Live Real Time 3D Echocardiography

310 Pages·2010·38.04 MB·English

by  Navin Nanda, Ming Chon Hsiung, Andrew P. Miller, Fadi G. Hage

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Live/Real Time 3D
Echocardiography
Live/ Real Time 3D Echocardiography N avin C. Nanda,
Ming Chon Hsiung, Andrew P. Miller and Fadi G. Hage
Published by 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-16141-1
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This book is dedicated to my late parents, Balwant Rai Nanda, MD, and Mrs. Maya Vati
Nanda; my wife, Kanta Nanda, MD; our children, Nitin Nanda, Anita Nanda Wasan, MD,
and Anil Nanda, MD; their spouses Sanjeev Wasan, MD, and Seema Tailor Nanda; and our
very cute grandchildren Vinay and Rajesh Wasan and Nayna Nanda.
Navin C. Nanda, MD
I dedicate this book to my parents, the late Yuan Hsiung, MD, and Wei Lee; and to my
wife, Wen Hsiung; and sons, Teddy, Richard, and Jerry.
Ming C. Hsiung, MD
I dedicate this book to my mother and father, Linda and Gordon Miller, who made all
things possible.
Andrew P. Miller, MD
This book is dedicated to my parents, Gabriel and Aida Hage, who have made me who I
am; my wife, Sulaf Mansur Hage, MD, for her never-ending support, encouragement, and
inspiration over the years; my son, Alexander F. Hage, for making it all worthwhile; and to
my colleagues and patients who I hope will benefit from this book.
Fadi G. Hage, MD
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Live/Real Time 3D
Echocardiography
Navin C. Nanda, MD, FACC, FAHA
Professor of Medicine, Division of Cardiovascular Diseases
Director, Heart Station/Echocardiography Laboratories
University of Alabama at Birmingham and
Director, Echocardiography Laboratory, The Kirklin Clinic
University of Alabama Health Services Foundation
Birmingham, AL, USA
Ming Chon Hsiung, MD
Physician, Division of Cardiology
Associate Researcher, Department of Medical Research and Education
Cheng Hsin General Hospital
Taipei, Taiwan, Republic of China
Andrew P. Miller, MD, FACC, FAHA
CardioVascular Associates, PC, Birmingham, AL, USA
and
formerly, Assistant Professor of Medicine
Division of Cardiovascular Diseases
University of Alabama at Birmingham
Birmingham, AL, USA
Fadi G. Hage, MD
Assistant Professor of Medicine
Division of Cardiovascular Disease
University of Alabama at Birmingham
Birmingham, AL, USA
and
Section of Cardiology
Birmingham Veteran’s Administration Medical Center
Birmingham, AL, USA
A John Wiley & Sons, Ltd., Publication
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Contents
Preface, vi 9 Ischemic Heart Disease, 128
1 Historical Perspective, 1 10 Cardiomyopathies, 137
2 3D Echocardiographic Technology, 13 11 Congenital Heart Disease, 155
3 How to do a 3D Echocardiogram: 12 Tumors and Other Mass Lesions, 218
Examination Protocol and Normal
13 Pericardial Disorders, 255
Anatomy, 23
14 Live/Real Time 3D Transesophageal
4 Mitral Valve, 55
Echocardiography, 263
5 Aortic Valve and Aorta, 72
15 The Challenges of Volume Ultrasound: Real
6 Tricuspid and Pulmonary Valves, 99 Time Full Volume Imaging, 283
7 Prosthetic Valves, 114 16 3D Wall Motion Tracking as the Ultimate
Technology for Wall Motion Analysis, 287
8 Left Ventricular and Right Ventricular
Function Assessment, 122 Index, 295
Companion DVD
This book is accompanied by a DVD with:
r A database of 384 movie clips
r Movie clips are all referenced in the text where
you see this symbol:
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Preface
Echocardiography has progressed to become the cardiac structures and chambers in three dimen-
most cost-effective noninvasive modality in the sions. A major advancement in 3D technology
assessment of cardiovascular disease entities. It occurred a few years ago with the introduction of
began in the 1950s and 60s as 1D A-mode and live/real time 3D transthoracic echocardiography.
