Three-Dimensional Transesophageal Echocardiography in Percutaneous Catheter-Based Cardiac Interventions

Figure 1. After obtaining the 2D-TEE bicaval view (A), multiplane reconstruction including the entire interatrial septum and surrounding structures should be performed (B). This reconstruction allows us to better appreciate the spatial relationship of the interatrial septum with the surrounding cardiac structures, and to better follow the catheter (white arrow).

Figure 2. TEE short-axis and long-axis views of a CoreValve showing incomplete expansion of the posterior aspect of the valve causing paravalvular leak (asterisk) (A,B). A 2D-TEE short-axis image post balloon dilatation showing trivial paravalvular leak (white arrow) (C). Real-time 3D-TEE image at a lower plane than (C), showing flattening of the posterior aspect of the CoreValve due to nodular calcification causing underdeployment (white arrow) (D). LA: left atrium; LV: left ventricle; AV: aortic valve.

Figure 3. A 3D-TEE image of the mitral valve obtained in “zoom mode” showing mitral valve anatomy from the atrial perspective. Aortic valve is at 12 o’clock position. A large anterior leaflet with associated scallops (A1, A2, A3) and a short and restricted posterior leaflet with individual scallops (P1, P2, P3) are shown from lateral to medial position from the atrial perspective. Note coaptation gaps visible as black holes along leaflet coaptation and between P1 and P2 scallops (A). Same view of the mitral valve shown in 3D transillumination imaging (TI) in dual mode with atrial perspective on the left and ventricular perspective of the mitral valve on the right. This mode allows further image enhancement by allowing focused visualization of area of interest with “light” mode. Note the tenting of the mitral valve both from atrial and ventricular perspectives in TI imaging mode (B). Preprocedural 3D cine full volume loop in the color Doppler mode with multiple image reconstructions demonstrating severe secondary mitral valve regurgitation (red arrow) with restriction of the posterior mitral leaflet (C). The broad jet of mitral regurgitation can be seen across the coaptation margin…

Figure 4. Real-time 3D-TEE image from the atrial perspective (Surgeon’s view) showing degenerative mitral valve with flail P2 scallop (asterisk) (A). A 3D-TEE image also from the atrial perspective during MitraClip placement showing the device arms (red arrow) situated at the A2/P2 interface with the mitral leaflets in the open position in diastole (B). A 3D-TEE image from the atrial (left) and ventricular (right) perspectives showing the mitral valve post MitraClip (asterisk) deployment at the A2/P2 interface and double orifice (C). AV: aortic valve.

Figure 5. Presents 2D-TEE images of a bi-commissural view with and without color show severely thickened restricted mitral valve prosthetic leaflets (red arrows) with turbulent flow (yellow arrow) in diastole (A). The 2D-TEE biplane image shows severely restricted mitral valve prosthetic leaflets in diastole (red arrows); overall findings consistent with bioprosthetic stenosis secondary to degeneration (B). Real-time 3D-TEE images with a TrueView (C) and glass view (D) projection from the atrial (left) and ventricular (right) aspect show severely restricted prosthetic mitral valve leaflets (asterisk), confirming degenerative bioprosthetic stenosis. Intraprocedural 2D-TEE images demonstrating the guidewire across the mitral prosthesis (red arrow) prior to delivery of the new mitral prosthesis (E); 3D-TEE view from the atrial perspective (en face view) confirms the guidewire position (asterisk) between the anterior and lateral leaflets of the mitral prosthesis (F). Standard (G) and TrueView (H) 3D-TEE projections from the atrial (left) and ventricular (right) perspectives depict the status post 29 mm Edwards Sapien (valve-in-valve replacement). LA: left atrium; LV: left ventricle; MV: mitral…

Figure 6. Two-dimensional TEE long-axis view with and without color Doppler demonstrating mechanical mitral prosthesis (asterisk) with anterolateral paravalvular leak (red arrow) (A). Three-dimensional multiplanar reconstruction confirming the anterolateral periprosthetic regurgitation (red arrow) (B). Real-time 3D-TEE color Doppler (atrial perspective) demonstrating anterolateral directed periprosthetic regurgitation adjacent to the mitral prosthesis at eleven o’clock (red arrow) (C). A smaller posterolateral defect (seen at nine o’clock) is also noted (yellow arrow). LA: left atrium; LV: left ventricle; MV: mitral valve.

Figure 7. Two-dimensional (A) and 3D-TEE (B) images demonstrating a wire (red arrow) across the anterolateral paravalvular defect. Real-time 3D-TEE standard (C) and TrueView (D) images showing the closure of the previously illustrated anterolateral paravalvular leak with a 10 mm Amplatzer closure device (asterisk). TrueView images of the atrial (left) and ventricular (right) perspectives of the mitral prosthesis (E) confirming the closure of the periprosthetic regurgitation (asterisk); the smaller posterolateral defect was not closed. The 3D-TEE image from atrial perspective demonstrates two residual jets of periprosthetic regurgitation. One residual leak is slightly posterior to the placed closure device (red arrow) and the second jet is the posterolateral one previously identified at nine o’clock (yellow arrow) (F). LA: left atrium; LV: left ventricle; MV: mitral valve.

Figure 8. Preoperative 2D-TEE images at gastroesophageal junction of the tricuspid valve at 0° (A) and 70° (B) with color Doppler demonstrating tricuspid annular dilatation and severe tricuspid regurgitation (two jets, yellow arrows). Real-time 3D-TEE image with color flow confirming two jets of tricuspid regurgitation (C): one jet is located between posterior and septal leaflets (red arrow) and the second jet is located between the anterior and septal leaflets (yellow arrow). A 3D-TEE multiplanar reconstruction prior to tricuspid clip placement reveals annular dimensions (yellow line) and valvular area (yellow circle) (D). Intraprocedural placement of the delivery system (asterisk) entering the right ventricle by multiplanar reconstruction to identify the location of the delivery catheter between the anterior and septal leaflets (E). Postprocedural 3D-TEE images from the right ventricle perspective show double orifice (white asterisks) tricuspid valve with excellent clip deployment position (red asterisk) (F). RA: right atrium; RV: right ventricle.

Figure 9. Mid-esophageal TEE images show 2D x-plane view at 55° and 145° (A) guiding the catheter (red arrow) into the left atrial appendage (asterisk). Real-time 3D-TEE multiplane reconstruction from the prior views can help guide the catheter (red arrow) into left atrial appendage (asterisk) (B–D). Postprocedure, using 3D-TEE images, the occlusion device is visualized and is well-expanded within the left atrial appendage (asterisk) (E), and no significant leak between the left atrium and left atrial appendage is noted when using TrueView techniques (F). LA: left atrium.

Figure 10. Two-dimensional TEE images with and without color Doppler of the right upper pulmonary vein (red asterisk). In the color Doppler images, the turbulent flow at the entrance of the right upper pulmonary vein into the left atrium (red arrow) suggests pulmonary vein stenosis (A). Real-time 3D-TEE images reveal a small central ridge at the orifice of the right upper pulmonary vein (red asterisk). Three-dimensional color-flow imaging demonstrates two jets of turbulent flow (red arrows) from the right upper pulmonary vein into the left atrium (B). Live 3D-TEE images of the right upper pulmonary vein (red asterisk), left and right atria, and interatrial septum. The catheter used in the procedure can be seen (red arrow) within the pulmonary vein (C). Status of 3D-TEE images post stent implantation in the right upper pulmonary vein from the long- and short-axis views (asterisk) (D). LA: left atrium; RA: right atrium; IAS: interatrial septum.