SPECIAL ARTICLES

Which Cardiac Structure Lies

Nearby? Revisiting Two-Dimensional
Cross-Sectional Anatomy
Francesco F. Faletra, MD, Siew Yen Ho, PhD, Laura Anna Leo, MD, Vera Lucia Paiocchi, MD, Sunil Mankad, MD,
Mani Vannan, MBBS, and Tiziano Moccetti, MD, Lugano, Switzerland; London, United Kingdom;
Rochester, Minnesota; and Atlanta, Georgia

Two-dimensional (2D) transthoracic echocardiography is one of the most used diagnostic tools in clinical car-
diology. Similarly, 2D transesophageal echocardiography is considered an indispensable tool for cardiologists
and cardiac anesthesiologists worldwide. However, because of their tomographic nature, both techniques
display only thin cut planes of a given area of the heart, which are far from representing the ‘‘anatomic reality.’’
It is widely accepted that experienced echocardiographers are able to reconstruct mentally a three-
dimensional image of any cardiac structure on the basis of their interpretation of multiple tomographic slices.
However, this may not be the case with less experienced echocardiographers. In particular, the authors
noticed that less experienced echocardiographers are almost totally unaware of which structures lie ‘‘nearby’’
a given 2D tomographic plane, that is, what is adjacent in the elevation plane. In this article, the authors report
the use of three-dimensional transesophageal echocardiographic images to discover which structures are
located nearby (i.e., ‘‘behind’’ and ‘‘in front’’) the corresponding 2D cross-sections. The authors believe that
this novel use of three-dimensional echocardiography is a unique aid to disclose what cannot be seen in a
given 2D cross-section, thereby expanding our understanding of 2D echocardiographic anatomy. This may
be an effective method to encourage all to ‘‘think’’ in three dimensions, even when they use 2D echocardiog-
raphy. (J Am Soc Echocardiogr 2018;31:967-75.)

Keywords: 2D transesophageal echocardiography, 3D transesophageal echocardiography, Cross-sectional

anatomy

Two-dimensional (2D) transthoracic echocardiography (2D TTE) ap-
peared in the diagnostic arena several decades ago as the natural evo-
lution of M-mode echocardiography,1 and today it is probably one of
the most used diagnostic tools in clinical cardiology, second only to
electrocardiography and chest radiography. Similarly, 2D transeso-
phageal echocardiography (TEE) has also evolved from its initial
configuration of a transesophageal probe with a single crystal2 to
monoplane, biplane, and multiplane 2D TEE.3 Nowadays, multipla-
nar 2D TEE is an indispensable tool for cardiologists, anesthesiologists,
and interventionalists.
However, both 2D TTE and 2D TEE provide real-time images
displaying a thin cut plane of a given area of the heart. In the
‘‘classic’’ 2D transesophageal left ventricular outflow view at
120 , for instance, leaflets of the mitral valve are visualized as
From the Cardiology Department, Fondazione Cardiocentro Ticino, Lugano,
Switzerland (F.F.F., L.A.L., V.L.P., T.M.); Cardiac Morphology, Royal Brompton
Hospital and Imperial College London, London, United Kingdom (S.Y.H.); the
Mayo Clinic, Rochester, Minnesota (S.M.); and the Piedmont Heart Institute,
Atlanta, Georgia (M.V.).
Conflicts of Interest: None.
Dr. Faletra has received speaking honoraria from Philips.
Reprint requests: Francesco F. Faletra, MD, Division of Cardiology, Fondazione
Cardiocentro Ticino, Via Tesserete 48, CH-6900 Lugano, Switzerland (E-mail:
francesco.faletra@cardiocentro.org).
0894-7317/$36.00
Copyright 2018 by the American Society of Echocardiography. All rights reserved.
https://doi.org/10.1016/j.echo.2018.04.014
two subtle lines of valvular tissue, moving during the cardiac cycle
and surrounded by a black background. Although this cross-section
is very popular, it is far from representing the entire ‘‘anatomic re-
ality’’ of the mitral valve.
The best imaging modality to comprehend the concept of a ‘‘thin’’
slice of tissue is probably the novel fluoroscopy-echocardiography
fusion imaging. In this modality, 2D TEE is merged within the fluoro-
scopic silhouette, and we can appreciate the real thinness of the cross-
sectional 2D images4 (Figure 1, Video 1 available at www.onlinejase.
com).
The development of the matrix-array transducer led to the ability to
visualize the heart in three dimensions with ultrasound. For the first
time, this transducer allowed the acquisition of three-dimensional (3D)
images that were ‘‘intrinsically’’ 3D (i.e., without the need for offline
reconstruction of adjacent slices) and in ‘‘real time’’ (i.e., displaying mo-
tion as it happens). Miniaturization of electronic circuits has made it
possible to compact thousands of piezoelectric crystals into the tip of a
transesophageal echocardiographic transducer, coupling the quality
of transesophageal imaging with a 3D display. As a result, most
structures of the heart are represented with anatomic details of unprec-
edented quality, faithfully mirroring the anatomical reality.5-8 As
3D echocardiography became widely available (at present, most
echocardiographic machines include 3D technology), it was
anticipated that 3D TTE and TEE would rapidly replace 2D TTE and
TEE. On the contrary, after a decade, 3D echocardiography is not yet
fully applied in routine clinical practice, and echocardiographers
are disinclined to use 3D echocardiography extensively. Most
laboratories perform complete 2D transthoracic or transesophageal
967
968 Faletra et al Journal of the American Society of Echocardiography
September 2018

