Aug 2026· European heart journal. Imaging methods and practice· Vol 4· 0 citations· 41 references
Medicine
TL;DR
Three-dimensional echocardiography, particularly transoesophageal 3DE, has become an essential imaging modality for integrating anatomical and functional information and plays a pivotal role in promoting a repair-oriented approach to the management of aortic valve disease.
Abstract
Abstract Aims The aortic valve (AV) and aortic root complex constitute a functional unit, and their integrated anatomical and dynamic assessment is essential for the management of AV disease. This review highlights the role of three-dimensional echocardiography (3DE) in the comprehensive evaluation of AV disease and its contribution to therapeutic decision-making. Methods and results Owing to close collaboration with cardiac surgeons, 3DE has significantly expanded the diagnostic information provided by imaging cardiologists and has become a key tool for guiding therapeutic strategies. In patients with significant aortic regurgitation (AR), detailed anatomical assessment of the cusps enables characterization of valve morphology and tissue quality, while multiplanar reconstruction provides accurate measurements of the virtual basal ring, coronary ostial height, and other key anatomical structures. Quantitative assessment of cusp geometry, including effective, geometric, and coaptation heights, allows precise identification of AR mechanisms, thereby facilitating repair-oriented surgical planning. In aortic stenosis (AS), 3DE improves evaluation of discordant or borderline cases through enhanced assessment of the left ventricular outflow tract and direct planimetric measurement of AV area. In addition, 3DE provides complementary information for procedural planning of both transcatheter and surgical AV replacement, particularly in patients with contraindications to computed tomography. Conclusion Three-dimensional echocardiography, particularly transoesophageal 3DE, has become an essential imaging modality for integrating anatomical and functional information. It improves diagnostic accuracy, supports individualized therapeutic planning, and plays a pivotal role in promoting a repair-oriented approach to the management of aortic valve disease.
BACKGROUND
Isolated tricuspid regurgitation (TR) is an independent mortality predictor. Despite improved surgical outcomes, complex tricuspid valve anatomy makes precise repair challenging. We evaluated the utility of computed tomography (CT) with radial-sectional view (RSV) for procedural planning and postoperative assessment.
CASE SERIES
Four patients with severe TR underwent surgical repair. Preoperative CT-RSV, generated using standard imaging workstations, provided a comprehensive anatomical map. Radial planes centered on the septal leaflet visualized coaptation gaps with anterior/posterior leaflets, the location of prolapse, and the severity of tethering. This "virtual surgery" enabled individualized strategies. In all cases, tricuspid valve repair was performed according to CT-based planning, resulting in marked reduction of TR.
CONCLUSIONS
CT-RSV provides a reproducible and accessible roadmap. By detailing septal-centric anatomy, it facilitates clearer visualization of leaflet and subvalvular structures compared with transesophageal echocardiography and enables reproducible quantitative assessment, thereby supporting individualized surgical planning and informing treatment strategy selection.
Y. Kitagata, Akihiro Isotani, Aya Miyazaki et al.· JACC Case Reports· 0 citations
Aortic valve repair (AVr) has evolved into a reproducible surgical strategy for selected patients with aortic regurgitation (AR), offering preservation of native tissue, avoidance of prosthesis-related complications, and favorable long-term outcomes when performed at expert centers. This narrative review summarizes contemporary concepts, indications, preoperative imaging work-up, and procedure selection for AVr in tricuspid (TAV) and bicuspid (BAV) aortic valves, with an emphasis on functional mechanisms and standardized annular and root stabilization. Recent international guidelines and key surgical series and registries addressing aortic valve repair, valve-sparing root replacement (VSRR), annuloplasty strategies, and bicuspid repair techniques were reviewed. Modern AVr is anchored in mechanism-based diagnosis of AR, systematic correction of cusp pathology, and stabilization of the functional aortic annulus (FAA), including the virtual basal ring, sinotubular junction, and aortic root. Current guideline recommendations support aortic valve repair in selected patients with severe AR at experienced centers when durable results are expected and recommend valve-sparing root replacement in young patients with aortic root dilation. Quantitative intraoperative quality control, including effective height targets, and durable annular stabilization are key determinants of repair longevity. AVr and VSRR represent mature surgical options for carefully selected patients with AR, particularly younger individuals with good cusp tissue and access to high-volume repair expertise. A mechanism-driven algorithm, including BAV-specific geometry restoration approaches such as the 180-degree reimplantation technique, may clarify the optimal procedure for each clinical scenario.
