Advances in ultrasound, computer, and electronics technology have permitted three-dimensional echocardiography (3DE) to become a clinically viable imaging modality, with significant impact on patient diagnosis, management, and outcome. Thanks to the inception of a fully sampled matrix transducer for transthoracic and transesophageal probes, 3DE now offers much faster and easier data acquisition, immediate display of anatomy, and the possibility of online quantitative analysis of cardiac chambers and heart valves. The clinical use of transthoracic 3DE has been primarily focused, albeit not exclusively, on the assessment of cardiac chamber volumes and function. Transesophageal 3DE has been applied mostly for assessing heart valve anatomy and function. The advantages of using 3DE to measure cardiac chamber volumes derive from the lack of geometric assumptions about their shape and the avoidance of the apical view foreshortening, which are the main shortcomings of volume calculations from two-dimensional echocardiographic views. Moreover, 3DE offers a unique realistic en face display of heart valves, congenital defects, and surrounding structures allowing a better appreciation of the dynamic functional anatomy of cardiac abnormalities in vivo. Offline quantitation of 3DE data sets has made significant contributions to our mechanistic understanding of normal and diseased heart valves, as well as of their alterations induced by surgical or interventional procedures. As reparative cardiac surgery and transcatheter procedures become more and more popular for treating structural heart disease, transesophageal 3DE has expanded its role as the premier technique for procedure planning, intra-procedural guidance, as well as for checking device function and potential complications after the procedure.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Cardiac magnetic resonance
Proximal isovelocity surface area
Transcatheter aortic valve implantation
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for imaging acquisition and display using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging. 2012;13:1–46.
Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015;16:233–70. Updated guidelines for chamber quantification using echocardiography.
Zamorano JL, Badano LP, Bruce C, et al. EAE/ASE recommendations for the use of echocardiography in new transcatheter interventions for valvular heart diseases. Eur Heart J. 2011;32:2189–214.
Farooqi KM, Sengupta PP. Echocardiography and three-dimensional printing: sound ideas to touch a heart. J Am Soc Echocardiogr. 2015;28:398–403.
Badano LP. The clinical benefits of adding a third dimension to assess the left ventricle with echocardiography. Scientifica (Cairo). 2014;2014:897431. Comprehensive review about assessment of left ventricular geometry and function by three-dimensional echocardiography.
Chan J, Jenkins C, Khafagi F, et al. What is the optimal clinical technique for measurement of left ventricular volume after myocardial infarction? A comparative study of 3-dimensional echocardiography, single photon emission computed tomography, and cardiac magnetic resonance imaging. J Am Soc Echocardiogr. 2006;19:192–201.
Sugeng L, Mor-Avi V, Weinert L, et al. Quantitative assessment of left ventricular size and function: side-by-side comparison of real-time three-dimensional echocardiography and computed tomography with magnetic resonance reference. Circulation. 2006;114:654–61.
Pouleur AC, le Polain de Waroux JB, Pasquet A, et al. Assessment of left ventricular mass and volumes by three-dimensional echocardiography in patients with or without wall motion abnormalities: comparison against cine magnetic resonance imaging. Heart. 2008;94:1050–7.
Mor-Avi V, Jenkins C, Kuhl HP, et al. Real-time 3-dimensional echocardiographic quantification of left ventricular volumes: multicenter study for validation with magnetic resonance imaging and investigation of sources of error. J Am Coll Cardol Cardiovasc Imaging. 2008;1:413–23.
Badano LP, Boccalini F, Muraru D, et al. Current clinical applications of transthoracic three-dimensional echocardiography. J Cardiovasc Ultrasound. 2012;20:1–22.
Shimada YJ, Shiota T. A meta-analysis and investigation for the source of bias of left ventricular volumes and function by three-dimensional echocardiography in comparison with magnetic resonance imaging. Am J Cardiol. 2011;107:126–38.
Dorosz JL, Lezotte DC, Weitzenkamp DA, et al. Performance of 3-dimensional echocardiography in measuring left ventricular volumes and ejection fraction: a systematic review and meta-analysis. J Am Coll Cardiol. 2012;59:1799–808.
Chahal NS, Lim TK, Jain P, et al. Population-based reference values for 3D echocardiographic LV volumes and ejection fraction. J Am Coll Cardiol Cardiovasc Imaging. 2012;5:1191–7.
