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European Journal of Echocardiography 2008 9(2):222-224; doi:10.1016/j.euje.2007.06.012
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org

Real-time three-dimensional echocardiography of congenital heart disease using a high frequency paediatric matrix transducer

John M. Simpson*

Evelina Children's Hospital, Congenital Heart Disease, Lambeth Palace Road, London SE1 7EH, UK

* Corresponding author. Tel: +44 2071882308; fax: +44 20 71882307. E-mail address: john.simpson{at}gstt.nhs.uk


   Abstract
Top
 Abstract
Remaining challenges
 References
 
New matrix transducers are now available for three-dimensional echocardiography which have a higher frequency and smaller footprint than previous matrix probes. This has resulted in better image resolution in infants and children. Current applications include assessment of cardiac morphology and function. Intraoperative epicardial techniques may be used in addition to a conventional transthoracic approach.

Keywords: Congenital heart disease; Echocardiography; Three-dimensional echocardiography; Matrix

Three-dimensional techniques are now firmly established for imaging of congenital heart defects. The current generation of real-time echocardiography systems permits full volumetric datasets to be obtained for either reconstruction on the ultrasound system itself or off-line on a computer using appropriate software. In addition, ‘live’ three-dimensional imaging is possible which shows details of morphology that is not evident with standard cross-sectional techniques.1 In addition to morphology, myocardial mass, functional information and ventricular dyssynchrony may be assessed.2,3

In congenital heart disease, three-dimensional echocardiography has been reported to provide additional information for atrioventricular septal defects,4 atrial septal defects,5 ventricular septal defects,5 aortic valve6 and right ventricular outflow tract.7 Assessment of left ventricular volume, ejection fraction and mass has been shown to correlate very well with results obtained by MRI with acceptably low observer variation.8,9

Once the three-dimensional dataset has been obtained it may be interrogated in any desired image plane. The viewing options include visualisation as a three-dimensional image or as a two-dimensional image cut in any desired axis (multi-planar reformatted) (Figure 1a and b). The ability to reinterrogate such volumetric datasets is a major advantage compared to conventional cross-sectional echocardiography, particularly with regard to surgical decision–making.


Figure 1
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  		Figure 1 (A) Three-dimensional apical four-chamber view of a four-year-old child with Ebstein's anomaly of the tricuspid valve. The atrial septal defect has been closed with an Amplatzer occlusion device. (B) Multi-planar reformatted image from the same patient. The different green, blue and red planes can be individually adjusted to produce the desired plane. The apical displacement of the tricuspid valve is demonstrated in the top-left pane (green outline). The relationship of the Amplatzer occlusion device to the aorta is demonstrated in the top-right pane (red outline). An oblique short-axis view of the left ventricle and atrialised portion of the right ventricle is demonstrated in the lower left pane (blue outline). RA — right atrium, RV — right ventricle, TV — tricuspid valve, Ao — aorta, and Amplatzer — Amplatzer atrial septal defect occlusion device (see colour version of this figure online).

 
The major probe technology for acquisition of three-dimensional datasets is matrix probes which permit acquisition of a pyramidal volumetric dataset over 4–8 cardiac cycles for grey-scale images or 7–14 cycles where colour flow Doppler data are also obtained (Philips Medical Systems, Andover, USA. General Electric Corporation, Milwaukee, USA.) The matrix probes are operated on the same ultrasound system as conventional probes and the matrix probes themselves can scan in standard cross-sectional modes as well as being used for three-dimensional imaging so that rapid switching between cross-sectional and three-dimensional modes is straightforward. Recently, matrix probes have become available which have an identical footprint to conventional paediatric ultrasound probes. The frequency of the initial matrix probes ranged from 1 to 4 MHz, which is lower than conventional ultrasound probes used in the paediatric age range. Recently, however, a new matrix probe (X7 probe, Philips Medical Systems) has been produced which is intended for paediatric use with a higher frequency (up to 7 MHz) and smaller footprint, which is desirable in this age range. This has a major impact on image resolution (Figure 1A and B).

At this author's centre, three-dimensional echocardiography has been utilised via an epicardial approach intraoperatively, particularly during surgery on atrioventricular valves.10 This approach overcomes any reduction of image quality related to intervening structures (Figure 2A and B). The smaller size of the paediatric matrix probe overcomes problems of access via the median sternotomy.


