TrueVue Plus Light and Glass Three‐Dimensional Echocardiography for Heart Diseases: A Revolution in Cardiovascular Imaging

ABSTRACT

Purpose

To explore the value and operational points of TrueVue, TrueVue Light, and TrueVue Glass, which are emerging, advanced three‐dimensional echocardiographic (3DE) technologies, for the clinical diagnosis of heart diseases.

Methods

Echocardiography examinations were performed in 272 patients with suspected structural heart diseases. Two‐dimensional (2D) and real‐time 3DE methods, including traditional and new 3D imaging techniques were used. The Likert scale was used to compare the novel and traditional techniques. The operational capabilities, advantages, and limitations of the new techniques were assessed.

Results

Twenty‐one (7.7%) patients had normal cardiac structure, 98 (36.0%) had congenital heart diseases, 70 (25.7%) had acquired valvular diseases, 43 (15.8%) had cardiomyopathy, and 40 (14.7%) had other cardiac structural abnormalities. TrueVue provided high‐resolution, realistic 3D images. TrueVue Light provided a virtual light source to apply light and shade effects that could be set at different locations and depths. TrueVue Glass was used for highlighting the borders of the chambers, thin valves, and vessels. The evaluation scores (Likert scale) of the novel 3DE tools were higher than those of traditional 3DE systems (p < 0.0001).

Conclusions

For viewing various cardiac lesions, novel 3DE imaging was preferred over conventional displays in all surveyed groups. The use of TrueVue, TrueVue Light, and TrueVue Glass 3DE provides effective reference information, increases the diagnostic accuracy and efficiency, and optimizes the workflow of doctors who diagnose and treat heart diseases.

TrueVue Light and Glass three‐dimensional echocardiography enhance photorealistic visualization of cardiac anatomy, offering improved structural delineation and potential value for more accurate diagnosis in heart disease.

Abbreviations

ASD

atrial septal defect

DCM

dilated cardiomyopathy

HCM

hypertrophic cardiomyopathy

LAA

left atrial appendage

LVNC

left ventricular noncompaction

MV

mitral valve

PA

pulmonary artery

PAA

pulmonary artery aneurysm

TAPVD

total anomalous pulmonary venous drainage

TEE

transesophageal echocardiography

TTE

transthoracic echocardiography

VSD

ventricular septal defect

2D

two‐dimensional

3D

three‐dimensional

1. Introduction

Three‐dimensional (3D) echocardiography (3DE) is an important tool for visualizing the spatial structure of the heart [1]. The continuous improvement of real‐time 3D (RT3D) transthoracic and transesophageal echocardiography (TTE and TEE, respectively) has resulted in dynamic 3D cardiac images and has received increasing attention from clinicians [2, 3, 4]. As 3DE allows for the visual diagnosis of complex cardiac anatomic and spatial relationships and simulates surgical views to enhance the preoperative evaluation of cardiac morphology and function, it has several advantages over the traditional two‐dimensional echocardiography (2DE). Therefore, 3DE is a practical tool for the diagnosis of heart diseases [5, 6, 7]. However, traditional 3DE has many shortcomings in practical applications, which limits its wider use. For example, cardiac surgeons or physicians may still believe that ultrasound images are not representative of pathological specimens and are difficult to interpret. This is because the visual resolution of the ultrasound imaging is inadequate, or the visualization of the outer contour of a bulging or malformed blood vessel may not be comprehensive. To achieve more realistic models, researchers have used 3D printing technology. However, these models are static and, thus, do not truly reproduce the functional and hemodynamic changes in intracardiac structures during the cardiac cycle [8, 9]. Virtual reality technology has also been used to fuse 3D cardiac images of the entire cardiac cycle into a digital model; however, this process is time‐ and energy‐consuming [10]. New 3DE technologies, including the TrueVue, TrueVue Light [11, 12], and TrueVue Glass, have been introduced in recent years [13], have impressive functions and imaging modes, and provide vivid images. However, there have been only a few studies on their applications [11, 14, 15, 16, 17]. Therefore, this study aimed to diagnose various cardiac lesions and structural abnormalities using these novel 3DE technologies and explore their value and potential applications.

1.1. Patients and Methods

A total of 272 patients (125 males and 147 females) who underwent echocardiography between January 2019 and June 2022 were recruited. The mean patient age was 22.9 years (standard deviation [SD]: 26.1 years; range: 1 day–81 years). Among the 272 examinations, 220 were acquired using RT3D‐TTE and 52 using RT3D‐TEE. This study is in accordance with the Declaration of Helsinki, and was approved by the Ethics Committee of the affiliated Hospital of our University (Approval No. 2019PS327K). Informed consent was obtained from each patient or their guardian.

