| Transthoracic real-time three-dimensional echocardiography (RT-3DE) is a novel technique, which depicts the heart and its structures in their realistic forms and has the potential to determine accurately cardiovascular anatomy, volume and function in the beating heart without reconstructions. However, it is important to create a standard examination method for RT-3DE, which should be able to accurately evaluate heart diseases with limited time consuming.Part I Methodological Study of Real-time Three-dimensional EchocardiographyObjectiveTo search a sectional diagnostic method which can simplify the visualization and recording of images, and to find the optimal initial two-dimensional views at the beginning of data acquisition and the optimal three-dimensional volumetric views.Methods94 pediatric patients (male 57, female 37, aged 3.13 ± 2.91 years) with congenital heart diseases, were examined by the full volume scan pattern of RT-3DE of Philips SONOS 7500 ultrasonic system with 4X Matrix tranceducer.Results1, 471 full volume three-dimensional (FV-3D) volumetric images were obtained in the 94 patients, and 425 (90.2%) volumetric images were satisfactory.21 Each of all the 425 FV-3D images could show several differentsegments of heart anatomic structure. The FV-3D volumetric images obtained at subcostal and apex could show all the segments of heart and great vessels.3^ The optimal method to show objective segment of heart anatomy.(l)The 4-chamber volumetric view was obtained as the subcostal FV-3D image was dissected coronally, which could display the position of the heart most directly.(2)The volumetric views of the posterior walls of left atrium and right atrium were obtained as the subcostal or apical FV-3D images were dissected in the plane parallel to the atrial posterior wall, which could display the openings of vena cava and pulmonary veins. The information was helpful in determining the vein-atrio connection.(3)The FV-3D images dissected in the sagittal, coronal and horizontal direction, could show the whole pictures of ventricles, papillary muscles and chordae tendineae. These were helpful in identifying the position of ventricles.(4)The 4-chamber volumetric views, the volumetric views of atrioventricular valve (AW) facing to ventricles and the volumtric views of AW facing to atria were obtained as the subcostal or apical FV-3D volumetric image were dissected coronally and in the plane parallel to annulus of AW, which could display the shapes and dynamic features of AW, and could be used to determine the atrio-ventricular connection.(5)The long volumetric views of main arteries, the volumetric views of semi lunar valves facing to ventricles and the volumetric views of semilumar valves at bird view were obtained as the subcostal, parasternal or apical FV-3D volumetric image was dissected sagittally and in the plane parallel to the annulus of semilumar valves, which could assess the position of the two main arteries, shapes and dynamic features of the two semilumar valves.(6)The 4-chamber volumetric view, the volumetric view of interventricular septum (IVS) facing to left ventricle (LV) and facing to right ventricle (RV) were obtained respectively as the subcostal, lower parasternal or apical FV-3D volumetric image was dissected coronally and in the sagittal plane parallel to IVS, which could evaluatethe position, size, shape and dynamic feature of ventricular septal defect (VSD).(7)The 4-chamber volumetric view, the volumetric view of interatrial septum (IAS) facing to left atrium (LA) and facing to right atrium (RA) were obtained respectively as the subcostal, lower parasternal or apical FV-3D volumetric image was dissected coronally and in the sagittal plane parallel to IAS, which could display the position, size, shape and dynamic feature of atrial septal defect (ASD).ConclusionsFull volume scan of RT-3DE should start with the apical or subcostal full volumetric imaging to obtain the information of the whole heart, and then undertake other objective examinations.Part II Application of Real-time Three-dimensional Echocardiography in the Diagnosis of Congenital HeartDiseases in ChildrenObjectiveTo evaluate the reliability of real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of congenital heart diseases (CHD).Methods62 consecutive pediatric patients (male 23, female 39, aged 3.25 ±2.88 years) with congenital heart diseases, were examined by using a commercial ultrasound scanner (SONOS 7500, Philips Medical Systems) equipped with a full-matrix array transducer (X4, 2-4 MHz). The sectional diagnostic method in part I was used to analyze the volumetric images. Meanwhile, other scan patterns of RT-3DE such as color three-dimensional imaging and live three-dimensional imaging were used as well. Based on the findings of angiocardiography and/or surgery, the results were compared with those diagnosed by two dimensional Color Doppler echocardiography (CDE).ResultsTechnically satisfactory volumetric images of RT-3DE were obtained in all subjects. These volumetric images could provide more accurate spacial information in aspects of intracardiac anatomy and the course of great arteries, including septal defects, valvular lesions and abnormal connection of the great arteries. In 62 patients, CHD diagnosed with RT-3DE were all conformed by surgical findings and/or angiocardiography. The major defects in 61 (98. 