Three-dimensional echocardiography in the clinical world

Prof. JL ZamoranoProf. JL Zamorano

Director CV instituteDirector CV institute

University Clinic SC, MadridUniversity Clinic SC, Madrid

Advantages of 3D.... additional advantages ?.

A B

How do you prefer to see a mitral prolapse?

Your preference

A B

Modes of 3D-Echocardiography.

Full volume.Full volume.Cropping: every orientation of the planes is possible

Advantages of 3D.Spatial manipulation.

Optimal alineation of structures.Views and planes impossible to get in 2D.

Single acquisition, multiple information.Easy approach to complex problems.Volumes calculation.

No geometrical assumption (Right ventricle).Precision MRI, (but faster and cheaper).

J Am Coll Cardiol 2004;43: 2091–6

Evaluation of Mitral valve area

MVA estimated byMVA estimated by::

2D Echo :2D Echo : PHTPHT

PlanimetryPlanimetry

PISAPISA

3D3D

GorlinGorlin

ConclusionsConclusions::

3D RT is very accurate in assessing MVA3D RT is very accurate in assessing MVA

3D RT showed better agreement.3D RT showed better agreement.

0.0 0.5 1.0 1.5 2.0 2.5

AVERAGE of Gorlin and RT3D

1.5

1.0

0.5

0.0

-0.5

-1.0

-1.5

Go

rlin

- R

T3D

Mean

0.08

-1.96 SD

-0.44

+1.96 SD

0.60

MV pre – post MVP

Conclusion: Conclusion: 3D RT better correlation with 3D RT better correlation with

Gorlin, after MVPGorlin, after MVP

Mitral Valve. Mitral stenosis.

Mitral valve. Mitral stenosis.

Anatomy of leaflets, comissures, subvalvular apparatus.

Planimetry of oriffice: superior to 2D.

Guide for balloon valvulotomy.

Score.

Oriffice post-valvuloplastia.

Complications.

3D: Best diagnostic tool for structural mitral evaluation.

Mitral valve. Mitral regurgitation.

Circulation, March 2003

Mechanism of Mi regurgitation

Mitral valve. Mitral regurgitation.

Volumes quantification.

3D colour doppler quantification: promising perspectives.

Mechanism of Mi regurgitation.

Lateral MR jets.Lateral MR jets.

Real Time 3D. New perspective

3D MVP.

3D Protocol: 4 steps3D Protocol: 4 steps 1) P short axis + cutting planes1) P short axis + cutting planes

A3A3

P3P3

A3A3

P3P3

A2A2

P2P2

A2A2

P2P2

A1A1

P1P1

A1A1

P1P1

3D MV Prolapse

3D Protocol: 4 steps3D Protocol: 4 steps 1) P Shurt axis guided cutting planes1) P Shurt axis guided cutting planes 2) Apical + guided planes2) Apical + guided planes 3) Full volume 3) Full volume 4) 3D color. MI. 4) 3D color. MI.

Agreement 3D vs TEE

p< 0,0001p< 0,0001

P2P2 k = 1

A2A2 k = 0.820

P3P3 k = 0.934 P1P1 k = 0.876

A1A1 k = 0.858A3A3 k = 0.821

P2P2P2P2

A1-P1A1-P1A1-P1A1-P1

A3-P3A3-P3A3-P3A3-P3

1.- 100% P22.- False negative (anterolateral region)3.- False positive (inferomedial region)

Volumes. 2D echo ?? 2D: Simpson

Problems: ¿Optimal alignement ? Geometric asumptions

Problems: ¿Optimal alignement ? Geometric asumptions

3D:3D: Volumes calculation Volumes calculation3D:3D: Volumes calculation Volumes calculation

Quantification of left ventricular volumes and ejection fraction using freehand transthoracic three-dimensional echocardiography: comparison with magnetic resonance imaging.