1.2. Examination and Imaging Methods

The Philips EPIQ CVx cardiovascular‐specific color Doppler ultrasound system (Philips, Andover, MA, USA) was used. The transducers used for echocardiographic image acquisition included the X5‐1 (1–5 MHz) or X7‐2 (2–7 MHz) for RT3D‐TTE and the X7‐2t (2–7 MHz) or X8‐2t (2–8 MHz) for RT3D‐TEE. All image post‐processing and image evaluations were performed offline using archived datasets stored in the institutional imaging database and analyzed with QLAB 13.0 or 15.0 software (Philips). All TTE and TEE examinations were performed by senior echocardiographers with more than 5 years of experience in advanced echocardiographic imaging, including RT3DE acquisition and post‐processing. Patients were asked to lie down and breathe evenly. The duration of each image acquisition was 3–5 cardiac cycles. Patients underwent TTE or TEE. When TEE was performed, patients underwent routine standardized preparations before the procedure [4]. Once satisfactory clarity was achieved on 2D images, the region of interest was selected, and an appropriate mode was used to acquire 3D data. The mode of 3D data acquisition was typical and included live 3D, 3D zoom, and full volume [2]. TrueVue and TrueVue Light were activated using the instrument touch panel, and the operator magnified the image until a suitable viewing area was found, activated the virtual light source, and moved the light source to the ideal location and depth within the anatomical space. The operator then evaluated the relevant deformities with the assistance of the light and shadow effects produced. Subsequently, TrueVue Glass was activated by selecting the “Glass” option in TrueVue imaging, which automatically blocks tissues surrounding the heart chambers and valves. The novel 3DE imaging modes were combined with color Doppler to display the spatial characteristics of intracardiac blood flow. In addition, cropping tools were used including the traditional six‐plane box crop and arbitrary plane crop, as well as the newer quick crop (which involves manually drawing an arrow with start and end points that represent the start and end planes of the observer's field of vision), face crop (rotating the structure to be cropped towards the observer and turning a knob to crop inwards), and iCrop (clicking on a square observation box containing the target structure to select the starting surface of observation and adjusting the location and size of the box). Several echocardiographic parameters, including gain, contrast, smoothness, brightness, depth of light source, and transparency, could be adjusted, and the target structure could be randomly rotated and stretched to the desired angle using touch controls. For structures such as valves and septa, dual volume mode was used to simultaneously display the 3DE images of two opposite views.

1.3. Scoring

A total of 26 investigators (12 sonographers, 8 cardiac surgeons, and 6 cardiologists specializing in interventional cardiac surgery; no limit to the years of work experience) were invited to evaluate the conventional and new 3DE series in terms of imaging performance for normal cardiac anatomical structures, various congenital and acquired cardiac abnormalities, and reference values to be used for clinical diagnoses. Scoring was performed using a 5‐point Likert scale, with “1” indicating strong disagreement or disapproval of the views stated in the questionnaire; conversely, a score of “5” indicated strong agreement. Twenty‐five representative cases (five from each disease category) were randomly selected, and all 26 investigators independently evaluated both conventional and novel 3DE images of the same cases using the Likert scale. Twenty‐five representative cases selected from the entire cohort of 272 patients were used exclusively for the Likert‐scale assessment, whereas the clinical applications and imaging findings reported in this study were derived from the complete patient cohort.

1.4. Statistical Analysis

Statistical analysis was performed using SPSS 26.0 (IBM Inc., Armonk, NY, USA). Categorical data are expressed as number of cases (percentage). To simplify the analysis of the Likert responses to the nonleading question design, all data were tested for normality using the Kolmogorov–Smirnov test. Results are reported as mean ± standard deviation and median (first interquartile range, third interquartile range) for normally distributed and non‐normally distributed data, respectively. Continuous, normally distributed data were compared using the independent samples t‐test. Data that were not normally distributed were compared using the Mann–Whitney U test. Statistical significance was set at p < 0.05.

2. Results

Among the 272 enrolled patients, adequate novel 3DE datasets were obtained in 266 (97.8%) patients. Surgical confirmation was available in 128 (47.1%) patients.

2.1. Mitral Valve Imaging

Mitral valve assessment included normal mitral valves, congenital mitral valve malformations (n = 9), rheumatic mitral valve disease, mitral valve prolapse, Barlow disease, infective endocarditis, and prosthetic mitral valves.

Compared with conventional 3DE, TrueVue and TrueVue Light provided improved visualization of mitral leaflet morphology, commissures, scallops, and subvalvular apparatus. In normal mitral valves, the natural indentations of the posterior leaflet and the spatial relationship between leaflets, chordae tendineae, and papillary muscles were more clearly demonstrated (Figure 1). TrueVue Glass also enabled macroscopic visualization of the fibrous skeletal architecture supporting the mitral annulus and adjacent cardiac structures (Supplementary Video 2). In addition, TrueVue Glass provided realistic visualization of left atrial appendage morphology, internal pectinate muscles, and different appendage configurations (Supplementary Video 3 & Figure 1). In patients with mitral cleft, the full extent of the cleft from the leaflet edge to the annulus could be appreciated (Figure 2). In acquired mitral valve lesions, leaflet thickening, prolapse, commissural fusion, stenotic orifice morphology and leaflet vegetations were more readily identified (Figure 3). In patients with severe mitral stenosis and atrial fibrillation, TrueVue also reproduced spontaneous echo contrast within the left atrium, providing realistic visualization of blood stasis (Supplementary Video 5). In prosthetic valves, TrueVue imaging enabled detailed visualization of prosthetic leaflets and sewing rings (Supplementary Video 6 & Figure 3). When combined with color Doppler, TrueVue Glass allowed simultaneous assessment of regurgitant jet origin, spatial extent, and paravalvular leakage (Supplementary Video 7 & Figure 3).