Abbreviations
echocardiographic studies, followed chines, temporal resolution remains low, especially when a large vol-
by a focused 3D examination ume size or 3D color Doppler is used.
2D = Two-dimensional only in those patients in Third, there is a common belief that experienced echocardiog-
3D = Three-dimensional whom it is believed that 3D raphers are able to mentally reconstruct a 3D image of cardiac struc-
echocardiography could potentially ture on the basis of the interpretation of multiple 2D cross-sections,
AF = Atrial fibrillation provide additional data (e.g., 3D thus making 3D echocardiography an optional if not an unnecessary
LAA = Left atrial appendage TTE to more precisely quantify tool. Although we may agree that experienced echocardiographers
left ventricular size and function, may instinctively reconstruct mentally a 3D image derived from
LAI = Left atrial isthmus 3D TEE in patients with mitral multiple 2D sections, this may not be entirely true for less experi-
LVOT = Left ventricular prolapse or flail to better enced echocardiographers. In particular, we noticed that they are
outflow tract characterize the pathoanatomy almost totally unaware of which structures lie ‘‘nearby’’ (i.e., behind
of the valve and the likelihood and in front) a given 2D tomographic plane, that is, what is adjacent
TEE = Transesophageal
echocardiography
of valve repair).9 in the elevation plane. Because 2D echocardiography will remain
There are at least three rea- for many years the primary imaging modality, in this article we
TTE = Transthoracic sons that may explain this reluc- report the use of 3D images to disclose which structures are located
echocardiography tance to apply extensively this ‘‘nearby’’ the corresponding 2D cross-sections. Knowledge of what
TV = Tricuspid valve technology. structure lies nearby a given cut plane may help less experienced
First, over decades, echocardi- echocardiographers in properly maneuvering the transducer. For
ographers and clinical cardiologists were accustomed to analyze the instance, knowing that the tricuspid valve (TV) lies behind the bi-
shape and movement of these 2D thin cut planes. A wide array of caval cross-sectional view may clarify that to obtain a cross-
2D transthoracic and transesophageal echocardiographic cross- sectional plane that includes a perpendicular plane of the TV, the
sectional planes have been standardized, precisely describing the car- echocardiographer must rotate the transducer clockwise. We are
diac structures that are intersected by the ultrasound beam. A huge convinced that this educational use of 3D echocardiography is a
number of articles and books have illustrated 2D cross-sections of unique tool to expand our understanding of 2D echocardiographic
normal and pathologic cardiac valves and chambers. Angiography, anatomy discovering what we do not see in a given 2D cross-
surgical inspections, and anatomic specimens have confirmed the section. In this study, we exclusively used transesophageal images
diagnostic accuracy of these 2D cross-sections, making 2D echocardi- because of the clarity of anatomic details, but the same applies to
ography the most powerful noninvasive diagnostic technique. 3D TTE. Finally, among countless potential tomographic planes,
Second, the frame rate of 2D echocardiography (i.e., the number we chose those 2D transesophageal echocardiographic cross-
of images per second) and its spatial resolution (i.e., the number of sections ‘‘nearby’’ which there are relevant anatomic structures
lines per sector [line density]) are still superior to the volume rate (sometimes behind or in front a given cross-section, there is only
(i.e., the number of volumes per second) and spatial resolution (i.e., an atrial or a ventricular wall seen in the ‘‘en face’’ perspective). In
the number of sectors per volume [sector density]) of 3D echocardi- particular, we disclose those cardiac structures lying ‘‘nearby’’ the
ography. Despite the high likelihood that in the near future, technical following ‘‘classic’’ 2D transesophageal echocardiographic cross-
improvements may reduce or even abolish these gaps between the sections: midesophageal long-axis view of the left ventricular
two technologies, in the most used routine echocardiographic ma- outflow tract (LVOT), midesophageal long-axis view of the aorta,

