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TheThirdUltrasoundDimensioninAnaesthesiaand
IntensiveCare
A.Ng,J.Swanevelder
BrJAnaesth.2015114(3):366369.
Theuseofperioperativeechocardiographyiswellestablishedincardiacandnoncardiacpractice. [1,2]Itisindicated
formonitoringpatientsatriskofhaemodynamiccomplications,andalsoinrescuesituationswhentheremaybe
cardiovascularinstability. [3,4]Therehavebeenadvancesintransoesophagealtransducertechnology,specificallythe
matrixarraytransducer,whichhasenabledtheacquisitionofthreedimensional(3D)imagesinrealtime.
Standardizationofthediagnosticuseof3Dechocardiographyhasbeenrecommendedbyofficialsonbothsidesof
theAtlantic. [5,6]Increasinglycomplexperioperativeapplicationsof3Dechocardiographyarealsobecoming
establishedforcardiacsurgeryandinthecatheterlaboratory.Thereisnowagrowingexpectationthatanaesthetists
shouldbeabletoobtainaccurateclinicalmeasurementstoguidedecisionsinthesesituations. [7]Thiseditorial
explorestheadditional3Ddatathatcouldbepotentiallyvaluable,overandabovestandardtwodimensional(2D)
ultrasoundimages.

Incurrentpractice,wearerequiredtoprovidemeasurementsoflength,area,andvolumeofacardiacstructure.Using
2Dimagingbyastandardphasedarraytransducer,itispossibletoobtaincrosssectionalimagessothatthelength
andareaofastructurearemeasurableinthespecificplanes,obtainedatthetimeofultrasoundscanning.Often,
several2Dimagesarerequired. [8]Volumetricestimationshavetobecalculatedfromgeometricassumptions
originatingfrommeasurementsoflengthandarea.Sincethedevelopmentandminiaturizationofthematrixarray
transducer,apyramidaldatasetofacardiacstructuremaybeobtainedfromthetransoesophagealposition.In
contrastwith2Dimagesofspecificplanes,thisvolumetricdatasetmaybeviewedsothatonecrosssectionalplane
maybeanalysedsimultaneouslyinrelationtoanother.Thismultiplanarreconstructionalsoenableslength,area,and
volumetobemeasured.Usingcurrentsoftware,threecrosssectionalimagesofastructurearedisplayed
simultaneouslyandoptimizedsothatthemeasurementofinterestmaybemadeasaccuratelyaspossible.One
advantageoftheseadditionaldatarelatestothetransoesophagealassessmentofleftventricular(LV)function.
Previously,wehaveexplainedthatvolumetricdataareunderestimatedby2Dimagesowingtotheinabilitytoviewthe
maximumlengthoftheLVinaspecificcrosssectionalplane. [9]ThisforeshorteningoftheLVisobviatedwhenthere
isapyramidaldatasetobtainedby3Dechocardiography.Recently,ithasbeenshownthatLVvolumemeasuredby
3Dechocardiographyintheintraoperativeperiodisgreaterthanthatobtainedby2Dechocardiography. [10]Inthe
overallquantificationofLVfunction,theseaccurate3Ddatasupplementthoseobtainedbyestablishedmethodssuch
asDoppler,tissueDoppler,andspeckletracking.

Usingthesamemethodofsimultaneousdisplayofcrosssectionalimages,measurementsofanylengthintheaortic
rootmaybemade.Inanaesthesiaandintensivecare,themainmeasurementisthatofthediameteroftheLVoutflow
tractwhichisusedforthecalculationofcardiacoutputfromtheequation:

?dctmLinkchronic_id='0901c7918085db43'object_id='0901c7918085db43'edit_widget_type=graphic??dctmEditor
selectedObject='0901c7918085db43'?