Fukuda S, Watanabe H, Daimon M, et al. Normal values of real-time 3-dimensional echocardiographic parameters in a healthy Japanese population: the JAMP-3D Study. Circ J. 2012;76:1177–81.
Aune E, Baekkevar M, Rodevand E, et al. Reference values for left ventricular volumes with real-time 3-dimensional echocardiography. Scand Cardiovasc J. 2010;44:24–30.
Muraru D, Badano LP, Peluso D, et al. Comprehensive analysis of left ventricular geometry and function by three-dimensional echocardiography in healthy adults. J Am Soc Echocardiogr. 2013;26:618–28.
Pickett CA, Cheezum MK, Kassop D, et al. Accuracy of cardiac CT, radionucleotide and invasive ventriculography, two- and three-dimensional echocardiography, and SPECT for left and right ventricular ejection fraction compared with cardiac MRI: a meta-analysis. Eur Heart J Cardiovasc Imaging. 2015;16:848–52.
Badano LP, Miglioranza Hartel M, Mihaila S, et al. Normative values and physiologic determinants of left atrial volumes and function: a three-dimensional echocardiographic study in healthy volunteers. Circ Cardiovasc Imaging. 2016;9(7):e004229. doi:10.1161/CIRCIMAGING.115.004229. Reference values for left atrial volumes obtained with three-dimensional echocardiography.
Peluso D, Badano LP, Muraru D, et al. Right atrial size and function assessed with three-dimensional and speckle tracking echocardiography in 200 healthy volunteers. Eur J Cardiovasc Imaging. 2013;14:1106–14. Reference values for right atrial volumes obtained with three-dimensional echocardiography.
Varnero S, Santagata P, Pratali L, et al. Head to head comparison of 2D vs real time 3D dipyridamole stress echocardiography. Cardiovasc Ultrasound. 2008;6:31.
Badano LP, Muraru D, Rigo F, et al. High volume-rate three-dimensional stress echocardiography to assess inducible myocardial ischemia: a feasibility study. J Am Soc Echocardiogr. 2010;23:628–35.
van den Bosch AE, Robbers-Visser D, Krenning BJ, et al. Comparison of real-time three-dimensional echocardiography to magnetic resonance imaging for assessment of left ventricular mass. Am J Cardiol. 2006;97:113–7.
Takeuchi M, Nishikage T, Mor-Avi V, et al. Measurement of left ventricular mass by real-time three-dimensional echocardiography: validation against magnetic resonance and comparison with two-dimensional and m-mode measurements. J Am Soc Echocardiogr. 2008;21:1001–5.
Avegliano GP, Costabel JP, Asch FM, et al. Utility of real time 3D echocardiography for the assessment of left ventricular mass in patients with hypertrophic cardiomyopathy: comparison with cardiac magnetic resonance. Echocardiography. 2016;33:431–6.
Shimada YJ, Shiota T. Meta-analysis of accuracy of left ventricular mass measurement by three-dimensional echocardiography. Am J Cardiol. 2012;110:445–52.
Marwick TH, Gillebert TC, Aurigemma J, et al. Recommendations on the use of echocardiography in adult hypertension: a report from the European Association of Cardiovascular Imaging (EACVI) and the American Society of Echocardiography (ASE). J Am Soc Echocardiogr. 2015;28:727–54.
Seo Y, Ishizu T, Aonuma K. Current status of 3-dimensional speckle tracking echocardiography: a review from our experiences. J Cardiovasc Ultrasound. 2014;22:49–57.
Muraru D, Cucchini U, Mihaila S, et al. Left ventricular myocardial strain by three-dimensional speckle-tracking echocardiography in healthy subjects: reference values and analysis of their physiologic and technical determinants. J Am Soc Echocardiogr. 2014;27:858–71. Reference values for three-dimensional strain components obtained using GE machine.
Badano LP, Cucchini U, Muraru D, et al. Use of three dimensional speckle-tracking to assess left ventricular myocardial mechanics: inter-vendor consistency and reproducibility of strain measurements. Eur Heart J Cardiovasc Imaging. 2013;14:285–93.
Morbach C, Lin BA, Sugeng L. Clinical application of three-dimensional echocardiography. Prog Cardiovasc Dis. 2014;57:19–31.