Figure 1 (A) Fluoroscopic-echocardiographic fusion imaging in which the transesophageal echocardiographic long-axis view is visu-
alized within the fluoroscopic silhouette of the heart in anteroposterior projection. (B) The same magnified imaged without fluoros-
copy. The thinness of 2D cross-sections (arrows) can be appreciated.
Journal of the American Society of Echocardiography
Volume 31 Number 9
HIGHLIGHTS
 2D echocardiography provides thin cross-sections of a given
cardiac structure.
 Experienced echocardiographers can reconstruct 3D images
based on 2D cross-sections.
 Less experienced echocardiographers are unaware of which
structures lie ‘‘nearby’’.
 3D echocardiography can disclose what we do not see in a
given 2D cross-section.
 3D echocardiography helps thinking in 3D even when 2D
echocardiography is used.
midesophageal four-chamber view, and midesophageal bicaval
view.10
MIDESOPHAGEAL LONG-AXIS VIEW OF THE LVOT
The 2D transesophageal echocardiographic midesophageal long-axis
view of the LVOT (110 –130 ) is one of the ‘‘classic’’ tomographic
planes that allows visualization of the left atrial cavity, the central scal-
lops of the anterior and posterior mitral leaflets (A2 and P2), the left
ventricle, the LVOT, the aortic leaflets, the aortic root, and a variable
extent of the tubular ascending aorta.11 This cross-section provides
diagnostic data for a large number of valvular diseases (such as mitral
prolapse and flail, aortic stenosis and regurgitation, aortic dilation and
dissection, aortic and mitral endocarditis, myxoma, and congenital de-
fects). More recently, this has been considered the most important
view to guide the correct grasping of mitral leaflets during percuta-
neous edge-to-edge mitral valve repair.12 In this cross-section, the
left atrial cavity appears completely black. By using the equivalent
3D transesophageal echocardiographic volumetric data set, at least
two relevant structures are located behind the 2D plane, namely,
the left atrial isthmus (LAI) and the orifice of the left atrial appendage
(LAA; Figure 2).
Figure 3A illustrates the position of the LAI and LAA when viewed
from an overhead perspective; Figures 3B, 3C, and 3D show the steps
used to achieve the 3D perspective equivalent to the 2D long-axis view.
Figure 2 (A) The ‘‘classic’’ 2D transesophageal long-axis view at 120 to 130 . This cross-sectional plane shows the left atrium (LA),
the central segments of the anterior (A2) and posterior (P2) mitral leaflets, the left ventricle (LV), and the aorta (Ao). (B) The same image
in 3D. Behind the cross-sectional plane are visible the LAI and the orifice of LAA. (C) Corresponding anatomic specimen.
Faletra et al 969
The electrophysiologists refer to the posterior-inferior region of the
left atrium between the left lower pulmonary vein and the mitral
annulus as the LAI or mitral isthmus. By creating a linear ablation
line connecting the medial border of the left lower pulmonary vein
and the vestibule in proximity to the lateral mitral commissure, elec-
trophysiologists have been able to interrupt an arrhythmic circuit
around the mitral annulus, which becomes particularly important in
patients with persistent atrial fibrillation (AF). From a strictly anatomic
point of view, this region generally is characterized by a smooth endo-
cardial surface without specific landmarks, although small crevices
may be found along the line of ablation.13 The wall is thin, with an
average transmural myocardial thickness ranging from 2.2 to
5.5 mm, with the thinnest part near the mitral annulus (range,
0.3–3.3 mm). The length of the LAI is highly variable, ranging from
2 to 5 cm. Both the left circumflex coronary artery and the coronary
sinus run in close proximity to the external aspect of LAI and may be
injured during AF ablation.
The LAA has been extensively studied with 2D and 3D TEE and is
a source of systemic embolism in patients with AF. Imaging of the
LAA has therefore been primarily focused on the presence of thrombi
and sludge inside the LAA. More recently, catheter-delivered LAA
closure devices, which have the aim of excluding the LAA from the
systemic circulation, have been considered a reasonable alternative
for patients with AF who are ineligible for, or are noncompliant
with, anticoagulation therapy. In these patients, to ensure a stable
positioning of the occlusion device into the LAA, quantitative assess-
ment of LAA (i.e., size of orifice and landing zone, length of the main
lobe) is crucial. Because of its complex morphology, it is likely that
measurements taken from a 3D data set are more precise than those
obtained with 2D TEE.14 Interestingly, in a deeper plane, two other
structures are relevant for electrophysiologists, namely, the left lateral
ridge and the left upper pulmonary vein (Figure 4, Video 2 available at
www.onlinejase.com). ‘‘In front’’ of this cut plane is located the left
side of the interatrial septum (Figure 5).
MIDESOPHAGEAL LONG-AXIS VIEW OF THE AORTA
The transesophageal long-axis view of the aorta enables the visualiza-
tion of the aortic root, including the sinuses of Valsalva, the sinotubu-
lar junction, and the noncoronary and right coronary leaflets. This
view is particularly useful for evaluating leaflet motion and for
970 Faletra et al Journal of the American Society of Echocardiography
September 2018

