Curr Anesthesiol Rep (2017) 7:291–298

DOI 10.1007/s40140-017-0226-5

CARDIOVASCULAR ANESTHESIA (J FASSL, SECTION EDITOR)

Role of 3D Echocardiography in Cardiac Surgery:

Strengths and Limitations
Edwin Wilberforce Turton 1 & Jörg Ender 1

Published online: 21 July 2017

# The Author(s) 2017. This article is an open access publication

Abstract Keywords Three-dimensional echocardiography (3DE) . 3D

Purpose of Review This review aims to highlight the gen- transesophageal echocardiography (TEE) . 3D transthoracic
eral and specific strengths and limitations of intraopera- echocardiography (TTE) . Intraoperative echocardiography .
tive 3D echocardiography. This article explains the value 3D data sets . 3D modes . Full volume (FV) . Color flow
of real-time three-dimensional transesophageal echocardi- Doppler (CFD) . Real time (RT) . Live . Zoom . Simultaneous
ography (RT 3D TEE) during cardiac surgery and cardiac multiplane/biplane/X-plane imaging . Cardiac surgery .
interventions. Interventions . Transcatheter procedures .
Recent Findings Recently published recommendations Echocardiographer . Spatial resolution . Temporal resolution .
and guidelines include the use of RT 3D TEE. RT 3 Guidelines and recommendations . Valvular surgery . Future
D TEE provides additional value particularly for guid- developments . Strengths . Limitations
ance during cardiac interventions (i.e., transcatheter mi-
tral valve repair, left atrial appendix and atrial septal
defect closures), assessment of the mitral valve in sur- Introduction
gical repair, measurement of left ventricular outflow
tract area for transcatheter valvular replacements, and Since the first use of transesophageal echocardiography
estimating right and left ventricular volumes and func- (TEE) during cardiac surgery in 1979 [1], two-
tion. The exact localization of paravalvular leakage is dimensional (2D) TEE has become a class I indication
another strength of RT 3D TEE. The major limitation for perioperative use in almost every major cardiac surgi-
is the reduced temporal resolution compared to 2D TEE. cal procedure [2].
Summary Three-dimensional echocardiography is a powerful Three-dimensional transesophageal echocardiography
tool that improves communication and accurate measure- (3D TEE) was first available as an offline model after
ments of cardiac structures. acquisition of multiple 2D examinations [3] that were
very time consuming and user unfriendly [4]. Real-time
3D transesophageal echocardiography (RT 3D TEE) using
a matrix probe evolved during the late 2000s [5] and led
to the widespread use of this technique in cardiac surgery
This article is part of the Topical Collection on Cardiovascular
Anesthesia today.
This article highlights the strengths and limitations of
* Jörg Ender RT 3D TEE in daily clinical practice during cardiac sur-
[email protected] gery and interventional cardiac procedures. This article is
Edwin Wilberforce Turton
divided into two parts. The first discusses the strengths
[email protected] and the limitations of 3D echocardiography in comparison
to 2D echocardiography (2DE), and the second outlines
1
Department of Anesthesiology and Intensive Care Medicine, Heart the specifics of RT 3D TEE looking at different cardiac
Center Leipzig, Struempellstr 39, 04289 Leipzig, Germany structures.
292 Curr Anesthesiol Rep (2017) 7:291–298

