3D echocardiography to plan aortic valve surgery and evaluate the results

Abstract

Three-dimensional transesophageal echocardiography (3D TEE) has become an indispensable tool for the anatomical and functional assessment of the aortic valve (AV). Accurately identifying the degree of regurgitation or stenosis is critical for therapeutic decision making; 3D TEE provides comprehensive morphological and functional descriptions, which have been improved by the introduction of new analytic methods. This review examines the development of 3D echocardiography in evaluating AV disorders, emphasizing its advantages over conventional 2D imaging. 3D TEE improves the accuracy of measures crucial to surgical planning and prosthesis selection, enabling real-time visualization of valve shape and dynamics. The widespread adoption of 3D echocardiography will contribute to improving the treatment of AV diseases as technology advances, thereby opening new horizons for more patient-tailored therapeutic strategies.

Keywords

Aortic valve / three-dimensional echocardiography / aortic surgery / transcatheter aortic valve replacement / multimodality imaging

References

[1] Surkova E,Aruta P.Current clinical applications of three-dimensional echocardiography: when the technique makes the difference.Curr Cardiol Rep2016;18:109

[2] Faletra FF,Flachskampf FA.Three-dimensional transoesophageal echocardiography: how to use and when to use-a clinical consensus statement from the European Association of Cardiovascular Imaging of the European Society of Cardiology.Eur Heart J Cardiovasc Imaging2023;24:e119-97

[3] Hagendorff A,Fehske W.Improvement in the assessment of aortic valve and aortic aneurysm repair by 3-dimensional echocardiography.JACC: Cardiovasc Imaging2019;12:2225-44

[4] Fan Y,Lee AP.Advances in procedural echocardiographic imaging in transcatheter edge-to-edge repair for mitral regurgitation.Front Cardiovasc Med2022;9:864341 PMCID:PMC8996060

[5] Piazza N,Schultz C,Serruys PW.Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve.Circ Cardiovasc Interv2008;1:74-81

[6] Underwood MJ,Deronck D,Dion R.The aortic root: structure, function, and surgical reconstruction.Heart2000;83:376-80 PMCID:PMC1729360

[7] le Polain de Waroux JB,Robert A.Mechanisms of recurrent aortic regurgitation after aortic valve repair: predictive value of intraoperative transesophageal echocardiography.JACC Cardiovasc Imaging2009;2:931-9

[8] Lang RM,Tsang W.American Society of EchocardiographyEuropean Association of EchocardiographyEAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography.Eur Heart J Cardiovasc Imaging2012;13:1-46

[9] Fiore G,Ingallina G.Accuracy and reliability of left atrial appendage morphology assessment by three-dimensional transesophageal echocardiographic glass rendering modality: a comparative study with computed tomography.J Am Soc Echocardiogr2023;36:1083-91

[10] Wollborn J,Sheu RD,Nyman CB.Real-time multiplanar reconstruction imaging using 3-dimensional transesophageal echocardiography in structural heart interventions.J Cardiothorac Vasc Anesth2023;37:570-81

[11] Lemaire G.Echocardiography of the aortic root: a practical approach for aortic valve-sparing surgery.Ann Cardiothorac Surg2023;12:194-212 PMCID:PMC10248922

[12] Papadopoulos K,Coisne A.Initial experience with the 4D mini-TEE probe in the adult population.J Clin Med2024;13:6450 PMCID:PMC11546711

[13] Iung B,Rosenhek R.EORP VHD II InvestigatorsContemporary presentation and management of valvular heart disease: the EURObservational Research programme valvular heart disease II survey.Circulation2019;140:1156-69

[14] Baumgartner H,Bermejo J.Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography.Eur Heart J Cardiovasc Imaging2017;18:254-75

[15] Otto CM.Valvular aortic stenosis: disease severity and timing of intervention.J Am Coll Cardiol2006;47:2141-51

[16] Nishi T,Tabata M.Accuracy and usefulness of aortic annular measurement using real-time three-dimensional transesophageal echocardiography: comparison with direct surgical sizing.J Cardiol2018;71:230-6

