*5.4.3. Other complications*

Three-dimensional imaging enables valve perforations to be viewed 'en face' providing precise localization and sizing of any defect, while a small number of case reports indicate a higher detection rate when compared to 2D TEE [94, 95]. One drawback of 3D is artifactual 'dropout', especially with thin valvular tissue and suboptimal gain settings, which can result in falsepositive findings. To confirm the finding, the defect should be visualized in systole and diastole and associated with a thickened rim surrounding the perforation [96]. Finally, 3D may assist with surgical planning when repair is contemplated [94, 96].

Three-dimensional TEE has the potential to demonstrate the extent and location of a valve aneurysm with greater accuracy than 2D imaging [97]. Similarly with perivalvular dehiscence, 3D is able to define the anatomic spatial relationship to surrounding structures and accurately define the location, size, and extent of the pathology [93]. One study showed the added benefit of 3D contrast TTE for accurately delineating the size and extent of a left ventricular pseudoaneurysm, when compared to 2D contrast TTE [98].

The role of 3D echo for right-sided IE is restricted to case reports and small case series [99, 100]. Sungur et al. [101] published the first study that compared 3D versus 2D TEE in tricuspid valve endocarditis against the gold standard of surgery. Three-dimensional imaging provided en-face visualization of all three TV leaflets in nine of 10 cases, allowing accurate identification and localization of multiple vegetations. In addition, 3D was able to better characterize vegetation morphology and size. Three-dimensional TEE also identified a tricuspid annular abscess that was missed on 2D TEE imaging. Three-dimensional TEE may add incremental value in localizing vegetations that are partly obscured by reverberation artifact on 2D imaging [99]. Because the right heart is located anteriorly in the chest, 3D TTE is particularly useful and has the potential to provide better imaging of the tricuspid valve.