Mannaerts HF, Van Der Heide JA, Kamp O, Papavassiliu T, Marcus JT, Beek A, Van Rossum AC, Twisk J, Visser CA. JASE 2003

Quantification of left ventricular volumes and ejection fraction using freehand transthoracic three-dimensional echocardiography: comparison with magnetic resonance imaging.

Mannaerts HF, Van Der Heide JA, Kamp O, Papavassiliu T, Marcus JT, Beek A, Van Rossum AC, Twisk J, Visser CA. JASE 2003

3D 3D underestimatunderestimateses volumes volumes

3D 3D underestimatunderestimateses volumes volumes

3D. Volumes

2D: Simpson biplane 3D (FV):

2 planes 4 planes 8 planes

CMR: Simpson

RT3D: Semiautomated border detection

Improved semiautomated quantification of LV volumes and EF using 3D echocardiography with a full matrix-array transducer: comparison with magnetic resonance imaging.

Caiani EG, Corsi C, Zamorano JL, Sugeng L, MacEneaney P, Weinert L, Battani R, Gutiérrez-Chico JL, Koch R, Pérez de Isla L, Mor-Avi V, Lang RM. JASE 2005 Aug

Improved semiautomated quantification of LV volumes and EF using 3D echocardiography with a full matrix-array transducer: comparison with magnetic resonance imaging.

Caiani EG, Corsi C, Zamorano JL, Sugeng L, MacEneaney P, Weinert L, Battani R, Gutiérrez-Chico JL, Koch R, Pérez de Isla L, Mor-Avi V, Lang RM. JASE 2005 Aug

Volúmenes 3DVolúmenes 3D

Volumes calculation – Slice view

Direct comparison with gold standard

Volumes calculation – Slice view

Direct comparison with gold standard

Aortic area with RT 3D echo ?

Aortic stenosis: Continuity equation

Cumulative error in several parametersDepending on good parasternal & apical acoustic windows

AAo = π ( )2DTSVI IVTTSVI

2 IVTAo

TSVITSVITSVITSVI

IVT TSVIIVT TSVI IVT TSVIIVT TSVI

Aortic stenosis: Continuity equation

Cumulative error in several parametersDepending on good parasternal & apical acoustic windows

AAo = π ( )2DTSVI IVTTSVI

2 IVTAo

TSVITSVITSVITSVI

IVT TSVIIVT TSVI IVT TSVIIVT TSVI

STROKE VOLUMESTROKE VOLUMESTROKE VOLUMESTROKE VOLUME

Aortic stenosis: Continuity equation

Cumulative error in several parametersDepending on good parasternal & apical acoustic windows

AAo =SV

IVTAo

TSVITSVITSVITSVI

IVT TSVIIVT TSVI IVT TSVIIVT TSVI

STROKE VOLUMESTROKE VOLUMESTROKE VOLUMESTROKE VOLUME

Aortic area: RT3D-Doppler hybrid approach

Aortic area:Invasive:

GorlinHakki

Echo:Continuity equationVolumetric SimpsonRT 3D

Correlation (linear association): Pearson rAbsolute agreement:

ICCa (Intraclass correlation coefficient – absolute)Lin’s coefficient

Aortic area with RT3D: Results

Limitations of 3D.

Quantification off-line ??.Time-consuming.

Full-volume mode: breath-hold. Image definition does not improve respect to 2D.Lower frame-rate.

Conclusions

3D is the best imaging for Mitral valve.3D is the best imaging for Mitral valve.New approach to mitral anatomy and mitral prolapse.3D planimetry: Best non-invasive methode for Mi stenosis.Mechanism of Mi regurgitation.Best option for complex problems, MVP, surgical repair..

3D colour Doppler: promising perspectives for 3D colour Doppler: promising perspectives for quantification of valvular regurgitations.quantification of valvular regurgitations.

Volume estimation… similar to MRIVolume estimation… similar to MRI

3 is the number !

ExécutifLégislatifJudiciaire

3D !!!