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Ann Thorac Surg 2008;86:875-881. doi:10.1016/j.athoracsur.2008.04.106
© 2008 The Society of Thoracic Surgeons
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Original Articles: Pediatric Cardiac

Impact of Multiplanar Review of Three-Dimensional Echocardiographic Data on Management of Congenital Heart Disease

Tara Bharucha, MRCPa, Kevin S. Roman, MDa, Robert H. Anderson, FRCPathb, Joseph J. Vettukattil, FRCPa,*

a Congenital Cardiac Centre, Southampton University Hospital Trust, Southampton, United Kingdom
b University College London, Institute of Child Health, London, United Kingdom

Accepted for publication April 29, 2008.

* Address correspondence to Dr Vettukattil, Congenital Cardiac Centre, Southampton University Hospital Trust, Tremona Road, Southampton, SO16 6YD, United Kingdom (Email: joseph.vettukattil{at}suht.swest.nhs.uk).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: In patients with congenital cardiac malformations, accurate diagnosis is critical in diagnosis and management. The multiplanar review mode (MPR) allows the operator to cut three-dimensional (3D) echocardiographic data sets in infinite planes, and to review the moving image in three simultaneous orthogonal planes. We sought to describe the clinical utility of MPR of 3D echocardiography for analysis of congenitally malformed hearts.

Methods: Cross-sectional and 3D MPR echocardiography was performed in 300 patients with congenitally malformed hearts.

Results: Analysis in multiplanar mode was possible in all patients. New, clinically important information, which altered management or changed the principal diagnosis, was obtained in 32 (11%) cases. This determined suitability for biventricular repair in 11 patients, clarified the morphology of atrioventricular valves in 7, helped in assessment of aortic, mitral, or prosthetic valvar disease in 13, and identified a vascular ring in the other patient.

Conclusions: 3D MPR is feasible in the setting of the congenitally malformed heart, permitting focused and in-depth analysis. This substantially improves the understanding of functional morphology, above the information derived from cross-sectional echocardiography. We recommend the use of the 3D format with MPR for patients with complex congenital cardiac disease.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Accurate elucidation of the functional anatomy of individual lesions is of critical importance to the management of patients with congenitally malformed hearts. Real time three-dimensional echocardiography (RT3DE) has emerged as a valuable tool in the diagnosis of, and clinical decision making for, these patients. The technique provides the clinician with new insight into cardiac anatomy and function during life, and allows viewing of intracardiac structures in a dynamic way [1, 2]. It provides accurate and reproducible measurements of the size and function of cardiac chambers [3], and offers additional information that may not be readily appreciated with cross-sectional echocardiography alone, for both simple and complex lesions [4–8]. The findings are known to correlate well with anatomic and surgical findings, and aid surgical planning [9–15].

Three-dimensional data sets may be analyzed in two main ways. First, "cropping," or three-dimensional (3D) reconstruction, of the data set allows the clinician to slice into the data set to the region of interest, and to display intracardiac structures from a chosen, clinically useful, aspect. In this way; for example, one may display the "surgeon's view." The second method is analysis using the multiplanar review mode (MPR) (Fig 1). This mode allows the operator to view the moving 3D data set simultaneously in three orthogonal windows, and to review the image in infinite planes by moving each of the three planes through the data set.


Figure 1
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  		Fig 1. Multiplanar review (MPR) analysis of a patient with discordant ventriculo-arterial connections, ventricular septal defect, and abnormal tricuspid valve. Each plane is positioned independently by the operator in order to focus on the area of interest, and examine the structure of interest. This figure shows the VSD, and there is an abnormal attachment of the anterior leaflet of the tricuspid valve to the atrial septum, as marked by the red arrow. The yellow arrow shows the septal leaflet of the tricuspid valve. The three-dimensional image is sliced to demonstrate the tricuspid valve opening and orientation of the left ventricle, aorta, and the VSD. At surgery, due to the anterior leaflet extending and attaching to the atrial septum, there were concerns about presence of tricuspid valve patency and adequacy of the valve to enable biventricular repair. However, presurgical MPR had clearly demonstrated the anatomy of the right atrioventricular valve. (Ao = aorta; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle; VSD = ventricular septal defect.)

