HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wolfgang Konertz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Borges, A. C. Articles by Baumann, G. Search for Related Content PubMed PubMed Citation Articles by Borges, A. C. Articles by Baumann, G.

Ann Thorac Surg 1996;61:1163-1167
© 1996 The Society of Thoracic Surgeons

---

Original Article: Cardiovascular

Preoperative Two- and Three-Dimensional Transesophageal Echocardiographic Assessment of Heart Tumors

Medical Department I and Department of Heart Surgery, Charité, Humboldt-University Berlin, Berlin, Germany

Accepted for publication December 5, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Two-dimensional transesophageal echocardiography is the most widely used diagnostic approach in the rare entity of heart tumors. The aim of this study was to assess the diagnostic usefulness of three-dimensional echocardiography in comparison with the two-dimensional technique in a rare clinical setting.

Methods. Twenty-seven patients (18 women; mean age, 49.7 ± 14 years) with a histologically proven diagnosis of a cardiac tumor were studied. The primary diagnosis was done by two-dimensional transthoracic echocardiography (n = 9) and transesophageal echocardiography (n = 18). In addition, we performed three-dimensional transesophageal assessment in 5 patients with left atrial myxomas. The echocardiographic findings were compared with the intraoperative appearance and pathologic diagnosis.

Results. The echocardiographically suspected diagnosis of a heart tumor in 29 cases was histologically correct in 27 patients (myxomas, 20; epicardial lipoma, 1; malignant epicardial mesothelioma, 1; metastatic processes of hypernephromas, 2; and undifferentiated tumors of the pericardium, 3). Only the combination of multiplane transesophageal and three-dimensional echocardiography was able to demonstrate the shape, dimensions, location, origin, surface, three-dimensional movement, and involvement of valves and was most useful in the preoperative diagnosis and planning.

Conclusions. Three-dimensional transesophageal echocardiography yields important additional clinical information and improves the operative planning. Three-dimensional echocardiography may become the best approach to study the anatomy and pathology of the heart as it provides an objective display of cardiac size and shape in heart tumors.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Primary cardiac tumors are extremely rare with a reported incidence ranging from 0.0017% to 0.28% in most autopsy studies [1–3], in other studies ranging from 0.2% to 2% [4]. Atrial myxomas compose 30% to 50% of most pathologic series with right atrial myxomas accounting for less than one quarter of these. Approximately 10% of all myxomas have multiple locations and some involve the valvular and subvalvular apparatus [3, 5]. Surgical removal is routinely recommended because of potential embolic phenomena.

The widespread use of echocardiography, as well as some of the newer noninvasive methods (for example, magnetic resonance imaging), has resulted in a substantial increase in the detection of patients with primary cardiac tumors, many of whom are asymptomatic. Recently, transesophageal echocardiography has been used in the interrogation of left atrial myxomas and has provided superior visualization of the tumor attachment sites because of better resolution of the posterior cardiac structures [5–11]. Mental reconstruction, which is performed generally by the observer, might be insufficient in cases of rare and complicated entities. Recently, a dynamic three-dimensional (3D) transesophageal echocardiographic imaging system has been introduced as a new diagnostic approach [12, 13]. To take full advantage of the ability to visualize the beating heart in three dimensions, it would be useful to display the anatomy as a surgeon would view it intraoperatively. The results of 3D echocardiography will be demonstrated.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Subjects
Out of 17,140 echocardiographic examinations performed in our echocardiography laboratory between 1985 and 1994, in 29 patients (0.15%) there was a suspicion of a heart tumor. All patients underwent surgical treatment and subsequent histological examination. In 27 patients (mean age, 49.7 ± 14 years; 18 women) a histologically proven heart tumor was found. Many patients were without symptoms or signs, the remainder of the patients demonstrated dyspnea (n = 3), atrial fibrillation (n = 2), cerebral embolism (n = 2), transient ischemic attack (n = 3), new appearance of a systolic cardiac murmur (n = 3), mild anemia (n = 2), and elevated erythrocyte sedimentation (n = 3), which occurred before echocardiographic examination.

Two-Dimensional Echocardiography
Echocardiographic examinations were performed using a Toshiba ultrasound system SSH 160 with a 3.75-MHZ transthoracic and a 5.0-MHZ transesophageal single plane transducer and a Toshiba ultrasound system SSH 270 with a 5.0-MHZ transesophageal multiplane transducer.

