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Advances in echocardiography have been responsible for enhancing our understanding of the mechanisms and progression of cardiovascular diseases. The introduction of new echocardiographic imaging modalities has greatly aided our ability to obtain early and precise disease diagnosis, while simultaneously allowing better means to guide medical or surgical care for patients with heart diseases. In this chapter, we discuss the role of these emerging echocardiographic technologies in the perioperative period.

Three-dimensional (3D) echocardiography has a long history with the first 3D-reconstruction of two-dimensional (2D) images described in 1974 and the first human 3D–transesophageal echocardiogram (TEE) performed in 1992.1,2 Until recently, 3D-TEE was performed using a rotational approach for sequential data acquisition, gated to electrocardiography (ECG) and respiration.2,3 Volume rendering and cropping of these reconstructed 3D volume data sets allowed display of structures of interest. However, these earlier approaches were limited by time-consuming acquisition and reconstruction processes (15 to 30 minutes), frequent artifacts, and the need for offline processing.4,5 As a consequence, reconstructive 3D-TEE remained primarily a research tool and did not make it into routine clinical practice. With the recent introduction of a 3D fully sampled matrix array TEE transducer, many of these limitations have been overcome. Based on novel electronic circuitry and a matrix array design of piezoelectric crystals within an otherwise conventional TEE probe, this new technology allows both real-time acquisition as well as live display of 3D images. This real-time 3D-TEE (RT-3D-TEE) system allows for excellent visualization of the mitral valve (MV), the interatrial septum (IAS), the left atrial appendage (LAA), pulmonary veins, and the left ventricle (LV), while imaging of the aortic valve (AV) and tricuspid valve (TV) will require further technological improvements.6,7 Due to its unique features of real-time acquisition, online rendering and cropping capabilities, accurate identification of the precise pathology and location of cardiac disease, and prompt quantification of 3D structures with built-in software, RT-3D-TEE is expected to soon become a standard of perioperative care and clinical practice. However, this emerging technology requires the echocardiographer to acquire new sets of skills to acquire and manipulate the 3D data sets so that they can reveal valuable information. With an emphasis on RT-3D-TEE, the following sections will combine practical recommendations with some of the key features of the emerging 3D technology.

Imaging Technology

Technologic advances in the 1990s have allowed improved reconstructive 3D echocardiography based on the acquisition of multiple, gated image planes using ECG and respiratory gating that limits the amount of motion artifacts. Post-processing of acquired images results in further optimization of these reconstructive 3D images. One significant drawback of these approaches to 3D echocardiography was that live, real-time (RT) imaging could not be achieved because the different imaging planes are acquired sequentially. Further, sequential and gated acquisition frequently resulted in motion artifacts. In the late 1980s, a sparse array matrix transducer containing 256 elements was designed to develop a new approach ...

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