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Prosthetic Heart Valves

Introduction Although echocardiography is the imaging modality of choice for cardiac heart valves, it still has significant limitations when imaging prosthetic cardiac valves. These limitations are significant with bioprosthetic valves and are particularly problematic with mechanical valves. The classic limitation is the inability to evaluate mitral regurgitation (MR) from the apical window in patients with mechanical prosthetic valves because of reverberation artifacts and acoustic shadowing. Many…

Planning and Guiding Mitral Valve Repair

Introduction Mitral valve prolapse is the most common structural cause of chronic mitral regurgitation leading to surgery in developed countries. The prevalence of mitral valve prolapse has been reported to be 2.5%. Mitral valve repair is the clear treatment choice for symptomatic severe mitral regurgitation and now asymptomatic mitral regurgitation in many cases. An important advance in assessing mitral valve disease has been the development and…

Mitral Stenosis

Introduction Mitral stenosis is quite uncommon in Western countries, yet it still is a frequent problem worldwide, particularly in developing countries. The low incidence in the United States, in particular, is largely because rheumatic fever resulting in rheumatic heart disease has been largely eradicated; nevertheless, occasional outbreaks do occur. The occurrence of rheumatic fever in Utah in the mid-1980s and early 1990s is notable. That particular…

Normal Mitral Valve Anatomy and Measurements

The complexity of the mitral valve is such that two-dimensional (2D) imaging does not adequately describe its anatomy and function. Indeed, the mitral valve apparatus is a dynamic three-dimensional (3D) structure composed of the saddle-shaped annulus; two asymmetric leaflets; multiple chordae tendineae of various lengths, thicknesses, and points of attachment; the left ventricular wall and the attached papillary muscles; and parts of the left atrium (…

Evaluation of the Aortic Valve

Introduction The aortic valve is the third largest valve in the body, behind the tricuspid and mitral valves, and has a typical valve area of 3 to 4 cm 2 . Despite its smaller size, it is arguably the most important because it lies between the high-resistance aorta and the high pressure–generating left ventricle. Like the pulmonary valve, the aortic valve is semilunar in nature; the major…

Three-Dimensional Transesophageal Echocardiography Systems

Introduction Technologic advances continue to propel cardiac visualization forward. Advances in miniaturization, computer processing, and algorithms continue to have significant momentum. New acquisition technologies, coupled with the ability to process, display, and quantify enormous amounts of data, have pushed echocardiography forward into becoming a modality that will change cardiac intervention as well. Today, three-dimensional transesophageal echocardiography (3DTEE) has generated near-optical cardiac images. An understanding of cardiac…

Integration of Three-Dimensional Echocardiography in Routine Clinical Practice

Introduction Two-dimensional echocardiography (2DE) has been one of the most established and ubiquitous diagnostic tools in cardiology over the past several decades. Echocardiography has come a long way from the early years of A and M modalities. Although transthoracic and transesophageal real-time three-dimensional echocardiography (RT3DE) is a significant advancement in technology, its values and limitations must be understood before using it on a daily basis. Many…

Historical Perspective on Three-Dimensional Echocardiography

Introduction Three-dimensional echocardiography (3DE) has been in existence since the 1970s, albeit with images that barely resembled a heart at that time. Throughout the 1970s and 1980s, 3DE was limited by computing power, both at the workstation and at the ultrasound level. In the 1990s, as both two-dimensional echocardiography (2DE) image quality and computing power dramatically improved, 3DE began to make strides as a possible clinical…

Future applications of strain imaging

Since its birth in the late 1990s, strain echocardiography has continued to grow over the past 20 years. Currently, global longitudinal strain (GLS) has been standardized for clinical application as a robust diagnostic and prognostic marker with substantial incremental value over the traditional indicators of systolic function such as left ventricular ejection fraction (LVEF) in various diseases. However, several challenges remain to be addressed. More work…

Evaluation of right ventricular function and pulmonary hypertension

The right ventricle plays a crucial role in determining patient functional status and prognosis in various conditions. Accordingly, the quantification of right ventricular (RV) function should be part of any routine echocardiographic workup. However, the assessment of RV size and function remains one of the most challenging and technically difficult tasks in echocardiography. There are many anatomic and functional peculiarities that distinguish the right ventricle from…

