Journal of Veterinary Cardiology (2024) 51, 53e63

www.elsevier.com/locate/jvc

Three-dimensional echocardiography:
technical aspects and imaging modalities*
G. Menciotti a,*, A. Tidholm b,c, M. Borgarelli a

a
Department of Small Animal Clinical Sciences, Virginia-Maryland College of
Veterinary Medicine, Blacksburg, VA, USA
b
Anicura Albano Animal Hospital, Rinkebyvägen 21, Danderyd, Sweden
c
Department of Clinical Sciences Faculty of Veterinary Medicine, Swedish University of
Agricultural Sciences, Uppsala, Sweden

Received 29 December 2022; received in revised form 6 November 2023; accepted 10 November 2023

This paper is part of the special issue on Advanced Cardiac Imaging edited by Brian Scansen.

KEYWORDS Abstract Real-time three-dimensional echocardiography (RT3DE) is increasingly

Volume; available in the veterinary field due to continuous reduction in costs and improve-
Voxel; ment of equipment. Much like its motion-mode and bi-dimensional counterparts,
Transthoracic; acquisition and analysis of RT3DE images and datasets is greatly improved by a thor-
Transesophageal ough understanding of the technological aspects, basic physic principles, and
knowledge of available modalities with their advantages and drawbacks. In this re-
view, the authors aim to describe how the currently available RT3DE technology has
evolved, explain technical aspects of the equipment, and illustrate the most com-
monly available modalities for image acquisition and visualization.
ª 2023 The Author(s). Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

*
A unique aspect of the Journal of Veterinary Cardiology is the emphasis of additional web-based images permitting the detailing
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* Corresponding author.
E-mail address: [email protected] (G. Menciotti).

https://doi.org/10.1016/j.jvc.2023.11.010
1760-2734/ª 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
54 G. Menciotti et al.

Historical aspects piezoelectric elements are arranged in a grid of rows

and columns (matrix) for a total of thousands of sin-
‘A system for ultrasonically imaging the human gle elements. In a 2D ultrasound transducer, each
heart in three dimensions’ was first described by piezoelectric element is connected by its own cable
Dekker et al. in 1974 [1] The system consisted of an to the echocardiographic machine, where a techni-
ultrasonographic transducer connected to a que called beamforming processes the signals both in
mechanical arm with five degrees of freedom to the phases of transmission and reception in order to
detect transducer position and aim (Fig. 1). The obtain focused beams. If the same approach was
acquired two-dimensional (2D) images were stored taken for RT3DE transducers, this would result in an
based on transducer location, and the system would unpractical amount of wiring as well as a very large
then allow the offline manipulation of the dataset circuit board requiring massive amount of power. To
acquired. Efforts were then invested in miniatur- overcome this limitation, matrix transducers employ
ization of the transducer’s tracking system with the several smaller circuit boards that group small arrays
development of ‘free-hand’ (i.e. not attached to a of elements (patches) directly in the probe, a process
mechanical arm) acoustic (spark gap) [2], electro- known as microbeamforming [14]; this allows mod-
magnetic or optical sensors. Most of these systems ern RT3DE transducers to have dimensions and cables
could be outfitted on regular transducers, but clin- that are comparable to 2D ones.
ical implementation was hindered by limitations The speed of ultrasound in tissue (i.e.
related to the size of the locators as well as the approximately 1540 m/s) provides a further
time-consuming process of image creation and impediment in RT3DE; when applied to a pyr-
analysis. In an attempt to resolve some of these amidal beam, regular ultrasound transducer’s
limitations, other approaches sought the acquis- scanning techniques would result in such a low
ition of consecutive 2D planes by either linear, fan- volume rate e measured in volume per second, the
like, or rotational standardized motion of the RT3DE equivalent of frame rate e that it would be
transducer. The set of images (datasets) acquired, clinically useless. Once again thanks to engineer-
were automatically stitched together and interpo- ing ingenuity a process called parallel receiving
lated by computer software [3e5]. As it is often the beam was implemented for RT3DE transducers in
case, early experiments for equipment validation which for each beam transmitted, the probe
included echocardiographic evaluation of several
mammalian hearts such as cows, dogs, goats, and
pigs [6e10].
The next and possibly most important techno-
logical breakthrough however came from imple-
mentation of the capability of acquiring volumes,
rather than sequential sets of single 2D planes.
This was achieved by researchers at Duke Uni-
versity by arranging phased-array piezoelectric
elements in multiple rows rather than just one
marking the beginning of real-time three-
dimensional echocardiography (RT3DE) [11e13].
Recent evolutions essentially refine and further
develop the same type of technology taking
advantage of the overall exponential progresses in
the fields of data optimization, increase in band-
widths of data transfer and processing, and system
miniaturization that allow to have continuously
smaller transducers, faster volume rates, higher
definition.

