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Figure 1.
Microscopic view of a
matrix array
transducer. Each small
square is an active
ultrasound element.
The size of a human
hair is shown for
comparison (arrows).
Figure 2.
Comparison between
the 2D image quality
obtained with a conventional transducer
and with a matrix
array 3D scanner from
a parasternal echo
window in the same
patient.
Figure 2a.
Image obtained with a
conventional
transducer
(S3 transducer with a
Sonos 7500).
Figure 2b.
Image obtained with a
matrix array 3D
scanner (X4 matrix
transducer).
Method
3D acquisition is based on a newly developed matrix
array transducer with more than 3000 active
elements (Figure 1). All elements of the matrix array
transducer transmit and receive. This leads to an
improved image quality when compared to that of
the first generation equipment, where only 256
elements transmitted and 256 others received. The
image quality in cut planes is now comparable to the
image quality of a conventional 2D transducer
(Figure 2).
Medical Clinic I,
University Hospital,
Aachen, Germany
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MEDICAMUNDI 47/2
August 2003
Figure 3.
3D scanning.
Figure 3a.
On-line 3D scanning.
The sector size
depends on chosen
image resolution or
line density, and is
about 30 by 50.
Figure 3b.
Wide-angle scanning.
A narrow sector is
scanned during each
of four consecutive
heart beats. The four
sectors (shown with
different color
coding) are integrated
automatically within a
fraction of second.
3D data analysis
MEDICAMUNDI 47/2
Realistic threedimensional
images are
generated in real
time.
All intracardiac
structures can be
visualized, including
catheters.
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35
Figure 4.
Different views of the
mitral valve and its
subvalvular apparatus
acquired via a parasternal echo window. The
papillary muscle and
chordae tendineae are
well defined.
LV = left ventricle;
LA = left atrium.
Figure 5.
Mid-systolic stop frame image of a prolapse of the posterior
leaflet of the mitral valve (arrow). Longitudinal view.
LA = left atrium;
LV = left ventricle; MVP = mitral valve prolapse.
Figure 6.
Secundum type atrial
septal defect (ASD);
en face view from the
right atrium.
Figure 7.
Aortic valve seen from the ascending aorta.
Figure 6a.
Diastolic stop frame.
Figure 6b.
Systolic stop frame.
The defect area is
significantly larger.
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August 2003
Figure 8.
Semi-automated
contour tracing in a
3D data set
(LV Analysis RT 1.1;
TomTec Imaging GmbH,
Unterschleiheim,
Germany).
Figure 8a.
The endocardial
boundaries are found
semi-automatically in
each cut plane (upper
right) of a previously
determined number
of long-axis cut planes
(shown in the righthand margin). The
points found on the
endocardium are
marked by yellow dots
(lower left) and finally
connected by a spline
algorithm: This results
in a contour (green
line, upper left) which
serves as a basis for
LV volume calculation
at this point in time.
Figure 8b.
Calculation of volume/
time curve of the LV
volume.
A surface-rendered LV
cast based on the semiautomatically found
endocardial boundaries
is shown in the upper
left panel.
The bulls-eye display
(lower left) will be used
at a later stage to
identify the individual
regions for wall motion
analysis.
Semi-automated
contour tracing is
automatically repeated
for every stop frame
(every 40 ms)
throughout the
complete heart cycle.
The volume is then
calculated for each
stop frame, resulting
in the volume/time
curve shown in the
lower right panel of
Figure 8b
(x-axis: time;
y-axis: volume).
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August 2003
37
Figure 9.
Improvement of
endocardial delineation
by the use of left heart
contrast agents.
Comparison of
unenhanced (above)
and enhanced (below)
long-axis planes of
the LV shows clearly
improved delineation
of the endocardial
borders. The contrast
agent was continuously infused.
Figure 10.
Generation of multiple short axis cut planes of the left ventricle.
The yellow lines mark the position of the short axis slices.
Figure 10a. Generation of tomographic cross sections).
Figure 10b. MRI-like view.
Figure 10c. Short axis slices from apical to basal.
Figure 11.
Set of short-axis cut
planes from a contrastenhanced 3D stress
echo at rest (upper
row), at low dose
dobutamine (middle
row) and during peak
dobutamine dose
(lower row).
Interpretation of wall
motion abnormalities
can be performed by
comparing the
corresponding shortaxis planes.
Figure 12.
Analysis of regional
(segmental) wall
motion based on semiautomated contour
tracings.
(LV Analysis RT 1.1;
TomTec Imaging GmbH,
Unterschleiheim,
Germany).
The volume/time
curves of each colorcoded segment in the
bull's eye view (lower
left) are represented in
the volume/time curve
in the lower right
panel (example in a
patient with no wall
motion abnormalities).
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August 2003
Future perspectives
Real-time 3D echo has several obvious advantages
which will undoubtedly become part of the clinical
routine in the future.
Wall motion abnormalities can be detected and
analyzed in 3D data sets as accurately as in serially
acquired conventional 2D cut planes [12]. The
velocity of acquisition of 3D data sets covering the
whole left ventricle makes this technique suitable
for use during dobutamine stress echo.
Consequently, this approach has been successfully
been used with the first generation real-time 3D
systems [13,14].
At that time, left heart contrast was used for better
endocardial delineation, especially during peak
dobutamine dose. This still seems to be necessary
with the second-generation real-time 3D
equipment [15].
Real-time 3D
echo has obvious
advantages and
will undoubtedly
be part of the
clinical routine.
Conclusion
Qualitative interpretation of rendered images, and
quantitative evaluation of 3D echocardiographic
data, have been shown to be clearly superior to
conventional 2D echo techniques. The emerging
integration of second-generation real-time 3D
echocardiography with matrix array transducers into
high-end 2D echocardiographic equipment extends
the benefits of more complete and precise
information to the clinical routine. However, benefits
with respect to prognosis and outcome have not yet
been shown for a variety of diseases, or for the
individual patients. A number of clinical studies are
currently under way which are expected to provide
the necessary evidence. Furthermore, real-time 3D
echocardiography is the only on-line 3D method,
even when compared with other 3D imaging
techniques such as magnetic resonance imaging
and computed tomography. Although these
modalities can also provide three-dimensional data
sets, including the complete heart, they are still are
based on post-acquisition reconstruction and not
on volumetric scanning.
MEDICAMUNDI 47/2
Qualitative and
quantitative
assessment of 3D
data is superior to
conventional 2D
techniques.
Real-time 3D
echo is the only
truly on-line 3D
method.
August 2003
39
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