Content uploaded by Joseph J Vettukattil
Author content
All content in this area was uploaded by Joseph J Vettukattil on Jul 06, 2016
Content may be subject to copyright.
CONGENITAL HEART DISEASE
Three dimensional
echocardiography in congenital
heart disease
Joseph John Vettukattil
Ultrasound imaging of the human heart has
undergone revolutionary changes along with recent
strides in computing power. Since the wider
acceptance of two dimensional (2D) echocardiog-
raphy in the 1970s, progress in this field had slowed
to some extent. However, the quest for three
dimensional (3D) ultrasound imaging of the heart
began in the early 1960s when Baum and Green-
wood introduced the concept by imaging the orbit
using a series of parallel slices.
w1
It was not until
1974, when Dekker and colleagues sought to
construct a 3D model of the heart using
a mechanical spatial locator,
1
that the concept
became more realistic. Their model was limited to
an open chest with fixed point imaging, requiring
all the desired images to be obtained from one
locationdan extremely slow and primitive process
suitable only for research.
In 1986 Martin and colleagues
w2
used a micro-
manipulator controlled transoesophageal trans-
ducer which marked the beginning of 3D
transoesophageal echocardiography (3DTOE). In
1991, Kuroda et al
2
described a 3D system that
rotated the TOE probe, and simultaneously
Woolschlager et al
w3
described a TOE system that
was able to take serial slices. Further development
of a rotating array like a propeller or a fan, parallel
to the imaging plane, overcame the problem of the
small ultrasound window. In 1989, Raqueno
reconstructed the conventional 2D colour flow
Doppler images into 3D volumes. TomTec
(Unterschleissheim, Germany) converted colour
velocity data through a post-processor to assign
different colours and used a transparency slider to
give the appearance of ‘see through’jets.
In 1990, Von Ramm and Smith
w4
from Duke
University used a real-time volumetric 3D system
with a matrix array probe. This utilised parallel
processing to obtain pyramidal volume which
displayed multiple image planes. In this model 2D
arrays steered the sound over an entire pyramidal
volume, allowing electronic steering and focusing in
both elevation and azimuth. Initially, 512 elements
were used, 256 for transmission and 256 for
receiving. Different images acquired had to be
aligned using mathematical interpolation and the
gaps were filled. Currently used matrix array probes
have >3000 active elements to produce true real-
time 3D echo images, while the most recent probes
can provide real-time 3D colour.
Early ultrasound systems permitted 3D acquisi-
tion, but manipulation of the data required further
developments. In the early 1990s TomTec
developed a commercially available offline analysis
system that could accept datasets from different
vendors. Later, online image manipulation was
available on the Philips 7500 system followed by the
IE33 system with advanced calculations through
Qlab (Philips Medical Systems, Andover, Massa-
chusetts, USA). Currently, Siemens, GE Medical, and
Toshiba have emerged with comparable alternative
systems.
3
This discussion is mainly based on the
IE33 system.
CLINICAL APPLICATION OF 3D IMAGING
Real-time 3D echocardiography (RT3DE) is some-
times referred to as 4D, when the dimension of
time is taken into consideration. It is a unique
method of accurately visualising the dynamic
morphology of the heart. Not only does it display
moving images in 3D, but it incorporates
the biometric datasets frozen in time, like iris photo-
graphy or finger printing. This enables the
cardiologist to bring the frozen virtual heart to life
and to dissect it, time and time again without
corrupting or altering the preserved information.
This helps to compare pre- and postoperative
anatomy and enhance learning by direct correlation
with intraoperative findings. It is also possible to
share the datasets electronically between profes-
sionals at different geographical locations where
data can be independently analysed without the
need for transferring patients.
RT3DE has revolutionised the clinical manage-
ment of congenital heart defects. The technique
provides additional information that substantially
alters clinical management in many patients.
4 5
Even
though most currently available echocardiography
systems come with the potential for 3D imaging,
its clinical utilisation is limited to a few centres
which have developed the expertise to implement it
for surgical or transcatheter interventions.
IMAGE ACQUISITION
Acquisition of 3D images may be from trans-
thoracic, transoesophageal, or epicardial surfaces.