Technical principles

As it can be appreciated from the previous section, Figure 1 Photograph of the five degrees of freedom
the key component of RT3DE is the transducer. Cur- arm including signal conditioners and stand. Reprinted
rently, commercially available RT3DE transducers with authorization from Dekker et al. Computers and
are often called matrix array probes because the Biomedical Research 1974.
Three-dimensional echocardiography 55

receives and analyzes multiple parallel beams,

therefore greatly increasing the volume rate of
acquisition [15,16]. However, this comes at the
expense of the signal-to-noise ratio and resolution.
Therefore, other techniques and image acquisition
modalities (i.e. 3D Zoom, multi-beat acquisition)
have been developed in an attempt to provide
both higher temporal and spatial resolution.
Another important consideration for optimizing
RT3DE acquisitions comes from understanding the
system’s point spread function. Simply put, the
point spread function of an optical system is the
degree of blurring in the representation of an
otherwise point object [17]. The point spread
function of RT3DE systems is minimal in the axial
dimension, while maximal in the elevation [15].
Therefore, less blurred images of a certain cardiac
structure will be obtained by using the axial
dimension (X-axis) for its representation (Fig. 2). Figure 2 Three-dimensional echocardiography trans-
ducers. The three-dimensional (matrix) transducer’s
For properly using and implementing RT3DE in the
beam is pyramidal, therefore, there is also an ‘ele-
clinical settings, it is important to understand the
vation’ component. Reprinted with authorization from
strengths and weaknesses of each acquisition Wang XF, Deng YB, Nanda NC, Deng J, Miller AP, Xie MX.
modality as they are often used in combination Live three-dimensional echocardiography: imaging prin-
during a specific echocardiographic study depen- ciples and clinical application. Echocardiography. 2003
ding on the specific need or structure to be Oct; 20(7): 593e604. https://doi.org/10.1046/j.1540-
visualized. 8175.2003.03106.x. PMID: 14536007.

use, is that since the entire pyramidal volume is

Image acquisition modalities acquired, cropping and analyses can be performed
both during the acquisition and in post-processing.
Multi-plane acquisition However, as previously described, this technique
often provides somewhat lower resolutions and/or
It is important to differentiate multi-plane acquis- slow volume rates, particularly compared to the
ition from multi-plane visualization. The latter is average cycle length of unsedated small animals
most often used as part of full-volume or multi-beat during echocardiographic examinations.
acquisition modalities and will be covered in the
next section. Multi-plane acquisition instead is a Multi-beat acquisition
real-time technique in which only selected lines of
piezoelectric elements are fired simultaneously. Multi-beat acquisition is a modality in which the
This results in visualization of two or more simul- machine divides the full volume to be acquired in
taneous 2D images with high resolution and frame smaller sub-volumes. Each sub-volume is then
rate (Fig. 3). The visualized planes are the only ones acquired during consecutive heartbeats (commonly
acquired, unless another modality is simultaneously four or six) and stitched together to provide a wide
activated. This technique has proven particularly volume of acquisition with high spatial and temporal
useful in recent years for guidance of advanced resolution (high volume rate). Electrocardiographic
interventional or hybrid cardiac procedures where gating is necessary, and it ensures that the sub-
maneuvering and deployment of intracardiac devi- volumes are acquired during the same phase of the
ces require both accurate spatial resolution and cardiac cycle. Respiratory gating, or breath-hold
high frame rates [18]. during acquisition, is also used in humans, but
impossible or impractical to implement in veterinary
Full-volume acquisition medicine. The biggest pitfall of this modality is that it
relies on the consistent position of the structures
The most intuitive and straightforward RT3DE insonated during several cardiac cycles. For this
acquisition modality, in full-volume acquisition of reason, sinus arrhythmia (which continuously
a pyramidal volume, is acquired and visualized in changes the cycle length on a beat-to-beat basis),
real-time. Its main advantage, besides the ease of respiratory motion, and slight transducer movement
56 G. Menciotti et al.