Three-Dimensional Echocardiography
Temporal and spatial registration of cardiac cross-sections were controlled by a computer-based steering logic considering both heart cycle and respiratory cycle variation. The video output of the echocardiographic system (Toshiba SSH 270, n = 3Au: explain; Apogee CX 200, ATL Corp, n = 2) was interfaced with the TomTec Echo-scan system (TomTec Imaging System, Northbrook) that contains both steering logic for image acquisition and the software for 3D reconstruction yielding a dynamic volume-rendered display [5]. In addition, any desired cross-section of the heart or selected structure that cannot be visualized in planes obtainable from standard precordial or transesophageal transducer positions can be computed and displayed in cine loop format at 25 frames per second (anyplane echocardiogram using the 5-MHZ multiplane transesophageal transducer, nterspec-ATL; n = 2). The multiplane probe allowed 3D data acquisition during 6 seconds at constant 180-degree rotation of the transducer array introduced into the midesophagus. Electronic parallel slicing allowed the generations of equidistant cross-sections (paraplane echocardiogram using the lobster tail, TomTec Imaging System).

The acquisition of parallel slices (slice distance, 0.65 to 1.00 mm) was performed using the TomTec Echo-scan in 5 patients with heart tumors. The transesophageal probe with a distal transducer tip thickness of 17 mm was modified in its distal portion such that the distal part of the probe was composed of a fully flexible assembly of multiple semicircular plastic segments (``lobster tail''). This distal section could be straightened mechanically by means of Bowden cables to serve as a rigid tube housing the 5-MHZ and 64-channel phased array transesophageal echocardiogram transducer with a tip width of 12 mm. A small water-filled offset balloon (inner cover sheath) surrounding the distal part of the probe provides a permanent contact with the outer cover sheath, which was water filled as well. The outer offset balloon provides contact to the esophageal wall. The water filling of both balloons could be modified during the examination to optimize imaging. The transducer position in the probe could be advanced automatically by a computer-controlled step-motor. Electrocardiogram gated images were stored digitally at constant phases of respiration and at constant positions of the esophageal probe.

Data Analysis
The data analysis of the data set was performed off-line using the analysis program of the imaging system. Therefore, an appropriate plane was defined by two-dimensional (2D) image reconstruction starting from one selected native 2D image. To define the appropriate plane the paraplane, anyplane, short axis, or long axis mode could be used alternatively. By means of this appropriate plane representing the cut plane of the 3D image the 3D surface reconstruction was performed using gradient shading, distance shading, or a combination of both. After these processes static or dynamic 3D views were produced.

All pathologic findings noted on the reconstructions were compared with the native, horizontal plane 2D images as well as standard transthoracic echocardiographic data.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
All benign intracardial tumors were myxomas (20 patients) and accounted for 73% of all tumors and were mainly located in the left atrium (Table 1). Echocardiographic transesophageal assessment was performed without any complications in all patients. Of 22 intracardiac tumors (20 myxomas and 2 hypernephromas) the transthoracic echocardiography could suspect a tumor in only 9 patients. In the other 13 patients the transesophageal assessment visualized the intracardiac tumor. There were no complications during and after insertion of the imaging probes into the esophagus.

View larger version (73K): [in this window] [in a new window]   Fig 1. . Three-dimensional echocardiography. From the three-dimensional data stored in the computer, any desired two-dimensional plane can be generated in real-time after data acquisition. (M = left atrial myxoma; 1 = right ventricle; 2 = left ventricle.)

View larger version (59K): [in this window] [in a new window]   Fig 2. . Comparison between reconstructed two-dimensional image (B) and three-dimensional image (A) of a large atrial myxoma (M). (LV = left ventricle; RV = right ventricle.)

View larger version (151K): [in this window] [in a new window]   Fig 3. . Simulation of the surgical view. Three-dimensional image of the left atrial myxoma (1) attached to the interatrial septum, viewed from the top of the left atrium. The mitral valve is open (2).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The diagnosis of cardiac tumors may by suggested by clinical and physical findings, in some cases systolic murmur is the only suggestion of a heart tumor [7, 8]. Complications include embolization, cyst and microabscess formation, syncope, and sudden death. Cardiac tumors, particularly cardiac myxomas, can produce a broad array of systemic findings including fever, cachexia, malaise, rash, clubbing, arthralgias, Raynaud's phenomenon, and episodic bizarre behavior, as well as systemic and pulmonary emboli. Different laboratory findings have been reported, including hypergammaglobulinemia, an elevated erythrocyte sedimentation rate, thrombocytosis, thrombocytopenia, polycythemia, leukocytosis, and anemia. More than 50% show symptoms, which are not specific.

