Second-generation real-time 3D echocardiography:

a revolutionary new technology

A. Franke1 and H.P. Khl1

Every imaging technique in cardiology aims at

complete visualization and comprehensive assessment
of cardiac morphology and pathomorphology. In
pursuit of this aim, echocardiography has undergone
a technological evolution over the last few decades,

The first 3D echocardiographic techniques were

based on serial acquisition of 2D images, which were
then combined into a 3D data set in an off-line
reconstruction. Due to the difficulties of ECG and
respiratory gating (which were needed in order to
avoid artifacts), and the complexity of the off-line
analysis, these reconstructive approaches were unable
to make their way into widespread clinical use.


Figure 1.
Microscopic view of a
matrix array
transducer. Each small
square is an active
ultrasound element.
The size of a human
hair is shown for
comparison (arrows).

Consequently, the development of real-time 3D

technology on the basis of matrix array transducers
was a real revolution [1,2]. The prototypes and the
first commercially available systems were able to scan
a pyramidal volume with an acceptable time resolution.
However, these first generation real-time 3D systems
were not designed to perform conventional highend 2D echo techniques, and the 3D image quality
was comparatively poor. These limitations prevented
widespread routine use of this technique.


Figure 2.
Comparison between
the 2D image quality
obtained with a conventional transducer
and with a matrix
array 3D scanner from
a parasternal echo
window in the same
patient.

In the mean time, second-generation real-time 3D

technology has emerged and has been implemented
in high-end 2D echo equipment. This article
describes the first clinical results obtained with the
new 3D technique (Live3DTM, Philips Medical
Ultrasound).

Figure 2a.
Image obtained with a
conventional
transducer
(S3 transducer with a
Sonos 7500).
Figure 2b.
Image obtained with a
matrix array 3D
scanner (X4 matrix
transducer).

Method
3D acquisition is based on a newly developed matrix
array transducer with more than 3000 active
elements (Figure 1). All elements of the matrix array
transducer transmit and receive. This leads to an
improved image quality when compared to that of
the first generation equipment, where only 256
elements transmitted and 256 others received. The
image quality in cut planes is now comparable to the
image quality of a conventional 2D transducer
(Figure 2).

Medical Clinic I,
University Hospital,
Aachen, Germany

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starting with the one-dimensional M-mode technique

in the 1950s, and developing via two-dimensional
imaging of cut planes in the 1970s to the appearance
of the first three-dimensional techniques in the
early 1990s.

August 2003


Figure 3.
3D scanning.
Figure 3a.
On-line 3D scanning.
The sector size
depends on chosen
image resolution or
line density, and is
about 30 by 50.
Figure 3b.
Wide-angle scanning.
A narrow sector is
scanned during each
of four consecutive
heart beats. The four
sectors (shown with
different color
coding) are integrated
automatically within a
fraction of second.

The first image and data processing takes place in

the transducer handle itself, which contains a data
processor comprising 16 miniaturized boards.
Real-time 3D acquisition is - at present - limited to
an angle of about 30 - 50 degrees. The volumetric
sector is displayed on-line on the screen of the
ultrasound system (Live3D scanning, Figure 3a).

3D data analysis

Qualitative analysis: visual interpretation

Three-dimensional data are visualized as rendered
images with virtual lighting, shadows and surfaces.
Unlike previous 3D reconstruction techniques,
these views are generated on-line, i.e. as soon as the
transducer is put on the chest. Any desired cut
plane can be created within the ultrasound system
by cropping the originally acquired data set.
Lighting, contrast and brightness can also be
changed to meet individual preferences during
scanning and image interpretation.
This type of visual interpretation is mainly used for
easier evaluation of the pathomorphology in
valvular and congenital heart disease. The majority
of clinical studies published to date have used 3D
reconstruction of transthoracic or transesophageal
images or first generation real-time 3D
echocardiography [3,4]. All intracardiac structures
can be visualized, including electrophysiological
and biopsy catheters [5].