and guidance of intracardiac devices (Fig. 5, Video

4). A drawback of this modality is that the operator
can lose the relationship between the visualized
structures and the surrounding ones.

Three-dimensional color Doppler

As per its 2D counterpart, a color Doppler region of

interest can be over-imposed to multi-plane or
three-dimensional images (either Full Volume,
Multi-beat, or 3D Zoom). When applied to three-
dimensional imaging, the region of interest is pyr-
amidal as well, providing theoretically a more
accurate evaluation of flows’ geometries and
Figure 3 Multi-plane image acquisition. During this
direction. This would overcome many limitations of
multi-plane acquisition two orthogonal planes are
simultaneously visualized. The one on the left is used as conventional color Doppler techniques like, for
a reference and a line (white arrows) can be swung to example, quantification of flow through non-
select the location of the orthogonal plane showed on circular orifices, eccentric jets, and wall-hugging
the right. In this case, the line is used to follow and flows [26e28]. This technique has indeed already
guide the movement a device introduced through been used in veterinary medicine for evaluation of
transapical approach and visible in the left ventricle in effective regurgitant orifice area [25]. One of the
both planes (green arrow). main limitations that currently prevents the clinical
widespread of this technique is the low volume rate
during the acquisition can result in stitching arti-
achievable with current technology.
facts, where the different sub-volumes are not
properly aligned to each other with resultant arti-
factual tissue discontinuation (Fig. 4 and Video 3).
Nonetheless, when stitching artifacts can be pre- Image visualization and post-processing
vented, this modality results in acquisition of a very
large RT3DE dataset, usually containing the entire Visualization of 3D images is a challenge on its
heart, with high volume rates, a very important own. Stereoscopic vision allows the operator to
factor for small animals. Datasets can then be ana- actually see images in three dimensions and
lyzed offline for visualization and quantification of although it is likely to be increasingly adopted in
several different cardiac structures [19e25]. the future, the requirement for special monitors
and eyewear are limitations to its widespread
Three-dimensional zoom adoption [29]. Besides multi-plane acquisition and
multi-plane visualization, the other RT3DE
In 3D Zoom modality, the operator selects the modalities face the challenge of representing 3D
position and size of a ‘sample box’, smaller than images on a 2D screen. Several solutions have been
the full volume, to encompass only the structure(s) implemented and different visualization modal-
or region of interest. The box size and position are ities are available for RT3DE; these can be used in
usually adjusted from simultaneous live multi- isolation or in combination for obtaining different
plane 2D images. Once the 3D Zoom function is information from the data acquired.
triggered, only the smaller volume of the box is
visualized en face (looking to it usually according Multi-plane visualization
to blood flow, for example atrial side for atrio-
ventricular valves and ventricular side for semi- Multi-plane visualization, also called multiplanar
lunar valves) and acquired. The biggest advantage reconstruction by some vendors, is usually available
of this technique is the rapid evaluation of a spe- both during acquisition (live), and during post-
cific region of interest, without the need for labor- processing of RT3DE and color RT3DE images. In
intensive cropping and orientation. Furthermore, contrast to multi-plane acquisition, in this modality,
since a smaller volume is acquired, this results in the volume acquired is three-dimensional and for this
higher volume rates and resolution compared to a reason, virtually any 2D cut plane can be selected to
full-volume acquisition. The most common appli- ‘slice’ the 3D volume. Furthermore, several different
cation of this modality is probably transesophageal 2D image planes can be simultaneously visualized.
evaluation of cardiac valves, congenital defects, Most commonly, a primary cut plane is selected in the
Three-dimensional echocardiography 57