Cardiac Surgery and Three-Dimensional The inherent physical properties of ultrasound and with
Echocardiography that the limitations of ultrasound imaging in general are equal-
ly applicable to 3D and 2D echocardiography. Additionally,
General Strengths and Limitations there are specific 3D-based artifacts such as stitching artifacts,
dropout, “blurring” or thickening, blooming, and rail road
Two-dimensional echocardiography to visualize the 3D struc- artifacts [8–10]. Dropout artifacts can mimic valvular perfora-
ture of the heart requires cognitive reconstruction from multi- tions and periprosthetic leaks [11].
ple 2D images. This is no longer required in 3D echocardiog- Another limitation comes with displaying 3D echocardio-
raphy. Further, while 2D echocardiography only reveals cross- graphic images on a 2D screen. In doing so, colors are used to
sectional views of the heart, 3D echocardiography is more give a sense of depth and reality [12••]. Therefore, accurate
akin to a Cartesian coordinate system [6••], enabling us to measurements cannot be made in RT 3D mode [13].
display the anatomic view of the heart. This simplifies com-
munication between physicians and allows for better orienta- Specific Strengths and Limitations (See Table 1)
tion, which is particularly helpful for image-guided interven-
tional procedures [2]. Left Ventricle Volume and Function
Because ultrasound propagation is equal in both 2D and 3D
echocardiography, the use of more Cartesian coordinate-like Simultaneous multiplane mode allows the recommended bi-
data to improve spatial orientation leads to reduced temporal plane measurement for ejection fraction of the same heartbeat,
resolution. Practically, the echocardiographer using 3D echo- whereas in 2D TEE assessment, it can only be performed in
cardiography has to decide between the optimal temporal and two different heartbeats [14].
spatial resolutions when imaging specific cardiac structures. With FV mode and multiple beat acquisitions, the left ven-
Both temporal and spatial resolutions play a role in the tricular volume and function can be more accurately deter-
quality of images produced by 3D echocardiography. Images mined by 3D than by 2D echocardiography when compared
need to be of adequate quality to allow qualitative and quan- to other image modalities like multidetector computed tomog-
titative assessment. Temporal resolution is displayed as vol- raphy (MDCT) or cardiac magnetic resonance imaging
umes per time unit (volume rate), and this can be increased by (CMRI) [15••]. Three-dimensional echocardiography is more
decreasing the volume size (sector) imaged. Spatial resolution accurate than both contrast enhanced 2D echocardiography
can be improved by reducing the volume acquired or by in- and 2D echocardiography alone in the measurement of LV
creasing the number of scan lines through the volume. ejection fraction, but still underestimates LV volumes com-
Increasing the number of scan lines for a specific volume will pared to CMRI [16]. The strength of left ventricular assess-
reduce its temporal resolution. ment with 3D echocardiography is that no geometric assump-
Different 3D modalities are available (i.e., wide-sector tion is necessary and that it is unaffected by foreshortening
zoom, narrow sector, full volume (FV) mode with and without [14]. The limitations are the lower temporal resolution and
color Doppler). The technical aspect of these different modal- that no normal values for 3D TEE are available so far.
ities will not be discussed in detail in this article, but it is Image acquisition time to assess LV function and volume is
explained elsewhere [7••]. equally between both 3D and 2D. But, analysis of the 3D data

Table 1 Structure-specific 3D mode and clinical utility

Structure View 3D Mode Clinical utility [7]

Mitral valve ME 0–120° ± CFD Multiplane, Zoom, FV Morphology (pathology), function, quantification—EROA and MVA
Aortic valve ME SAX and LAX views ± CFD Multiplane, Zoom, Live Valvular surgery and interventions esp. transcatheter
valvular replacements (TAVR)
Tricuspid valve ME 4C, 0°–30°, TG SAX (40°) Multiplane, Zoom, Live Unstudied (transcatheter procedures experimental)
Pulmonary valve UE 90°, ME 3C 120° ± CFD Multiplane, Zoom Limited visualization with TEE
IAS ME 0° view Multiplane, Zoom, FV Atrial septal defect, patent foramen ovale
LV ME 0°–120° views Multiplane, FV Volume, mass, EF, dysynchrony, deformation parameters
RV ME 0°–120° Multiplane, FV Volume, EF
LAA ME 0°, 45°, 60°, 90° Multiplane, Live, Zoom Thrombus

Modified from [14]