4%) diagnosed by RT-3DE were consistent with those by CDE. However, minor defects were corrected or supplemented by RT-3DE in 6 patients (9.7%).ConclusionsRT-3DE is more accurately in diagnosing CHD as compared with CDE.Part HI Assessment of Left and Right Ventricular Volumes, and Mass by Real-time Three-dimensional Echocardiography:An Animal StudyObjectiveTo assess the method and the accuracy of RT-3DE for quantifying the ventriclar volumes, stroke volume (SV) and mass.MethodsThe study population consisted of 10 normal pigs (male 4, female 6, weight 20. 60+1. 88kg). Their cardiac functions were detected when they were in basic condition and after saline was injected through central venous to induce volume overload, then after blood was flown away through artery to induce low volume state. Measurements were hold in all condition as follows:K Left ventricular SV (LVSV) was assessed with RT-3DE, PiCCO thermodilution method (PiCCO) and other methods including biplane Simpson formula, Teichholtz formula and Doppler technique. To acquire full-volume volumetric datasets of the left ventricle by RT-3DE, the apical approach was used. The RT-3DE datasets were analyzed using a 4D Cardio-view RT 1. 2 (TomTec Imaging Systems, Munich, Germany)2> Right ventricular SV (RVSV) was assessed with RT-3DE, Swan-Ganzpulmonary thermodilution (PATD), and other methods including biplane Simpson formula and Doppler technique. To acquire full-volume volumetric datasets of the right ventricle by RT-3DE, full volume imaging was performed from the apical and parasternal windows respectively.3% Tricuspid annulus systolic excursion (TASE) was recorded with ME to evaluate the global systolic function of right ventricle.4n Left ventricular mass and right ventricular free wall mass were assessed with RT-3DE and compared with the actual ventricular myocardium weight.ResultsK Left ventricular stroke volumeLVSV determined by RT-3DE, biplane Simpson formula, Teichholtz formula, Doppler technique was 23.15+12.8ml, 21.24 + 9.00ml, 28.18 + 15.48ml, 35.68 + 12.80ml, which except for that measured by Doppler did not show significant difference as compared with that measured by PiCCO (26.03±11.56ml) with significantly linear correlation. The r value was 0.9598, 0.8982, 0.9197 and 0.8985 respectively.2-? Right ventricular stroke volumeRVSV determined by the parasternal approach of RT-3DE, apical approach of RT-3DE, biplane Simpson formula, method of Doppler was 18. 64±10.84ml, 13. 74+8. 17ml, 12. 36 + 5. 45ml, 35. 10 + 13. 56ml, which except for that measured by Doppler did not show significant difference as compared with that measured PATD (24. 13 + 11. 33ml) with significantly linear correlation. The r value was 0.9328, 0.8828, 0.6856 and 0.8316 respectively.3> Global systolic function of right ventricleRVSV determined by the parasternal approach of RT-3DE, biplane Simpson formula, method of Doppler was 18. 01 + 7. 53ml, 10. 65 + 5. 94ml and 37.87 + 11. 32ml respectively, which were all significantly correlated with TASE (7.14+1.97mm). The r value was 0.93, 0.48 and 0.83 respectively.4? Left ventricular massEnd-diastolic mass of left ventricle (57. 02 + 4. 86g) determined byRT-3DE was correlated better with actual value (63. 07±6. 44g) (r=0. 87) rather than end-systolic measurement (56. 34 + 4. 8g) (r=0. 78).5,. Right ventricular free wall massEnd-diastolic mass of right ventricle free wall (19.07+1.95g) determined by RT-3DE was correlated better with actual value (20.78 + 2.70g) (r=0.74) rather than end-systolic measurement (16.63+1.54g) (r=0.68).Conclusions1. RT-3DE permits a noninvasively and relatively precise measurement of left and right ventricular volume, SV and mass.2. Right ventricular volume determined with the parasternal approach of RT-3DE is more reliable.3. Ventricular mass measured by RT-3DE at end-diastolic frame is more reliable.Part IV Assessment of Left and Right Ventricular Volumes by Real-time Three-dimensional Echocardiography: A Clinical Study in Complex Congenital Heart DiseaseObjectiveTo evaluate the accuracy of RT-3DE in ventricular volume quantification and the reliability of RT-3DE in the systolic function assessment in complex congenital heart disease.Methods19 consecutive pediatric patients (male 14, female 5, aged 2.65 + 2. 46 years) with complex congenital heart diseases were recruited into the study.K RT-3D full volume imaging was performed from the apical or subcostal window. And the RT-3DE datasets were analyzed using a 4D Cardio-view RT 1. 2 (TomTec Imaging Systems, Munich, Germany) to quantify the EDV, ESV and SV of ventricle.2> The mitral annulus systolic excursion (MASE) and TASE were...
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