Figure 4 Stitching artifacts. Real-time three-dimensional transesophageal echocardiography of a stenotic pulmonic

valve. The images were acquired with multi-beat acquisition and a stitching artifact is clearly visible as a straight line
of misalignment in all the two-dimensional and three-dimensional planes (red arrows). Multi-plane visualization was
also used for measuring both the diameters and the area of the stenotic orifice.

reference image and several other orthogonal and slicing, and cropping. Orientation is the most
parallel planes are visualized (multiplanar visual- intuitive one and consists of moving the image
ization) (Figs. 4e6). This modality allows precise around a fixed point to obtain the best viewpoint
alignment with cardiovascular structures of interest for the structure of interest. Slicing most com-
and complex multi-level functional assessments, like monly indicates the use of several parallel sliced
assessment of minimal stenotic orifices or stress planes from the RT3DE volume, while cropping is
echocardiography [30,31]. In veterinary medicine, the process through which any image plane is used
this technique was used for assessing mitral regur- to ‘cut’ through the acquired volume and obtain
gitant effective and anatomic regurgitant areas visualization of the structures cut by this plane. It
[19,25,32,33]. is worth noticing that this increased capability of
freely orienting and cutting through cardiac
Volume rendering structures poses the problem of nomenclature
standardization. This issue has been addressed in
Volume rendering is probably the most common the human field by Nanda et al. [35] and then
RT3DE visualization modality. In these images, the adopted by the European Association of Echo-
surface of cardiac structures is rendered by con- cardiography and American Society of Echo-
verting voxels (the smallest discrete element of a cardiography [34]. Since the described
three-dimensional image) into pixels. Two main nomenclature uses planes relative to the heart
controls e a threshold value and a transparency itself rather than the heart orientation to the
value e can be manually adjusted to determine body, this can be easily applied to animals as well
what appears solid vs. transparent. The perception and the authors of this paper support the adoption
of depth is created by ingenious use of different of this nomenclature in veterinary RT3DE applica-
color intensities and hues of each pixel [34] with tions. Briefly, transverse planes are perpendicular
lighter colors used for near structures (most com- to the long axis of the heart and each divide it into
monly represented in shades of yellows) while two segments, one viewed ‘from apex’, the other
darker colors (usually shades of blue) are used for ‘from base’; the sagittal plane is a longitudinal
farther structures. plane that divides the heart into two segments,
Volume-rendered images can be manipulated one viewed ‘from the left’, the other ‘from the
either live or offline by processes of orientation, right’; and the coronal plane, divides the heart
58 G. Menciotti et al.

Figure 5 Transesophageal three-dimensional en face view of a patent ductus arteriosus. A small box (green dashed
rectangles) is selected and oriented so that the structure of interest is visualized in three-dimensions from a pref-
erential point of view (green dot on the dashed boxes). In this example, transesophageal echocardiography was used
to visualize a patent ductus arteriosus minimal ductal diameter en face from the ampulla, looking towards the pul-
monary artery. Furthermore, multi-plane visualization was used to assess the ductus. Each plane is color coded for
ease of interpretation: the yellow line in panels A and B, is the C5 plane; the green line in panels A and C5 is plane B;
the blue line in panels B and C5 is plane A. The planes were aligned to measure the ductus from several orthogonal
views that were aligned with the ductus’ main axes. As can be noted from the three-dimensional image as well as
plane C5, the ductus is very oval with the wider diameter (Dist B) w40 % bigger than the shorter one (Dist A).