CFD color flow Doppler, EROA effective orifice area, EF ejection fraction, IAS interatrial septum, 4C four chamber, FV full volume, LAX long axis, ME
midesophageal, MVA mitral valve area, SAX short axis, TEE transesophageal echocardiography, TG transgastric
Curr Anesthesiol Rep (2017) 7:291–298 293

set takes on average 2 min longer [17]. In addition, a special measurement of the MV area is as accurate as with 2D TEE
software package for 3D analysis, not automatically included [32].
when buying a 3D system, is required.
Especially advantageous in the perioperative setting, nearly Localization of Paravalvular Leakage
all left ventricular dimensions can be measured based on a
single FV data set when using 3D TEE. This may be important Paravalvular leaks can be exactly located [33] and quantified
in cardiac surgery when the patient is either unstable or there is [34].
not enough time for a comprehensive 2D TEE examination
[18]. Multislice imaging of the ventricle can be performed, Aortic Valve
and regional wall motion and function can be assessed using
this single data set. Three-dimensional echocardiography can accurately display
the anatomy of the aortic valve in most patients and simplify
Right Ventricle Volume and Function communication between physicians [35], but in some patients,
the imaging is limited due to acoustic shadowing [8] and echo
The complex geometry of the right ventricle makes it impos- dropout especially in degenerative calcified aortic cusps [9••].
sible to evaluate right ventricular ejection fraction (EF) using Subvalvular aortic membranous structures as well as dy-
2D TEE. For experienced echocardiographers with access to namic left ventricular outflow tract (LVOT) obstruction can be
special software, it is recommended to use 3D-derived right diagnosed by 3D echocardiography [36], but low temporal
ventricular EF [14]. Good accuracy and correlation for 3D resolution may miss the dynamic obstruction [37].
right ventricular function in cardiac surgical patients with pre- Assessment of left ventricular outflow area with 3D echo-
operative 3D transthoracic echocardiography examinations cardiography has been shown to correlate better with multi-
have been shown in the perioperative setting [19, 20]. The slice computed tomography (MSCT) compared to 2D echo-
main limitations are the need for special software and image cardiography [38, 39] and is, therefore, recommended [40••].
quality. Sizing of transcatheter (transcatheter valvular replacements
(TAVR)) valves is discussed in the section on transcatheter
Mitral Valve procedures/interventional procedures.
Pathology can be assessed by 2D and additionally by 3D
The non-planar anatomy of the mitral valve (MV) complex TEE before aortic root, valve-sparing aortic, or valve repair
lends itself to 3D assessment. It is more intuitive to assess the surgery [24••, 41].
MV using 3D echocardiography than to reconstruct this three-
dimensional structure using multiple 2D views [21, 22]. The Quantification of Aortic Valve Disease (Aortic Regurgitation
MV can be displayed from the left atrial side and the left and Aortic Stenosis)
ventricle side using one 3D echocardiography image or data
set [7••]. Assessment of the mechanism of MV pathology can In aortic stenosis, 3D TEE can be used to measure left ven-
be done accurately [23, 24]; and 3D TEE is especially superior tricular outflow area and diameter [40••]. Semi-automated 3D
to 2D TEE in viewing complex MVanatomy and determining measurements seem to be better as compared to direct
pathology [25••, 26]. planimetry [42]. The underestimation of the LVOT area in
Three-dimensional MV assessment especially for MV re- the 2D method may lead to overestimation of aortic stenosis.
pair surgery can be used to predict the probability of success- Therefore, 3D echocardiography may have an impact on sur-
ful MV repair and to assess the result after repair [6••, 27], gical decision making in these cases [39, 43]. Recent recom-
both leading to optimal outcomes after surgery [28]. mendations suggest the use of 3D TEE or MSCT to measure
the LVOT and to use this measurement in the quantification of
Quantification of Mitral Valve Disease ( Mitral Regurgitation aortic valve area [40••].
and Mitral Stenosis) The use of 3D color flow is not recommended in quantifi-
cation of aortic regurgitation due to the low temporal and
Color flow Doppler in FV mode can be used to measure the spatial resolutions, except in patients with multiple jets [41].
VC area (VCA) and the proximal isovelocity surface area In these patients, overestimations or underestimations of the
(PISA) by planimetry [24••, 29], overcoming the caveats of jet size may occur.
flow-derived calculation in 2D TEE [30]. The most important
limitations are the temporal and spatial resolutions and cum- Tricuspid Valve
bersome offline analysis [24••].
Three-dimensional TEE is remarkable in its ability to as- The assessment of the tricuspid valve (TV) and its pathology
sess commissural fusion [31] in rheumatic MV disease, and its has to include assessment of the right ventricle and right
294 Curr Anesthesiol Rep (2017) 7:291–298