M-mode techniques, wherein a single pencil thin This innovative technique utilizes a transducer
ultrasonic beam was used to image the heart. which broadcasts hundreds of ultrasound beams
This limited modality was replaced in the early through the heart simultaneously resulting in
seventies by real time 2D echocardiography which a large 3D dataset that can then be cropped to
revolutionized the field of noninvasive cardiac provide a comprehensive view of different cardiac
diagnosis. It did not take long before practically structures from any desired angle. The transducer
every large hospital in the United States, and soon was subsequently miniaturized leading to the
after elsewhere in the world, offered this modality. development of live/real time transesophageal
The 2D technique essentially consisted of rapidly echocardiography in 2007. Both of these modalities
moving the single ultrasonic beam (mechanically supplement conventional 2D imaging by providing
in the beginning and later on electronically) so that additional information in a variety of clinical
larger segments of various cardiac structures could scenarios.
be visualized simultaneously. However, it provided The aim of this book is to provide a comprehen-
visualization of only thin slices through the heart sive, state-of-the-art review of both live/real time
and it became apparent to many of us as soon as 3D transthoracic and transesophageal echocardio-
it was developed that even though it was a huge graphy illustrating both normal and pathologic car-
improvement over M-mode, it still did not give us diovascular findings. This book predominantly de-
full structural information. For example, the mitral scribes our experience with these two new modal-
leaflets appeared only as two thin “lines” moving ities in the clinical setting in our Echocardiogra-
in the cardiac cycle and the entire extent of leaflet phy Laboratories at the University of Alabama at
surfaces could not be viewed. In essence, the images Birmingham and the Kirklin Clinic and Cheng-
still bore no similarity whatsoever to the mitral Hsin Medical Center, Taipei, Taiwan, Republic of
valve visualized at surgery or anatomically, which China. It also covers the contributions of other in-
was our pursuit. In developing 3D technology, early vestigators in the field. A major highlight of the
attempts were made to stitch the thin 2D planes book is the large number of illustrations, over 800,
together to reconstruct full-volume 3D images, which detail the technique of performing live/real
but the enormous computer time taken to do this time 3D echocardiograms and demonstrate the var-
precluded its widespread clinical use. The advent of ious cardiovascular pathologies encountered by us.
transesophageal echocardiography in the late 1980s These also serve to emphasize the superiority of 3D
provided further impetus to the development of echocardiography over conventional 2D imaging in
3D echocardiography because of superior quality several clinical situations. Since the echo images we
images obtained by this technique and advances obtain and interpret in our day-to-day clinical prac-
in computer technology. This resulted in several tice are moving images and not static ones, we have
publications from investigators in many countries also prepared a DVD to accompany this book. The
demonstrating the advantages of viewing various DVD contains a large number of movie clips, over
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Preface vii
350, which serve to supplement the static illustra- (Dr. Wei-Hsian Yin, head, Dr. Mason S. Young, and
tions in the book. Dr. Shen Kou Tsai) for providing us full clinical
The book is organized into 16 chapters. The support. Most of all, we are grateful to the Division
first chapter provides a brief glimpse of the his- of Cardiovascular Surgery, especially Dr. James K.
torical aspects of 3D echocardiography. The second Kirklin, Dr. Albert D. Pacifico, Dr. David McGiffin,
chapter written by Dr. Ivan Salgo of Philips Med- Dr. James Holman, and Dr. Octavio E. Pajaro from
ical Systems describes the basics and technical as- the University of Alabama at Birmingham as well as
pects of live/real time 3D transthoracic and trans- Dr. Jeng Wei, Dr. Yi-Cheng Chuang, Dr. Chung-Yi
esophageal echocardiography. We are grateful to Chang, and Dr. Sung-How Sue from the Division
him for preparing this chapter for the book. Chapter of Cardiovascular Surgery of Cheng Hsin General
3 details normal anatomy, examination protocols, Hospital, Taipei, Taiwan, not only for facilitating the
and the technique for performing live/real time 3D performance of 3D intraoperative transesophageal
transthoracic echocardiography. This should prove echocardiography but also for providing us surgical
especially useful to the beginners. Abnormalities af- correlation in the patients operated upon by them.
