Letter to the Editor

3D-TEE image artifact of a ventricular septal defect below thetricuspid valve

Erica D. Wittwer a,⁎, Kent H. Rehfeldt a, Rakesh M. Suri b

a Department of Anesthesiology, Mayo Clinic, Rochester, MN, United Statesb Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States

⁎ Corresponding author at: RO_MB_02_860ANE, 200 FirUnited States. Tel.: +1 507 255 1246; fax: +1 507 255 4

E-mail address: Wittwer.erica@mayo.edu (E.D. Wittw

http://dx.doi.org/10.1016/j.ijcard.2014.04.1950167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved

Please cite this article as: Wittwer ED, et al,http://dx.doi.org/10.1016/j.ijcard.2014.04.19

a r t i c l e i n f o

Article history:

Received 14 April 2014Accepted 17 April 2014Available online xxxx

Keywords:Transesophageal echocardiographyArtifactVentricular septal defect

(TV) septal leaflet (Fig. 1B). However, transgastric imaging demonstrat-ed flow through a smaller, circular defect (Fig. 1C, D). At surgery, a 2 cm,well-circumscribed defect was found and repaired (Fig. 1E, F) with noresidual shunt.

This case demonstrates artifacts impacting both 2-D and 3-D TEE. Alarger defect appeared in the ME views due to drop-out from increasedtransducer to defect distance (attenuation) and shadowing from poste-rior structures between the TEE probe and theVSD. 3-D TEE imaging hasbeen demonstrated to be valuable, particularly in mitral valve disease

Images obtained via transesophageal echocardiography can behelpful for planning and implementing treatment for patients. Crucialdecisions are frequently made based on the images obtained. The im-portance of understanding these images and the potential artifactsthatmay be present is demonstrated by a recent review article that spe-cifically discusses artifacts in 3-D echocardiography. In this article,Faletra et al. describes 3-D imageswith artifacts as appearingmore real-istic than artifacts seen on 2-D imaging [1]. Artifacts seen with 2-D im-aging have been well described [2] and may be easier to discern.Examples of artifacts impacting 2-D imaging that also plague 3-D imag-ing include blurring, shadowing, dropout, or gain artifacts [1].

A 53 year oldmale presentedwith an ischemic ventricular septal de-fect (VSD). Intra-operative transesophageal echocardiography (TEE)was performed.Mid-esophageal (ME) 3-D images showed an extensive,

st St. SW, Rochester, MN 55902,267.er).

.

3D-TEE image artifact of a ve5

serpiginous defect (Fig. 1A) also visualized below the tricuspid valve's

[3]. TV imaging, belowwhich this defect was located, has increased dif-ficulty with one report of optimal visualization in 11% of TVs [4]. While3-D TEE images can aid in operative decision making, artifacts can im-pact 3-D TEE images [1] and artifact recognition is imperative. Alterna-tive views should be sought when discrepant 2-D or 3-D images areobtained.

References

[1] Faletra FF, Ramamurthi A, Dequarti MC, Leo LA, Moccetti T, Pandian N. Artifacts inthree-dimensional transesophageal echocardiography. J Am Soc Echocardiogr2014;27:453–62.

[2] Pamnani A, Skubas NJ. Imaging artifacts during transesophageal echocardiography.Anesth Analg 2014;118:516–20.

[3] Grewal J, Mankad S, FreemanWK, et al. Real-time three-dimensional transesophagealechocardiography in the intraoperative assessment of mitral valve disease. J Am SocEchocardiogr 2009;22:34–41.

[4] Sugeng L, Shernan SK, Salgo IS, et al. Live 3-dimensional transesophageal echocardi-ography initial experience using the fully-sampled matrix array probe. J Am CollCardiol 2008;52:446–9.

ntricular septal defect below the tricuspid valve, Int J Cardiol (2014),

Fig. 1. A: 3-Dmid-esophageal view. Ventricular septum viewed from the left ventricle with an apparent serpiginous ventricular septal defect (VSD). B: 3-Dmid-esophageal view. The mi-tral valve (MV) at the top of the image and tricuspid valve (TV) in the lower left. VSD visualized just below the TV level. C: 2-D and color Doppler trans-gastric short axis view. Left to rightshunt through the VSD. D: 3-D trans-gastric view. Ventricular septum viewed from the RV. Awell-circumscribed VSD is seen below the TV. E: The surgically exposed VSD viewed throughthe TV. This well-circumscribed VSD correlates with Panels C and D. F: Surgical view of the VSD post repair viewed through the TV.

e2 E.D. Wittwer et al. / International Journal of Cardiology xxx (2014) xxx–xxx

Please cite this article as: Wittwer ED, et al, 3D-TEE image artifact of a ventricular septal defect below the tricuspid valve, Int J Cardiol (2014),http://dx.doi.org/10.1016/j.ijcard.2014.04.195