[17] Dima CN,Mornos C.Three-dimensional transesophageal echocardiography as an alternative to multidetector computed tomography in aortic annular diameter measurements for transcatheter aortic valve implantation.Biology2021;10:132 PMCID:PMC7916087

[18] Bleakley C,Monaghan M.3D transoesophageal echocardiography in the TAVI sizing arena: should we do it and how do we do it?.Echo Res Pract2017;4:R21-32

[19] Mehrotra P,Jansen K.Differential left ventricular outflow tract remodeling and dynamics in aortic stenosis.J Am Soc Echocardiogr2015;28:1259-66

[20] Nanditha S.Comparison of flow-independent parameters for grading severity of aortic stenosis using intraoperative transesophageal echocardiography - a prospective observational study.Ann Card Anaesth2020;23:425-8 PMCID:PMC7879882

[21] Gaspar T,Sachner R.Three-dimensional imaging of the left ventricular outflow tract: impact on aortic valve area estimation by the continuity equation.J Am Soc Echocardiogr2012;25:749-57

[22] Saitoh T,Izumo M.Comparison of left ventricular outflow geometry and aortic valve area in patients with aortic stenosis by 2-dimensional versus 3-dimensional echocardiography.Am J Cardiol2012;109:1626-31

[23] Kapadia SR,Makkar RR.PARTNER trial investigators5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial.Lancet2015;385:2485-91

[24] Leon MB,Mack MJ.PARTNER 2 InvestigatorsTranscatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med2016;374:1609-20

[25] Mack MJ,Thourani VH.PARTNER 3 InvestigatorsTranscatheter aortic-valve replacement in low-risk patients at five years.N Engl J Med2023;389:1949-60

[26] Forrest JK,Deeb GM.Low Risk Trial Investigators5-year outcomes after transcatheter or surgical aortic valve replacement in low-risk patients with aortic stenosis.J Am Coll Cardiol2025;85:1523-32

[27] Vahanian A,Praz F.ESC/EACTS Scientific Document Group2021 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J2022;43:561-632

[28] Hayashida K,Lefèvre T.Impact of CT-guided valve sizing on post-procedural aortic regurgitation in transcatheter aortic valve implantation.EuroIntervention2012;8:546-55

[29] Lehmkuhl L,Von Aspern K.Inter-individual variance and cardiac cycle dependency of aortic root dimensions and shape as assessed by ECG-gated multi-slice computed tomography in patients with severe aortic stenosis prior to transcatheter aortic valve implantation: is it crucial for correct sizing?.Int J Cardiovasc Imaging2013;29:693-703 PMCID:PMC3608865

[30] Rong LQ,Salemi A.Three-dimensional echocardiography for transcatheter aortic valve replacement sizing: a systematic review and meta-analysis.J Am Heart Assoc2019;8:e013463

[31] Smith LA,Bhan A.Real-time three-dimensional transesophageal echocardiography adds value to transcatheter aortic valve implantation.J Am Soc Echocardiogr2013;26:359-69

[32] Blanke P,Webb JG.Oversizing in transcatheter aortic valve replacement, a commonly used term but a poorly understood one: dependency on definition and geometrical measurements.J Cardiovasc Comput Tomogr2014;8:67-76

[33] Akinseye OA,Ibebuogu UN.Clinical outcomes of coronary occlusion following transcatheter aortic valve replacement: a systematic review.Cardiovasc Revasc Med2018;19:229-36

[34] Mauri V,Deuschl F.Impact of device landing zone calcification patterns on paravalvular regurgitation after transcatheter aortic valve replacement with different next-generation devices.Open Heart2020;7:e001164 PMCID:PMC7223472

[35] Hassan M,Wahba WA,Baghdady Y.Agreement between 4D transesophageal echocardiography and multi-detector computed tomography in measuring aortic root dimensions and coronary ostia heights.Int J Cardiovasc Imaging2023;39:1561-9 PMCID:PMC10427530

[36] de Agustin JA,Olmos C.Current usefulness of transesophageal echocardiography in patients undergoing transcatheter aortic valve replacement.J Clin Med2023;12:7748 PMCID:PMC10743683