 
Published work on 3D echocardiography, to the best of our knowledge, has thus far addressed only the first method, being focused on the 3D visualization of morphology in fixed anatomic planes. In this study, we have used the versatility of MPR to cut the data set in anatomically appropriate planes to visualize the heart in an attitudinally appropriate manner. Once the appropriate plane is established, then further 3D reconstruction is possible. We sought to investigate the clinical utility of MPR in analysis of 3D data sets from patients with congenitally malformed hearts by determining when the findings substantially contributed to the clinical management over and above the findings obtained with standard cross-sectional interrogation.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Approval was obtained from the local research ethics committee, who waived the need for signed consent, as 3D echocardiography is part of our routine clinical investigation.

Between October 2004 and December 2006, RT3DE data sets were acquired in 300 patients, including complex congenitally malformed hearts, in addition to routine cross-sectional studies. All patients were unsedated and spontaneously breathing. A commercial system for imaging (Philips Sonos 7500 or IE33; Philips Healthcare, Hamburg, Germany) with a 3 to 5 MHZ matrix phased array transducer was used to perform the standard cross-sectional echocardiographic assessment and to acquire RT3DE images. Images were acquired and analyzed prospectively, or retrospectively analyzed when additional data before surgery were requested. Stored full volume RT3DE data sets were assessed off-line using Qlab software version 4.1 (Philips Medical Systems) for the earlier patients, and version 5.0 when this became available. Cross-sectional findings were analyzed and reported according to our standard clinical practice, and the same operators subsequently performed analysis of the 3D data sets by MPR, and recorded additional findings. All decisions on intervention or change in management plan before or after RT3DE was taken at a joint clinical conference involving a minimum of 3 cardiologists and a surgeon.

Multiplanar Review
Multiplanar review analysis of RT3DE data was carried out as follows. The RT3DE data set was opened in the MPR facility. The MPR mode allows the operator to position each of the three planes through the structure of interest, in order to display intracardiac anatomy in an attitudinally appropriate manner. The operator may examine each structure of interest, for example, each valve, by "sliding" the 3 planes through the moving data set, and in this way may examine the entire heart.

Details of Patients
There were 300 patients in total. Their ages ranged from 1 day to 47 years. The main diagnoses are shown in Table 1.


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  		Table 1 Distribution of Diagnostic Details in Study Population
 

   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Imaging quality was sufficient to allow multiplanar analysis in all patients. In 32 (11%) cases, management was substantially altered by the new MPR-derived information as follows (Table 2).


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  		Table 2 Distribution of Diagnostic Group Where MPR Substantially Contributed to Management
 
Establishment of suitability for biventricular repair in 11 patients
This group included 2 patients with isomerism of the left atrial appendages, 1 with isomerism of the right atrial appendages, 1 with atrioventricular septal defect and common atrioventricular junction (Fig 1), 2 with mirror-imaged atrial arrangement and discordant atrioventricular connections, and 1 with right-sided heart and double outlet right ventricle. The relationship of the arterial trunks to the ventricles and ventricular septal defect was unclear in 2 patients on cross-sectional interrogation alone, but was clarified with 3D MPR, and both patients were shown to be suitable for biventricular repair, which was carried out successfully. Of these patients, one had isomerism of the left atrial appendages with double outlet right ventricle, and one had mirror-imaged atrial arrangement with concordant atrioventricular connections and double outlet right ventricle.

In 5 patients who had previously been palliated with cavopulmonary anastomosis or Fontan circulation, 3D MPR established suitability for biventricular repair, which was achieved successfully in all. In 2 patients, one with severe Ebstein's malformation and one with atrioventricular septal defect and unbalanced ventricles, the technique revealed unsuitable morphology for biventricular repair.