FIGURE 1.

TrueVue imaging of normal cardiac structures. (A) TrueVue Light shows the overall morphology of the atrial septum (Case #1) with the fossa ovalis (arrow) via the LA view. (B) Anatomic morphology of the MV (#3). Leaflets and their scallops are observed in the LA view with the natural notches (arrows) of the posterior leaflet (left). The middle panel shows the stereoscopic mitral apparatus with the leaflet connected to the papillary muscle via the tendon cord during diastole as viewed from the LV aspect; the right panel shows the MV with arrows indicating the two natural anatomic notches using TrueVue Glass surgical view. (C) Anatomical morphology of the AV (#7). The left and middle panels show TrueVue Light and Glass displaying the valve opening in systole; the right shows the valve closure in diastole and the three coronary sinuses by TrueVue Glass. (D) The coronary arteries at the aortic root are shown originating from the left (left, arrow) and right coronary ostium (right, arrow) by TrueVue Glass (#7). (E) Evaluation of the atrial appendage (#11). TrueVue Light shows the frontal view of the opening of the LAA (left); the lateral view of the finger‐like LAA cavity and pectinate muscles (middle, arrows) and the wide RAA with inner pectinate muscles (right, arrows). (F) TrueVue Glass showing the LAA opening and the three small lobular structures (arrows) at the blind end from the LA aspect (#14). (G) The TrueVue Glass mode was used to view the various types of LAA; from left to right, the weathervane, cactus, and chicken wing types (Cases #16, #20, and #21, respectively). (H) TrueVue Glass display of the contours of the aortic arch and brachiocephalic vessels (arrows). The echocardiography method used for acquiring each image is shown in the lower right corner. # represents the ordinal number of the database case. AAr, aortic arch; AO, aorta; AV, aortic valve; FO, fossa ovalis; IVC, inferior vena cava; LA, left atrium; LAA, left atrial appendage; LCA, left coronary artery; LCS, left coronary sinus; LCCA, left common carotid artery; LCSA, left subclavian artery; LV, left ventricle; MV, mitral valve; NCS, non‐coronary sinus; PA, pulmonary artery; RAA, right atrial appendage; RBCA, right brachiocephalic artery; RCA, right coronary artery; RCS, right coronary sinus; SVC, superior vena cava; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography.

FIGURE 2.

TrueVue imaging for the diagnosis of congenital heart diseases. (A) TrueVue Light imaging shows the secundum ASD with a soft rim (arrow, left, Case #23) and primum ASD (right, #31). (B) TrueVue Glass shows a mesh‐type ASD (left, arrows, #37) and another huge ASD (middle, #43) with its full course of the atrial left‐to‐right shunt (dashed arrow) after adding color Doppler (right). All the images described above are LA views. (C) TrueVue Light shows a VSD (left, arrow, #45), color Doppler facilitates visualization of the spatial course of the ventricular shunt (middle, arrow), and TrueVue Glass shows a clear outline of the defect from the LV view (right, arrow). (D) In pulmonary stenosis (#75), TrueVue Glass plus color Doppler show reduction in the systolic opening of the pulmonary valve via the pulmonary view (left, arrow) and the eccentric flow forming a vortex in the widened artery (right, dotted arrow). (E) In the bicuspid AV malformation (#77), TrueVue Light shows a two‐lobed valve from the LV side, with a fish‐mouth‐like opening (left, arrow) instead of the normal triangular opening; the right panel shows a straight line instead of normal “Y” shape when closed by TrueVue Glass (arrow). (F) TrueVue Glass shows the rare single‐orifice AV, which opens in a narrow circle in systole (#83, arrow). G, In the MV cleft (#91), TrueVue Glass shows a large, complete cleft (arrow) in the anterior leaflet from the edge to the annulus via the surgical view. (H) In an endocardial cushion defect (#95), the atrioventricular valve is viewed from the LV side, TrueVue Glass reveals only one annulus in diastole, a group of open atrioventricular valves, and the absence of normal mitral and tricuspid structures (left); the common atrioventricular valve is composed of five small leaflets in systole (right, arrows) clearly indicating a complete type. (I) In TAPVD (#111), TrueVue Glass shows a smooth LA wall and an upward sloping anomalous lumen‐like structure (arrow) behind the LA (left), which, with increased transparency and color, is observed to flow upward through the vertical vein and into the right SVC via the innominate vein; the aortic arch (solid arrow) below the anomalous draining PV vessel is visible (middle panels), leading to the diagnosis of supracardiac TAPVD. CTA 3D reconstruction is consistent with echocardiography (right). # represents the ordinal number of each case. ASD, atrial septal defect; CTA, computed tomography angiography; RA, right atrium; RSVC, right superior vena cava; RV, right ventricle; TAPVD, total anomalous pulmonary venous drainage; VSD, ventricular septal defect; VV, vertical vein.

FIGURE 3.