atrium. Three-dimensional echocardiography allows accurate Interventional Cardiac Procedure

evaluation of right ventricle function and volumetric assess-
ment with specialized and costly software. The complexity of cardiac surgery and interventional
Using biplane 3D TEE mode at different levels of the procedures is increasing, and intraoperative and
esophagus and stomach makes it possible to accurately iden- intraprocedural three-dimensional imaging is necessary
tify the different leaflets [44•]. to guide these [49, 50].
Color flow Doppler (CFD) can be added to the FV set to
more accurately assess insufficiency or stenosis of the valve Transcatheter Valvular Replacements
[23, 44]. Vena contracta area (VCA), especially in the pres-
ence of multiple jets, can be assessed by 3D color Doppler While MSCT is the gold standard for sizing the aortic valve,
echocardiography [24••]. Nevertheless, over- or underestima- 3D TEE is an accurate alternative in units where MSCT is not
tion may occur with inadequate spatial resolution. The three- available or in situations where it is contraindicated [50–52].
dimensional proximal isovelocity surface area (PISA) method The simultaneous multiplane mode can be used to correctly
in functional tricuspid regurgitation is clinically feasible and align the long axis of the aortic valve to measure the annulus
more correct than the 2D PISA method [45]. Planimetry of the accurately [52•]. Both simultaneous multiplane mode and RT
tricuspid annulus can be done accurately and can detect ec- 3D TEE are used during these procedures. With 3D TEE,
centric dilatation in the presence of severe tricuspid regurgita- annular distances to both coronary arteries can be measured
tion [46]. using the multiplanar reconstruction (MPR) mode [50, 52,
The greater distance between the probe and the TV and the 53]. Assessing the position of the valve prosthesis on the bal-
non-perpendicular alignment make imaging of the TV by RT loon is better done with 3D TEE, because it can guide the
3D TEE difficult [24••]. correct positioning of the prosthesis in relation to the valve
annulus and surrounding structures. The path of the guide wire
through the LV and around the subvalvular apparatus of the
Pulmonary Valve MV is better visualized with RT 3D TEE [54]. Three-
dimensional TEE can also be used to assess post-
The thin leaflets of the pulmonary valve (PV) are situated in implantation results, including the occurrence of intravalvular
the far field from the TEE probe, and an echo dropout artifact and paravalvular regurgitation [50, 52].
is frequently encountered. Therefore, RT 3D TEE has no ad-
vantage over 2D TEE in the clinical evaluation of the PV. Paravalvular Leakage Diagnosis