Elucidation of atrioventricular valvar morphology in 7 patients
In 3 patients with atrioventricular septal defects, the technique provided new information regarding the structure of the left atrioventricular valve, which impacted on surgical management. In the other 4 patients the technique provided new information regarding the right atrioventricular valves. One of these patients having a ventricular septal defect, discordant ventriculo-arterial connections, and an abnormal tricuspid valve thought to be inadequate, one having Ebstein's malformation, in whom additional calcification of the mitral valve was demonstrated on 3D MPR but not 2D echocardiography, and two with dysplastic tricuspid valves.

Clarification of the mechanism of mitral regurgitation in 6 patients
In these patients, the mechanism of atrioventricular valve regurgitation was demonstrated and decisions regarding the need for surgical intervention were altered appropriately. For example, in one patient after surgical closure of a ventricular septal defect closure, cross-sectional interrogation had revealed apparently severe mitral regurgitation and reparative surgery had been scheduled. The MPR analysis revealed a fistulous connection between the left ventricle and the left atrium. In the others, by defining the severity of regurgitation or the mechanism of regurgitation, use of the technique either facilitated or avoided surgery.

Demonstration of the detailed anatomy of the aortic valve in 5 patients
In 3 of these patients, the mechanism of aortic regurgitation was unclear after cross-sectional imaging, but clarified by MPR analysis. In 2 patients, the level of obstruction within the left ventricular outflow tract could not be determined on multiple cross-sectional echocardiograms, but MPR clearly demonstrated the mechanism of obstruction. In one of these patients, obstruction was demonstrated at two distinct levels.

The mechanism of paraprosthetic valvar leak shown in 2 patients
In both these patients, MPR provided enough information to facilitate interventional catheter occlusion of the paravalvar leaks, including the demonstration of two discrete regurgitant orifices where cross-sectional interrogation had demonstrated only one.

Identification of a vascular ring in 1 patient
In this patient, multiplanar review demonstrated a double aortic arch, and the infant proceeded to surgery without the requirement for any further imaging.

Additional information regarding valvar morphology and intracardiac measurements was available in most cases, which clarified the functional anatomy and increased confidence in clinical decision-making, but did not substantially alter the direction of care. There were no patients in whom MPR findings were subsequently found to be erroneous, either on further echocardiographic studies or at surgery.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
We have examined patients representing a cross-section of children and adults with congenitally malformed hearts, focusing on multiplanar review (MPR) as a unique method for analysis of 3D data sets, and establishing its impact on clinical decision-making. Our experience endorses the findings of those who have found that transthoracic 3D echocardiography is feasible and aids diagnosis of patients with complex congenital cardiac disease [8, 16].

Evaluation of patients with complex malformed hearts has now become possible away from the bedside. Newer software such as Qlab and TomTec (TomTec, Munich, Germany) have incorporated techniques to reveal the morphology of the congenitally malformed heart in attitudinally appropriate planes, while retaining the ability to assess dynamic function. Although acquisition of the 3D data sets takes only seconds, MPR facilitates offline examination of the data set with retained coordinates and tissue characteristics, allowing repeated and detailed interrogation of the cardiac structure. Simultaneous visualization of the dissected anatomy in three orthogonal planes aids in the use of this modality as a transition between cross-sectional and 3D echocardiography. A further advantage of the technique is its utility in reconstructing a full 3D image from the planes cut in attitudinally appropriate fashion. The operator may choose the plane which best displays the anatomy, but avoids inadvertent cropping of structures or overlying of structures of interest. This helps in avoiding some of the artifact, which may be created by direct cropping of the data set.

During analysis by MPR, the data set is cut in three planes simultaneously, providing three sets of dynamic planes, each similar to a cross-sectional image (Fig 2). The operator may position the planes through the structures under study and while studying a valve, for example, may study each leaflet individually; thus establishing the relationship to each of the other leaflets. "Sliding" the planes across the whole width of the valve in each plane allows examination of the valve in its entirety. Our experience shows that such multiplanar analysis is of particular benefit in the examination of valvar morphology in congenitally malformed hearts, and also in demonstrating the mechanism of valvar regurgitation.