As in earlier reconstructive 3D echocardiographic

techniques, real-time 3D data can be analyzed in
two different ways: first in a more or less qualitative
way by observing the rendered images of the
endocardial and valvular surfaces, and secondly by
quantitative evaluation of manually or semiautomatically traced structures.

Figure 4 shows different views of the mitral valve and

its subvalvular apparatus acquired via a parasternal
echo window, while Figures 5 through 7 show
examples of perspectives and views which only can
be achieved with 3D imaging, including a view of
a prolapsing mitral leaflet (Figure 5) as well as the
en face view of an atrial septal defect (Figure 6) and

Acquisition of wide-angle (full-volume) volumetric

data sets, which are needed for covering larger
cardiac structures such as the complete left ventricle,
still requires a modified form of ECG gating. In
this case, four sectors of about 23 by 90 are
scanned during four consecutive heart beats, without
moving the transducer. The four sectors are
automatically integrated within a fraction of a
second to provide a pyramidal 90 by 90 data set
(Figure 3b).

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Realistic threedimensional
images are
generated in real
time.

All intracardiac
structures can be
visualized, including
catheters.

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35


Figure 4.
Different views of the
mitral valve and its
subvalvular apparatus
acquired via a parasternal echo window. The
papillary muscle and
chordae tendineae are
well defined.
LV = left ventricle;
LA = left atrium.


Figure 5.
Mid-systolic stop frame image of a prolapse of the posterior
leaflet of the mitral valve (arrow). Longitudinal view.
LA = left atrium;
LV = left ventricle; MVP = mitral valve prolapse.


Figure 6.
Secundum type atrial
septal defect (ASD);
en face view from the
right atrium.

Figure 7.
Aortic valve seen from the ascending aorta.

Figure 6a.
Diastolic stop frame.
Figure 6b.
Systolic stop frame.
The defect area is
significantly larger.

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Figure 7a. Normal tricuspid valve.

Figure 7b. Bicuspid valve.

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Figure 8.
Semi-automated
contour tracing in a
3D data set
(LV Analysis RT 1.1;
TomTec Imaging GmbH,
Unterschleiheim,
Germany).
Figure 8a.
The endocardial
boundaries are found
semi-automatically in
each cut plane (upper
right) of a previously
determined number
of long-axis cut planes
(shown in the righthand margin). The
points found on the
endocardium are
marked by yellow dots
(lower left) and finally
connected by a spline
algorithm: This results
in a contour (green
line, upper left) which
serves as a basis for
LV volume calculation
at this point in time.

Figure 8b.
Calculation of volume/
time curve of the LV
volume.
A surface-rendered LV
cast based on the semiautomatically found
endocardial boundaries
is shown in the upper
left panel.
The bulls-eye display
(lower left) will be used
at a later stage to
identify the individual
regions for wall motion
analysis.

Semi-automated
contour tracing is
automatically repeated
for every stop frame
(every 40 ms)
throughout the
complete heart cycle.
The volume is then
calculated for each
stop frame, resulting
in the volume/time
curve shown in the
lower right panel of
Figure 8b
(x-axis: time;
y-axis: volume).

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37


Figure 9.
Improvement of
endocardial delineation
by the use of left heart
contrast agents.
Comparison of
unenhanced (above)
and enhanced (below)
long-axis planes of
the LV shows clearly
improved delineation
of the endocardial
borders. The contrast
agent was continuously infused.

Figure 10. 
Generation of multiple short axis cut planes of the left ventricle.
The yellow lines mark the position of the short axis slices.
Figure 10a. Generation of tomographic cross sections).
Figure 10b. MRI-like view.
Figure 10c. Short axis slices from apical to basal.


Figure 11.
Set of short-axis cut
planes from a contrastenhanced 3D stress
echo at rest (upper
row), at low dose
dobutamine (middle
row) and during peak
dobutamine dose
(lower row).
Interpretation of wall
motion abnormalities
can be performed by
comparing the
corresponding shortaxis planes.


