3D echocardiography (3DE) will gain increasing acceptance as a routine clinical tool as the technology evolves due to advances in technology andcomputer processing power. Images obtained from 3DE provide more accurate assessment of complex cardiac anatomy and sophisticatedfunctional mechanisms compared with conventional 2D echocardiography (2DE), and are comparable to those achieved with magnetic resonanceimaging. Many of the limitations associated with the early iterations of 3DE prevented their widespread clinical application; however, recentsignificant improvements in transducer and post-processing software technologies have addressed many of these issues. Furthermore, the mostrecent advances in the ability to image the entire heart in realtime and fully automated quantification have poised 3DE to become more ubiquitousin clinical routine. Realtime 3DE (RT3DE) systems offer further improvements in the diagnostic and treatment planning capabilities of cardiacultrasound. Innovations such as the ability to acquire non-stitched, realtime, full-volume 3D images of the heart in a single heart cycle promise toovercome some of the current limitations of current RT3DE systems, which acquire images over four to seven cardiac cycles, with the need forgating and the potential for stitch artifacts.
2D echocardiography (2DE) is a common diagnostic and treatment planning tool in clinical cardiology, especially for the assessment of left ventricular (LV) volume and function. However, traditional 2DE is severely limited by its dependence on geometrical assumptions, which can lead to inaccuracies in volume quantification.1 Because 3D echocardiographic (3DE) imaging eliminates geometrical assumptions and image plane positioning error, the technique offers the potential for more accurate assessment of complex cardiac anatomy and sophisticated functional mechanisms.
Early attempts at 3DE using images produced by freehand reconstruction from multiple gated 2D images required spatial tracking of each image. These initial attempts at 3DE of LV volumes and mass and LV ejection fractions (LVEF) produced superior results to 2DE, comparable to those of nuclear magnetic resonance (NMR) imaging.2,3 Although 3DE has been around for nearly two decades, limitations in the early iterations of the technology prevented their widespread clinical application. While advances in transducer and post-processing software technologies have addressed many issues, it is the most recent advances in the ability to image the entire heart in realtime and fully automated quantification that have poised 3DE to become more ubiquitous in clinical routine. The introduction and increasing availability of realtime 3DE (RT3DE) have the potential to further improve the diagnostic and treatment planning capabilities of cardiac ultrasound. While cardiac magnetic resonance imaging (MRI) is the current gold standard, this imaging modality may require the injection of a contrast agent, is not suitable for patients with implanted cardiac devices, and can be more costly.
The Evolution of 3D Echocardiography
The acquisition of the first 3D cardiac ultrasound images dates back to 1974.4 This was followed by the development of early 3DE techniques, whereby 3DE images were obtained by offline sequential reconstruction of 2D images.2,3,5 However, these methods had limitations related to acquisition and post-processing: the images obtained were often of a relatively poor spatial and temporal resolution, while the reconstruction of the 2D data sets to produce 3D images was time-consuming and only available offline. More recently, matrix-array transducers have been introduced. These transducers contain an array of piezoelectric elements that are capable of scanning pyramidal volumes rather than 2D thin slices.
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- Lang RM, Bierig M, Devereux RB, et al., Recommendations for chamber quantification, Eur J Echocardiogr, 2006;7:79–108.
- Gopal AS, Keller AM, Rigling R, et al., Left ventricular volume and endocardial surface area by threedimensional echocardiography: comparison with twodimensional echocardiography and nuclear magnetic resonance imaging in normal subjects, J Am Coll Cardiol, 1993;22:258–70.
- Gopal AS, Schnellbaecher MJ, Shen Z, et al., Freehand three-dimensional echocardiography for determination of left ventricular volume and mass in patients with abnormal ventricles: comparison with magnetic resonance imaging, J Am Soc Echocardiogr, 1997;10:853–61.
- Dekker DL, Piziali RL, Dong E, Jr., A system for ultrasonically imaging the human heart in three dimensions, Comput Biomed Res, 1974;7:544–53.