Figure 3 (A) Large pyramidal data set acquisition showing from an overhead perspective the mitral valve (MV), the TV, the aorta (Ao),
and the interatrial septum (IAS). The white asterisk denotes the LAA. The red asterisk denotes the LAI region. (B) The dotted line marks
the cropping plane. (C) The inferior half of the 3D volume data set has been removed. (D) The superior half of the 3D volume data set
shown in (C) is rotated around the x axis (curved arrow) to obtain a perspective equivalent to the 2D long-axis view.

Figure 4 Slight angulations and rotations from a 3D data set better show the anatomic relationship between the LAA, left lateral ridge
(LLR), left upper pulmonary vein (LUPV), aortic root (Ao), anterior mitral leaflet (AML), and lateral commissure (LC).
Journal of the American Society of Echocardiography
Volume 31 Number 9 Faletra et al 971

Figure 5 (A) Same image as Figure 3. An asterisk marks the interatrial septum (IAS). (B) The image is rotated counterclockwise so that
the TV remains at the top of the image. The dotted line marks the cropping plane. (C) The inferior half of the 3D volume data set has
been removed. (D) The superior half of the 3D volume data set shown in (C) is rotated around the x axis (curved arrow) to obtain a 3D
perspective, which shows the left side of IAS as seen in an ‘‘en face view.’’ Ao, Aorta; MV, mitral valve.

