Multimodality echocardiography in structural heart disease: the evolving role of the interventional imager

Figures

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  Figure 1. 3D TEE image of the mitral valve in ‘zoom mode’ showing anatomy from the atrial perspective, with the aortic valve at the 12 o’clock position. The large anterior leaflet (A1, A2, A3) and shorter posterior leaflet (P1, P2, P3) are shown from lateral to medial orientation. Coaptation gaps appear as dark spaces along the coaptation line and between the P1 and P2 scallops (A). The same view in 3D transillumination imaging (TI) dual mode provides atrial (left) and ventricular (right) perspectives, enhancing leaflet visualization with ‘light’ mode and demonstrating mitral valve tenting (B). A pre-procedural 3D cine full-volume colour Doppler loop with multiple image reconstructions reveals severe secondary mitral regurgitation (red arrow) with restriction of the posterior mitral leaflet (C). The broad regurgitant jet is visualized across the coaptation margin (asterisk) in the 3D ‘glass’ mode, highlighting leaflet tenting and the regurgitant jet origin (D). During MitraClip deployment, 3D TEE ensures correct clip orientation (asterisk) perpendicular to the coaptation line (E). Two clips were placed—one lateral to the other—to address the broad jet. Post-procedural 3D TTE shows a…

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  Figure 2. 2D TEE bicommissural views with and without colour Doppler demonstrate severely thickened and restricted bioprosthetic mitral valve leaflets (red arrows) with diastolic turbulent flow (yellow arrow) (A). The 2D TEE biplane image further confirms marked leaflet restriction in diastole, consistent with degenerative bioprosthetic stenosis (B). Real-time 3D TEE images using 3D transillumination imaging (TI) TrueView (C) and glass-view (D) projections from atrial (left) and ventricular (right) perspectives highlight restricted leaflet motion (asterisk), confirming prosthetic degeneration. Intraprocedural 2D TEE imaging shows the guidewire traversing the stenotic mitral prosthesis (red arrow) before valve delivery (E), while the 3D atrial ‘en face’ view confirms correct guidewire positioning (asterisk) between the anterior and lateral prosthetic leaflets (F). Post-deployment standard (G) and TrueView (H) 3D TEE images from both perspectives display the implanted 29 mm Edwards Sapien valve-in-valve prosthesis.1 LA, left atrium; LV, left ventricle; MV, mitral valve.35

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  Figure 3. After acquiring the 2D TEE bicaval view (A), multiplanar reconstruction encompassing the entire IAS and adjacent cardiac structures is performed (B). This reconstruction enhances visualization of the spatial relationship between the IAS and surrounding anatomy, facilitating precise tracking of the catheter.35

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  Figure 4. Echocardiographic assessment of patent foramen ovale (PFO) using bubble contrast test. (A) Two-dimensional transoesophageal echocardiography (TEE) image demonstrating transient leftward bowing (‘septal bounce’) of the IAS toward the left atrium (LA, arrow) following release of the Valsalva manoeuvre, indicating a pressure gradient favouring right-to-left shunting. (B) Contrast-enhanced TEE showing microbubble passage from the right atrium (RA) through a patent foramen ovale into the LA (arrow), confirming the presence of an interatrial communication. (C) Transthoracic echocardiography (TTE) images obtained during contrast study demonstrating right-to-left shunt upon Valsalva release, with leftward deviation of the atrial septum (arrow). LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.

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  Figure 5. Preoperative 2D TEE images at the gastroesophageal junction of the tricuspid valve at 0° (A) and 70° (B) with colour Doppler demonstrate significant annular dilatation and severe tricuspid regurgitation with two distinct jets (yellow arrows). Real-time 3D TEE imaging with colour flow confirms the presence of two regurgitant jets (C): one between the posterior and septal leaflets (red arrow) and another between the anterior and septal leaflets (yellow arrow). A 3D TEE multiplanar reconstruction prior to clip placement delineates annular dimensions (yellow line) and valve area (yellow circle) (D). Intraprocedural multiplanar reconstruction identifies the delivery system (asterisk) crossing into the right ventricle between the anterior and septal leaflets (E). Post-procedural 3D TEE images from the right ventricular perspective demonstrate a double-orifice tricuspid valve (white asterisks) with optimal clip deployment (red asterisk) (F).1 RA, right atrium; RV, right ventricle.35

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  Figure 6. Mid-oesophageal TEE images depict a 2D x-plane view at 55° and 145°, guiding the catheter (red arrow) into the left atrial appendage (asterisk) (A). Real-time 3D-TEE multiplanar reconstruction from these views further facilitates catheter guidance into the left atrial appendage (B–D). Postprocedure, 3D-TEE imaging shows the occlusion device fully expanded within the left atrial appendage (asterisk) (E), with TrueView imaging confirming the absence of significant residual flow between the left atrium and left atrial appendage (F).1 LA, left atrium.35

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  Figure 7. 2D TEE long-axis view with and without colour Doppler shows a mechanical mitral prosthesis (asterisk) with anterolateral paravalvular leak (red arrow) (A). Three-dimensional multiplanar reconstruction confirms the anterolateral periprosthetic regurgitation (red arrow) (B). Real-time 3D-TEE colour Doppler from the atrial perspective demonstrates the anterolateral regurgitation adjacent to the prosthesis at eleven o’clock (red arrow) and a smaller posterolateral defect at nine o’clock (yellow arrow) (C).1 LA, left atrium; LV, left ventricle; MV, mitral valve.35

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  Figure 8. 2D (A) and 3d-TEE (B) images depict a guidewire (red arrow) across the anterolateral paravalvular defect. Real-time 3D-TEE standard (C) and transillumination imaging (TI) TrueView (D) images show closure of the anterolateral defect using a 10 mm Amplatzer device (asterisk). TrueView images from atrial (left) and ventricular (right) perspectives (E) confirm successful closure of the periprosthetic regurgitation (asterisk), while the smaller posterolateral defect remains untreated. The 3D-TEE atrial view (F) demonstrates two residual periprosthetic jets: one just posterior to the closure device (red arrow) and the pre-existing posterolateral jet at nine o’clock (yellow arrow).1 LA, left atrium; LV, left ventricle; MV, mitral valve.35