fecting the mitral, aortic, tricuspid, and pulmonary We also thank Dr. Pohoey Fan, Associate Professor
valves and the aorta are described in Chapters 4 of Medicine in the Division of Cardiovascular Dis-
through 6. Prosthetic heart valves are discussed in ease at the University of Alabama at Birmingham,
Chapter 7. This is followed by Chapters 8–10, which for his help and support.
cover 3D echocardiographic assessment of left and We are most grateful to the Clinical and Research
right ventricular function, ischemic heart disease, Fellows, Medical Residents, and Observers, both
and cardiomyopathies. The largest chapter, Chap- past and present, from the Echocardiography Lab-
ter 11, deals with congenital cardiac lesions. An- oratories at the University of Alabama at Birming-
other large chapter, Chapter 12, deals with tumors ham who directly or indirectly helped in the perfor-
and other mass lesions. We are most grateful to mance of 3D echocardiography and in preparation
Dr. Michael Faulkner, Internal Medicine Resident, of this book. They are: Elsayed Abo-Salem, Gopal
for his help in writing the text portion of Chapter Agrawal, Sujood Ahmed, Raed A. Aqel, Naveen
12. Pericardial disorders are described in Chapter Bandarupalli, Oben Baysan, Ravindra Bhard-
13. One of the newest innovations, live/real time waj, Monodeep Biswas, Kunal N. Bodiwala, Hari
3D transesophageal echocardiography is covered Bogabathina, Marcus L. Brown, Todd M. Brown,
in detail in Chapter 14. Some of the most recent Manjula V. Burri, Preeti Chaurasia, Anand Chock-
advances in 3D technology, real time full-volume alingam, Bryan Cogar, Onkar Deshumkh, Harvin-
imaging, and 3D wall tracking, including 3D assess- der S. Dod, Christopher Douglas, Kurt Duncan,
ment of strain, strain rate, twist, and torsion, are dis- Rajarshi Dutta, Sibel Enar, Ligang Fang, William
cussed in Chapters 15 and 16. These were written by S. Fonbah, William A. A. Foster, Ebenezer Frans,
Kutay Ustuner and Matthew Paul Esham of Siemens Sujit R. Gandhari, Isha Gupta, Mohit Gupta, Sachin
Healthcare and Tetsuya Kawagishi, William Kenny, Hansalia, Thein Htay, T. Fikret Ilgenli, Vatsal Inam-
Berkley Carpenter, and Willem Gorissen of Toshiba dar, Gultekin Karakus, Saritha K. Kesanolla, Deepak
Medical Systems Corporation. We would like to ex- Khanna, Visali Kodali, William D. Luke, Jr, Pavan
press our heartfelt gratitude to all of them for doing Madadi, Edward F. Mahan III, Ravi K. Mallavarapu,
this. Jayaprakash Manda, Carlos Martinez-Hernandez,
We must also thank several individuals in our Farhat Mehmood, Anjlee Mehta, Deval Mehta,
universities who have contributed directly or in- Vijay K. Misra, Virenjan Narayan, Sadik Raja Pan-
directly to the growth and development of 3D war, Vinod Patel, Koteswara R. Pothineni, Ganga
echocardiography in our Echocardiography Lab- Prabhakar, A. N. Ravi Prasad, Xin Qi, Sanjay Rajdev,
oratories. First and foremost, we are grateful to all Barugur S. Ravi, Venkataramana K. Reddy, Venu
present and past members of the Division of Car- Sajja, Kumar Sanam, Upasana Sen, Maninder S.
