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Accurate information and data is vital when performing a procedure with the intentions to correct an abnormality within the heart. “Morphologic description of ventricular septal defect (VSD) is mandatory before performing the newly developed transcatheter closure procedure. Inaccurate estimation of defect size has been reported using conventional two-dimensional (2D) transthoracic echocardiography (TTE)” (Hadeed, 2016, p. 777). Hadeed et al (2016) discuss the differences between 2DTTE and three-dimensional transthoracic echocardiography (3DTTE) and how 3DTTE can improve the diagnosis of a VSD. But what is VSD? Why is 2DTTE not as effective as 3DTTE in determining the dimensions (or the morphologic description) of the defect? The human heart consists of four chambers with each having a specific role in the circulatory system.
There are two smaller chambers called the left and right atria and two larger chambers called the left and right ventricles. Both ventricles function to circulate the blood to different regions in the body: the right pumps the blood to the lungs to release CO₂ and pick up oxygen, the left pumps the oxygenated blood to the rest of the body. Due to differing functions and pressures within the ventricles, they must be separated from each other in order to work as efficiently as possible. The interventricular septum (IVS) is the wall between the left and right ventricles. This muscular structure divides the chambers allowing for the multiple functions to occur. When the IVS does not form correctly during development, the condition can become a VSD leaving a hole within the structure and causing complications. The septal defect can occur in the membranous portion of the septum or the muscular portion of the IVS. The membranous portion is the superior section of the septum, located near the aortic and tricuspid valves. Inferior to the membranous portion is the muscular segment consisting of the inlet, outlet, and trabecular regions. During fetal development, the IVS can form improperly leaving an opening or a window within the septum which allows blood flow between the right and left ventricles (“Stanfordchildrens”, 2018). The overload of blood from the left side to the right, can cause major complications such as Eisenmenger’s syndrome in which the shunt then becomes right-to-left and can lead to pulmonary hypertension, displacement of the aorta, and right ventricular hypertrophy.
In many cases, before a procedure can be performed on a patient with a VSD, there needs to be strong information and data on the morphologic description of the defect. Hadeed et al (2016) discuss the use of 3DTTE and its importance in measuring VSDs on a study involving forty-eight children. This procedure provides accurate details on the dimensions of the defect during all cardiac cycles making an easier and precise assessment possible. Although 2DTTE provides accurate data for many conditions, it has limitations and is shown to be less effective than 3DTTE when analyzing septal defects. Using multiple planes allows 3DTTE an advantage as it has the ability to capture the entire shape of the defect throughout the motion of the cardiac cycle.
According to Hadeed et al. (2016) “Real-time 3D en face views offer a direct visualization of VSD shape motion from either the left or right ventricle” (781). The irregularity of the defect and its shape can be better visualized using 3DTTE. Before the cardiac surgeon can perform the surgical procedure, knowing the size and shape of the VSD is vital for determining the correct dimensions for the closure device. Collected Data Studies show that measuring VSDs with just 2DTTE can lead to inaccurate findings and may lead to the wrong sizing for closure devices as a result. Therefore, it is vital that the defect is recorded as accurately as possible to minimize any further complications. By using multiple planes to measure the size and shape from different locations, 3DTTE presents stronger and more reliable data. “The 3D data set analysis was performed using multiplanar reconstruction mode” (Hadeed et al, 2016, p. 778). Figure 1 (Hadeed et al, 2016, p. 779) demonstrates the use of 3DTTE and how effective it is for understanding the true morphology of the defect as it uses multiple planes to view the defect at different angles. Figure A demonstrates a membranous VSD while figure B shows a muscular VSD being measured using MPR mode.
The red line establishes the plane obtained from the axis being positioned along the IVS to include the entire VSD. This plane allowed for the VSD area and minimal and maximal diameters to be measured. Hadeed et al. (2016) explains how they compared results from 3DTTE measurements of the defect size with the measurements obtained from the surgical approach in forty-eight children with muscular and membranous VSDs. By observing the septal defect from the right ventricular side, the 3DTTE provided results comparable to the surgical measurements. This method allowed strong verification of the reliability of data for this procedure. “However, we found a close correspondence between maximal diameter obtained by 3DTTE and maximal surgical diameter. This confirms the high accuracy of 3DTTE for VSD sizing” (Hadeed et al, 2016, p. 780). The same study assessed the minimal and maximal measurements from 2DTTE and differentiated between all three. Table 1 (Hadeed et al, 2016, p. 782) demonstrates the maximal diameters obtained by using 2DTTE, 3DTTE, and surgical measurements. All results were compared and further prove the quality and reliability of 3DTTE. An obvious and strong correlation was observed between surgical measurements and those made by 3DTTE. The maximal VSD diameter was measured using 2DTTE, 3DTTE and surgically.
