Echocardiography. 2018;35:855–859. wileyonlinelibrary.com/journal/echo
© 2018 Wiley Periodicals, Inc.
1 | INTRODUCTION
Evaluation of the pulmonary valve (PV) by both M- mode and two-
dimensional transthoracic echocardiography (2DTTE) has always
been a challenge due to its close proximity to the left lung and un-
certainty about which cusps have been included in the thin slices
obtained by 2DTTE. In general, only one or two leaflets are imaged
by 2DTTE in a teenager or adult even when the pulmonary artery is
prominent or enlarged. On the other hand, with the large datasets
acquired by live/real time three- dimensional (3D)TTE, the poten-
tial exists for imaging all the three leaflets of the PV. There are only
a few studies assessing the PV by 3DTTE, but none of them have
commented on individual cusp identification.
The aim of the pres-
ent preliminary study was to assess the usefulness and incremental
value of 3DTTE over 2DTTE in imaging and identifying individual
cusps of the PV in patients who were 15 years or older and in whom
only two cusps of the PV could be detected by 2DTTE.
2 | MATERIALS AND METHODS
This study included 21 patients, 4 females and 17 males, ages rang-
ing from 15 to 90 years (mean 54 years, Table 1), in whom, only two
leaflets of the PV could be visualized on 2DTTE. An S5- 1 transducer
and a commercially available Philips (Andover, MA, USA) iE33 ultra-
sound system were utilized for all 2DTTE examinations where an at-
tempt was made to delineate as many cusps of the PV as possible
using various views including the parasternal aortic short axis and
the mitral–pulmonic plane.
All patients also underwent 3DTTE per-
formed in the standard manner immediately after 2DTTE using an
X3- 1 transducer and the same ultrasound system.
All 3DTTE data-
sets were meticulously cropped using multiple plane angulations and
the PV leaflets were visualized from different perspectives includ-
ing enface views. Both full- volume and multiplanar reconstruction
(MPR) modes were obtained and analyzed using Q- LAB 10.2 soft-
ware by Philips (Andover, MA, USA).
RESEARCH FROM OR IN COLLABORATION WITH
THE UNIVERSITY OF ALABAMA AT BIRMINGHAM
Three- dimensional transthoracic echocardiographic
identification of individual cusps of the pulmonary valve:
Potential misidentification by the two- dimensional technique
Mahmoud Elsayed MBBCh
| Ming C. Hsiung MD
| Navin C. Nanda MD
| Naga Sai Shravan Turaga MBBS
Elsayed, Hsiung and Nanda equally contributed to this study.
Department of Internal Medicine, Michigan
State University, East Lansing, MI, USA
Division of Cardiology, Cheng Hsin General
Hospital, Taipei, Taiwan
Division of Cardiovascular
Disease, University of Alabama at
Birmingham, Birmingham, AL, USA
Department of Internal Medicine, Louisiana
State University, Lafayette, LA, USA
Navin C. Nanda, University of Alabama at
Birmingham, Birmingham, AL, USA.
We demonstrate the incremental value of live/real time three- dimensional transtho-
racic echocardiography (3DTTE) over the two- dimensional modality in the identifica-
tion of all three cusps of the pulmonary valve in patients in whom only two leaflets
could be detected by the latter technique. This was because of the ability of 3DTTE
to view the cusps enface permitting assessment of relationship to one another and
the surrounding cardiac structures. In addition, 3DTTE showed not only the potential
errors that can occur in pulmonary valve cusp identification when the two-
dimensional modality is used alone but also how some of these errors can be avoided
by paying attention to the surrounding structures.
echocardiography, individual cusps of pulmonary valve, pulmonary valve, three-dimensional
echocardiography, transthoracic echocardiography, two-dimensional echocardiography