Surkova E, Muraru D, Iliceto S, et al. The use of multimodality cardiovascular imaging to assess right ventricular size and function. Int J Cardiol. 2016;214:54–69. Review about the use of non-invasive cardiac imaging to assess the right ventricle in different cardiac conditions.
Muraru D, Spadotto V, Cecchetto A, et al. New speckle-tracking algorithm for right ventricular volume analysis from three-dimensional echocardiographic data sets: validation with cardiac magnetic resonance and comparison with the previous analysis tool. Eur Heart J Cardiovasc Imaging. 2015. [Epub ahead of print].
Lu X, Nadvoretskiy V, Bu L, et al. Accuracy and reproducibility of real-time three-dimensional echocardiography for assessment of right ventricular volumes and ejection fraction in children. J Am Soc Echocardiogr. 2008;21:84–9.
Leibundgut G, Rohner A, Grize L, et al. Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients. J Am Soc Echocardiogr. 2010;23:116–26.
Gopal AS, Chukwu EO, Iwuchukwu CJ, et al. Normal values of right ventricular size and function by real-time 3-dimensional echocardiography: comparison with cardiac magnetic resonance imaging. J Am Soc Echocardiogr. 2007;20:445–55.
Bin Zhang Q, Sun JP, Gao RF, et al. Feasibility of single-beat full-volume capture real-time three-dimensional echocardiography for quantification of right ventricular volume: validation by cardiac magnetic resonance imaging. Int J Cardiol. 2013;168:3991–5.
De Simone R, Wolf I, Mottl-Link S, et al. Intraoperative assessment of right ventricular volume and function. Eur J Cardiothorac Surg. 2005;27:988–93.
Tamborini G, Marsan NA, Gripari P, et al. Reference values for right ventricular volumes and ejection fraction with real-time three-dimensional echocardiography: evaluation in a large series of normal subjects. J Am Soc Echocardiogr. 2010;23:109–15.
Maffessanti F, Muraru D, Esposito R, et al. Age-, body size-, and sex-specific reference values for right ventricular volumes and ejection fraction by three-dimensional echocardiography: a multicenter echocardiographic study in 507 healthy volunteers. Circ Cardiovasc Imaging. 2013;6:700–10. Reference values for right ventricular volumes and ejection fraction obtained with three-dimensional echocardiography.
Ozawa K, Funabashi N, Takaoka H, et al. Utility of three-dimensional global longitudinal strain of the right ventricle using transthoracic echocardiography for right ventricular systolic function in pulmonary hypertension. Int J Cardiol. 2014;174:426–30.
Smith BCF, Dobson G, Dawson D, et al. Three-dimensional speckle tracking of the right ventricle: toward optimal quantification of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol. 2014;64:41–51.
Ozawa K, Funabashi K, Takaoka H, et al. Consistencies of 3D TTE global longitudinal strain of both ventricles between assessors were worse for 2D, but better for 3D ventricular EF. Int J Cardiol. 2015;198:140–51.
Atsumi A, Ishizu T, Kameda Y, et al. Application of 3-dimensional speckle tracking imaging to the assessment of right ventricular regional deformation. Circ J. 2013;77:1760–8.
Addetia K, Maffessanti F, Yamat M, et al. Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension. Eur Heart J Cardiovasc Imaging. 2016;17:564–75.
Chandra S, Salgo IS, Sugeng L, et al. Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging. 2011;4:24–32.
Tamborini G, Muratori M, Maltagliati A, et al. Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions. Eur J Echocardiogr. 2010;11:778–85.
de Groot-de Laat LE, Ren B, McGhie J, et al. The role of experience in echocardiographic identification of location and extent of mitral valve prolapse with 2D and 3D echocardiography. Int J Cardiovasc Imaging 2016; in press
Izumo M, Shiota M, Kar S, et al. Comparison of real-time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography for quantification of mitral valve prolapse in patients with severe mitral regurgitation. Am J Cardiol. 2013;111:588–94.
Kagiyama N, Toki M, Hara M, et al. Efficacy and accuracy of novel automated mitral valve quantification: three-dimensional transesophageal echocardiographic study. Echocardiography. 2016;33:756–63.