SincethelongaxisoftheLVoutflowtractcanbeoptimallydisplayed,possibleunderestimationsoroverestimations
areminimized,avoidingerrorswhichwouldbesquaredintheequation.Furthermore,inthecatheterlaboratory,
multiplanardisplayoftheaorticrootenablesthedistancebetweentheaorticannulusandtheleftcoronaryostium[11]

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tobemeasured,sothatthemostappropriatesizeandtypeoftranscatheteraorticvalvemaybeimplantedinthe
correctposition. [12]

Moreover,itcannowbeappreciatedthatstructuressuchastheleftventricularoutflowtractandaorticannulusmay
beovalshapedratherthanabsolutelycircular.Theimportanceofthisanatomicalinformationisthatcalculationsofan
areasuchasthatoftheaorticannulusfromtheformulaofacircle[Area=(diameter2/4)]maybeinaccurate.In
thismethod,thereisanincorrectgeometricassumptionwhichismagnifiedsincethediameterissquared.Any
inaccuracymayaffectsizingoftheappropriateaorticvalvenotonlyduringopensurgerybutparticularlyduring
transcatheteraorticvalveimplantation. [12]Inthelattersituation,complicationssuchassevereparaprostheticaortic
regurgitation[13]orpatientprostheticmismatchmayoccur.

Measurementsofareaextendtothequantificationofseverityofvalvularstenosis.Planimetryofthemitralvalvearea
fromatraditional2Dimageislikelytoprovideanoverestimatedmeasurement.Sincethestenoticleafletsforma
funnelshapedstructure,theremaybeexcessiveangulationandforeshorteningina2Dimage,leadingtoan
underestimationofseverityofmitralstenosis. [14,15]However,froma3Ddataset,themitralvalvemaybeviewedin
simultaneouscrosssectionalplanes,allowingplanimetryofthebordersoftheopenleaflets(Fig.1)attheappropriate
level. [16]Similarly,theareaoftheaorticvalvemaybeobtainedbymultiplanaranalysisandplanimetry,givingvalues
whichhavebeenshowntodifferfromtraditionalmeasurementsobtainedduringapplicationofthecontinuityequation.
[17]

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Figure1.

Multiplanarviewsofthestenoticmitralvalvedisplayedafteracquisitionofa3Ddataset.Themultiplanesare
optimized,sothatthemitralvalveareamaybemeasuredbyplanimetry.LA,leftatrium.(A)Imageshowingthe
funnelshapedmitralvalve(yellowarrow)inoneplane.(B)Imageshowingthemitralvalve(yellowarrow)inanother
plane.(C)Imageshowingthemitralvalveenface.Thisviewisrequiredformeasurementofmitralvalveareaby
planimetry(redarrow).(D)Imageshowingthethreeplanesofthe3Ddatasetrelativetoeachother.

Otherthanmeasurementsofvolume,length,andarea,weusethismultiplanaranalysisofthe3Ddatasetduring
valverepair.Beforeaorticvalverepair,itispossibletoidentify,confirm,andquantifymalcoaptationbetweenadjacent
cuspsandhencethemechanismofaorticvalvedysfunction.Incontrast,using2Dechocardiography,therecanbe

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someuncertaintyregardingwhichtwocuspsofanaorticvalvewiththreecuspsareseeninthelongaxisview. [18]
Theirpositiondependsonthepositionoftheprobeandtheplanarangleusedduringthetimeof2Dimageacquisition.

Thesameproblemoccursduringanaesthesiaformitralvalverepairwhenseveral2Dcrosssectionalimagesat
differentlevelsarerequiredtoidentifythelocationandmechanismofpathologicalchanges.Fortunately,froma3D
pyramidaldataset,simultaneousanalysisinmultipleplanesmaybeobtained.Thisprocessallowsacrosssectional
planeofassessmenttomoveacrosstheanteriorandposteriorleafletssothatthepreciselocationandmechanismof
relativelycomplexmalcoaptationoftheleaflets,suchascommissuralprolapse,maybedetected. [19,20]The
consequenceofthemalcoaptation,thatistosay,theregurgitantjet,mayalsobelocalizedaccuratelyina3Dimage
andsoassistthesurgeontomakethemostappropriaterepair. [21]Furthermore,theremaybeimprovedaccuracyof
quantificationofmitralregurgitation.In2Dimaging,wemeasurethewidthofthevenacontractaandmake
hemisphericalassumptionstocalculateitsarea.However,using3Dcolourimaging,itispossibletovisualizethe
volumetricvariabilityofthejet,toavoidsuchageometricassumptionandthustoreducemeasurementerror. [22,23]