TrueVue imaging for the diagnosis of valvular diseases. (A) TrueVue Light showing MV adhesions and stenosis (arrow) in rheumatic heart disease (Case #121) (diastole, LA view). (B) TrueVue Light from the LA side shows diastolic prolapse in P1 and P3 regions of the MV (#125) into the LA (left, arrows); color Doppler shows regurgitation at the site of systolic prolapse (right, arrows). (C) In a patient with prolapse of the MV P2 region (#133), TrueVue Glass surgical view shows a bulge of the valve into the LA (left, arrow); color Doppler shows regurgitation by dual volume mode. The black arrow shows the LA view of the regurgitation into the LA, and the blue arrow shows the corresponding LV view of the regurgitation entering from the LA (middle and right, arrows represent direction of regurgitation). (D) Infective endocarditis (#139) is observed by TrueVue Light as multiple irregular vegetations on the anterior mitral leaflet (left, arrows) and is confirmed by intraoperative findings (right, arrows). (E), Application of TrueVue Light to Barlow's MV (#143) seen from the LA with a floppy, redundant valve and a wavy edge (arrow) during diastole. (F) TrueVue Light synchronously shows the metal prosthetic MV (arrows) opening by dual volume mode (#152) from the LA and LV aspect. (G) The prosthetic biological MV and valve holder (dotted line) observed via the TrueVue Glass dual volume mode (#167) from the LA and LV aspect. (H) Simultaneous visualization of the perivalvular leak after prosthetic metal MV replacement using TrueVue Light (left) and Glass (right) with a dual volume view of both the LA and LV (#177, arrows indicate the location of the leak). (I) Regurgitation from the perivalvular leak observed in the abovementioned patient after adding color to TrueVue Light and Glass (LA view, arrows indicate the location of the regurgitation origin). (J) In a patient with an AV lesion, TrueVue Glass shows a severe eccentric regurgitation originating from the AV orifice into the LV in lateral (middle) and top (right) views because of the non‐coronary leaflet contracture (arrow) (#183, left). # represents the number of the case from whom the image was acquired.

2.2. Aortic Valve Imaging

Aortic valve assessment included normal valves and congenital or acquired aortic valve abnormalities, including bicuspid and unicuspid valves, calcific degeneration, and contracture lesions.

Compared with conventional 3DE, the novel rendering modes improved visualization of cusp morphology, commissural anatomy, and valve opening geometry. TrueVue Light enhanced appreciation of leaflet thickness and opening configuration. TrueVue Glass facilitated identification of coronary ostia and proximal coronary artery lumens (Figure 1). In bicuspid valves, the fish‐mouth systolic opening and abnormal closure line were clearly visualized (Figure 2). In patients with aortic regurgitation, Glass imaging combined with color Doppler demonstrated the origin and 3D course of eccentric regurgitant jets (Figure 3).

2.3. Septal Defects and Atrioventricular Septal Defects

This category included atrial septal defects (n = 22), ventricular septal defects (n = 21), and endocardial cushion defects (n = 3).

Compared with conventional 3DE, TrueVue imaging provided clearer delineation of defect size, shape, surrounding rims, and spatial relationships with adjacent structures (Figure 2). TrueVue Glass with color Doppler enabled visualization of the complete shunt pathway. In ventricular septal defects, en‐face visualization of the defect margins was improved. In endocardial cushion defects, the common atrioventricular annulus and leaflet configuration could be directly visualized, facilitating classification of the lesion (Figure 2).

2.4. Pulmonary Valve and Great Vessel Abnormalities

This group included pulmonary valve stenosis (n = 11), patent ductus arteriosus (n = 14), anomalous pulmonary venous drainage (n = 3), transposition of the great arteries (n = 3), pulmonary artery sling (n = 1), and other great vessel abnormalities.

Compared with conventional 3DE, TrueVue Glass provided improved visualization of the spatial relationships between valves, vessels, and blood flow pathways (Figure 1). In pulmonary valve stenosis, reduced systolic valve opening and post‐stenotic turbulent flow patterns were demonstrated more clearly (Figure 2). In anomalous pulmonary venous drainage, the entire anomalous venous pathway, including the vertical vein and its connection to systemic veins, could be followed using Glass rendering with color Doppler (Supplementary Video 4 & Figure 2). In transposition of the great arteries and other vessel malformations, abnormal spatial relationships between the great arteries were more readily appreciated. In patent ductus arteriosus, the morphology of the ductus and shunt pathway could be visualized three‐dimensionally.

2.5. Cardiomyopathy

Cardiomyopathy was identified in 43 patients, including dilated cardiomyopathy (n = 17), hypertrophic cardiomyopathy (n = 15), and left ventricular noncompaction (n = 11).

Compared with conventional 3DE, TrueVue rendering enhanced visualization of myocardial surface morphology and intracavitary structures. In left ventricular noncompaction, trabeculations and deep intertrabecular recesses were more clearly delineated (Supplementary Video 8). In hypertrophic cardiomyopathy, localized myocardial thickening and cavity deformation were better appreciated. TrueVue Glass provided intuitive visualization of ventricular remodeling and chamber geometry in dilated cardiomyopathy, particularly spherical enlargement of the left ventricle (Figure 4).

FIGURE 4.