Figure 2
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  		Figure 2 (A) Epicardial three-dimensional echocardiogram demonstrating a flail chord of the A2 leaflet of the mitral valve. This image demonstrates the unsupported anterior mitral valve leaflet and the flail chord. (B) In this view the three-dimensional dataset has been cropped to allow a view from the left atrial side of the mitral valve. The ruptured chord is clearly seen. LV — left ventricle and LA — left atrium.

 

   Remaining challenges
Top
 Abstract
 Remaining challenges
References
 
Despite the advances in three-dimensional echocardiographic techniques, there are challenges which remain. The resolution of the current matrix probes does not quite match those of conventional ultrasound probes, although the development of higher frequency probes for paediatric use has been a major advance. Acquisition of the volumetric dataset still has to be performed over several cardiac cycles so that the problem of movement or respiratory motion artefact remains. However, if such artefacts do occur, they are readily identifiable, minimising the chance of diagnostic error. The basic physics of ultrasound is not altered by the acquisition of a three-dimensional dataset, so that the technique remains dependent on crosssectional image quality. The frame rates achievable on three-dimensional echocardiography have improved recently (greater than 50 frames per second) but remain lower than those obtained using conventional cross-sectional probes which can be in excess of 100 frames per second. This remains a problem for fast moving structures such as atrioventricular valves and also for functional information such as the calculation of left ventricular ejection fraction where accurate determination of end-diastolic and end-systolic volumes is crucial.


   References
Top
 Abstract
 Remaining challenges
 References
 

  1. Seliem MA, Fedec A, Cohen MS, Ewing S, Farrell PE Jr, Rychik J, et al. Real-time 3-dimensional echocardiographic imaging of congenital heart disease using matrix-array technology: freehand real-time scanning adds instant morphologic details not well delineated by conventional 2-dimensional imaging. J Am Soc Echocardiogr (2006) 19:121–9.[CrossRef][Web of Science][Medline]
  2. Lang RM, Mor-Avi V, Sugeng L, Nieman PS, Sahn DJ. Three-dimensional echocardiography: the benefits of the additional dimension. J Am Coll Cardiol (2006) 48:2053–69.[Abstract/Free Full Text]
  3. Marx GR, Sherwood MC. Three-dimensional echocardiography in congenital heart disease: a continuum of unfulfilled promises? No. A presently clinically applicable technology with an important future? Yes. Pediatr Cardiol (2002) 23:266–85.[CrossRef][Web of Science][Medline]
  4. Hlavacek AM, Crawford FA Jr, Chessa KS, Shirali GS. Realtime three-dimensional echocardiography is useful in the evaluation of patients with atrioventricular septal defects. Echocardiography (2006) 23:225–31.[CrossRef][Web of Science][Medline]
  5. Cheng TO, Xie MX, Wang XF, Wang Y, Lu Q. Real-time 3-dimensional echocardiography in assessing atrial and ventricular septal defects: an echocardiographic-surgical correlative study. Am Heart J (2004) 148:1091–5.[CrossRef][Web of Science][Medline]
  6. Sadagopan SN, Veldtman GR, Sivaprakasam MC, Keeton BR, Gnanapragasam JP, Salmon AP, et al. Correlations with operative anatomy of real time three-dimensional echocardiographic imaging of congenital aortic valvar stenosis. Cardiol Young (2006) 16:490–4.[CrossRef][Medline]
  7. Anwar AM, Soliman O, Bosch AE, McGhie JS, Geleijnse ML, Cate FJ, et al. Assessment of pulmonary valve and right ventricular outflow tract with real-time three-dimensional echocardiography. Int J Cardiovasc Imaging (2006).
  8. van den Bosch AE, Robbers-Visser D, Krenning BJ, McGhie JS, Helbing WA, Meijboom FJ, et al. Comparison of real-time three-dimensional echocardiography to magnetic resonance imaging for assessment of left ventricular mass. Am J Cardiol (2006) 97:113–7.[CrossRef][Web of Science][Medline]
  9. van den Bosch AE, Robbers-Visser D, Krenning BJ, Voormolen MM, McGhie JS, Helbing WA, et al. Real-time transthoracic three-dimensional echocardiographic assessment of left ventricular volume and ejection fraction in congenital heart disease. J Am Soc Echocardiogr (2006) 19:1–6.[CrossRef][Web of Science][Medline]
  10. Rawlins DB, Austin C, Simpson JM. Live three-dimensional paediatric intraoperative epicardial echocardiography as a guide to surgical repair of atrioventricular valves. Cardiol Young (2006) 16:34–9.[CrossRef][Web of Science][Medline]

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This Article
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