diovascular Disease at the University of Alabama at Sidhu, Anurag Singh, Harpreet Singh, Preeti Singh,
Birmingham headed by Dr. Robert Bourge and at Vikramjit Singh, Ashish Sinha, Thouantosaporn
the Cheng Hsin General Hospital, Taipei, Taiwan Suwanjutah, Sailendra K. Upendram, Dasan
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viii Preface
E. Velayudhan, Srinivas Vengala, Bryan J. Wells, and and Denise Usrey all from the University of Alabama
Pridhvi Yelamanchili. Hospital and The Kirklin Clinic as well as Hsin-
We deeply appreciate the help of Lindy Chap- Hsien Tseng, Chi-Yeh Teng, and Li-Na Lee from
man, Administrative Associate at the University of Cheng Hsin General Hospital, Taiwan, Taipei.
Alabama at Birmingham, who provided excellent Finally, we are grateful to our families for their
editorial and secretarial assistance, and Diane Bliz- support during the innumerable hours we spent
zard, Office Associate, for her help. We would also on this project: Dr. Nanda’s wife, Kanta K. Nanda,
like to thank our clinical sonographers for their MD, sons, Nitin Nanda and Anil Nanda, MD, and
help. These are: Beverly Black, Latonya Bledsoe, daughter Anita Nanda Wasan, MD; Dr. Hsiung’s
Rosalyn Boatwright, Audrey Brown, Lynn Devor, wife Wen Hsiung and sons Teddy, Richard, and
Cynthia Dudley, RN, Crystal Green, May Hullett, Jerry; Dr. Miller’s wife, Jane Emmerth, and children
Emily Milhouse, Peggy Perry, Lucia Sanderson, Aaron and Sarah Miller; and Dr. Hage’s wife, Sulaf
Sharon Shirley, RN, Octavia Story, Gayle Williams, Mansur Hage, MD, and son Alexander F. Hage.
Navin C. Nanda, MD
Ming C. Hsiung, MD
Andrew P. Miller, MD
Fadi G. Hage, MD
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CHAPTER 1
1
Historical Perspective
The history of echocardiography is a series of but this method could not record or view 3D
successful advancements in the technology to images. This method was further developed by
image the heart. This started with A-mode images other investigators to allow for the ability to model
derived by a thin ultrasound beam and advanced organs and calculate volumes [12]. Ghosh et al. [9]
to M-mode displays and then to 2D examination developed a simple approach that was able to image
of the heart in motion. This was followed by the the left ventricle (LV) in 3D. This approach used a
addition of Doppler and color Doppler, the recent 2D transducer that was mounted on a mechanical
introduction of tissue Doppler, speckle imaging, arm that allowed it to rotate around its axis and
contrast echocardiography, and 3D reconstruction, measured the degrees of rotation. Placement of
and ultimately the development of real time 3D the transducer in this way ensured that any other
transthoracic echocardiography (3DTTE) [1–3]. form of motion or tilting was not allowed. This
It is, therefore, not surprising that on top of its transducer could then be placed on the patient’s
predecessors, this new technique has proven useful, chest wall at the cardiac apex and rotated every few
versatile, and revolutionary in the assessment of degrees in a sequential manner to obtain multiple
cardiovascular diseases. In this book, we will discuss slices of the heart, at end systole and end diastole,
in detail the benefits of this developing technology which were then computer-reconstructed to obtain
and its incremental value on top of 2DTTE and/or 3D images of the LV (Figure 1.1). The volumes
2D transesophageal echocardiography (2DTEE). obtained using this method were validated by
Although 2DTTE revolutionized noninvasive angiography [9]. This work was further extended
imaging, its limitations in clinical practice soon be- by Raqueno et al. [13] and Schott et al. [14]
came clear. 2DTTE provides real time tomographic to successfully incorporate velocity information
images resembling thin slices of cardiac structures and color-coded reconstruction. This allowed 3D
that require mental reconstruction of 3D cardiac imaging of the magnitude of flow disturbance
structures. This has shown clinical value but has that accompanies valvular regurgitation. Similarly,
been imperfect due to the complex geometrical data on flow patterns obtained by color Doppler
anatomy of most cardiac structures. Since this could be easily merged with the 3D-reconstructed
imaging modality is noninvasive, does not utilize images of the LV since both datasets were ob-
harmful radiation, and is portable unlike many of tained in the same coordinate system (Figure 1.2)
its competitors, there has been a great interest in [13].