TrueVue imaging for the diagnosis of cardiomyopathy and other heart diseases. (A) TrueVue Light shows extensive muscle trabeculae (arrows) in LVNC (Case #232). (B) A patient with bilateral VNC (#235) has excessive muscular trabeculae and columns (arrows) in both lower and middle parts of the ventricles observed by TrueVue Light. (C) HCM (#237) with TrueVue Light showing intracavitary muscle texture and thickening of the ventricular septum. (D) TrueVue Glass shows the deformed LV in LEOPARD syndrome (#241) caused by non‐uniform thickening of the lower myocardium (left), which differs from the normal myocardium (right). (E) From left to right, the chambers are depicted with TrueVue Glass: normal (#3), LV spherical dilatation in DCM (#246), apical ventricular aneurysm (arrows) after infarction (#249), and apical HCM causing narrowing of the LV apical chamber (#252, arrow). The dotted line indicates the LV border. (F) TrueVue with a light source to illuminate the LV shows attached thrombus clusters in the apical region (#255, arrows), and Glass rendering shows the filling defect (arrows) when the chambers are contoured. (G) TrueVue Light shows an irregular, cauliflower‐like tumor attached to the MV (#257, left, arrow). TrueVue Glass shows the boundary and multi‐lobular morphology of the tumor (right, arrow). (H) TrueVue Light shows rhabdomyosarcoma (#260, arrows), and Glass magnifies the RV localization showing the detailed stereoscopic features (right, arrows). (I) A diffuse dilatation of the RCA in Kawasaki disease (#263); the Glass mode is used to place the light source anteriorly to show the internal features of the lumen to confirm the absence of thrombosis (left). The light is placed inside the aorta, and the image cutting method is modified to preserve the complete external contours of the coronary arteries (right). (J) Postoperative LPA pseudoaneurysm (arrows) in a patient with tetralogy of Fallot (#265). TrueVue Glass reveals the outer contour of the aneurysm from the short axis of the aorta (left), compared with CTA same‐angle imaging (right). (K) TrueVue Glass shows the dorsal view of the abovementioned patient's pseudoaneurysm (left, arrow), compared with a CTA 3D reconstruction (right, arrow). # represents the number of the case. DCM, dilated cardiomyopathy; HCM, hypertrophic cardiomyopathy; IVS, interventricular septum; LPA, left pulmonary artery; LVNC, left ventricular noncompaction; PAA, pulmonary artery aneurysm; RPA, right pulmonary artery.

2.6. Other Structural Abnormalities

Other lesions included intracardiac thrombi (n = 13), cardiac tumors (n = 8), Kawasaki disease‐related coronary artery dilatation (n = 7), pericardial effusions (n = 9), and pulmonary artery pseudoaneurysms (n = 3).

Compared with conventional 3DE, TrueVue Light improved visualization of thrombus morphology and attachment sites through enhanced contrast between the thrombus and surrounding blood pool (Figure 4). For cardiac tumors, lesion borders, surface irregularities, and lobulated morphology were more clearly depicted (Figure 4). In Kawasaki disease, TrueVue Glass enabled simultaneous assessment of luminal and external coronary artery morphology (Figure 4). In pulmonary artery pseudoaneurysms, the external contours demonstrated by Glass rendering closely resembled those observed on computed tomography angiography (Figure 4).

2.7. Comparison of Novel and Traditional 3DE Images

Regarding the five categories of cardiac‐related images for the questions that needed to be evaluated, novel 3DE consistently achieved a higher Likert score than those obtained using traditional 3DE (all p < 0.001) (Table 1). No significant differences were observed between the three groups of cardiac specialists when comparing the Likert scale scores for normal cardiac structures visualized using novel (p = 0.39) or traditional (p = 0.09) 3DE technologies or for cardiac abnormalities visualized using novel (p = 0.96) or traditional (p = 0.40) 3DE.

TABLE 1.

Quality scoring of observation content according to different diseases.