vertically into two segments, one viewed ‘from

above’, the other ‘from below’ (Fig. 7).
Recently, two more options for volume render-
ing visualization were developed: trans-
illumination and transparency rendering. These
are also called photorealistic renderings. In these
modalities, tissue is usually colored in shades of
pink, more closely resembling the real color of
cardiovascular structure, and the operator can
both define the level of transparency of tissue and
shine a virtual light source that is freely movable
to highlight the structures of interest (Videos 1 and
2 e Supplemental material). These techniques are
receiving great attention in recent years in the
human medical field as they seem to improve the Figure 6 Multi-plane visualization. After a full-volume
diagnostic utility of RT3DE [36e39]. acquisition, virtually any cut plan can be obtained and
visualized simultaneously. In this example, four planes
were aligned to show a standardized apical four-chamber
Surface rendering
view (top left), a two-chamber view (top right), a short
axis at the level of the papillary muscles (bottom left),
In this modality, the structure of interest is and a left ventricular inflow-outflow view (bottom right).
traced either manually or through a semi- or Note that, for ease of interpretation, the planes are color
fully-automated process and then represented as a coded. For example: panel B e green, top right e shows
cast model. The model can either be represented as the plane that is cut by moving the green line visualized in
a wire frame, in which the surface is divided into a panels A and C5.
Three-dimensional echocardiography 59

Figure 7 Standardized cropping planes. Transverse planes are perpendicular to the long axis of the heart and each
divide it into two segments, one viewed ‘from apex’, the other ‘from base’; the sagittal plane is a longitudinal plane
that divides the heart into two segments, one viewed ‘from the left’, the other ‘from the right’; and the coronal
plane, divides the heart vertically into two segments, one viewed ‘from above’, the other ‘from below’. Reprinted
with authorization from Lang et al. J Am Soc Echocardiogr 2012.

pre-determined number of small geometrical sub- strain on a ventricle, or prolapsing portions of

segments, or as a solid object (Fig. 8). Furthermore, atrioventricular valves (Fig. 9).
the information derived from complex analyses can
be color-coded and visually represented on the Post-processing
cast’s surface for more readily available inter-
pretation, like for example areas of high or low As it can be inferred from some of the previous sec-
tions, one of the biggest advantages of RT3DE is
the extremely wide range of image analysis and vis-
ualization possible from a single acquisition.
Most human and veterinary echocardiographic

Figure 8 Surface rendering of the right ventricle.

These surface renderings of the right ventricle were
obtained by a semi-automated analysis of transthoracic Figure 9 Mitral valve model showing prolapse. A
full-volume multi-beat real-time three-dimensional model of the mitral valve was created by semi-
echocardiographic acquisition of a dog. After tracing the automated analysis of transthoracic full-volume multi-
contours of the right ventricle, the softwaree creates a beat real-time three-dimensional echocardiographic
model of the ventricle that can be represented as a solid acquisition of a dog using dedicated softwaref. A mid-
object (A) or mesh (B). The complex shape of the right systolic frame is shown. Areas of prolapse are color-
ventricle can be clearly appreciated. These images were ized by the software in red. It is immediately evident a
oriented so that the pulmonic valve is on the left, purple prolapse of part of A1 scallop and the entire A2 scallop
ring on the solid rendering, while the tricuspid annulus is of the mitral valve. There is also lack of leaflet coap-
on the right (blue ring). tation and the valve annulus appears somewhat flat.
60 G. Menciotti et al.

