Pulmonary valve assessment by three‐dimensional echocardiography

Abstract

The pulmonary valve (PV) has historically been ignored by imaging studies. Disorders of the PV encountered in adult cardiac patients are increasingly encountered due to advanced care of patients with congenital heart disease and associated PV diseases. Despite advances in PV imaging, multiple challenges remain when it comes to obtaining high quality PV images. While 2D TTE is the usual initial imaging tool for PV, excellent views of the PV annulus and its one or two leaflets are obtained in less than half of patients. The 3D echocardiography en face view allows all three leaflets to be evaluated concurrently, as well as assessments of the RV outflow tract and main pulmonary artery, which has improved quantitative assessment of PV diseases. Increasing image quality and experience with live/real time 3D TEE amplifies its utility in accurate evaluation and helps guide and monitor successful percutaneous PV interventions. 2D TTE remains the first line diagnostic tool; however, 3D TTE and 3D TEE provide better image quality which increases diagnostic accuracy and guidance to therapy. In this review article, we stress improvement in 3D echocardiography and its role in diagnostic and therapeutic options for PV diseases.

An unexpected sight—En face pulmonary valve

“…5 Knowledge of PV morphology may play a role in guiding surgical or interventional procedures in patients with valvular disease. 6,7 However, assessment of PV morphology using 2D TTE can be challenging. Due to its high anterior plane, retrosternal placement and proximity to the left upper lung lobe, comprehensive evaluation can be difficult.…”

“…Due to its high anterior plane, retrosternal placement and proximity to the left upper lung lobe, comprehensive evaluation can be difficult. 1,6,8 2D TTE typically shows the pulmonary artery in its long axis, which only two leaflets can be seen. A short-axis view of the PV is not usually obtained by 2D TTE, however in rare cases, patients with congenital heart disease or pulmonary hypertension, an en face view can be obtained.…”

“…10 However, these findings were dependent on the initial quality of the 2D image and are operator dependant, with successful PV imaging associated with a longer learning curve. 6,7,10 In some cases, transoesophageal echocardiography may provide better visualisation of the PV than TTE. 5,12 However, due to its anterior position in the chest, the TTE approach is often superior to the transoesophageal echocardiography.…”

“…5,8 Other cardiac imaging modalities such as computer tomography and magnetic resonance imaging may also be considered to further assess complex cardiac anatomy and allow for functional and morphological evaluation of the PV. 6,8…”

“…Knowledge of PV morphology may play a role in guiding surgical or interventional procedures in patients with valvular disease 6,7 . However, assessment of PV morphology using 2D TTE can be challenging.…”