[37] Shibayama K,Jilaihawi H.3D assessment of features associated with transvalvular aortic regurgitation after TAVR: a real-time 3D TEE study.JACC Cardiovasc Imaging2016;9:114-23

[38] Khalique OK,White JM.Impact of methodologic differences in three-dimensional echocardiographic measurements of the aortic annulus compared with computed tomographic angiography before transcatheter aortic valve replacement.J Am Soc Echocardiogr2017;30:414-21

[39] Kato N,Noguchi M.Superiority of novel automated assessment of aortic annulus by intraoperative three-dimensional transesophageal echocardiography in patients with severe aortic stenosis: Comparison with conventional cross-sectional assessment.J Cardiol2018;72:321-7

[40] Dumesnil JG.Prosthesis-patient mismatch: an update.Curr Cardiol Rep2011;13:250-7

[41] Head SJ,Osnabrugge RLJ.The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27 186 patients with 133 141 patient-years.Eur Heart J2012;33:1518-29

[42] Lancellotti P,Chambers J.Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging.Eur Heart J Cardiovasc Imaging2016;17:589-90

[43] Zoghbi WA,Chamsi-Pasha MA.Guidelines for the evaluation of prosthetic valve function with cardiovascular imaging: a report from the American Society of echocardiography developed in collaboration with the society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography.J Am Soc Echocardiogr2024;37:2-63

[44] Pibarot P,Stewart J.Incidence and sequelae of prosthesis-patient mismatch in transcatheter versus surgical valve replacement in high-risk patients with severe aortic stenosis: a PARTNER trial cohort-a analysis..J Am Coll Cardiol2014;64:1323-34

[45] ISO. International Standard, ISO 5840:2015. Cardiovascular implants-cardiac valve prostheses. International Organization for Standardization (ISO), 2015. Available from: https://www.iso.org/standard/77033.html#lifecycle [Last accessed on 19 Aug 2025]

[46] Durko AP,Pibarot P.Characteristics of surgical prosthetic heart valves and problems around labelling: a document from the European Association for Cardio-Thoracic Surgery (EACTS)-The Society of Thoracic Surgeons (STS)-American Association for Thoracic Surgery (AATS) valve labelling task force.Eur J Cardiothorac Surg2019;55:1025-36

[47] Mazzolai L,Lanzi S.ESC Scientific Document Group2024 ESC Guidelines for the management of peripheral arterial and aortic diseases.Eur Heart J2024;45:3538-700

[48] Michelena HI,Evangelista A.Endorsed by the Heart Valve Society (HVS)European Association of Cardiovascular Imaging (EACVI)Society of Thoracic Surgeons (STS)American Association for Thoracic Surgery (AATS)Society for Cardiovascular Magnetic Resonance (SCMR)Society of Cardiovascular Computed Tomography (SCCT)North American Society for Cardiovascular Imaging (NASCI) and the International Bicuspid Aortic Valve Consortium (BAVCon)International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes.Eur J Cardiothorac Surg2021;60:448-76

[49] Paulis R.Surgical anatomy of the aortic valve and root-implications for valve repair.Ann Cardiothorac Surg2019;8:313-21 PMCID:PMC6562095

[50] Malas T,Sohmer B.Is aortic valve repair reproducible?.Can J Cardiol2015;31:1497.e15-22

[51] Berrebi A,Lansac E.Systematic echocardiographic assessment of aortic regurgitation-what should the surgeon know for aortic valve repair?.Ann Cardiothorac Surg2019;8:331-41 PMCID:PMC6562091

[52] Lang RM,Narang A.3-dimensional echocardiography: latest developments and future directions.JACC Cardiovasc Imaging2018;11:1854-78

[53] Hahn RT,Adams MS.Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists.J Am Soc Echocardiogr2013;26:921-64

[54] Smer A,Anugula D.Three-dimensional echocardiographic assessment of the aortic valve and the aorta.Echocardiography2022;39:1011-27

