Real Time Three-Dimensional Transesophageal Echocardiographic Evaluation of Aortic Valve Perforation

Objectives: This study evaluated the feasibility of real time three-dimensional transesophageal echocardiography (RT3DTEE) in the diagnosis and localization of aortic valve perforation. Methods Aortic valve perforation was diagnosed in 12 patients by multiplane two-dimensional transesophageal echocardiography (2DTEE). We studied the feasibility of RT3DTEE using en face view in detection and precise localization of the aortic valve perforation. The artifactual dropout on RT3D images of aortic valve can mimic perforation and lead to a false positive diagnosis. We defined a true perforation as the hole with thicker margin and its visibility in both systole and diastole. We combined the RT3D images from 10 subjects with relatively normal aortic valve without perforation (test group) with the 12 with perforation for a blind review by an experienced echocardiographer. Results There were 14 perforations in 12 patients. The perforation was located in the left coronary cusp in 1, the noncoronary cusp in 7, and the right coronary cusp in 6 patients. In the subgroup of 9 patients with 11 perforations, all were confirmed at surgery. In test group the artifact mimicking perforation was frequently encountered (7/10 or 70%). However, they did not meet the criteria for true perforation except in 1 (1 false positive). All true perforations were correctly recognized. Conclusions En face imaging with RT3DTEE can be used to confirm aortic valve perforation and its spatial location. However, RT3D should be used as an extension to comprehensive 2DTEE and color flow imaging.