While most interventions for structural heart
disease require advanced planning, transthoracic
images ought to be acquired as part of 2D imaging
<Additional references are
published online only. To view
these references please visit the
journal online (http://heart.bmj.
com).
Correspondence to
Dr Joseph John Vettukattil,
Paediatric Cardiology, Wessex
Cardiac Centre, Southampton
University Hospital NHS Trust,
Southampton, SO16 6YD, UK;
joseph.vettukattil@suht.swest.
nhs.uk
Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488 79
Education in Heart
in the outpatient setting. Other settings in which
images may be acquired include ventilated patients
(preoperative or intensive care). Epicardial images
are acquired from the open chest perioperatively.
After selection of an appropriate 3D probe, as in
2D imaging, the received images are displayed on
the screen in 2D mode. Depending on the clinical
need, either live 3D, multiplane, full volume 3D
loops (FVL), or colour 3D mode is selected and the
corresponding images acquired. Depending on
clinical necessity and urgency, further image
manipulation is performed.
Practical points for 3D image acquisition
Probe position
The best window for 3D image acquisition is the
location from where the best possible image of
the structure under evaluation is obtained. Ideally,
the ultrasound beam should align perpendicular
to the structure under investigation. For example,
Figure 1 Clinical applications of 3D echocardiography. (A) Dyssynchrony assessment of the left ventricle in a patient with cardiomyopathy. The left
ventricular wall in this illustration is divided into 15 segments and the time to peak contraction is plotted. See the variation in the point of peak
contraction. The dynamic image illustrates visually the degree of dyssynchrony which is also seen on contraction front mapping. (B) Measurement of
left ventricular volume and function using Qlab. Semi-automated tracing of the endocardium in two orthogonal planes and transverse plane is illustrated.
(C) Illustration of a common atrioventricular valve with two separate orifices. The zone of apposition between the superior and inferior bridging leaflets
can be clearly seen with a coaptation failure at the centre. (D) 3D colour angiography of the great arteries in a patient with right pulmonary artery from
the main pulmonary artery and left pulmonary artery from the aorta with a patent arterial duct connecting the pulmonary artery and aorta.
80 Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488
Education in Heart
to acquire the structural details of the mitral valve
and sub-valve apparatus, the probe is placed at the
position of the apical impulse with the patient in
the lateral position. If the surgical view of the
mitral valve from the left atrium is required, the
best image would be obtained from the parasternal
position centreing on the mitral valve.
Gain setting
The gain is usually set high, aiming for uniform
echogenicity of the structure under evaluation, and
the controls are adjusted to get the best blood tissue
separation. Other important aspects of acquisition
are: centreing and choosing appropriate elevation,
and full visualisation of the structure of importance
in two orthogonal planes. All images should
avoid movement artefacts and ideally be
synchronised with the ECG and respiration.
Always ensure that a few FVLs in both colour and
grey scale of the anatomic structure under evalua-
tion are obtained for post-processing. A good 2D
image is a precursor for good 3D. Live 3DE for
interpretation of structural heart disease can often
be misleading and is best avoided, except in trans-
oesophageal echocardiography (3DTOE) with
zoom mode.
Figure 2 Anomalies of the tricuspid valve. (A) 3D echocardiography of a patient with Ebstein’s anomaly. Atrialised right ventricle with bifoliate
closure of the tricuspid valve, resulting from fusion of the mural and septal leaflets. (B) Rotational anomaly of the tricuspid valve in Ebstein’s anomaly
illustrated by the short axis view of the tricuspid valve when the mitral valve is seen opening in the long axis of the heart. (C) Large anterosuperior
leaflet (ASL) in Ebstein’s anomaly illustrating the ‘keyhole’ defect at the ventricular septum due to poor coaptation between the ASL and
non-delaminated septal leaflet. (D) Dysplastic tricuspid valve with large right atrium and fenestrated ASL. There is a large deficiency at the coaptation
point due to non-delaminated septal leaflet thickened and rolled edges of the dysplastic ASL. There is no evidence of rotational abnormality.
Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488 81
Education in Heart
3DTOE
The resolution of 3DTOE images is far superior to
transthoracic 2D images, and better anatomic
delineation is now possible with the high spatial and
temporal resolution. However, patient size can limit
the use of 3DTOE, as it is currently recommended
only for those over 25 kg, although images have been
successfully obtained in complex cases in children
weighing about 20 kg. Practical use of 3DTOE is
mainly for the assessment of complex defects where
the surface 3D resolution is suboptimal or for
interventional procedures. These include closure of
atrial or ventricular septal defects,
w5
transcatheter
aortic valve implantation,
w6
trans-septal interven-
tions like paravalvular leak,
w7
mitral valve annulo-
plasty,
6
or left atrial appendage occlusion.
w8
Real-time 3D zoom mode has significantly enhanced
the capability of RT3DE by visualising live anatomic
details for transcatheter interventions and defining
details of the cardiac pathology.
COLOUR 3D
The availability of live colour 3D imaging has
further enhanced the clinical application of 3D
imaging. This includes quantification of regurgitant
lesions, defect sizing, colour 3D angiography,
7 8
and
for the differentiation of artefacts from anatomic
defects. Direct comparison of 3D echocardiography
(3DE) and colour 3D images, acquired from iden-
tical positions and planes, helps to delineate gain
related dropouts from actual defects.
Post-processing
Image manipulation on the system
RT3DE can be a single volume dataset with low
resolution or a compilation of ECG gated 3D
datasets stitched together to display a full volume
dataset from four to seven consecutive cardiac
cycles. On live 3D imaging, on zoom mode,
a smaller section of the live 3D window can be
viewed in detail. Most recent developments in 3D
imaging include live colour 3D and multiplane
cropping.
Post-processing is also possible on most currently
available 3D equipment. For example, the Philips
IE33 system uses built-in Qlab software for instant
image manipulation. Using this mode, acquired
datasets can be further dissected to analyse the
anatomy of the structure of interest or to quantify
the lesion. This facility allows defect sizing during
3D assessment of intracardiac defects like atrial
and ventricular septal defects or paravalvular
leaks during transcatheter closure. The details are
elaborated under offline analysis.
Offline analysis
Offline analysis is software dependent. The most
commonly used software is Qlab and Image Arena
(TomTec). Two different techniques are used for
the evaluation of the 3D morphology during
post-processing: the fixed plane approach, and
multi-planar reformatting (MPR).
Fixed plane approach (cropping box)
In this technique, the 3D dataset is displayed in
a cube (pyramid in cube) and the sides of the cube
move in a fixed plane, cutting the pyramidal 3D
dataset of the heart from all six aspects. There is
also provision of a free moving crop adjustment
plane which could be used for further image
dissection. Though the fixed plane approach is
easier to perform, this is not ideal for clinical use as
it is fraught with significant errors of interpreta-
tion. Since the cardiac structures are not cut in
anatomic planes, they may be inappropriately cut
or lost, resulting in data that are often misleading
or inaccurate. Superimposition of artefacts or
structures beyond the plane may give the impres-
sion of cardiac anomalies. The best way to analyse
the dataset and reconstruct 3D images from it is by
Figure 3 (A) Multi-planar reformatting (MPR) of the subaortic area in a newborn weighing 2.6 kg with interrupted aortic arch and severe sub-aortic
stenosis. On 2D cross-sectional imaging the sub-aortic area (arrow) measured 1.7 mm, suggesting severe narrowing. On 3D MPR the orthogonal plane
(arrow) shows a square orifice which measured 1.733.7 mm, suggesting no significant obstruction on the cut plane. The patient underwent successful
biventricular repair without significant residual outflow tract obstruction. (B) MPR of an atrioventricular septal defect showing an abnormal angle
formed by the left atrioventricular valve at the crux, suggestive of poor outcome.