obtaining the dimensions of the aortic root at different levels
(Figure 6A). The equivalent 3D transesophageal perspective clearly
shows the structures lying behind this cross-sectional slice, namely,
the left coronary leaflet and the interleaflet triangle between left cor-
onary leaflet and noncoronary leaflet (Figure 6B, Video 3 available at
www.onlinejase.com).
The interleaflet triangles are the consequence of the coronet-
shaped attachments of the aortic leaflets on the aortic root and can
be defined as an extension of LVOT between the hinge lines of adja-
cent semilunar leaflets. These triangles reach the sinotubular junction,
where the attachments of two adjacent leaflets form the commissure.
In particular, the triangle lying ‘‘behind’’ the 2D cross-section of the
long-axis view of the aorta between the left and noncoronary sinuses
is made up by fibrous tissue that is in continuity with the mitral-aortic
fibrous curtain. This triangle is the largest and separates the left ven-
tricular cavity from the transverse pericardial sinus. In small aortic
roots, the mitral-aortic continuity and the corresponding fibrous inter-
leaflet triangle are the site for the enlargement of the aortic annulus
(Figures 6C and 6D).
TRANSESOPHAGEAL FOUR-CHAMBER VIEW
The 2D transesophageal four-chamber view is usually displayed in an
‘‘anatomically correct’’ orientation (i.e., apex of the heart at the bot-
tom and atria at the top of the screen, with left-sided structures to
the left and right-sided structures to the right of the patient).8 As
the corresponding transthoracic four-chamber view, this cross-
section is one of the most informative views, as it includes the right
atrium, the septa, the mitral valve, and the TVs. The diagnostic process
of a large number of pathologies of the ventricles, atria, and atrioven-
tricular valves may take advantage of this cross-section. The right atrial
cavity, limited by the atrial wall, interatrial septum, and TV, appears as
an empty black chamber. Conversely, in the corresponding 3D trans-
esophageal four-chamber perspective, the right atrium includes
several relevant anatomic structures lying in a plane deeper than
that of 2D four-chamber cross-plane, such as the cavotricuspid
isthmus, the Eustachian valve, the coronary sinus ostium, and the
Thebesian valve6 (Figure 7, Video 4 available at www.onlinejase.
com).
Anatomically the cavotricuspid isthmus is a roughly quadrilateral
endocardial region extending from the Eustachian valve to the hinge
line of the TV. This region is part of a macroreentrant circuit that sus-
tains typical atrial flutter. Thus, a linear ablation line from the middle
part of the Eustachian valve attachment to the middle part of the TV
hinge usually terminates the arrhythmia. However, anatomic variants
(i.e., deep pouch or length of the cavotricuspid isthmus) may prolong
the duration of an otherwise straightforward procedure. The LAA
and right atrial appendage lie anteriorly (i.e., ‘‘in front’’) to this tomo-
graphic plane (Figure 8).
972 Faletra et al Journal of the American Society of Echocardiography
September 2018

Figure 6 (A) ‘‘Classic’’ 2D TEE of the aorta in the long-axis view with the noncoronary leaflet (NCL) and right coronary leaflet (RCL). (B)
The same image in 3D. Behind the cross-sectional plane, the left coronary leaflet (LCL) is clearly visible. The arrow shows the inter-
leaflet triangle between the NCL and LCL (dotted line). This triangle is in connection with the mitral-aortic continuity. (C) shows the
aortic valve from an overhead perspective. The arrow points to the location of the interleaflet triangle (ILT) between the NCL and LCL.
(D) The 3D volumetric data set has been cropped and rotated to visualize ‘‘en face’’ the ILT and the mitral-aortic continuity (arrow).

Figure 7 (A) The classic 2D four-chamber view. This cross-section slice only shows the lateral wall (LW) of the right atrium (RA) and
the interatrial septum (IAS). (B) On the contrary, 3D TEE with the same perspective shows several important structures for electro-
physiologists, namely, the Eustachian valve (EV), coronary sinus ostium (CS), and cavotricuspid isthmus (CVTI). (C) Corresponding
anatomic specimen.