Live 3D zoom TEE images can be used to correctly localize

Atria paravalvular leaks. Care should be taken not to mistake echo
dropout artifacts as paravalvular leaks. The size of the dehis-
Three-dimensional echocardiography is more accurate in cence can be determined by acquiring a FV set with CFD to
measuring left atrial (LA) and right atrial (RA) volumes and confirm leakage and to measure its size [50].
compares well with CMRI measurements [14]. Using RT 3D
TEE, the atria cannot be fully measured due to the close prox- Transcatheter Mitral Valve Repair
imity of the TEE probe to the atria. However, nearby struc-
tures can be visualized anatomically in detail (i.e., pulmonary Guidance RT 3D TEE and simultaneous multiplane mode are
vein ostia into the LA, vena cavae ostia, coronary sinus osti- strongly recommended for guidance of transcatheter edge to
um, crista terminalis, eustachian valve, and fossa ovalis in the edge MV repair with the MitraClip® [55–58].
RA) [47]. The Cardioband® direct annuloplasty MV repair is done
with fluoroscopic and 2D/3D TEE guidance. Simultaneous
biplane and 3D TEE are used for transseptal puncture and
Great Vessels RT 3D TEE (wide-sector zoom) to assess anchoring position
and final adjustment [59].
Three-dimensional TEE is more sensitive and detects cases of RT 3D TEE can be used in addition to 2D TEE and fluo-
aortic aneurysms and dissections that are missed with 2D roscopy to help with coronary sinus identification during the
TEE. The dissection flap appears in 3D TEE as a tissue flap. indirect coronary sinus annuloplasty technique [60].
The linear image of the dissection membrane can be mistaken Mitral stenosis can be treated by balloon valvotomy if
for an artifact in a 2D examination. The involvement of the found suitable for the procedure. Three-dimensional TEE
right coronary artery ostium in aortic dissections is more ac- can be used to assess the mitral commissural fusion to further
curately diagnosed by 3D TEE [48]. determine suitability for this procedure. Three-dimensional
Curr Anesthesiol Rep (2017) 7:291–298 295

TEE with its simultaneous biplane mode is used for correct the capabilities of 3D imaging [76]. Combined TEE and fluo-
transseptal puncture [57, 61]. roscopy merged/fused images may play a role in improved
outcomes [28, 54].
Left Atrial Interventions Three-dimensional strain and strain rate as parameters of
myocardial deformation for the assessment of the left ventri-
Intra-atrial Septum and Left Atrial Appendix Three-dimen- cle, right ventricle, and left atrium will play an important role
sional TEE is superior to 2D TEE in the spatial information in chamber quantification in the future [77, 78•].
that it provides to delineate the variant anatomy of a patent
foramen ovale (PFO) and of atrial septal defects (ASD). The
en-face image of the intra-atrial septum allows for spatial ori- Conclusion
entation and counting of defects. RT 3D TEE is also very
suitable to guide the intervention. Offline MPR is useful for For the first time, RT 3D TEE allows for the anatomical dis-
correct measurement of ASD size through precise alignment, play of most cardiac structures and pathologies, therefore fa-
can indicate rim deficiencies, and allows measurement rela- cilitating improved communication between physicians. It ad-
tionships to important structures like the aorta [62•]. ditionally allows for more accurate quantification of some
The sizing of the left atrial appendix (LAA) can be done by stenotic as well as regurgitant pathologies. Further develop-
RT 3D TEE [63]. Two-dimensional TEE significantly under- ment in 3D technology and the definition of normal values are
estimates the maximal LAA orifice compared to RT 3D TEE the next steps to increase the clinical value of RT 3D TEE.
preclosure and during the procedure [64]. Additionally, RT 3D
TEE is useful in ruling out a LAA thrombus [50]. Compliance with Ethical Standards

Infective Endocarditis and Cardiac/Aortic Sources Conflict of Interest Edwin Wilberforce Turton and Jörg Ender declare
they have no conflict of interest.
of Embolism
Human and Animal Rights and Informed Consent This article does
Infective endocarditis (IE) and its complications can readily be not contain any studies with human or animal subjects performed by any
diagnosed and further clarified by the use of intraoperative 2D of the authors.
TEE. Three-dimensional TEE FV and real-time modes reveal
Open Access This article is distributed under the terms of the Creative
pathology that is not readily seen with 2D echocardiography Commons Attribution 4.0 International License (http://
[65]. There is a good correlation between 3D TEE assessment creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
of pathology and corresponding operative findings [66]. distribution, and reproduction in any medium, provided you give appro-
Morphology and size of valvular vegetations can be assessed, priate credit to the original author(s) and the source, provide a link to the
Creative Commons license, and indicate if changes were made.
superior to 2D TEE [67].
Three-dimensional and multiplane imaging are suggested
to confirm or exclude cardiac masses in the cardiac chambers
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