PML AML Figure 1. Biplane Mode (X-plane) acquisition with 3D transoesophageal echocardiography. Left side panel: reference plane mid-oesophageal 4 chamber.

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3D Echocardiography. u 3D Transesophageal echocardiography has become practical for intraoperative use u Technology provides 3D visualization of MV and.

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PML AML Figure 1. Biplane Mode (X-plane) acquisition with 3D transoesophageal echocardiography. Left side panel: reference plane mid-oesophageal 4 chamber view. Right side panel: 2D image of the mitral valve from a plane rotated 95⁰ from the reference plane. AML- anterior mitral leaflet; PML – posterior mitral leaflet.

Ao SURGEON’S VIEW Figure 2. 3D Zoom acquisition of the mitral valve as seen from the atrial perspective by 3D transoesophageal echocardiography. The images is then rotated in such a way that the aorta is located anteriorly (flipped image indicated by arrow). Ao –aorta.

Figure 3. Full Volume Gated Acquisition with 3D transoesophageal echocardiography. Acquisition is done over 4 cardiac cycles that enables a good temporal resolution (32 volumes per second).

Figure 4. Full Volume Color Flow Doppler acquisition with 3D transthoracic echocardiography. The full volume color Doppler is reconstructed by stitching together 4 narrow pyramidal sets. Off line analysis enables evaluation of vena contracta area by direct planimetry. En face

A B C D AML AML AML Ao PML PML PML SURGEON’S VIEW LATERAL VIEW VENTRICULAR VIEW VENTRICULAR VIEW AML AML AML PML Ao Figure 5. 3D transthoracic echocardiography evaluation in a patient with dilated cardiomyopathy and secondary mitral regurgitation. Apical systolic displacement of the mitral valve leaflets coaptation point as seen from a lateral aspect (Panel A, yellow arrow, the blue dotted line represents the mitral annulus plane). Apical and lateral displacement of the papillary muscles exerting a tethering effect on the mitral leaflets in mid-systole as seen from the ventricular view (Panel B, yellow arrows). For rapid recognition of the anatomic landmarks the ventricular aspect of the mitral valve apparatus is also shown in diastole (Panel C). Funnel shape morphology of the mitral valve as seen from the atrial perspective in the same patient (Surgeon’s view, Panel D). All images are reconstructed from the same 3D pyramidal data set. AML- anterior mitral leaflet; PML- posterior mitral leaflet; Ao- aorta. PML PML

ALC PMC Ao A B Figure 6. Surgeon’s view of the mitral valve in a patient with secondary mitral regurgitation (SMR) and idiopathic dilated cardiomyopathy showing the funnel shape of the mitral valve as seen from the atrial perspective (3D transthoracic echocardiography, Panel A). The chosen frame is in mid-systole, tethering on the MV leaflets being maximal (Panel A, yellow arrow indicating mid-systole on the ECG tracing). For easy recognition of the anatomic landmarks the valve is also shown in diastole (Panel B). Ao-aorta; ALC –anterolateral commissure; PMC – posteromedial commissure.

Figure 7. Mitral annular reconstruction from 3D transoesopageal datasets with measurement of the antero-posterior diameter of the mitral annulus (green continuous line).

Commissural diameter = 4.33 cm Anterior leaflet area = 11 cm² Tenting volume = 3 cm² Tenting height = 0.8 cm Commissural diameter = 4.33 cm Anterior leaflet area = 11 cm² Posterior leaflet area = 4.9 cm² Figure 8. Mitral valve morphology reconstruction from 3D transoesopageal datasets with measurement of the mitral valve tenting volume and height, intercommissural diameter and anterior and posterior leaflet area.

PSLA 2-Ch Figure 9. 2D transthoracic evaluation from the parasternal short axis view at the level of the mitral valve in a patient with secondary mitral regurgitation (SMR) showing the elliptical shape of the vena contracta (VC) of the regurgitant jet (green dotted line). Measurement of VC from the parasternal long axis view (PSLA) would underestimate the severity of the MR (white line) while measurement from the 2-chamber view (2-Ch) would overestimate its severity (black arrow). PSLA- parasternal long axis view; 2-Ch – 2 chamber view.

VC Area = 0.23 cm² Figure 10. Vena contracta (VC) area measurement by 3D transthoracic echocardiography in a patient with secondary mitral regurgitation and dilated cardiomyopathy. After full volume color Doppler acquisition with the 3D transthoracic probe from the apical window the 3D data set is cropped to derive the area of the vena contracta of the regurgitant jet. Direct planimetry of the vena contracta area is possible (white line enclosed area). The dotted green line represents the orthogonal plane in which the VC area measurement was done.

Figure 11. Instantaneous “Full volume” 3D transthoracic echocardiography with the assessment of the effective regurgitant orifice (ERO) area and regurgitant volume of a secondary mitral regurgitation by direct 3D measurement of proximal isovelocity surface area.