MIDESOPHAGEAL BICAVAL VIEW
This cross-sectional view is used primarily for visualizing the fossa
ovalis and the septum secundum, crista terminals, and right atrial
appendage. For left heart percutaneous procedures (i.e., LAA
closure, mitral clip, paravalvular leak closure, and, more recently,
valve-in-valve, valve-in-ring, and implantation of a mitral prosthesis
on the native annulus), this view is used for establishing the
superior-inferior location to guide septal puncture. Switching from
2D to 3D, the TV is seen in the ‘‘en face’’ perspective in the deeper
plane (Figure 9). This 3D perspective showing the tricuspid leaflets
‘‘en face’’ is one of the perspectives used in a novel, off-label, trans-
catheter edge-to-edge intervention for functional tricuspid regurgita-
tion using the mitral clip system (Figures 10A and 10B, Video 5
Journal of the American Society of Echocardiography
Volume 31 Number 9 Faletra et al 973

Figure 8 (A) Large pyramidal data set acquisition showing from an overhead perspective the mitral valve (MV), the TV, and the aorta
(Ao). The dotted line indicates the cross-sectional plane that intersects structures visualized in the 2D TEE four-chamber view. (B–D)
Steps to obtain what lies ‘‘in front.’’ Thus, while behind the 2D four-chamber view, we see the cavotricuspid isthmus and surrounding
structures (Figure 7), ‘‘in front’’ of the same cut plane are located both the LAA and right atrial appendage (RAA).

Figure 9 (A) A ‘‘classic’’ 2D transesophageal bicaval view with the superior vena cava (SVC) in its long-axis orientation. (B) The same
image in 3D. In a deeper plane, the orifice of TV in diastolic phase is visible in an ‘‘en face’’ perspective. (C) The corresponding
anatomic specimen. CT, Crista terminalis; FO, fossa ovalis; LA, left atrium; RA, right atrium; RAA, right atrial appendage.

available at www.onlinejase.com). In this perspective, the anterior
leaflet is on the right with the commissure between septal and ante-
rior leaflet close to the aorta, while the posterior leaflet is on the left
and the septal leaflet is on the near field (close to the atrial septum).
Hahn15 suggested to standardize the imaging display of the en face
view of the TV with the interatrial septum (and then septal leaflet)
placed inferiorly (6 o’clock position) regardless of the position of
other structures. Notably, the septal leaflet should be located inferi-
orly in order to visualize the TV in the operating room with the
anterior and posterior leaflets on the left and right side respectively
(Figures 10C and 10D). It is not surprising that the 3D data set, ob-
tained from the 2D midesophageal bicaval view, includes the four-
chamber view. Figure 11 and Video 6 (available at www.onlinejase.
com) show the several steps to obtain the four-chamber starting
from a bicaval view.
CONCLUSION
Anatomy with 2D echocardiography is described, showing dozens of
standardized cross-sections and labeling only those structures that
appear in such sections. Cardiac structures that lie in the elevation
plane adjacent to any given cross-section, being ‘‘invisible’’ on 2D
TEE, are usually neglected.
974 Faletra et al Journal of the American Society of Echocardiography
September 2018

Figure 10 (A) Three-dimensional transesophageal bicaval perspective. This perspective shows the anterior (A), posterior (P), and
septal (S) leaflets in ‘‘en face’’ perspective in (A) systole and (B) mid-diastole. (C,D) Surgical view (see text). Ao, Aorta.