are three-dimensional, the ultrasonographer’s

effect on the data is logically less relevant, as prob-
lems related to oblique or not aligned image planes is
virtually nonexistent. It is now clearly recognized in
humans that, given the complex shape of cardiac
structures, RT3DE provides superior assessment than
conventional echocardiography for volumetric and
functional assessments since it does not rely on
geometrical assumptions [34]. Validation of RT3DE in
veterinary medicine is limited by availability and
intrinsic limitations of gold standard methods, such
as cardiac magnetic resonance image, computed
Figure 10 3D printed models of canine mitral valves. tomography, thermodilution e nonetheless, many
The mitral valves of two canine patients were 3D printed studies have already been undertaken [40e49].
based on real-time three-dimensional echocardiographic Lastly, it is also important to notice how RT3DE
images. The valves were magnified (2) to emphasize datasets allow the performance of conventional 2D
differences in order to be used for teaching purposes. It measurement, as the images can be sliced, crop-
can be appreciated how the valve on the left has a flat ped, and rotated to visualize standardized 2D
annulus and an anterior leaflet prolapse as consequence image planes that can be then measured as pre-
of myxomatous valvular degeneration, while the one on viously (Figs. 4e6).
the right is from a healthy dog and has a clear saddle-
shape. The thin nature of valves presents a challenge
for 3D printing. For example, these models were created
Three-dimensional printing
by stereolithography, since the more common fused
deposition modeling printers were not able to represent Printing from RT3DE images is feasible, although
fine details appropriately. The support structure is definitely not as straightforward as printing regular
automatically created by the 3D printing software and echocardiographic images. A detailed description
can be cut out from the valve model if needed. of the process is beyond the scope of this review;
however, some key points will be presented.
laboratories use RT3DE as an addition to conven-
Briefly, several different types of 3D printers are
tional echocardiography. However, with further
commercially and professionally available, and the
technological development, it is not unreasonable to
characteristics of the printing media as well as the
think that in the future a comprehensive echo-
printing modality should be taken into account
cardiographic evaluation could be performed by only
when considering the final product and its inten-
acquiring RT3DE images. In the authors’ laboratories,
ded use. The input required by most 3D printers is
for example, the same full-volume multi-beat
a virtual model in the format of an.STL file. Gen-
acquisition dataset can be analyzed using different
eration and optimization of such files before
software packagesdeg in order to obtain left and right
printing usually requires one, or often more than
ventricular volumes, stress and strain, left and right
one, dedicated software package and expertise.
atrial volumes, anatomic regurgitant orifice areas,
Nonetheless, direct export to.STL files is increas-
and advanced morphologic analysis of the mitral
ingly being embedded in RT3DE software packages
valve. One of the disadvantages of these software
while the cost of 3D printing is exponentially
packages is that they rely on proprietary software
decreasing and with it, its availability increasing in
algorithms for calculations and, therefore, require a
similar fashion (Fig. 10).
‘leap of faith’ from the operator. Nonetheless, the
vast majority of softwares leave full control to the
operator to verify and correct semi-automated
tracking; furthermore, since the images analyzed Final remarks

Implementation of RT3DE in veterinary echo-

cardiography laboratories is slowly but steadily
d
4D LV-ANALYSIS 3, TOMTEC Imaging Systems GmbH, Unters- happening. Technological progresses are constantly
chleissheim, Germany. improving this technology making it more afford-
e
4D RV-FUNCTION 3, TOMTEC Imaging Systems GmbH,
able, user-friendly, and capable of acquiring images
Unterschleissheim, Germany.
f
4D MV-ASSESSMENT 2, TOMTEC Imaging Systems GmbH, with higher definition and faster volume rates
Unterschleissheim, Germany. through smaller probes’ footprints, hence better
g
4D CARDIO-VIEW 3, TOMTEC Imaging Systems GmbH, suitable to image most veterinary patients.
Unterschleissheim, Germany.
Three-dimensional echocardiography 61

Nonetheless, as any new technique, operators face

a steep learning curve in the process of image visualization was used to align the two-
acquisition, optimization, and analysis. Most newer dimensional planes with the stenotic orifice
echocardiographic machines can now integrate 3D and measure its diameters and area. The
panel in the bottom right shows a surface
analysis software packages directly on the cart,
rendering of the pulmonic leaflets and
while some advanced analyses still require a dedi-
stenotic orifice visualized from the post-
cated workstation. stenotic dilatation. Stitching artifacts can be
noted crossing the image in all the two-
Author contributions dimensional planes as well as in the surface
rendering.
All the authors have substantially and equally Video 4 Surface rendering of a deployed Amplatz
contributed to the writing and revision of this Canine Duct Occluder. Surface rendered
review manuscript. All the authors approve the image obtained after successful deployment
final version to be published. of an Amplatz Canine Duct Occluder. This
image was obtained with multi-beat
acquisition and then cropped in order to
Supplementary data visualize only the device, which has normal,
unstressed conformation. Notice the level of
detail of the rendering that can be obtained
Supplementary data associated with this arti-
with this technique.
cle can be found, in the online version, at
https://doi.org/10.1016/j.jvc.2023.11.010.

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