Evaluation of 25 cases randomly selected from the following five categories (five cases were randomly selected from each category) of cardiac structures with corresponding questions	Sonographers (n = 12)			Surgeons (n = 8)			Cardiologists (n = 6)
	Likert score a			Likert score a			Likert score a
	Conventional 3DE	New series of 3DE	P value	Conventional 3DE	New series of 3DE	P value	Conventional 3DE	New series of 3DE	P value
1. Normal cardiac structure	2 (2, 3)	4 (4, 5)	<0.0001	2 (1, 3)	4 (3.3, 5)	<0.0001	2 (1, 3)	4 (3, 5)	<0.0001
The fossa ovalis on the interatrial septum can be clearly seen as a relatively thin structure.	2 (1, 3)	4 (4, 5)	0.01	2 (1, 2)	4 (3, 5)	0.001	3 (2, 3)	5 (4, 5)	0.04
Two natural notches on the posterior mitral leaflet can be seen.	2 (1, 2.3)	4 (3, 5)	0.001	2 (1, 2)	4 (3, 5)	0.001	2 (1, 2)	4 (3, 4)	0.002
The overall 3D structure of the mitral apparatus can be visualized, consisting of the leaflets connected to the corresponding papillary muscle by the relevant tendon cords.	2 (2, 3)	4 (3, 5)	0.03	2 (1.3, 2)	4 (3, 4)	<0.0001	2 (2.2, 3)	4 (3, 5)	0.001
The opening of the coronary artery and the lumen of the proximal segment can be clearly displayed.	2 (1, 2)	4 (3, 5)	<0.0001	2 (1, 3)	4 (4, 5)	<0.0001	2 (1, 2)	4 (3.3, 5)	<0.0001
The pectinate muscles, lobes, and outer contours of the two atrial appendages are clearly shown.	2 (1, 2)	5 (4, 5)	<0.0001	2 (1, 2)	5 (4, 5)	<0.0001	2 (2, 3)	5 (4, 5)	<0.0001
It can provide spatial information of sufficient value for the morphological observation of the aortic arch and cephalic vessels.	2 (2, 3)	5 (4, 5)	0.001	2 (2, 3)	5 (4, 5)	0.001	2 (1, 3)	4 (3, 4)	0.004
2. Congenital heart diseases	2 (2, 3)	4 (3, 5)	<0.0001	2 (1, 3)	5 (4, 5)	<0.0001	2 (1, 3)	4 (4, 5)	<0.0001
The boundaries of the septal defect are clearly shown, and the 3D images are very similar to those seen intraoperatively.	3 (3, 4)	5 (4, 5)	<0.0001	2 (2, 3)	5 (4, 5)	0.001	2 (2, 3)	4 (4, 5)	<0.0001
It can provide valuable stereoscopic images of the PV, including leaflet number and activity status, for those diagnosing PV abnormalities in 2DE.	2 (1, 2)	3 (2, 5)	0.03	2 (1, 2)	4 (3, 5)	<0.0001	2 (1.2, 2)	3 (2, 5)	0.001
The entire pathway of blood flow in the lumen of an abnormally located vessel can be seen more clearly.	2 (1, 2)	4 (3, 5)	<0.0001	2 (1, 3)	4 (3, 5)	<0.0001	2 (1, 2)	4 (3, 5)	0.004
In cases of ECD, the number and connection characteristics of the abnormal atrioventricular valves can be clearly demonstrated.	3 (2, 3)	4 (4, 5)	0.04	3 (2, 3)	5 (4, 5)	0.002	3 (2, 3)	4 (4, 5)	0.02
A quicker diagnosis was made with the aid of 3D imaging.	4 (3, 4)	5 (4, 5)	0.04	4 (3, 4)	5 (4, 5)	0.13	3 (2, 4)	5 (4, 5)	0.17
The pathological pattern of the abnormal anatomy is well understood and grasped prior to surgery.	3 (2.3, 5)	4 (4, 5)	0.01	4 (3, 5)	4 (4, 5)	0.77	4 (3.3, 4)	4 (4, 5)	0.27
Communication efficiency is enhanced by showing the patient a 3D image of the lesion.	3 (3, 4)	4 (4, 5)	0.04	3 (3, 4)	5 (4, 5)	<0.0001	2 (1, 3)	4 (3.5, 5)	<0.0001
3. Required valvular diseases	2 (2, 3)	4 (4, 5)	<0.0001	2 (1.3, 2)	4 (3, 5)	<0.0001	2 (2, 3)	4 (3, 5)	<0.0001
The dynamic 3D morphology of the diseased valve is truly visible.	2 (2, 3)	4 (4, 5)	0.001	3 (2, 3)	4 (4, 5)	0.03	3 (2, 3)	4 (4, 5)	0.02
Realistic restoration of the valve's thin sensation and more avoidance of pseudo tissue echogenicity loss.	2 (1, 2)	4 (3, 5)	<0.0001	2 (2, 3)	3 (3, 4)	0.03	2 (1, 2)	4 (2, 5)	0.003
The display of abnormal additional echoes on the valve is vivid and has a realistic feel.	2 (2, 3)	4 (4, 5)	0.002	2 (2, 3)	5 (4, 5)	<0.0001	2 (2, 3)	4 (3, 5)	0.01
The stereo morphology of the abnormal valve is similar to that seen intraoperatively.	3 (2, 4)	4 (4, 5)	<0.0001	2 (1.3, 2)	5 (3, 5)	0.001	2 (2, 3)	4 (3, 5)	0.001
On 3D images, the stereoscopic morphology of the prosthetic valve and the clarity of the border and residual shunt information that are displayed can be sufficient for a confident assessment.	3 (2, 3)	4 (4, 5)	0.001	2 (2, 3)	4 (4, 5)	<0.0001	2 (1, 2)	5 (4, 5)	<0.0001
Communication efficiency is enhanced by showing the patient a 3D image of the lesion.	4 (3, 4)	5 (4, 5)	0.4	3 (3, 4)	4 (4, 5)	0.01	2 (2, 3)	4 (4, 5)	<0.0001
4. Cardiomyopathy	2 (2, 3)	4 (4, 5)	<0.0001	2 (1, 2)	5 (4, 5)	<0.0001	2 (2, 3)	4 (4, 5)	<0.0001
Myocardial texture‐like anatomical pathology specimens can be seen.	2 (1, 2)	4 (3, 5)	<0.0001	2 (1, 2)	4 (3, 5)	<0.0001	2 (2, 3)	4 (4, 5)	0.002
The spatial pattern of the crypt formed by multiple myocardial trabeculae in the heart cavity can be visualized.	2 (2, 3)	4 (4, 5)	0.002	2 (2, 3)	4 (3.3, 5)	<0.0001	2 (2, 3)	4 (3, 5)	0.03
It can show irregular changes in the contour of the heart chambers owing to asymmetric thickening of the myocardium.	2 (2, 3)	4 (4, 5)	0.01	2 (1, 2)	5 (4, 5)	<0.0001	2 (1, 2)	4 (3, 5)	<0.0001
It can show corresponding overall changes in the contour of the heart chambers owing to localized ventricular aneurysm or dilated cardiomyopathy.	2 (2, 3)	5 (4, 5)	<0.0001	2 (1, 2)	5 (4, 5)	<0.0001	2 (1, 2)	5 (4, 5)	<0.0001
Communication efficiency is enhanced by showing the patient a 3D image of the lesion.	2 (2, 3)	5 (4, 5)	<0.0001	2 (2, 3)	5 (4, 5)	<0.0001	2 (2, 3)	4 (4, 5)	<0.0001
5. Other cardiac structural abnormalities	2 (2, 3)	4 (3, 5)	<0.0001	2 (2, 3)	5 (4, 5)	<0.0001	2 (1, 3)	4 (3, 5)	<0.0001
The stereoscopic morphology and surface features of the intracardiac thrombus can be clearly visualized.	2 (1, 2)	3 (3, 5)	0.03	2 (2, 3)	5 (4, 5)	0.01	2 (1, 2)	4 (3, 5)	<0.0001
The display of the spatial morphology, borders, and surface features of the cardiac mass can provide sufficient diagnostic confidence to determine if the growth is benign or malignant.	2 (2, 3)	4 (3.3, 5)	<0.0001	2 (2, 3)	4 (4, 5)	<0.0001	2 (1, 3)	4 (3, 5)	0.002
Communication efficiency is enhanced by showing the patient a 3D image of the lesion.	2 (1.5, 2)	4 (3, 5)	0.002	3 (2, 4)	5 (4, 5)	0.03	2 (2, 3)	5 (4, 5)	<0.0001
All five categories	2 (2, 3)	4 (4, 5)	<0.0001	2 (1, 3)	5 (4, 5)	<0.0001	2 (1, 3)	4 (3, 5)	<0.0001