Lee AP-W, Fang F, Jin CN, et al. Quantification of mitral valve morphology with three-dimensional echocardiography—can measurement lead to better management? Circ J. 2014;78:1029–37.
Buck T, Plicht B. Real-time three-dimensional echocardiographic assessment of severity of mitral regurgitation using proximal isovelocity surface area and vena contracta area method. Lessons we learned and clinical implications. Curr Cardiovasc Imaging Rep. 2015;8:38.
Chandra S, Salgo IS, Sugeng L, et al. A three-dimensional insight into the complexity of flow convergence in mitral regurgitation: adjunctive benefit of anatomic regurgitant orifice area. Am J Physiol Heart Circ Physiol. 2011;301:H1015–24.
Shanks M, Siebelink H-MJ, Delgado V, et al. Quantitative assessment of mitral regurgitation: comparison between three-dimensional transesophageal echocardiography and magnetic resonance imaging. Circ Cardiovasc Imaging. 2010;3:694–700.
Marsan NA, Westenberg JJM, Ypenburg C, et al. Quantification of functional mitral regurgitation by real-time 3D echocardiography: comparison with 3D velocity-encoded cardiac magnetic resonance. J Am Coll Cardiol Cardiovasc Imaging. 2009;2:1245–52.
Thavendiranathan P, Liu S, Datta S, et al. Quantification of chronic functional mitral regurgitation by automated 3-dimensional peak and integrated proximal isovelocity surface area and stroke volume techniques using real-time 3-dimensional volume color Doppler echocardiography: in vitro and clinical validation. Circ Cardiovasc Imaging. 2013;6:125–33.
Zeng X, Levine RA, Hua L, et al. Diagnostic value of vena contracta area in the quantification of mitral regurgitation severity by color Doppler 3D echocardiography. Circ Cardiovasc Imaging. 2011;4:506–13.
Zamorano J, Cordeiro P, Sugeng L, et al. Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. J Am Coll Cardiol. 2004;43:2091–6. This study validated three-dimensional echocardiography as the reference standard for residual mitral orifice area measurement.
Sugeng L, Weinert L, Lammertin G, et al. Accuracy of mitral valve area measurements using transthoracic rapid freehand 3-dimensional scanning: comparison with noninvasive and invasive methods. J Am Soc Echocardiogr. 2003;16:1292–300.
Zamorano J, Perez de Isla L, Sugeng L, et al. Non-invasive assessment of mitral valve area during percutaneous balloon mitral valvuloplasty: role of real-time 3D echocardiography. Eur Heart J. 2004;25:2086–91.
Anwar AM, Attia WM, Nosir YFM, et al. Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography. J Am Soc Echocardiogr. 2010;23:13–22.
Soliman OII, Anwar AM, Metawei AK, et al. New scores for the assessment of mitral stenosis using real-time three-dimensional echocardiography. Curr Cardiovasc Imaging Rep. 2011;4:370–7.
Stankovic I, Daraban AM, Jasaityte R, et al. Incremental value of the en face view of the tricuspid valve by two-dimensional and three-dimensional echocardiography for accurate identification of tricuspid valve leaflets. J Am Soc Echocardiogr. 2014;27:376–84.
Mediratta A, Addetia K, Yamat M, et al. 3D echocardiographic location of implantable device leads and mechanism of associated tricuspid regurgitation. J Am Coll Cardiol Cardiovasc Imaging. 2014;7:337–47.
Addetia K, Yamat M, Mediratta A, et al. Comprehensive two-dimensional interrogation of the tricuspid valve using knowledge derived from three-dimensional echocardiography. J Am Soc Echocardiogr. 2016;29:74–82.
Fukuda S, Saracino G, Matsumura Y, et al. Three-dimensional geometry of the tricuspid annulus in healthy subjects and in patients with functional tricuspid regurgitation: a real-time, 3-dimensional echocardiographic study. Circulation. 2006;114:I492–8.
Miglioranza MH, Mihaila S, Muraru D, et al. Dynamic changes in tricuspid annular diameter measurement in relation to the echocardiographic view and timing during the cardiac cycle. J Am Soc Echocardiogr. 2015;28:226–35.
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012;33:2569–619.