Figure 2
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  		Fig 2. Septatability of AVSD in an isomeric patient demonstrated by 3D MPR. The green panel corresponds to the 2D echocardiographic image. The left AV valve measured only 14.5 mm (D5) in this 6-year-old boy compared with the right AV valve component measuring 28 mm (D6). However on 3D MPR, the red panel shows the orientation of the left ventricle (LV) in a different plane (anterior-posterior) demonstrating adequacy of the left AV valve for biventricular repair (Left AV valve diameter 22.4 mm, D7). Cross-sectional planes with the attitudinally appropriate section of both red and green planes are demonstrated in the left lower corner (blue panel). The sliced 3D plane in the right lower corner demonstrates the profile of the left atrioventricular valve. (LA = left atrium; LAVV = left atrioventricular valve; LV = left ventricle; MPR = multiplanar review; RA = right atrium; RV = right ventricle; RAVV = right atrioventricular valve.)

 
This facility also allows precise measurement of intracardiac structures. Each structure can be accurately delineated and then measured using the tools for quantification included in the software supplied by the manufacturer. For example, a valvar orifice may be defined by cross-reference between the three planes, and then traced to establish its area. Similarly, atrial or ventricular septal defects may be delineated and measured, and valvar regurgitant jets may be assessed in 3D color.

We have also found that MPR analysis is possible in most subjects in whom image quality is not adequate for 3D volume rendering or cropping. It is also far less sensitive to an artifact created by patient movement or respiration during acquisition.

We have often obtained information from MPR analysis of the 3D echocardiogram that has allowed us to proceed without obtaining other forms of imaging. For example, some of our patients had been scheduled for cardiac magnetic resonance imaging, which in young children requires a general anesthetic, but MPR analysis of the 3D echocardiographic data set provided the information required to proceed with clinical management.

We routinely now use MPR analysis as an adjunct to cross-sectional imaging in assessment of certain complex abnormalities, such as to assess valvar morphology in those having atrioventricular septal defects with common atrioventricular junction. Three-dimensional echocardiography has been demonstrated to be of major benefit in this group, and to provide additional information over and above cross-sectional imaging in patients both before and after surgical repair [6, 17, 18]. We use MPR to aid in the assessment of borderline cases, such as those in whom the decision is difficult whether to pursue palliative surgery or biventricular repair, and as a routine part of our examination of patients with Ebstein's malformation. Obstruction of the left ventricular outflow tract is another clinical arena in which MPR is extremely valuable in demonstrating the site and nature of the obstruction. The patients in this series are not consecutive; our population is partially selected in that we did not conduct a randomized study, but rather this cohort was part of our early experience. It is possible that if MPR evaluation was carried out in a more targeted fashion, focusing on the patient groups suggested by this initial study, that it would generate clinically useful data on a higher proportion of patients than the 11% found in this group of patients.

With MPR as an established method of preoperative assessment, we find that it is unnecessary to perform transesophageal studies on our patients. It has already been shown that conventional 3D echocardiography can reduce operative time [19]. By contributing increased anatomic detail perioperatively, MPR could also contribute to reduction of operative time, albeit that this potential requires further research.

The MPR analysis of 3D data sets acquired transthoracically has a relatively short learning curve and is easily and rapidly applied to daily clinical practice. The data sets take but seconds to acquire and can be processed away from the bedside, a feature of particular benefit in the examination of children. Cross-sectional images can be reconstructed from the 3D images in multiple planes, independent of the site of acquisition of the data set.