Abbreviations: ECD, endocardial cushion defects; PV, pulmonary valve; 2DE, two‐dimensional echocardiography; 3D, three‐dimensional.

^a 5‐point scoring system, “1” indicating strong disagreement and “5” indicating strong agreement. Scores are expressed as median (interquartile range). P < 0.05 was considered statistically significant.

3. Discussion

TrueVue is a brand new rendering mode that uses an artificial intelligence platform built into the latest instruments to display anatomical structures via 3D images using more realistic colors and textures [11] with enhanced resolution[14]. Most of the preliminary studies regarding the clinical application of TrueVue are case studies reporting preoperative and postoperative evaluations of the left atrial appendage and its closure, atrial septal defect closure, mitral valve repair, and prosthetic valve placement. The visualization provided by TrueVue is superior to that provided by traditional real‐time 3D echocardiography (RT3DE) based on comparisons with intraoperative images [18, 19]. The use of the novel TrueVue series of 3DE technologies produced images with photorealistic rendering effects using high‐resolution flesh tone visualization. The images resembled the anatomical pathological specimens, such as the opening and course of the coronary arteries, pectinate muscles in the atrial appendage, and congenital notches in the valves; these details are difficult to visualize with traditional 3DE. With the TrueVue Light virtual light source, the operator was able to illuminate the target structure, or place the light source behind defects, clefts, or channels to achieve a transparent effect, which enhanced the diagnostic efficiency. TrueVue Glass automatically blocked off denser extracardiac tissues and converted them into transparent glass‐like echoes, which allowed for a clear display of the spatial morphology within the cardiac chambers and realistically thin, valve‐like echoes that resembled the anatomy of the heart more closely. The combination of these advanced 3DE features not only enabled the diagnosis of abnormal structures but also elucidated the characteristics of other normal structures in the patient's heart.

TrueVue Light allows for the data processing of 3DE images using a new operating platform that is simpler and more intuitive. It allows the operator to optimize the images using simple touch controls, and its workflow is more suited to the mindset of clinical radiologists, which can enhance diagnostic efficiency. The new virtual light source technology is of particular importance for displaying target structures in 3D cardiac images. The location and depth of the light source can be altered to simulate realistic light and shadow effects, which in turn can reflect thickness, transparency, layers, depth, and other characteristics of anatomical structures. By placing the light source anteriorly, the target structure can be illuminated more brightly. When the light source is placed behind the target structure, the thicker myocardium, thinner valves, fossa ovalis, and transparent pericardial effusions can be identified. The light source can also be placed inside structures distal to the heart. In addition, enhancing the shadow effects results in more realistic 3D images. Therefore, the novel 3DE technology significantly increases the quality of images compared to that of those obtained using traditional RT3DE.

Operators should gradually acquire the skills to use the novel technologies effectively. For example, placing the light source directly above the target structure may lead to an effect like reflective light, whereas placing the light source to the side of the target structure results in different shadows owing to the differences in tissue texture, producing an effect that enhances the clarity of lesion contours. Images obtained after valve replacement surgery highlight the fact that TrueVue cannot distinguish exogenous devices from cardiac tissues. Therefore, we recommend a flexible combination of these methods depending on the actual case.

