Clinical Investigation
3-Dimensional Echocardiography: Methodology
Taking Command of Three-Dimensional Stitching Artifacts: From an Annoyance to an Easy Tool for Navigating Three-Dimensional Transesophageal Echocardiography

https://doi.org/10.1016/j.echo.2022.09.013Get rights and content

Highlights

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    3D TEE stitching artifacts occur parallel to the probe's 2D multiplane rotation angle.

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    Cardiac imagers can move stitching artifacts to assess structures of interest.

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    Stitching artifact manipulation can help with image orientation and optimization.

Despite many recent advances in three-dimensional (3D) transesophageal echocardiography (TEE) imagining, the process of orienting 3D TEE images is nonintuitive and uses assumptions based on idealized anatomy. Correlating two-dimensional TEE cross-sectional images to 3D reconstructions remains an additional challenge. In this article, we suggest the repurposing of the stitching artifact generated in 2-beat electrocardiogram-gated 3D TEE as a means of exactly orienting 3D images within a patient's unique anatomy. We demonstrate the application of this strategy to assess a normal mitral valve to localize scallops of mitral valve prolapse and to visualize typical left atrial appendage two-dimensional cuts in a 3D space. By taking command of stitching artifacts, cardiac imagers can successfully navigate the complex structures of the heart for optimal, individualized echocardiographic views.

Section snippets

Background

In 1999, national organizations started publishing guidelines containing instructions for specific, anatomically directed cross-sectional transesophageal views to standardize the multiplane 2D TEE examination.8 To assess the MV, the original guidelines presented 6 different 2D views: (1) midepigastric (ME) 4 chamber, (2) ME mitral commissure, (3) ME 2 chamber, (4) ME long axis, (5) transgastric basal short axis, and (6) transgastric 2 chamber.8 Ever since, guidelines have been updated with 2D

Innovation

From our practice using modern TEE probes that are capable of both 2D and 3D imaging, we have discovered that the location of stitching artifacts can not only be predicted but can also be controlled using multiplane angle rotation. Protocols for 3D TEE examination specify multiplane rotation angles only when using 2D views as part of the process for acquiring optimal 3D reconstructions. Once in the 3D mode, the previously set 2D multiplane angle is generally considered irrelevant and therefore

Areas of Future Study

We purposefully used basic concepts in 3D TEE to describe the stitching artifact. However, the strategy can be applied for complex structural procedures, including optimizing 2D visualization of the grasp angle for mitral clip procedure, improving the guidance of LAA occlusion device deployment, and improving 2D imaging guidance in tricuspid edge-to-edge repair. Conceptually, the strategy is not limited to TEE, and the same phenomenon also occurs with 3D transthoracic echocardiography. These

Conclusion

Previously considered an annoying pitfall of ECG-gated 3D echocardiography, we hereby suggest an inherent utility of stitching artifacts. The primary objective of the stitching artifact strategy is to provide a very simple, cost-free method for easy correlation between 2D and 3D cuts in real time, as opposed to often costly postprocessing commercial software. While experienced echocardiographers are very familiar with identifying routine anatomy (i.e., the mitral scallops) in 2D and 3D imaging

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Conflicts of Interest: None.

Roberto M. Lang, MD, FASE, served as guest editor for this report.

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2022 by the American Society of Echocardiography.