In conclusion, use of the multiplanar mode is feasible in patients with congenitally malformed hearts. The technique provides additional information that substantially alters clinical management in many patients.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Maeno YV, Benson LN, McLaughlin PR, Boutin C. Dynamic morphology of the secundum atrial septal defect evaluated by three dimensional transoesophageal echocardiography Heart 2000;83:673-677.[Abstract/Free Full Text]
  2. Handke M, Schäfer DM, Müller G, Schöchlin A, Magosaki E, Geibel A. Dynamic changes of atrial septal defect area: new insights by three-dimensional volume-rendered echocardiography with high temporal resolution Eur J Echocardiogr 2001;2:46-51.[Abstract/Free Full Text]
  3. Lang RM, Mor-Avi V, Sugeng L, Nieman P, Sahn D. Three-dimensional echocardiography: the benefits of the additional dimension J Am Coll Cardiol 2006;48:2053-2069.[Abstract/Free Full Text]
  4. Sadagopan SN, Veldtman GR, Sivaprakasam MC, et al. Correlations with operative anatomy of real time three-dimensional echocardiographic imaging of congenital aortic valvar stenosis Cardiol Young 2006;16:490-494Oct.[Medline]
  5. Abe H, Nakatani S, Kanzaki H, Hasegawa T, Miyatake K. The structural and dynamic recognition of discrete subaortic stenosis by real-time three-dimensional transthoracic echocardiography J Echo 2005;3:48-49.
  6. Singh A, Romp RL, Nanda NC, et al. Usefulness of live/real time three-dimensional transthoracic echocardiography in the assessment of atrioventricular septal defects Echocardiography 2006;23:598-608.[Medline]
  7. van den Bosch AE, Ten Harkel DJ, McGhie JS, et al. Feasibility and accuracy of real-time 3-dimensional echocardiographic assessment of ventricular septal defects J Am Soc Echocardiogr 2006;19:7-13Jan.[Medline]
  8. Chan KL, Liu X, Ascah KJ, Beauchesne LM, Burwash IG. Comparison of real-time 3-dimensional echocardiography with conventional 2-dimensional echocardiography in the assessment of structural heart disease J Am Soc Echocardiogr 2004;17:976-980.[Medline]
  9. Vogel M, SY Ho, RH Anderson. Comparison of three dimensional echocardiographic findings with anatomical specimens of various congenitally malformed hearts Br Heart J 1995;73:566-570.[Abstract/Free Full Text]
  10. van den Bosch AE, Ten Harkel DJ, McGhie JS, et al. Surgical validation of real-time transthoracic 3D echocardiographic assessment of atrioventricular septal defects Int J Cardiol 2006;112:213-218.[Medline]
  11. Chen FL, Hsiung MC, Nanda N, Hsieh KS, Chou MC. Real time three-dimensional echocardiography in assessing ventricular septal defects: an echocardiographic-surgical correlative study Echocardiography 2006;23:562-568.[Medline]
  12. Fabricius AM, Walther T, Falk V, Mohr FW. Three-dimensional echocardiography for planning of mitral valve surgery: current applicability? Ann Thorac Surg 2004;78:575-578.[Abstract/Free Full Text]
  13. Bharucha T, Ho SY, Vettukattil JJ. Multiplanar review analysis of three-dimensional echocardiographic datasets gives new insights into the morphology of subaortic stenosis Eur J Echocardiogr 2008[Epub ahead of print].
  14. Vettukattil JJ, Bharucha T, Anderson RH. Defining Ebstein's malformation using three-dimensional echocardiography Interact Cardiovasc Thorac Surg 2007;6:685-690.[Abstract/Free Full Text]
  15. Sivaprakasam MC, Vettukattil JJ. 3-D echocardiographic imaging of double aortic arch Eur J Echocardiogr 2006;7:476-477.[Abstract/Free Full Text]
  16. Salustri A, Spitaels S, McGhie J, Vletter W, Roelandt JR. Trans-thoracic three-dimensional echocardiography in adult patients with congenital heart disease J Am Coll Cardiol 1995;26:759-767.[Abstract]
  17. Hlavacek AM, Crawford FA, Chessa KS, Shirali GS. Real-time three-dimensional echocardiography is useful in the evaluation of patients with atrioventricular septal defects Echocardiography 2006;23:225-231.[Medline]
  18. Miller AP, Nanda NC, Aaluri SA. Three-dimensional transesophageal echocardiographic demonstration of anatomical defects in AV septal defect patients presenting for reoperation Echocardiography 2003;20:105-109.[Medline]
  19. Dall'Agata A, Cromme-Dijkhuis AH, Meijboom FJ, et al. Use of three-dimensional echocardiography for analysis of outflow obstruction in congenital heart disease Am J Cardiol 1999;83:921-925.[Medline]



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