P1712 How the speed and high-level data acquisition of 3D Echocardiography benefitted surgical planning in a complex aortic root abscess case
Authors: Ahluwalia V , Demetriades P , Abdelsalam H , Rai K , Osman F , Parmar J , Khan J N 
Published: January 2020

Abstract

Introduction
Despite 3D echocardiography (3DE) obtaining significantly greater data than 2D echocardiography (2DE), its underutilised in assessing cardiac anatomy and dynamics. It eliminates the need for geometric modelling and assumptions about cardiac shape and permits high levels of post processing, with a single 3DE volumetric image allowing (a) generation of unlimited multiplanar reconstruction (MPR) 2D images, (b) reconstruction of volume-rendered 3D images and (c) real-time live 3D imaging. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia, but diagnosed using rapid 3DE-TOE under sedation.
Case
A 25-year-old-female intravenous drug user presented to our institution with collapse after a 1-month history of constitutional symptoms. Her background included bicuspid aortic valve disease with severe aortic stenosis. On admission, leucophilia (WCC 18x109/L), anaemia (Hb 70g/L) and Staphylococcus Aureus bacteraemia were present. Bedside transthoracic echocardiography (TTE) revaled a likely aortic root abscess. Cardiac surgeons recommended urgent surgery. The patient was highly anxious however and refused pre-operative TOE under general anaesthesia. She reluctantly agreed to a ‘fast’ TOE under sedation. She tolerated a study of only 7 minutes with only single 3D image acquisitions of the mitral and aortic valves and aortic root being necessary for post-processed generation of highly detailed anatomical assessment of endocarditis, permitting surgical planning (Figs 1-4). These demonstrated severe infection of both aortic valve leaflets, perforation of the major leaflet, severe mixed aortic valve disease and infection throughout the aortic root with multiple abscess cavities. She subsequently underwent urgent bioprosthetic aortic valve replacement and root reconstruction and made an excellent recovery.

Discussion
Valve endocarditis with leaflet destruction and aortic root abscesses are potentially fatal, requiring urgent surgery. The preferred standard for diagnosing aortic root abscesses is TOE over TTE. This is because of the greater anatomical resolution of intracardiac structures, crucial in pre-operative surgical planning. Due to the need for a diagnostic TOE study here in this complex case rapidly, the ability to obtain such a vast amount of post processed data using two rapidly acquired TOE 3D images under sedation rather than anaesthesia was crucial in guiding the cardiac surgeon and benefitting her clinical outcome.

Conclusion
We encourage clinicians to use 3DE routinely in patients needing detailed and accurate anatomical and functional assessment, and in those that are complex or technically difficult given its ability to rapidly produce unrivalled echocardiographic data through unlimited post-processed MPR images including volume-rendered and colour-doppler.
Abstract P1712 Figure. 4 MPR 2D images from single 3DE image