The average 2DTTE measurement was 8. 5 mm with a range of 2. 3 mm above and below. Compared to the measurements by 3DTTE, averaging 11. 9 and a range of 3. 4 mm above and below, 2DTTE was further off from the calculations done surgically. With only a difference of 0. 30 mm, the average 3DTTE maximal VSD diameter measurement was very close to the average measurement of 12. 2 mm done surgically. By comparing 2DTTE and 3DTTE measurement with those done surgically, further evidence was established on the importance of 3DTTE for this congenital defect. “The mean difference between surgical and 3D measurements was 0. 25 mm, with 95% of values ranging from 1. 35 to 0. 85 mm. The mean maximal 2D diameter was significantly lower than mean surgical measurements” (Hadeed, 2016, pg. 779). Using 2DTTE not only produced inaccurate results but underestimated maximal VSD diameters as well. Surgical and 3D measurements were very similar averaging in a range of 0. 50 mm and only a 0. 25 mm difference. Another study done by Tandon et al. was based on the size and shape of a VSD in a five-year-old also confirmed the importance of 3DTTE in comparison to the reliability of 2DTTE. Tandon et al. (2010) analyzed the measurements of a perimembranous VSD using 3DTTE and 2DTTE with the conclusion being similar to that of Hadeed. “Two-dimensional echocardiography is useful for diagnosis but combining it with real-time three-dimensional echocardiography helps in a more detailed evaluation” (Tandon et al, 2010, p. 87).
Using 2DTTE allowed the VSD to be discovered but 3DTTE was necessary for accurate measurements to be completed. A study by Ahmed, Gok and Yuzbas et al. (2014) evaluated a patient with a perimembranous VSD along with a ruptured sinus of valsalva (SVA) and explains the difficulties of using 2DTTE and how 3DTTE can improve accuracy in the results. Two turbulent jets were identified using 2D Doppler images which appeared to originate from different locations. 2DTTE methods provided details such as when the jets were present, whether in systole or diastole, but the distinction of which jet was from the VSD and which was from the SVA was clearly defined with 3D views. “3DTTE further delineated these 2 defects clearly showing one of them arising from the right SVA and the other from the ventricular septum providing increased conﬁdence in diagnosis. 3DTTE also permitted en face viewing of the entrance of these defects in the right ventricle enabling assessment of the shape and size of both oriﬁces and their exact locations” (Ahmed et al, 2014, p. 779-780). Diagnosing this type of defect when associated with a ruptured sinus can be difficult with 2DTTE, therefore it is necessary to apply 3D procedures for precision. The relationship between a VSD and a double-chambered right ventricle (DCRV) in a twelve-year-old male was assessed in the study by Kharwar, Dwivedi and Sharma (2015). They discovered there were limitations when examining the DCRV using 2DTTE but the 3DTTE results were more reliable when measuring the VSD. “Although the muscle bundle could not be clearly demonstrated, the anatomical relationship between the membranous VSD, subaortic membrane and the RVOT muscle bundle was clearly delineated with 3DTTE.
The exact shape of the VSD as viewed from the RV and the LV side was clearly delineated with the help of 3D echocardiography” (Kharwar et al, 2015, p. 325). The study portrayed just how accurate 3DTTE is when diagnosing septal defects.
The IVS is a unique structure that needs to be analyzed in multiple planes to fully understand its characteristics. “The ventricular septum is curved and therefore does not lie in a single plane” (Armstrong et al, 2010, p. 590). Feigenbaum’s (2014) explains how complex it can be to measure a defect within the IVS. As predicted by Feigenbaum, 3DTTE has developed with techniques that allow this method to accurately measure VSDs and provide detailed information regarding the morphologic description. In comparison with 2DTTE, the outcome from measuring VSDs using 3DTTE was significantly more effective as Hadeed et al. (2016) substantiates in his study involving forty-eight children. The study shows a weak correlation between the surgical findings and 2DTTE measurements while also demonstrating the strong correspondence of 3DTTE measurements with those calculated surgically.
Using just the 2D procedure, the defect sizes were measured showing smaller results than from the 3D and surgical approach. Tandon et al. (2010) also determined that 3DTTE is necessary to gain a full understanding of the size and shape of the defect while measuring a perimembranous VSD. Other studies further validate the importance of 3DTTE for VSD measurements. Ahmed et al. (2014) demonstrated the need for a 3D approach when determining the origin of two separate jets involving the left ventricular outflow tract as the distinction was not made clear by 2DTTE. Discovering the exact size and shape of the VSD involved was made possible by 3DTTE as explained by Ahmed et al (2014). The complexity of the IVS makes 2DTTE a less reliable technique for diagnosing and obtaining the morphologic description of a VSD. With the help of 3DTTE, correct measurements of the defect can be acquired. The research obtained when comparing 2D and 3DTTE provides sonographers with a better understanding of the importance of 3DTEE and its proven role in minimizing any further complications in corrective surgery that would be caused by the underestimation of the shape and size of the septal defect.
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