[55] Boodhwani M,Watremez C.Assessment and repair of aortic valve cusp prolapse: implications for valve-sparing procedures.J Thorac Cardiovasc Surg2011;141:917-25

[56] Zoghbi WA,Bonow RO.Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance.J Am Soc Echocardiogr2017;30:303-71

[57] Ranard LS,Nishimura R.Heart Valve CollaboratoryImaging methods for evaluation of chronic aortic regurgitation in adults: JACC state-of-the-art review.J Am Coll Cardiol2023;82:1953-66

[58] Agricola E,Mele D.Real-time three dimensional transesophageal echocardiography: technical aspects and clinical applications.Heart Int2010;5:e6 PMCID:PMC3184702

[59] Stoebe S,Jurisch D.Analysis of chronic aortic regurgitation by 2D and 3D echocardiography and cardiac MRI.Echo Res Pract2018;5:51-62

[60] Ewe SH,van der Geest R.Accuracy of three-dimensional versus two-dimensional echocardiography for quantification of aortic regurgitation and validation by three-dimensional three-directional velocity-encoded magnetic resonance imaging.Am J Cardiol2013;112:560-6

[61] Choi J,Kim M.Automatic quantification of aortic regurgitation using 3D full volume color doppler echocardiography: a validation study with cardiac magnetic resonance imaging.Int J Cardiovasc Imaging2015;31:1379-89

[62] Shanks M,Delgado V.Quantitative assessment of mitral regurgitation: comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging.Circ Cardiovasc Imaging2010;3:694-700

[63] Shiota T.3D echocardiography: the present and the future.J Cardiol2008;52:169-85

[64] Connor B,Clark DE.Improved quantification of aortic regurgitation with direct regurgitant jet measurement by four-dimensional flow cardiovascular magnetic resonance in complex congenital heart disease.J Cardiovasc Magn Reson2025;27:101876 PMCID:PMC12053713

[65] Belli M,Prandi FR.Diagnosis of atrial cardiomyopathy: from the electrocardiogram to the new opportunities with multimodality imaging.J Cardiovasc Med2025;26:88-101

[66] Schäfers HJ,Marom G.Cusp height in aortic valves.J Thorac Cardiovasc Surg2013;146:269-74

[67] Schäfers HJ,Aicher D.A new approach to the assessment of aortic cusp geometry.J Thorac Cardiovasc Surg2006;132:436-8

[68] Schäfers HJ,Langer F.Preservation of the bicuspid aortic valve.Ann Thorac Surg2007;83:S740-5; discussion S785

[69] Schäfers HJ.The 10 commandments for aortic valve repair.Innovations2019;14:188-98

[70] De Paulis R,De Kerchove L.Current status of aortic valve repair surgery.Eur Heart J2025;46:1394-411

[71] Ehrlich T,Vojacek J.State-of-the art bicuspid aortic valve repair in 2020.Prog Cardiovasc Dis2020;63:457-64

[72] Rodríguez-Palomares JF,Guala A,Evangelista A.Mechanisms of aortic dilation in patients with bicuspid aortic valve: JACC state-of-the-art review.J Am Coll Cardiol2023;82:448-64

[73] La Mura L,Musella F.Aortic regurgitation in bicuspid aortic valve: the role of multimodality imaging.J Clin Med2024;13:3924 PMCID:PMC11242072

[74] Italiano G,Fusini L.Feasibility and accuracy of the automated software for dynamic quantification of left ventricular and atrial volumes and function in a large unselected population.J Clin Med2021;10:5030 PMCID:PMC8584703

[75] Marigliano AN,Casas J.Aortic regurgitation: from valvular to myocardial dysfunction.J Clin Med2024;13:2929 PMCID:PMC11122337

[76] Tretter JT,Najm HK.Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm.Ann Cardiothorac Surg2023;12:295-317 PMCID:PMC10405341

[77] Hahn RT,Douglas PS.Comprehensive echocardiographic assessment of normal transcatheter valve function.JACC Cardiovasc Imaging2019;12:25-34

[78] Komiya T,Nonaka M.Is small cusp size a limitation for aortic valve repair?.Eur J Cardiothorac Surg2019;56:497-502