Dear Sir,Successful percutaneous treatment for ruptured sinus of valsalva aneurysm (RSOVA) is being increasingly reported and it has performed with using different devices.[1] Three-dimensional transesophageal echocardiography (3DTEE) has become the interesting imaging tool for diagnosis and evaluation of RSOVA. The application of real-time 3DTEE in the diagnosis and transcatheter closure of RSOVA signify the important role of 3DTEE in performing of this procedure. Aneurysm neck, diameter of rupture site and the distance to the right coronary artery can be measured by 3DTEE, accurately. The relationship between the RSOVA, the aortic valve, and the right ventricle can be shown exactly by real time 3DTEE. The precise shape of RSOVA can be revealed by 3DTEE because it enables complete assessment of the mouth of the aneurysm by visualizing it en face. Compared with two-dimensional (2D) TEE, 3DTEE provided more accurate delineation of the defect location and orientation and may help in choosing of an appropriate device for closure. Visualization of the defect in 3DTEE from different angles and flow acceleration across the defect demonstrated by volumetric color flow helps in accurate localization of the anatomic defect.[2] Another advantage of 3DTEE compared with 2DTEE, is that wind suck can be appear as an echo-free space around the aortic sinus, falsely resembling the limited dissection of the aortic root with false lumen with ruptured aortic annulus, resulting in aortic regurgitation,[3]3DTEE could help us make the correct diagnosis in such cases. Also, patients of RSOVA with multiple rupture sites better evaluated by 3DTEE than 2DTEE. In 2DTEE demonstration of coexisting a doubly committed subarterial ventricular septal defect (VSD) is problematic. 3DTEE can provide clear images for diagnosis of the VSD closely adjacent to the RSOVA.[4] In the low cardiac output state, due to the very low flow 2D color Doppler examination may not be helpful, but it is not matter for 3DTEE.[5]Three-dimensional transesophageal echocardiography provides optimal deployment of the device and superior guidance, as compared to 2DTEE. Furthermore, inappropriate device position and compromise of aortic valve function resulting in aortic regurgitation can be avoided with 3DTEE guidance.Postprocedure 3DTEE can be show that the device is in appropriated position with a proper distance from right coronary artery ostium, the function of aortic valve is intact and residual shunt. Assessment of these complications better done by 3DTEE than 2DTEE. However, frame rate of 3DTEE is <2DTEE.
CONCLUSION
Three-dimensional transesophageal echocardiography represents an important adjunctive tool to demonstrate the RSOVA with better delineation of its characteristics such as the site of rupture into the cardiac chambers, the size, shape of the defect, associated defects such as VSD, however, it has lesser frame rate compared with 2DTEE. We recommend more usage of 3DTEE in catheterization laboratory for the guidance of RSOVA device closure.