82 Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488
Education in Heart
Figure 4 3D echocardiography illustration of the varation in the morphology of atrial septal defects. (A) Oval fossa
viewed from the right atrium showing a small patent foramen ovale. (B) Aneurysm of the atrial septum protruding
into the right atrium with multiple sieve-like defects. (C) Two atrial septal defects with guide wires going through before
device closure. (D) Spiral margins of a small secundum atrial septal defect which has adequate margins separating
it from adjoining structures but unsuitable for device closure. (E and F) What appears to be a separate foramen
ovale and a fenestrated atrial septal defect coalesce together to form a single large defect with a flap on 3D dynamic
imaging. Accurate differentiation of these anatomic variations is crucial in successful intervention without
complications.
Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488 83
Education in Heart
using MPR.
4 9
All discussions in this article will be
based on this technique.
MPR
The most important aspect of 3DE is its ability
to slice the dynamic cardiac structures in infinite
planes through the three dimensions. This method
of analysing the anatomy is termed as ‘multi-planar
reformatting’or ‘multi-plane review’. We have
improvised this technique of moving the
slicing planes simultaneously in an anatomically
appropriate manner throughout the cardiac cycle,
displaying the images attitudinally appropriate for
visualising the structure under evaluation. This
technique is most useful in studying and under-
standing cardiac morphology, especially when the
resolution of the images are poor and a visually
useful image may not be obtainable for 3D display.
MPR may be considered equivalent to anatomic
dissection of a pathology specimen with its ability
to preserve the specimen despite repeated slicing. It
also helps as a mode of transition through multiple
frames of familiar 2D images to 3D images, having
the advantage of an added plane displaying the
depth aspect. When image resolution is poor,
especially with transthoracic images, MPR helps to
differentiate true anatomic structures from arte-
facts. Apart from delineation of structural
anatomy, the other important application of MPR
is in defect sizing and quantification of regurgitant
lesions or paravalvular leaks.
TECHNIQUE OF MPR
The purpose of MPR is to interpret and reconstruct
cardiac morphology accurately for display while
preserving the anatomic planes of dissection and
orientation. There are three important steps
involved in using MPR: alignment, analysis, and 3D
display.
Alignment
Using post-processing software, the stored FVL is
brought to display on screen. The three dissecting
planes are adjusted, focusing on the structure of
anatomic interest frozen in the phase of the cardiac
cycle which displays its details best. For example, if
the mitral valve is being evaluated to assess the
degree of prolapse, then an end systolic frame is
taken from a dataset acquired from the left atrial
(LA) view, whereas to study the supra-mitral
membrane, a diastolic frame viewed from the LA is
desirable. Once the frame is chosen, one of the
dissecting planes is brought to the centre of the
structure under evaluation to cut it along its long
axis (sagittal plane). Another cutting plane is then
brought perpendicular to this plane, cutting the
structure along its long axis (coronal plane).
The third plane is then brought to transect both
the above planes at their short axis. Each plane of
dissection is continuously readjusted to obtain best
visualisation of the anatomy.
Analysis
Moving one plane of dissection reformats the
cardiac structures dissected by that plane into the
corresponding position and displays it in a panel
representing that plane. Anatomic variation
brought about by this change is carefully observed.
This action is repeated by moving each plane until
structural details are clearly understood. Sometimes
different volumes may be analysed to confirm that
the observation is not due to artefacts. If the same
structural differences are seen in all the corresponding
planes in more than one dataset, then that lesion is
considered real. The dynamic details of the lesion
Figure 5 3D imaging of the aortic valve. (A) Trifoliate
closure of symmetrical leaflets. (B) Bicuspid aortic valve
with a very small right coronary cusp with no evidence
of restriction to opening on dynamic imaging.
(C) Symmetrical cusps in a bicuspid aortic valve with
restricted opening on dynamic imaging. Accurate
measurement of the aortic ‘annulus’ is possible with
multi-planar reformatting which is significantly different
from 2D measurements, especially in deciding the balloon
size for valvuloplasty.
84 Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488
Education in Heart
are studied further by unfreezing the structure and
carefully observing it throughout the cardiac cycle.
Once adequate knowledge about the lesion is
obtained, it is further interpreted on the basis of
clinical and haemodynamic data.
3D visualisation
Once the anatomical details and clinical pathology
are understood by MPR, 3D reconstruction is
performed based on available software. If resolu-
tion of the images are not adequate for 3D visu-
alisation, then the MPR images may be displayed
as such.