Ischemic heart disease

Ischemic heart disease (IHD) Myocardial mechanics in IHD Regional function and IHD In 1935, Tennant and Wiggers demonstrated that a coronary occlusion almost immediately induced a regional wall motion abnormality. Nowadays, such ischemic wall motion abnormalities can be detected by standard echocardiography before electrocardiogram (ECG) changes or angina pectoris occur (the so-called ischemic cascade) and allow an assessment of the localization and extent of the ongoing…

Strain in valvular diseases

Valvular diseases may be viewed as a model of how inappropriate loading conditions can lead to cardiac dysfunction, symptoms, and finally death. A paradox of valvular heart diseases is that, in contrast to diseases of myocardium, there is often discordance between normal left ventricular (LV) ejection fraction (EF) but decreased LV long axis function (quantified by LV global longitudinal strain [LV GLS]). Thus, to understand the…

Detection and characterization of diastolic dysfunction

Basics of diastolic function Left ventricular (LV) filling results from active relaxation and diastolic chamber compliance, and LV diastolic dysfunction (DD) is the result of impaired LV relaxation and increased LV chamber stiffness with increased LV filling pressures (FP). Until the 1970s, these two aspects of diastolic function were assessed by cardiac catheterization measurements. The isovolumic relaxation rate of pressure decline (tau) as a measure of…

Temporal dispersion of contraction, arrhythmias, and dyssynchrony and role in resynchronization therapy

Pathophysiology of dispersed ventricular contraction The prediction of sudden cardiac arrest from ventricular arrhythmias remains challenging. Ventricular arrhythmias can occur from all major myocardial diseases and are the most common cause of sudden cardiac death. Malignant arrhythmias are most frequently due to coronary artery disease but can also originate from nonischemic cardiomyopathies. Patients who are at risk of suffering from ventricular arrhythmias can receive medical treatment…

Evaluation and monitoring of patients with cardiomyopathies (including myocardial infiltration)

Cardiomyopathy is a general term used to describe a heterogeneous group of diseases that result in impairment of ventricular function. Clinical manifestations of these diseases can range from an asymptomatic state to heart failure, arrhythmias, or sudden cardiac death (SCD). Cardiac imaging, in particular echocardiography, plays a vital role in the diagnosis and management of affected individuals, and recently strain imaging has garnered great interest due…

Evaluation of patients with heart failure

An estimated 6.2 million Americans older than 20 years suffer from heart failure. As the population ages and heart failure treatments improve, this number is expected to increase, with more than 8 million affected individuals in 2030. The frequency of heart failure with reduced ejection fraction (HFrEF, left ventricular EF [LVEF] <40%) is decreasing, whereas that of heart failure with preserved ejection fraction (HFpEF) is increasing…

Detection of subclinical heart failure

Introduction Limitations of left ventricular ejection fraction for detection of subclinical cardiomyopathy Left ventricular ejection fraction (LVEF) plays a primary role in the diagnosis and management of cardiovascular disease. However, in many scenarios, a reduction in LVEF occurs at a late stage of disease, is often irreversible, and is associated with poor prognosis. Furthermore, LVEF as a measure of myocardial function has several limitations. First the…

Strain imaging applications and techniques

Background The assessment of left ventricular (LV) function is a fundamental requirement in many clinical situations in cardiology. Numerous techniques are used for this purpose, and a number of parameters can be employed, although ejection fraction (EF) is by far the most established. Echocardiography is the most widely used technique for the assessment of LV function because it is widely available and relatively inexpensive and can…

Echocardiography in Patients With Heart Failure With Preserved Ejection Fraction

The American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) define heart failure with preserved ejection fraction (HFpEF) as the clinical syndrome of heart failure (HF) with evidence of a left ventricular ejection fraction (LVEF) 50% or greater. An estimated 6.5 million adult Americans have HF, and over the past 30 years, there has been a rise in the prevalence of HFpEF from 41%…

Pulmonary Hypertension

Clinical Manifestations Pulmonary hypertension, defined hemodynamically, refers to a broad range of conditions with a final common feature of raised arterial pulmonary pressures. Symptoms are nonspecific and include lethargy, reduced exercise capacity, and breathlessness. Clinical signs, when present, are compelling—edema and ascites, precordial heave, altered heart sounds, and arrhythmia. Unfortunately, clinical symptoms and signs are detected months or indeed years after the onset of the process…