further development of this technology. This led to The field of 3D echocardiography was further
several attempts to develop 3D echocardiography strengthened by the introduction of TEE with its
[4–10]. Morris and Shreve [11] introduced the superior 2D image quality (compared to 2DTTE)
spark gap position-locating approach (an acoustic due to the close proximity of the probe in the esoph-
spatial locating system) to provide 3D coordinates, agus to the heart, allowing the use of higher fre-
quency and higher resolution transducers, which
led to the development of 3DTEE. Investigators
Live/ Real Time 3D Echocardiography N avin C. Nanda, used a monoplane TEE probe mounted on a slid-
PMuibnlgis hCehdo bny H 2s0i1u0n gB,l aAcnkwdreelwl P Pu.b lMishililnegr aLntd. F IaSdBi NG:. 9 H78a-g1e-405-16141-1 ing carriage within a casing. Transverse sections
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2 Live/Real Time 3D Echocardiography
Apical
axis
90°
60°
30°
0°
Rotation
Transducer Diastole Systole
(a) (b)
Figure 1.1 3D reconstruction of the left ventricle. (a) The then reconstructed by the computer to form 3D
apical axis rotation method is shown in which the end-diastolic (left) and end-systolic (right) views of the left
transducer is rotated in few degree increments to obtain ventricle. (Reproduced from Ghosh et al. [9], with
multiple 2D images of the heart. (b) These images were permission.)
◦
at various parallel cardiac levels were obtained by The probe was angulated at 90 and manually ro-
moving the probe up and down the esophagus in tated in a clockwise direction in small increments to
small increments by a computerized system, and provide sequential longitudinal images, which were
the images were then reconstructed to provide 3D then reconstructed in 3D since their spatial orien-
images (Figure 1.3) [15,16]. Electrocardiographic tation and relationship to each other was known.
and respiratory gating was performed to allow for Offline, the endocardial surface and the intima of
the spatial and temporal registration of images [15]. the great vessels were manually traced to allow the
The large size of the probe, however, precluded rou- conversion of the images to a digital format which
tine clinical use. Attempts were then made to use was reconstructed in 3D (Figure 1.4) [17]. Nanda
a regular biplane TEE probe for 3D imaging [17]. et al. [18] then used a multiplane TEE transducer to
A protractor mounted on the bite guard was used reconstruct 3D images by ensuring that the probe
to accurately determine the probe rotation angle. remains stationary at a given level and rotating it
◦
at 18 intervals at a time (Figure 1.5). Offline, the
images were digitized by using a frame grabber and
the digitized frames were imported into a 3D mod-
eling program which provided a 3D-reconstructed
image of the LV (Figure 1.6) [18]. The superior
image quality of TEE images allowed for a much
better quality of reconstructed 3D images, and this
reignited the interest in 3D echocardiography (Fig-
ure 1.7) [19]. Furthermore, the ability to slice the
3D dataset using dissecting planes in any direction
allowed for the accurate measurement and the visu-
alization of defects and masses from any direction
(Figures 1.8 and 1.9) [20]. The 3D reconstruction
Figure 1.2 Overlay of the high- and the low-velocity of images from multiplane TEE was widely utilized
isopleths obtained by color Doppler with the reconstructed
by multiple investigators to provide clinically use-
image of the left ventricular endocardium is shown. Blue,
ful incremental information over 2D imaging and
low-velocity isopleth; Red, high-velocity isopleth.
even resulted in the publication of a book with
(Reproduced from Raqueno et al. [13], with permission.)