Taramasso M, Pozzoli A, Guidotti A, et al. Percutaneous tricuspid valve therapies: the new frontier. Eur Heart J. 2016. [Epub ahead of print]. Review about the new devices for transcatheter treatment of functional tricuspid regurgitation.
Rodes-Cabau J, Taramasso M, O’Gara PT. Diagnosis and treatment of tricuspid valve disease: current and future perspectives. Lancet. 2016. [Epub ahead of print].
Pothineni KR, Duncan K, Yelamanchili P, et al. Live/real time three-dimensional transthoracic echocardiographic assessment of tricuspid valve pathology: incremental value over the two-dimensional technique. Echocardiography. 2007;24:541–52.
Faletra F, La Marchesina U, Bragato R, et al. Three dimensional transthoracic echocardiography images of tricuspid stenosis. Heart. 2005;91:499.
Badano LP, Agricola E, Perez de Isla L, et al. Evaluation of the tricuspid valve morphology and function by transthoracic real-time three-dimensional echocardiography. Eur J Echocardiogr. 2009;10:477–84.
Muraru D, Tuveri MF, Marra MP, et al. Carcinoid tricuspid valve disease: incremental value of three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging. 2012;13:329.
Sugeng L, Weinert L, Lang RM. Real-time 3-dimensional color Doppler flow of mitral and tricuspid regurgitation: feasibility and initial quantitative comparison with 2-dimensional methods. J Am Soc Echocardiogr. 2007;20:1050–7.
Chen TE, Kwon SH, Enriquez-Sarano M, et al. Three-dimensional color Doppler echocardiographic quantification of tricuspid regurgitation orifice area: comparison with conventional two-dimensional measures. J Am Soc Echocardiogr. 2013;26:1143–52.
Song JM, Jang MK, Choi YS, et al. The vena contracta in functional tricuspid regurgitation: a real-time three-dimensional color Doppler echocardiography study. J Am Soc Echocardiogr. 2011;24:663–70.
de Agustin JA, Viliani D, Vieira C, et al. Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification. J Am Soc Echocardiogr. 2013;26:1063–72.
Khalique OK, Kodali SK, Paradis JM, et al. Aortic annular sizing using a novel 3-dimensional echocardiographic method: use and comparison with cardiac computed tomography. Circ Cardiovasc Imaging. 2014;7:155–63.
Jilaihawi H, Doctor N, Kashif M, et al. Aortic annular sizing for transcatheter aortic valve replacement using cross-sectional 3-dimensional transesophageal echocardiography. J Am Coll Cardiol. 2013;61:908–16.
Hahn TH, Little SH, Monaghan MJ, et al. Recommendations for comprehensive intraprocedural echocardiographic imaging during TAVR. J Am Coll Cardiol Cardiovasc Imaging. 2015;8:261–87.
Lancellotti P, Pibarot P, Chambers J, et al. Recommendations for the imaging assessment of prosthetic heart valves: a report from the European Association of Cardiovascular Imaging endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2016;17:589–90.
Franco E, Almeria C, de Agustin JA, et al. Three-dimensional color Doppler transesophageal echocardiography for mitral paravalvular leak quantification and evaluation of percutaneous closure success. J Am Soc Echocardiogr. 2014;27:1153–63.
Wunderlich NC, Beigel R, Swaans MJ, et al. Percutaneous interventions for left atrial appendage exclusion: options, assessment, and imaging using 2D and 3D echocardiography. J Am Coll Cardiol Cardiovasc Imaging. 2015;8:472–88.
Dr. Elena Surkova has received a research grant from the European Society of Cardiology.
Dr. Diana Cherata is a recipient of a research grant founded by the European Association of Cardiovascular Imaging.
Conflict of Interest
Elena Surkova, Denisa Muraru, Patrizia Aruta, Gabriella Romeo, Jurate Bidviene, Diana Cherata, and Luigi P. Badano declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Echocardiography
Rights and permissions
About this article
Cite this article
Surkova, E., Muraru, D., Aruta, P. et al. Current Clinical Applications of Three-Dimensional Echocardiography: When the Technique Makes the Difference. Curr Cardiol Rep 18, 109 (2016). https://doi.org/10.1007/s11886-016-0787-9
- Three-dimensional echocardiography
- Left ventricle
- Right ventricle
- Mitral valve
- Tricuspid valve
- Interventional procedures