Łukasz Jaworski, S. Beta, Maria Nowak et al.· Cardiology Journal· 0 citations
Aortic stenosis (AS) is the most common degenerative valvular disease in elderly patients and is linked to high morbidity and mortality. Accurate diagnosis and risk stratification are critical for effective management. Transthoracic echocardiography is the standard diagnostic tool, but its reliance on flow-dependent parameters can lead to inconsistent grading, especially in low-flow, low-gradient, or normal-flow, low-gradient AS. Advanced echocardiographic methods, such as 3D imaging, stress echocardiography, and Doppler indices, such as the mean gradient-to-effective orifice area ratio, improve the evaluation of AS severity and assist in clinical decision-making. Computed tomography provides a flow-independent evaluation of AS. It uses noncontrast calcium scoring with sex-specific thresholds, along with contrast-enhanced angiography, for detailed anatomical assessment. These modalities are essential for procedural planning, particularly for transcatheter aortic valve replacement. Cardiac magnetic resonance (CMR) provides additional prognostic information. It quantifies myocardial remodeling and fibrosis, which are associated with outcomes and recovery potential. Emerging technologies are expanding diagnostic capabilities in AS. Examples include 18F-sodium fluoride positron emission tomography for detecting microcalcification, artificial intelligence-based ECG and echocardiography for early diagnosis, and 4D flow CMR. Integration of echocardiography, computed tomography, CMR, and emerging positron emission tomography and artificial intelligence-based approaches can help address diagnostic uncertainty. This integration helps refine AS subtype classification and inform individualized intervention strategies.
H. Itani, M. Moumneh, A. Zayed et al.· Cardiology in Review· 0 citations
Transcatheter aortic valve implantation is increasingly performed in younger and lower-risk patients, shifting attention toward long-term prosthetic valve durability. While transthoracic echocardiography remains the cornerstone of follow-up, it primarily reflects global hemodynamics and may not detect early structural or geometric abnormalities after implantation. Hypoattenuated leaflet thickening and reduced leaflet motion, collectively referred to as subclinical leaflet thrombosis, represent dynamic phenomena that may precede overt valve dysfunction. Growing evidence suggests that prosthesis geometry, including under-expansion, ellipticity, commissural misalignment, canting and implantation depth, may alter neo-sinus flow and promote thrombotic substrate formation. Multidetector computed tomography enables integrated assessment of leaflet morphology, perivalvular thrombus, and prosthetic geometry, providing insights into the mechanical determinants of thrombosis. In this State-of-the-Art review, we examine the role of multimodality imaging in identifying thrombogenic valve phenotypes and propose a pragmatic imaging framework integrating echocardiography with selective multidetector computed tomography to support individualized post-TAVI surveillance and management.
M. Moscarelli, Philippe Pibarot, N. V. vanMieghem et al.· European Journal of Cardio-T...· 0 citations
Degenerative mitral stenosis (MS) related to mitral annular calcification (MAC) is increasingly observed in elderly patients and differs fundamentally from rheumatic MS. While rheumatic MS is characterized by commissural fusion and a funnel-shaped orifice at the leaflet tips, MAC produces a rigid, tubular geometry with maximal narrowing at the annular level. Conventional two-dimensional echocardiography often provides unreliable assessment of degenerative MS: anatomical evaluation is challenging because the valve has a non-planar, tubular geometry and calcification can create acoustic shadowing, and hemodynamic measurements, such as transmitral gradients, may also be misleading, as coexisting atrial or diastolic dysfunction can elevate gradients and overestimate the severity of stenosis. Three-dimensional echocardiography enables multiplanar reconstruction tailored to the underlying etiology, allowing precise planimetric measurement of the true anatomical mitral valve area. In rheumatic MS, measurements are aligned at the leaflet tips, whereas in degenerative MS, the narrowest orifice at the annular level is accurately captured. Recognizing these morphological differences ensures that three-dimensional planimetry provides an anatomically faithful and clinically meaningful assessment of MS across different etiologies.
Gregorio Menzà, A. Navazio· The Cardiology· 0 citations