Figure 12.
Analysis of regional
(segmental) wall
motion based on semiautomated contour
tracings.
(LV Analysis RT 1.1;
TomTec Imaging GmbH,
Unterschleiheim,
Germany).
The volume/time
curves of each colorcoded segment in the
bull's eye view (lower
left) are represented in
the volume/time curve
in the lower right
panel (example in a
patient with no wall
motion abnormalities).

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August 2003

the frontal view of a tricuspid and bicuspid aortic

valve (Figure 7).
Quantitative analysis: determination of segmented
cardiac structures
3D echo is known to be superior to 2D echo with
regard to the quantification of volumes and masses.
This is true for the left and right ventricle,
pericardial effusion, intracardiac masses, defects,
and endocardial surfaces. This has been convincingly
demonstrated by many studies over the last few
years [6, 7, 8]. Furthermore, volumes and masses
determined by 3D echo have an extremely high
correlation with all other gold standards [9,10,11].
Until recently, however, every quantitative analysis
was time consuming and depended on a number of
slices in which the cardiac structure of interest had
to be traced manually.
New algorithms based on image post-processing and
(semi-)automated border detection may significantly
decrease the necessary time for contour tracing and
will lead to a widespread clinical use of the precise
quantification capabilities of 3D echocardiography.
Some examples of the results achieved so far are
shown in Figures 8 through 10.

Future perspectives
Real-time 3D echo has several obvious advantages
which will undoubtedly become part of the clinical
routine in the future.
Wall motion abnormalities can be detected and
analyzed in 3D data sets as accurately as in serially
acquired conventional 2D cut planes [12]. The
velocity of acquisition of 3D data sets covering the
whole left ventricle makes this technique suitable
for use during dobutamine stress echo.
Consequently, this approach has been successfully
been used with the first generation real-time 3D
systems [13,14].
At that time, left heart contrast was used for better
endocardial delineation, especially during peak
dobutamine dose. This still seems to be necessary
with the second-generation real-time 3D
equipment [15].

Off-line interpretation of a set of several comparable

short-axis cross-sections of the left ventricle may be
easier and more sensitive than conventional 2D
stress echo, which is known to have a low interobserver agreement (Figure 11).

Real-time 3D
echo has obvious
advantages and
will undoubtedly
be part of the

Newly developed algorithms not only allow precise

determination of end-systolic and end-diastolic
volumes, but also analysis of their cyclic changes, as
well as regional wall motion and LV contraction
patterns (Figure 12). This may be an additional aid
for the examiner to more reliably interpret wall
motion abnormalities, temporal differences in wall
motion (e.g. in patients with bundle branch block
or in biventricular pacing) or even changes of the
diastolic LV function [16].

clinical routine.

The emerging integration of color Doppler

information, and the still experimental combination
with myocardial contrast echocardiography [17]
for perfusion imaging, will add technically
challenging but nevertheless exciting new fields to
the modality of real-time 3D echocardiography.

Conclusion
Qualitative interpretation of rendered images, and
quantitative evaluation of 3D echocardiographic
data, have been shown to be clearly superior to
conventional 2D echo techniques. The emerging
integration of second-generation real-time 3D
echocardiography with matrix array transducers into
high-end 2D echocardiographic equipment extends
the benefits of more complete and precise
information to the clinical routine. However, benefits
with respect to prognosis and outcome have not yet
been shown for a variety of diseases, or for the
individual patients. A number of clinical studies are
currently under way which are expected to provide
the necessary evidence. Furthermore, real-time 3D
echocardiography is the only on-line 3D method,
even when compared with other 3D imaging
techniques such as magnetic resonance imaging
and computed tomography. Although these
modalities can also provide three-dimensional data
sets, including the complete heart, they are still are
based on post-acquisition reconstruction and not
on volumetric scanning.

MEDICAMUNDI 47/2

Qualitative and
quantitative
assessment of 3D
data is superior to
conventional 2D
techniques.

Real-time 3D
echo is the only
truly on-line 3D
method.

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39

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