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Assessing left ventricular function is a common indication for echocardiography. It generally requires expert echocardiographer estimation and is somewhat subjective and prone to reader discordance. Mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement for left ventricular function. The aim of this study was to examine the accuracy of MAPSE for predicting left ventricular ejection fraction (EF) on the basis of a large cohort of consecutive echocardiograms.The study design was a retrospective analysis of 600 two-dimensional echocardiographic studies performed in a single laboratory. MAPSE measurement was performed by an untrained observer and compared with the EF as determined by an expert echocardiographer. The first 300 studies served as a calibration cohort to establish an algorithm for predicting EF on the basis of MAPSE measurement. The following 300 studies served as a verification cohort to test the accuracy of the established algorithm.Using the first 300 studies, an algorithm was developed to predict EF. Cutoff values for normal EF (≥11 mm for women and ≥13 mm for men) and severely reduced EF (6 mm for men and women) were identified. For the intermediate-range MAPSE values, a gender-specific regression equation was calculated to generate a predicted EF. Using this algorithm, predicted EFs were determined for the 300 patients in the verification cohort. By comparing the predicted EF and the expert-reported EF, positive and negative predictive values, sensitivity (73%-92%), specificity (81%-100%), and accuracy (82%-86%) of MAPSE for predicting EF were calculated.MAPSE measurement by an untrained observer was found to be a highly accurate predictor of EF.

Catheter-based mitral valve clip repair (CBMCR) is feasible for selected patients with mitral regurgitation (MR). Two-dimensional (2D) transesophageal echocardiography (TEE) is the standard modality for evaluating MR and procedural guidance. Recently, real-time three-dimensional TEE became available. The aim of this study was to evaluate the value of combined 2D and three-dimensional TEE for CBMCR. In evaluating MR for CBMCR, the confidence of interpretation of 2D TEE was compared with that of combined imaging for the localization of major valve pathology. In patients who underwent CBMCR, the outcomes and the duration of CBMCR were compared.In this retrospective study, MR evaluation was performed by 2D TEE alone and by combined imaging in 80 and 57 patients, respectively. CBMCR was guided by 2D TEE alone in 20 patients and by combined imaging in 39 patients.Examination by combined imaging allowed en face visualization of mitral valve anatomy and MR jet origin. The confidence of interpretation by combined imaging was higher than for 2D TEE (1.1 ± 0.3 vs 1.8 ± 0.7, P.001).The guidance of CBMCR by combined imaging facilitated alignment of the catheter trajectory, clip positioning, and orientation of clip arms. The procedural success and final MR grade were not different between the two study groups. However, the procedural time of CBMCR using combined imaging compared with that using 2D TEE guidance alone was shorter (241 ± 58 vs 201 ± 68 min, P = .035).The use of combined imaging compared with 2D TEE alone appears to enhance the confidence of interpretation concerning mitral pathology and catheter-clip system location and may also reduce CBMCR time.

Background There are currently no standardized three-dimensional (3D) transesophageal echocardiographic (TEE) views of the interatrial septum and atrial septal defects (ASDs). Without a standardized approach, it is difficult to ascertain the important anatomic relationships (such as the location of the aortic rim of an ASD), to perform relevant measurements (such as the size of an ASD or the size of its rims), or to guide the deployment of catheters and devices during atrial septal closure. Methods Using a 3D TEE matrix-array transducer, 706 TEE studies were performed over a 14-month period. The purpose of the study was to develop a standardized protocol for anatomically correct orientation of 3D TEE images of the interatrial septum and ASDs. Results Among 706 TEE studies, there were 23 patients with ASDs, representing 3.3% of the study population. Eighteen patients had secundum ASDs, two had primum ASDs, and three had sinus venosus ASDs of the superior vena cava type. A protocol for properly orienting 3D TEE images of the interatrial septum and ASDs was developed. When the images are acquired at an angle of 0°, the septum is properly oriented by the tilt-up-then-left maneuver. The initial 3D TEE image in first tilted up to reveal the right atrial side of the septum. Then the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum; the aortic rim is on the left, the superior vena cava on the top, and the right-sided pulmonary vein ostia on the right side of the screen. For acquisitions at a higher angle, the rotate-left-in-z-axis maneuver is used. The image is first tilted up to reveal the right atrial side of the septum, as in the tilt-up-then-left maneuver. The image is then rotated counterclockwise in the z axis until the superior vena cave is at 12 o'clock. Finally, the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum. Conclusions The use of standardized tilt-up-then-left and rotate-left-in-z-axis maneuvers enhances the diagnosis of ASDs, ascertains the important anatomic relationships of ASDs to surrounding structures, and facilitates communication between echocardiographers obtaining 3D TEE images and interventional cardiologists or cardiac surgeons performing ASD closures.

Background Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. Methods The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n = 25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n = 10), left atrial appendage obliteration (n = 11), left atrial or pulmonary vein ablation for atrial fibrillation (n = 5), percutaneous closures of prosthetic valve dehiscence (n = 10), percutaneous aortic valve replacement (n = 6), and percutaneous closures of ventricular septal defects (n = 2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. Results The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. Conclusion RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.

A 78-year-old man with coronary artery disease, prior myocardial infarction, and heart failure was referred for coronary artery bypass surgery. Left ventricular (LV) angiography showed the presence of a large apical aneurysm and, therefore, surgery included exclusion of the aneurysm using an aneurysmorphaphy patch. Myocardial viability study was not performed at this stage. An echocardiogram was performed 2 months after the surgery. The study showed that the aneurysm cavity was not clotted as had been expected (Figure Because of partial patch dehiscence there was a communication between the aneurysm cavity and the body of the LV. Color Doppler showed that in systole there was flow from the aneurysm into the ventricle and in diastole the flow reversed–from the LV into the aneurysm (Figure 2). Continuous wave Doppler confirm this to-and-fro flow.

A 49-year-old woman was referred to our laboratory for a stress echocardiogram. She had been in her usual state of health until 3 months prior, when she had palpitations and mild dyspnea on exertion. Her history was significant for ductal breast carcinoma, for which she had undergone mastectomy several years ago. Her physical examination and electrocardiography results were unremarkable. On her resting echocardiogram a very large mass (6 6 cm) was noted in the right atrium (Figure 1). The mass was solid, sessile, and occupied the entire right atrium. The interatrial septum was indented by the mass. Based on this finding the stress test was cancelled and the patient was referred for operation. The patient underwent resection of the tumor, which was attached to the right atrial wall, parallel to the atrioventricular groove, and filled the entire right atrium. The mass was resected completely with the attached atrial wall tissue, and there was reconstruction of the coronary sinus to the right atrium with closure of the surgically created atrial septal defect. The operative and postoperative course was unremarkable, and the patient was discharged home in good condition. Pathologic examination of the resected mass demonstrated proliferation of enlarged vessels filled with blood, consistent with cavernous hemangioma (Figure 2).