- Gordon EP, Schnittger I, Fitzgerald PJ, et al., Reproducibility of left ventricular volumes by two-dimensional echocardiography, J Am Coll Cardiol, 1983;2:506–13.
- von Ramm OT, Smith SW, Real time volumetric ultrasound imaging system, J Digit Imaging, 1990;3:261–6.
- Sheikh K, Smith SW, von Ramm O, et al., Real-time, threedimensional echocardiography: feasibility and initial use, Echocardiography, 1991;8:119–25.
- Wang XF, Deng YB, Nanda NC, et al., Live threedimensional echocardiography: imaging principles and clinical application, Echocardiography, 2003;20:593–604.
- Arai K, Hozumi T, Matsumura Y, et al., Accuracy of measurement of left ventricular volume and ejection fraction by new real-time three-dimensional echocardiography in patients with wall motion abnormalities secondary to myocardial infarction, Am J Cardiol, 2004;94:552–8.
- Jenkins C, Bricknell K, Hanekom L, et al., Reproducibility and accuracy of echocardiographic measurements of left ventricular parameters using real-time three-dimensional echocardiography, J Am Coll Cardiol, 2004;44:878–6.
- Kuhl HP, Schreckenberg M, Rulands D, et al., Highresolution transthoracic real-time three-dimensional echocardiography: quantitation of cardiac volumes and function using semi-automatic border detection and comparison with cardiac magnetic resonance imaging, J Am Coll Cardiol, 2004;43:2083–90.
- Gutierrez-Chico JL, Zamorano JL, Perez de Isla L, et al., Comparison of left ventricular volumes and ejection fractions measured by three-dimensional echocardiography versus by two-dimensional echocardiography and cardiac magnetic resonance in patients with various cardiomyopathies, Am J Cardiol, 2005;95:809–13.
- Caiani EG, Corsi C, Sugeng L, et al., Improved quantification of left ventricular mass based on endocardial and epicardial surface detection with real time three dimensional echocardiography, Heart, 2006;92:213–19.
- Hare JL, Jenkins C, Nakatani S, et al., Feasibility and clinical decision-making with 3D echocardiography in routine practice, Heart, 2008;94:440–45.
- Mannaerts HF, van der Heide JA, Kamp O, et al., Early identification of left ventricular remodelling after myocardial infarction, assessed by transthoracic 3D echocardiography, Eur Heart J, 2004;25:680–87.
- Matsumura Y, Hozumi T, Arai K, et al., Non-invasive assessment of myocardial ischaemia using new real-time three-dimensional dobutamine stress echocardiography: comparison with conventional two-dimensional methods, Eur Heart J, 2005;26:1625–32.
- Franke A, Real-time three-dimensional echocardiography in stress testing: bi- and triplane imaging for enhanced image acquisition, Cardiol Clin, 2007;25:261–5.
- Takeuchi M, Otani S, Weinert L, et al., Comparison of contrast-enhanced real-time live 3-dimensional dobutamine stress echocardiography with contrast 2-dimensional echocardiography for detecting stressinduced wall-motion abnormalities, J Am Soc Echocardiogr, 2006;19:294–9.
- Bax JJ, Abraham T, Barold SS, et al., Cardiac resynchronization therapy: Part 1—issues before device implantation, J Am Coll Cardiol, 2005;46:2153–67.
- Kapetanakis S, Kearney MT, Siva A, et al., Real-time threedimensional echocardiography: a novel technique to quantify global left ventricular mechanical dyssynchrony, Circulation, 2005;112:992–1000.
- Marsan NA, Bleeker GB, Ypenburg C, et al., Real-time three-dimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy, J Cardiovasc Electrophysiol, 2008;19:392–9.
- Marsan NA, Henneman MM, Chen J, et al., Real-time three-dimensional echocardiography as a novel approach to quantify left ventricular dyssynchrony: a comparison study with phase analysis of gated myocardial perfusion single photon emission computed tomography, J Am Soc Echocardiogr, 2008;21:801–7.
- Kjaergaard J, Petersen CL, Kjaer A, et al., Evaluation of right ventricular volume and function by 2D and 3D echocardiography compared to MRI, Eur J Echocardiogr, 2006;7:430–38.