Depending on the software, various specialised
products dealing with specific clinical or functional
aspects are possible. This includes right ventricular
(RV) and left ventricular (LV) 3D volume analysis
with semi-automated stroke volume, cardiac
output, and dyssynchrony assessment (figure 1).
Other applications are calculation of the chamber
area, myocardial mass, 3D speckle tracking, mitral
valve planimetry, and quantification of annular
displacement.
CLINICAL APPLICATION OF RT3DE IN SPECIFIC
CONGENITAL HEART DEFECTS
A detailed discussion of clinical application of 3D
echocardiography is beyond the scope of this
article. A brief discussion follows.
Reconstruction of cardiac morphology
Accurate reconstruction of the morphology of the
semilunar valves or the mitral and tricuspid valves
with details of the sub-valve apparatus is possible
with 3DE. Visualisation of the dynamic
morphology and structural details is unparallelled
as it is not possible even during surgery when the
heart is stopped. Recently, 3DE has given much
insight into the understanding of Ebstein’s malfor-
mation,
5 10
leading to better clinical and surgical
management (figure 2). Another important contri-
bution of 3D is in the understanding of complex
Figure 6 Abnormalities of the left atrioventricular valve. (A) 3D visualisation of the morphology of double orifice valve
in association with atrioventricular septal defect. (B) Rheumatic mitral valve stenosis with thickened and rolled up valve
edges and shortened cordi. Large left atrium demonstrating chronicity of the lesion. (C) Trifoliate left atrioventricular
valve demonstrating the zone of apposition between the superior and inferior bridging leaflets with a separate coaptation
point differentiating the left atrioventricular valve in an atrioventricular septal defect from a cleft mitral valve.
(D) Crescentic appearance of a supra-mitral membrane sparing the aortic aspect.
Characteristics of Ebstein’s anomaly demonstrable by 3D echocardi-
ography
<Rotational anomaly of the tricuspid valve
<Apical displacement of septal and mural leaflets leading to atrialisation of the
right ventricle
<Failure of delamination of tricuspid valve leaflets
<Valve dysplasia
<Abnormalities of tension apparatus
<Myocardial abnormalities
<Reduced size of the functional right ventricle
<Variation in anatomy and function of the systemic ventricle
<Coexistent cardiac anomalies
Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488 85
Education in Heart
heart defects, especially the atrioventricular septal
defects (AVSDs).
11 12
The application of 3D MPR
to dissect cardiac anomalies in anatomically
appropriate planes has led to biventricular repair of
some complex single ventricles.
4
This group
includes those with ‘unbalanced AVSD’, criss-cross
heart, straddling atrioventricular (AV) valves, and
double inlet or double outlet ventricles (figure 3).
Other clinical applications include visualisation of
sub-aortic pathology and complex left ventricular
outflow tract obstructions,
9
double chambered
ventricles, and variation in septal morphology
(figure 4) and its defects.
13 w9 w10
3DE is also used
in understanding the morphological details of the
aortic valve and accurate measurement of the valve
area, aiding in appropriate catheter interventions
14
(figure 5). Mitral valve planimetry and quantifica-
tion of regurgitation using advanced 3D software is
now possible as it “provides complementary infor-
mation as to the mechanisms and sites of AV valve
failure in congenital heart disease”.
15 w11 w12
Accurate visualisation of mitral and tricuspid valve
defects leads to the assessment of the double orifice
mitral valve, paravalvular leak, and other mitral
valve pathologies (figure 6). The aortic arch and the
great vessels can also be better visualised in children
using RT3DE, aiding in the diagnosis of vascular
abnormalities including the double aortic arch.
w13
Volumetry, cardiac deformation imaging, and
dyssynchrony assessment
Accurate quantification of volume changes during
the cardiac cycle is essential for understanding
cardiac physiology and its alteration in disease.
Currently, most volumetric methods use geometric
assumptions. Accurate volumetry of the left
ventricle by RT3DE is now possible
16
and it has
challenged the need for cardiac MRI, especially in
children who may need general anaesthesia.