Inadditiontoadultpractice,3Dechocardiographyhasrevolutionizedtheclinicalassessmentandsubsequent
managementofcongenitalheartdefects. [24]Forinstance,duringdeviceclosureofinteratrialandventricularseptal
defects,3Dimagingfacilitatesimprovedappreciationofcardiacmorphologyandguidanceofacardiaccatheter
throughanorifice.Furthermore,aftermultiplanarreconstructionofthe3Dpyramidaldataset,theseptaldefectmay
bedisplayedenfaceshowingitsareaandshape.Inthisway,appropriatemeasurementsoflengthmaybemade
beforeselectionanddeploymentofaclosuredevice. [25]Unfortunately,during2Dimaging,severalcrosssectional
imageshavetobeobtainedtoguidethecatheterandtofindthelongestlengthinanattempttoavoidan
underestimatedmeasurement.

Despitethesestrengths,inparticularquantificationofLVvolume,3Dechocardiographyhasweaknesses,particularly
inrelationtoultrasoundresolutionandexpertiserequired.Althoughelevationalspatialresolutionisobtained,there
areproblemswithaxialandlateralresolutionsincesomestructuresofinterestwithinapyramidaldatasetarenot
perpendiculartothedirectionoftheultrasoundbeam.In2Dechocardiography,astructureisbestviewedwhenitis
perpendiculartothedirectionoftheultrasoundbeamandthusasclearaspossible.Inaddition,present3D
transducersacquireimagesofmuchlowertemporalresolutionthanthosefromthe2Dmodality.Tominimizethis
reduction,theusermayhavetocompromiseonaxialandlateralresolutionbyreducingthenumberofscanlinesper
frame(calledlinedensity),toreducethesizeofimage,andtoacquireECGgatedsubvolumesofastructurewhich
arestitchedtogether.Intheintraoperativeperiod,themainimplicationsfortheanaesthetistarethattheacquisitionof
largevolumessuchastheLVandimageswith3DcolourDoppler,havetobeacquiredoverafewcardiaccycles,
providedthepatienthasaregularrhythmandisnotinatrialfibrillation.Therehastobecommunicationwiththe
theatreteamtoavoidtheuseofdiathermy,andrespirationhastobeheld.Aftertemporaryacquisition,theventilator
hastoberestartedandtheimagehastobecheckedfortheabsenceofstitchartifactsbeforepermanentstoragefor
furtheranalysis.Inadditiontostitchartifacts,someanatomicalstructuresmayappearthinner,thicker,orlargerthan
theyshouldbe,leadingtodropout,blooming,andblurringartifacts,respectively. [26]

Otherthanissueswithresolution,muchexpertiseisrequiredtoprocessthepyramidaldataset.Inadditiontothe
useofmultiplanarreconstructionanalysisforspecificmeasurements,thepyramidaldatasethastobecroppedso
thatthestructureswithinitmaybeviewed,withappropriategain,brightness,andcontrast.Despiterecent
modificationstofacilitatecropping,expertiseisneededsincethestructureofinterestwillhavetoberotatedto
displaythefeaturesinanappropriateanatomicalposition.Furthermore,despiteitssemiautomatedfeatures,
volumetricanalysisoftheLVisstilloperatordependentandhencesubjecttosomeinaccuracy.Inatimedependent
environmentsuchastheoperatingtheatreorinthepresenceofhaemodynamicinstability,analysisofa3Ddataset
maynotalwaysbepractical[27]unlessthereisadditionalanaestheticassistance.

Inconclusion,theuseofechocardiographyhasgonefromstrengthtostrengthsinceitsintroductionintothe
perioperativearenaover20yrago.Therearecoursesandaccreditationprocessesforqualityassurancenotonlyfor
itsuseintheoperatingtheatre[28]butalsoforintensivecarepractice. [29]Inthenext5yr,weenvisagethattheuseof

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3Dultrasoundimagingwillbeincreasinglyroutineandmayextendtootherareasofanaestheticpractice. [30]This
processwillbefacilitatedbydisseminationofexpertise,automationfromdevelopmentsinsoftware,andenhanced
transducertechnology.Inthisway,wewillbeabletomeetincreasingexpectationsandimproveoutcomesinthe
perioperativeperiod.

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BrJAnaesth.2015114(3):366369.2015OxfordUniversityPress

Copyright2007TheBoardofManagementandTrusteesoftheBritishJournalofAnaesthesia.PublishedbyOxford
UniversityPress.Allrightsreserved.

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