Although 2D transthoracic echocardiography has become the diagnostic technique of choice in the evaluation of cardiac tumors, it may be difficult to make a definitive diagnosis in some patients, especially those with a small acoustic window. The developed technique of 2D transesophageal echocardiography allows visualization of the atria, atrial septum, and portions of the left and right ventricles and thus demonstrated to be superior to transthoracic 2D echocardiography in obtaining useful preoperative information. Transesophageal echocardiography could provide useful information about the origin and extension through the fossa ovalis and the severity of transvalvular regurgitation.

Two-dimensional transesophageal echocardiography is the most widely used noninvasive method for the diagnosis of cardiac tumors. Three-dimensional transesophageal echocardiography allowed superior visualization of the size and attachment of left atrial myxomas, and involvement of the mitral valve, and it is a helpful approach in planning of the surgical treatment (ie, surgical access and the necessity of an interatrial patch in all cases). Dynamic 3D echocardiography could give exact spatial information about the shape and surface of the intracardiac masses, about the movement of the satellites, about the involvement of the mitral valve, the obstruction of mitral valve annulus, or laceration of the mitral valve leaflets. The advantage of 3D echocardiography to perform anyplane cardiac imaging allows the surgeon to derive a 2D view of the heart in any desired plane, which are most informative for operative planning. It was possible to simulate intraoperative visualization of cardiac structures and study dynamic surgical anatomy in a real-time manner, provide a better understanding of the topographic aspects, and define the spatial relations of structures more reliably. There are more indications for 3D echocardiography to demonstrate the advantages such as in volumetric measurements of the aneurysmatic left ventricle, in congenital heart diseases, and in mitral valve disease as previously described [13–15].

The acquisition of parallel equidistant imaging planes does not eliminate the differential resolution of structures regarding the position in the plane, but the distribution of different spatial resolutions is constant within the cubic 3D data set [5]. Although the probe for parallel slicing is slightly larger than the conventional probes, there were no problems for the patients during insertion of the probe into the esophagus. In some cases the assessment of the whole heart within one scanning might be problematic; if strict parallel slicing is used, the left ventricular apex may not be well seen. Rotational scanning is one of the methods proposed for image acquisition and offers some advantages over other scanning techniques. Images can be acquired during a routine transesophageal study using a multiplane (rotable) transducer. With further development of the imaging and digitizing systems the problem for rotational sampling of oversampling in the near field and under sampling in the far field of the transducer will be reduced and may only limit volumetric measurements. Newer computer algorithms will further shorten the image processing time to minutes and seconds. The technical development of easier and faster display of 3D images will contribute to the goal of easy access and use.