Assessment of RV function is equally important in
congenital heart disease, especially when the right
ventricle is a systemic ventricle as in the Mustard or
Senning operations, congenitally corrected trans-
position, or in single ventricles with RV
morphology. It is also important in assessing
ventricular interaction and RV function in tetralogy
of Fallot. It is difficult to capture the dilated right
heart within the sector width of currently available
transducers. However, some authors maintain that
RT3D3 “is a very sensitive tool to identify RV
dysfunction in patients with congenital heart
disease and could be applied clinically to rule out
RV dysfunction or to indicate additional quantita-
tive analysis of RV function”.
w14
The utility of RT3DE to track volume changes
during the cardiac cycle has led to its use in cardiac
dyssynchrony assessment and resynchronisation
therapy (CRT): “The dyssynchrony measurements
by tissue Doppler and RT3DE are not comparable
and are unable to predict the response to CRT”.
w15
However, quantification of LV mechanical dyssyn-
chrony by 3DE is reproducible and is “an excellent
predictor of response to CRT in selected patient
cohorts and may be valuable in identifying a target
population for CRT irrespective of QRS
morphology and duration”.
17
Children with LV
dysfunction demonstrate increased intraventricular
LV dyssynchrony, “in a pattern that is negatively
correlated with LV systolic function”.
w16 18
Most
studies on cardiac dyssynchrony use ECG gated
images stitched from multiple cardiac cycles and
have limited clinical application due to variation in
cardiac cycle length resulting from sinus
arrhythmia. Recent developments in cardiac defor-
mation imaging using 3D volumes from a single
cardiac cycle and advanced quantification software
will significantly improve CRT in congenital heart
disease.
LIMITATIONS OF 3D
3D relies on gain settings and depth delineation to
aid 3D visualisation. As gain settings can be
confounded with echogenicity of structures, positive
or negative artefacts need to be accurately identified.
Even though the digital data is in 3D, stereoscopic
display is not currently possible. Post-processing
is software dependent and online utilisation
of the software in standard echocardiography
equipment has restricted use. The available software
is not focused on the need of the congenital cardiol-
ogist as the industry continues to have an adult bias.
Frame rate remains low leading to poor optical
Clinical applications of 3D echocardiography
<Structure and morphology of heart defects
<Deformation imaging
<Volumetry: left ventricle, right ventricle, muscle mass
<Colour 3D and 3D colour angiography
<Quantification of regurgitation
<Defect sizing
<Delineation of functional morphology of valves including Ebstein’s anomaly
and atrioventricular septal defect
<Septation of complex defects
<Cardiac catheter interventions (defect sizing, catheter manipulation)
Important milestones in real-time 3D echocardiography
<1950: M mode imaging
<1961: Baum and Greenwood introduce early concept of 3D imaging of the
orbit
<1970: 2D echocardiography
<1974: Dekker and colleagues construct 3D model of the heart using
mechanical spatial locator
<1977: Matsumoto describes stereoscopic display of a wire frame model of
cardiac chambers
<1986: Martin and associates use micromanipulator controlled 3D trans-
oesophageal echocardiography (TOE)
<1989: Raqueno reconstructs conventional 2D colour flow Doppler images
<1990: Von Ramm and Smith use real-time volumetric 3D matrix array probe
<1991: Kuroda describes 3D system that rotated the TOE probe
<2002: Real-time 3D echocardiography available for clinical use
86 Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488
Education in Heart
resolution, though 3DTOE has much improved
image resolution. The post-processing technique
varies widely among cardiologists and there is an
urgent need for a unified protocol. As image analysis
is the backbone of RT3DE, training in post-
processing is needed for wider acceptance and clinical
utilisation.
FUTURE DIRECTIONS
Though some progress has been made in 3DE,
14 19
age, sex and body weight matched standardised
normal values for cardiac chambers and vessels is an
important requirement. Similarly, quantification of
myocardial deformation in both biventricular and
univentricular circulation in pre- and postoperative
states is essential to define and understand
the progression of pathology. Improvement in
3D technology may allow 3D display and visual-
isation using glasses, 3D screen or by holographic
projection. The appropriate mode for publication in
this field will remain in the electronic media
(eg, http://www.3dechocardiography.com) rather
than printed media as the latter cannot display the
dynamic and time related changes. Post-processing
of 3D datasets on the echocardiography system
rather than on a stand alone computer would
enable instantaneous definition of detailed
morphology and measurements. Ultrasound
tracking of the catheter tip would enhance the
application of RT3DE in complex interventions.