Figure 11 Three-dimensional transesophageal echocardiographic imaging of various steps of postprocessing shown in Video 6
(available at www.onlinejase.com). (A) Bicaval view showing the superior vena cava (SVC), the inferior vena cava (IVC), the Eustachian
valve (EV), the fossa ovalis (FO), and the right atrial (RA) and left atrial (LA) cavities. (B) Image obtained after right-to-left rotation
around the y axis (curved arrow). The arrow shows the action of resetting cropping to obtain the full pyramidal data set shown in
(C). (D) Same image of (C). The violet plane crops the 3D data set through the elevational direction (arrow) to obtain a 3D image equiv-
alent to the 2D transesophageal echocardiographic four-chamber view. (F) A slight rotation around the y axis (curved arrow) shows a
medial aspect with the orifice of coronary sinus (CS). CVTI, Cavotricuspid isthmus; TV, tricuspid valve.
Journal of the American Society of Echocardiography
Volume 31 Number 9
To our knowledge, this is the first article to highlight what we miss
on 2D imaging in the most commonly used 2D transesophageal sec-
tions as shown side by side with the corresponding 3D perspectives
and with anatomic specimens. In our mind, this may be an effective
method to teach all users of echocardiography to ‘‘think’’ in three di-
mensions even when they use 2D echocardiography.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found at https://doi.
org/10.1016/j.echo.2018.04.014.
REFERENCES
1. Wann LS, Weyman AE, Feigenbaum H, Dillon JC, Johnston KW,
Eggleton RC. Determination of mitral valve area by cross-sectional echo-
cardiography. Ann Intern Med 1978;88:337-41.
2. Frazin L, Talano JV, Stephanides L, Loeb HS, Kopel L, Gunnar RM. Esoph-
ageal echocardiography. Circulation 1976;54:102-8.
3. Seward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr.,
Edwards WD, et al. Transesophageal echocardiography: technique,
anatomic correlations, implementation, and clinical applications. Mayo
Clin Proc 1988;63:649-80.
4. Jone PN, Ross MM, Bracken JA, Mulvahill MJ, Di Maria MV, Fagan TE.
Feasibility and Safety of using a fused echocardiography/fluoroscopy im-
aging system in patients with congenital heart disease. J Am Soc Echocar-
diogr 2016;29:513-21.
5. Sugeng L, Shernan SK, Salgo IS, Weinert L, Shook D, Raman J, et al. Live 3-
dimensional transesophageal echocardiography initial experience using
the fully-sampled matrix array probe. J Am Coll Cardiol 2008;52:446-9.
6. Faletra FF, Ho SY, Auricchio A. Anatomy of right structures by real-Time 3D
transesophageal echocardiography. J Am Coll Cardiol Img 2010;3:966-75.
Faletra et al 975
7. Faletra FF, Nucifora G, Ho SY. Imaging of atrial septum using real-time
three-dimensional transesophageal echocardiography: technical tips,
normal anatomy and its role in transseptal puncture. J Am Soc Echocar-
diogr 2011;24:593-9.
8. Faletra FF, Ho SY, Regoli F, Acena M, Auricchio A. Real-time three dimen-
sional transesophageal echocardiography in imaging key anatomical struc-
tures of the left atrium: potential role during atrial fibrillation ablation.
Heart 2013;99:133-42.
9. Faletra FF, Demertzis S, Pedrazzini G, Murzilli R, Pasotti E, Muzzarelli S,
et al. Three-dimensional transesophageal echocardiography in degener-
ative mitral regurgitation. J Am Soc Echocardiogr 2015;28:437-48.
10. Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al.
Guidelines for performing a comprehensive transesophageal echocardio-
graphic examination: recommendations from the American Society of
Echocardiography and the Society of Cardiovascular Anesthesiologists. J
Am Soc Echocardiogr 2013 Sep;26:921-64.
11. Tajik AJ, Seward JB, Hagler DJ, Mair DD, Lie JT. Two-dimensional real-time
ultrasonic imaging of the heart and great vessel. Technique, image orienta-
tion, structure identification and validation. Mayo Clin. Proc 1978;53:
271-303.
12. Silvestry FE, Rodriguez LL, Hermann HC, Rohatgi S, Weiss SJ, Stewart WJ,
et al. Echocardiographic guidance and assessment of percutaneous repair
for mitral clip regurgitation with the Evalve MitralClip: lesson learned from
EVEREST I. J Am Soc Echocardiogr 2007;20:1131-40.
13. Wittkampf FHM, van Oosterhout MF, Loh P, Derksen R, Vonken E-j,
Slootweg PJ, et al. Where to draw the mitral isthmus line in catheter
ablation of atrial fibrillation: histological analysis. Eur Heart J 2005;26:
689-95.
14. Nucifora G, Faletra FF, Regoli F, Pasotti E, Pedrazzini G, Mocetti T, et al.
Evaluation of left atrial appendage with real-time 3_dimensional transeso-
phageal echocardiography: implication for catheter-based left atrial
appendage closure. Circ Cardiovasc Imaging 2011;4:514-23.
15. Hahn RT. State-of-the-art review of echocardiographic imaging in the eval-
uation and treatment of functional tricuspid regurgitation. Circ Cardiovasc
Imaging 2016;9. pii: e005332.