The most important advantage of 3D echocardiography, however, is that views simulating intraoperative visualization can be displayed. Three-dimensional echocardiography opens a new window to intracardiac anatomy, presenting images not available by conventional 2D echocardiograms. Tumors, as well as valves can be displayed as viewed through the atrium or the opposite atrium. Three-dimensional echocardiography provides an objective display of cardiac size and shape throughout the cardiac cycle. These views have been validated by comparison with heart specimens. The surgeon is able to have a look in advance at what will be found during operation, with the additional information on function.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Borges, Medical Department I, Charité, Humboldt-University Berlin, Schumannstrasse 20-21, 10117 Berlin, Germany.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Strauss R, Merliss R. Primary tumor of the heart. Arch Path Lab Med 1945;39:74–8.
2. Heath D. Pathology of cardiac tumors. Am J Cardiol 1968;21:315–27.[Medline]
3. Smith ST, Hautamaki K, Lewis JW, Serwin J, Alam M. Transthoracic and transesophageal echocardiography in the diagnosis and surgical management of right atrial myxoma. Chest 1991;100:575–6.[Abstract/Free Full Text]
4. Sayler WR, Page DL, Hutchins GM. The development of cardiac myxomas and papillary endocardial lesions from mural thrombus. Am Heart J 1975;89:4–17.[Medline]
5. Johansson L. Histogenesis of cardiac myxomas: an immunohistochemical study of 19 cases, including one with glandular structure, and review of the literature. Arch Pathol Lab Med 1989;113:735–41.[Medline]
6. Diflo T, Cantelmo NL, Haudenschild CC, Watkins MT. Atrial myxoma with remote metastasis: case report and review of the literature. Surgery 1992;111:352–6.[Medline]
7. Hwang JJ, Lien WP, Kuan P, Hung CR, How SW. Atypical myxoma. Chest 1991;100:550–1.[Abstract/Free Full Text]
8. Sütsch G, Jenni R, von Segesser L, Schneider J. Heart tumors: appearance and diagnosis. Schweiz med Wschr 1991;121:621–9.
9. Tazelaar, HD, Locke TJ, McGregor CGA. Pathology of surgically excised primary cardiac tumors. Mayo Clin Proc 1992;67:957–65.[Medline]
10. Samdarshi TE, Mahn EF, Nanda NC, Guthrie FW, Bernstein IJ, Kirklin JW. Transesophageal echocardiographic diagnosis of multicentric left ventricular myxomas mimicking a left atrial tumor. J Thorac Cardiovasc Surg 1992;103:471–4.[Abstract]
11. Obeid AI, Marvasti M, Parker F, Rosenberg J. Comparison of transthoracic and transesophageal echocardiography in diagnosis of left atrial myxoma. Am J Cardiol 1989;63:1006–8.[Medline]
12. Wollschlager H, Zeiher AM, Kasper W, Geibel A, Just H. Transesophageal echo computer tomography of the heart. In: Roelandt JRTC, Sutherland GR, Iliceto S, Linker DT, ed. Cardiac ultrasound. Edinburgh: Churchill Livingstone, 1993:181–5.
13. Pandian NG, Roelandt J, Nanda NC, et al. Dynamic three-dimensional echocardiography: methods and clinical potential. Echocardiography 1994;11:237–59.[Medline]
14. Borges AC, Bartel T, Müller S, Baumann G. Dynamic three-dimensional transesophageal echocardiography using a computed tomographic imaging probe-clinical potential and limitation. Int J Cardiac Imag (in press)
15. Bartel T, Müller S, Geibel A. Preoperative assessment of cor triatriatum in an adult by dynamic three dimensional echocardiography was more informative than transoesophageal echocardiography or magnetic resonance imaging. Br Heart J.1994;72:498–9.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. J.H. Chong, D. A. Richards, R. Chard, T. McKay, and L. Thomas Two-dimensional and three-dimensional transthoracic echocardiography in surgical planning for right atrial metastatic melanoma Eur J Echocardiogr, March 1, 2008; 9(2): 286 - 288. [Abstract] [Full Text] [PDF]

				R. M. Lang, V. Mor-Avi, L. Sugeng, P. S. Nieman, and D. J. Sahn Three-Dimensional Echocardiography: The Benefits of the Additional Dimension J. Am. Coll. Cardiol., November 21, 2006; 48(10): 2053 - 2069. [Abstract] [Full Text] [PDF]

				G. Shanmugam Primary cardiac sarcoma. Eur. J. Cardiothorac. Surg., June 1, 2006; 29(6): 925 - 932. [Abstract] [Full Text] [PDF]

				C. Pederzolli, A. Terrini, A. Ricci, A. Motta, L. Martinelli, and A. Graffigna Pulmonary valve lipoma presenting as syncope Ann. Thorac. Surg., April 1, 2002; 73(4): 1305 - 1306. [Abstract] [Full Text] [PDF]

				M. Jianyang, Z. Xiuhui, Y. Hongsheng, D. Li, Z. Huaibin, and S. Yingkang Sarcomatous mesothelioma in the left ventricle: A rare entity J. Thorac. Cardiovasc. Surg., August 1, 2001; 122(2): 394 - 395. [Full Text] [PDF]

				J. J. Alcocer, W. E. Katz, and B. G. Hattler Surgical Treatment of Lipomatous Hypertrophy of the Interatrial Septum Ann. Thorac. Surg., June 1, 1998; 65(6): 1784 - 1786. [Abstract] [Full Text] [PDF]

				A. C. Borges, K. Gellert, M. Dietel, G. Baumann, and C. Witt Acute Right-Sided Heart Failure Due to Hemorrhage Into a Pericardial Cyst Ann. Thorac. Surg., March 1, 1997; 63(3): 845 - 847. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wolfgang Konertz Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Borges, A. C. Articles by Baumann, G. Search for Related Content PubMed PubMed Citation Articles by Borges, A. C. Articles by Baumann, G.