Simplification of post-processing to reconstruct 3D
images from post-processed MPR planes would
substantially improve its clinical application and
would help to move away from the erroneous use
of fixed plane cropping.
Competing interests In compliance with EBAC/EACCME guidelines,
all authors participating in Education in Heart have disclosed potential
conflicts of interest that might cause a bias in the article. JJV is
author of the website http://www.3dechocardiography.com.
Provenance and peer review Commissioned; internally peer
reviewed.
REFERENCES
1. Dekker DL, Piziali RL, Dong E Jr. A system for ultrasonically
imaging the human heart in three dimensions. Comput Biomed Res
1974;7:544e53.
2. Kuroda T, Kinter TM, Seward JB, et al. Accuracy of 3 dimensional
volume measurement using biplane transesophageal
echocardiographic probe: in vitro experiment. J Am Soc
Echocardiogr 1991;4:475e84.
3. Laser KT, Bunge M, Hauffe P, et al. Left ventricular volumetry in
healthy children and adolescents: comparison of two different real-
time three-dimensional matrix transducers with cardiovascular
magnetic resonance. Eur J Echocardiogr 2010;11:138e48.
4. Bharucha T, Roman KS, Anderson RH, et al. Impact of multiplanar
review of three-dimensional echocardiographic data on
management of congenital heart disease. Ann Thorac Surg
2008;86:875e81.
<A good review on the clinical application of 3D
echocardiography in congenital heart disease.
5. Bharucha T, Anderson RH, Lim ZS, et al. Multiplane review of
three-dimensional echocardiography gives new insights into the
morphology of Ebstein’s malformation. Cardiol Young
2010;20:49e53.
6. Balzer J, Ku
¨hl H, Rassaf T, et al. Real-time transesophageal three-
dimensional echocardiography for guidance of percutaneous
cardiac interventions: first experience. Clin Res Cardiol
2008;97:565e74.
7. Hlavacek A, Lucas J, Baker H, et al. Feasibility and utility of
three-dimensional color flow echocardiography of the aortic arch:
The “echocardiographic angiogram”. Echocardiography
2006;23:860e4.
<The concept of the colour echocardiographic angiogram is
explained here.
8. Sivaprakasam MC, Jayasekara P, Roman KS, et al. Real time
three-dimensional color Doppler echocardiographic characterization
of regurgitant orifice area in children with mitral regurgitation.
Circulation 2006;114:II_727.
9. Bharucha T, Ho SY, Vettukattil JJ. Multiplanar review analysis of
three-dimensional echocardiographic datasets gives new insights
into the morphology of subaortic stenosis. Eur J Echocardiogr
2008;9:614e20.
10. Vettukattil JJ, Bharucha T, Anderson RH. Defining Ebstein’s
malformation using three-dimensional echocardiography. Interact
Cardiovasc Thorac Surg 2007;6:685e90.
<This article helps to differentiate between tricuspid valve
dysplasia and Ebstein’s anomaly.
11. Anderson RH, Wessels A, Vettukattil JJ. Morphology and
morphogenesis of atrioventricular septal defect with common
atrioventricular junction. World Journal of Paediatric and
Congenital Cardiac Surgery 2010;1:59e67.
<A detailed review of atrioventricular septal defects and
discussion of 3D anatomy.
