Realtime Three-dimensional Echocardiography - A Perspective

Realtime Three-dimensional Echocardiography - A Perspective

Roelandt Jos RTC, Krenning Boudewijn J, Van Den Bosch Annemien E
European Cardiology 2005
Published: May 2005
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Introduction
The heart is a dynamic organ and places special demands on three-dimensional (3-D) techniques. To understand its physiology and pathophysiology, not only the spatial distribution of its structures is important but also their movement during the cardiac cycles. Previous approaches to 3-D echocardiography (3-DE) were offline and based on sequential rotational scanning and acquisition of multiple cross-sectional images together with their spatial position using internal co-ordinate reference systems. These methods were hampered by long acquisition and analysis times in combination with limited image quality. Realtime 3-D echocardiography (RT 3-DE) now allows visualisation of the heart and its structure dynamics in a realistic fashion with instantaneous online volumerendered reconstruction.1-5

The availability of volumetric data sets allows retrieval of an infinite number of cardiac cross-sections. This capability provides an improved understanding of unpredictable morphology and decreases the variability in interpretation of complex pathology among investigators.5-7 In particular, typical 3-DE parameters, such as ejection fraction, segmental wall function, left ventricle (LV) shape and flow jets, become important diagnostic parameters based on 3- DE.

RT 3-DE
RT 3-DE allows online acquisition of a 3-D data set without the need for echocardiogram (ECG) and respiratory gating, avoiding spatial motion artefacts. RT 3-DE is first based on novel matrix phased-array transducer technology in which the elements are arranged in a two-dimensional (2-D) grid.8 The first system consisted of a sparse matrix phased array transducer of 512 elements to scan a 60º x 60º pyramidal volume using parallel processing technology. More recently, Philips Medical Systems introduced the live 3-D system using a matrix phasedarray transducer with 3,000 transmit–receive elements. In this transducer, multiple recordings are automatically performed, based on ECG gating, to cover the LV in a full volume data set. This is particularly useful in dilated ventricles because of the limited sector angle. The multidirectional beam steering capability enables visualisation of two views of the heart simultaneously. Although experience remains limited, promising results have been reported.

Image Rendering and Analysis
To display the heart in three dimensions, reconstruction and display of 3-D images from the processed 3-D data sets is essential. The term rendering indicates the procedure whereby structures are reconstructed in the computed memory.7 The volume-rendered 3-D data set can be electronically segmented and sectioned. To display intracardiac structures, the heart can be opened by choosing a cutting plane and the image can be reconstructed beyond this plane as if the heart is cut open in surgery.9 The display and analysis of size, shape and motion of cardiac structures from any desired perspective becomes possible and allows one to address any clinical question offline without reexamination of the patient. By manipulation of the cutting planes and rotation of the 3-D image the ideal projection can be obtained.10 The mitral and tricuspid valves can be viewed from above (electronically simulating atriotomy) or from below (as with ventriculotomy). Likewise, the aortic valve can be visualised from above with electronic aortotomy and from below looking through the left ventricular outflow tract. In the dynamic mode display, the opening and closing of the cardiac valves can be observed. Interatrial and -ventricular septa can be examined en face with more accurate perception of their spatial relationship with adjacent structures. Most notably in patients with congenital heart disease, special structures can be identified by various display projections including unconventional views.

Wire-frame or surface-rendered reconstructions of selected structures are obtained from manually or electronically derived contours in cross-sectional images generated from the data set. This approach allows for the assessment of characteristics such as structure and shape and for improved quantification of left ventricular volume and function.11

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