- Sugeng L, Coon P, Weinert L, et al., Use of real-time 3- dimensional transthoracic echocardiography in the evaluation of mitral valve disease, J Am Soc Echocardiogr, 2006;19:413–21.
- Jenkins C, Chan J, Bricknell K, et al., Reproducibility of right ventricular volumes and ejection fraction using realtime three-dimensional echocardiography: comparison with cardiac MRI, Chest, 2007;131:1844–51.
- Prakasa KR, Dalal D, Wang J, et al., Feasibility and variability of three dimensional echocardiography in arrhythmogenic right ventricular dysplasia/ cardiomyopathy, Am J Cardiol, 2006;97:703–9.
- Levine RA, Handschumacher MD, Sanfilippo AJ, et al., Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse, Circulation, 1989;80:589–98.
- Otsuji Y, Handschumacher MD, Schwammenthal E, et al., Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry, Circulation, 1997;96:1999–2008.
- Watanabe N, Ogasawara Y, Yamaura Y, et al., Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography, J Am Coll Cardiol, 2005;45:763–9.
- Liel-Cohen N, Guerrero JL, Otsuji Y, et al., Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography, Circulation, 2000;101: 2756–63.
- Zamorano J, Cordeiro P, Sugeng L, et al., Real-time threedimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach, J Am Coll Cardiol, 2004;43:2091–6.
- Gutierrez-Chico JL, Zamorano Gomez JL, Rodrigo-Lopez JL, et al., Accuracy of real-time 3-dimensional echocardiography in the assessment of mitral prolapse. Is transesophageal echocardiography still mandatory?, Am Heart J, 2008;155:694–8.
- Agricola E, Oppizzi M, Pisani M, et al., Accuracy of realtime 3D echocardiography in the evaluation of functional anatomy of mitral regurgitation, Int J Cardiol, 2008;127: 342–9.
- De Simone R, Glombitza G, Vahl CF, et al., Threedimensional color Doppler: a new approach for quantitative assessment of mitral regurgitant jets, J Am Soc Echocardiogr, 1999;12:173–85.
- Breburda CS, Griffin BP, Pu M, et al., Three-dimensional echocardiographic planimetry of maximal regurgitant orifice area in myxomatous mitral regurgitation: intraoperative comparison with proximal flow convergence, J Am Coll Cardiol, 1998;32:432–7.
- Chan KL, Liu X, Ascah KJ, et al., Comparison of real-time 3-dimensional echocardiography with conventional 2-dimensional echocardiography in the assessment of structural heart disease, J Am Soc Echocardiogr, 2004;17: 976–80.
- Salustri A, Spitaels S, McGhie J, et al., Transthoracic threedimensional echocardiography in adult patients with congenital heart disease, J Am Coll Cardiol, 1995;26:759–67.
- Niemann PS, Pinho L, Balbach T, et al., Anatomically oriented right ventricular volume measurements with dynamic three-dimensional echocardiography validated by 3-Tesla magnetic resonance imaging, J Am Coll Cardiol, 2007;50:1668–76.
- Papavassiliou DP, Parks WJ, Hopkins KL, et al., Threedimensional echocardiographic measurement of right ventricular volume in children with congenital heart disease validated by magnetic resonance imaging, J Am Soc Echocardiogr, 1998;11:770–77.
- van den Bosch AE, Robbers-Visser D, Krenning BJ, 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.
- Del Pasqua A, Sanders SP, de Zorzi A, et al., Impact of three-dimensional echocardiography in complex congenital heart defect cases: the surgical view, Pediatr Cardiol, 2009;30:293–300.
- Marsan NA, Tops LF, Nihoyannopoulos P, et al., Real-time three dimensional echocardiography: current and future clinical applications, Heart, 2009;95:1881–90.
- Mor-Avi V, Jenkins C, Kuhl HP, et al., Real-time 3-dimensional echocardiographic quantification of left ventricular volumes: multicenter study for validation with magnetic resonance imaging and investigation of sources of error, JACC Cardiovasc Imaging, 2008;1:413–23.