12. Bharucha T, Sivaprakasam MC, Haw MP, et al. The angle of the
components of the common atrioventricular valve predicts the
outcome of surgical correction in patients with atrioventricular
Practical points for 3D image acquisition
<Probe position: perpendicular to the structure under evaluation
<Gain setting: high gain aiming for uniform echogenicity of the structure under
evaluation
<Controls adjusted to get the best blood tissue separation
<Image centreing at appropriate elevation and sector width
<Full visualisation of the structure of importance in two orthogonal planes
<Avoid movement artefacts and use synchronisation with ECG and respiration
<Acquire multiple full volume 3D loops in colour and grey scale from same
window
<3D zoom for transoesophageal echocardiography with biplane width
adjustment
You can get CPD/CME credits for Education in Heart
Education in Heart articles are accredited by both the UK Royal College of
Physicians (London) and the European Board for Accreditation in Cardiologyd
you need to answer the accompanying multiple choice questions (MCQs). To
access the questions, click on BMJ Learning: Take this module on BMJ
Learning from the content box at the top right and bottom left of the online
article. For more information please go to: http://heart.bmj.com/misc/education.
dtl
<RCP credits: Log your activity in your CPD diary online (http://www.
rcplondon.ac.uk/members/CPDdiary/index.asp)dpass mark is 80%.
<EBAC credits: Print out and retain the BMJ Learning certificate once you
have completed the MCQsdpass mark is 60%. EBAC/ EACCME Credits can
now be converted to AMA PRA Category 1 CME Credits and are recognised
by all National Accreditation Authorities in Europe (http://www.ebac-cme.
org/newsite/?hit¼men02).
Please note: The MCQs are hosted on BMJ Learningdthe best available
learning website for medical professionals from the BMJ Group. If prompted,
subscribers must sign into Heart with their journal’s username and password.
All users must also complete a one-time registration on BMJ Learning and
subsequently log in (with a BMJ Learning username and password) on every
visit.
Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488 87
Education in Heart
septal defect and common atrioventricular junction. J Am Soc
Echocardiogr 2008;21:1099e104.
<The complexity of alignment of the ventricular septum and
common AV valve components may be understood better
by reading this paper.
13. Roberson DA, Cui W, Patel D, et al. Three-dimensional
transesophageal echocardiography of atrial septal defect:
a qualitative and quantitative anatomic study. J Am Soc
Echocardiogr 2011;24:600e10.
14. Sadagopan SN, Veldtman GR, Sivaprakasam MC, et al.
Correlations with operative anatomy of real time three-dimensional
echocardiographic imaging of congenital aortic valvar stenosis.
Cardiol Young 2006;16:490e4.
15. Bharucha T, Sivaprakasam MC, Roman KS, et al. Mitral valve
annular function in children with normal and regurgitant valves:
a three dimensional echocardiographic study. Cardiol Young
2008;18:379e85.
<This article illustrates the difference in the mitral valve
annular function in children compared to adults.
16. Friedberg MK, Su X, Tworetzky W, et al. Validation of 3D
echocardiographic assessment of left ventricular volumes, mass,
and ejection fraction in neonates and infants with congenital heart
disease: a comparison study with cardiac MRI. Circ Cardiovasc
Imaging 2010;3:735e42.
<A comparative study on 3DE vs MRI for LV volumetry.
17. Kapetanakis S, Bhan A, Murgatroyd F, et al. Real-time 3D echo in
patient selection for cardiac resynchronization therapy. JACC
Cardiovasc Imaging 2011;4:16e26.
<A good paper for understanding the role of 3D in CRT.
18. Raedle-Hurst TM, Mueller M, Rentzsch A, et al. Assessment of
left ventricular dyssynchrony and function using real-time
3-dimensional echocardiography in patients with congenital right
heart disease. Am Heart J 2009;157:791e8.
19. Tamborini G, Marsan NA, Gripari P, et al. Reference values for
right ventricular volumes and ejection fraction with real-time three-
dimensional echocardiography: evaluation in a large series of
normal subjects. J Am Soc Echocardiogr 2010;23:109e15.
<A source of reference values for normal 3D indices.
At BMJ Group we have resources available
to you at every stage of your career.
Whether you are a medical student or doctor in
training looking to keep up with the latest news
and prepare for exams, or a qualified doctor who
wants the latest medical information, to attend
conferences, or looking for your next job, BMJ
Group has something to offer. For the latest
information on all of our products and services
register to receive email updates at
group.bmj.com/registration
BMJ Group, supporting you
throughout your career…
88 Heart 2012;98:79e88. doi:10.1136/heartjnl-2011-300488
Education in Heart