TrueVue Glass, which has recently been released, allows operators to make solid structures transparent to highlight internal structures that were originally obscured [13], such as the contour of the heart cavity or the entire structure of the inflow and outflow tract through thin valves. This is currently the most technologically advanced 3D mode. For example, in traditional RT3DE and TrueVue, the aortic arch is obstructed by surrounding bone and mediastinum tissues, which hinder image clarity [4, 20]. However, in the TrueVue Glass mode, these obstacles can be removed, resulting in a clear image of the arch and its branches. Previous studies used formula‐ and model‐based calculations or drawing or tracing of the endocardium to reconstruct the shape of the heart cavity [21]. These techniques are time‐consuming and prone to bias. TrueVue Glass overcomes these limitations. For example, a casting‐like effect that was previously only possible in computed tomography‐ or magnetic resonance‐based 3D reconstruction can be achieved using TrueVue Glass to assess the morphology of the left atrial appendage. This enables physicians to observe images with a quality that has never been achieved in echocardiography and will alter the mindset of and protocols followed by sonographers. The combination of TrueVue Glass, color Doppler, and increased transparency settings enables the visualization of blood flow that is otherwise obstructed by the valves and myocardium, which simplifies the evaluation of cardiac hemodynamic changes. It should be emphasized that, in dilated cardiomyopathy, the value of TrueVue Glass lies primarily in its ability to provide intuitive visualization of chamber geometry and global remodeling rather than quantitative assessment. Accurate evaluation of ventricular dilatation and function continues to rely on validated volumetric and functional measurements, while TrueVue Glass serves as a complementary imaging tool for illustrating anatomical morphology and enhancing spatial understanding.

To the best of our knowledge, this was the first study to systematically apply this array of novel 3DE technologies and explore their imaging and diagnostic capabilities for various normal and abnormal structures of the heart. Our study includes the first application of these technologies to the diagnosis of certain complex and rare congenital heart diseases, as well as the diagnosis of various cardiomyopathies. We also explored the imaging methods and effects for cardiac thrombi, tumors, and other lesions, providing new approaches and diagnostic clues for the 3DE diagnosis of structural heart diseases.

However, this study has some limitations. As with traditional RT3DE, despite the higher resolution provided by this new series of 3DE technologies, the quality of the raw 2D images remains a limitation, especially when converting the images to TrueVue. Because TrueVue‐based rendering relies heavily on the quality of the original 2D and 3D datasets, patients with favorable acoustic windows were more likely to yield optimal images, which may limit the generalizability of the findings. Therefore, the production of vivid 3DE images remains dependent on the operator's understanding of cardiac anatomy. Moreover, the application of the light source is related to the operator's subjective perception of light and shadow effects. Furthermore, the proportion of patients with congenital heart disease was relatively high in this study, and additional imaging data for other types of lesions are needed. The majority of patients were in sinus rhythm. Further studies are required to evaluate the feasibility and image quality of TrueVue imaging in patients with atrial fibrillation and other significant arrhythmias. Although the clinical imaging findings presented in this study were derived from the entire cohort of 272 patients, the subjective Likert‐scale evaluation was based on only 25 representative cases. Consequently, these results should be regarded as preliminary evidence of perceived imaging advantages rather than definitive proof of clinical utility, and further validation in larger prospective cohorts is warranted. The future integration of ultrasound equipment with artificial intelligence will enable the automatic identification of anatomical landmarks within 3D structures and provide directional indicators that rotate with the images, such as those that indicate the direction of the aorta. These features will facilitate the understanding of complex lesions and will be helpful for those new to the field. A direct comparison between RT3D‐TTE and RT3D‐TEE was beyond the scope of the present exploratory study. Future studies with larger disease‐specific cohorts should compare the incremental value of TrueVue technologies between transthoracic and transesophageal imaging. Future prospective studies with larger patient cohorts and systematic comparisons between novel 3DE findings and intraoperative observations are warranted to further validate the diagnostic accuracy and clinical utility of these technologies. Despite the promising visualization capabilities of the TrueVue series, image quality remains dependent on high‐quality source datasets, operator expertise, and appropriate post‐processing. Consequently, these technologies should currently be regarded as complementary tools rather than replacements for conventional echocardiographic assessment.

4. Conclusions

TrueVue, TrueVue Light, and TrueVue Glass are a series of new tools that comprehensively and significantly improve 3DE imaging. Compared to traditional 3DE, TrueVue provides a new rendering mode, resulting in ultrasound images that closely resemble real anatomy. The intelligent control process and placement of virtual light sources significantly improve the evaluation and observation of the target structure. TrueVue Glass can make the tissues surrounding the heart transparent while also displaying the heart cavity and thin heart valves more intuitively. It can also be superimposed with color Doppler to display the spatial course of blood flow more vividly and comprehensively. In summary, this series of new 3DE technologies provides practical information for the evaluation of cardiac structures and lesions and has potential clinical applications.

Funding

This work was funded by the Young Scientists Fund of the National Natural Science Foundation of China (81901763), and 345 Talent Project of Shengjing Hospital (M0282). The funding assisted in the collection of clinical data and publication fees.

Ethics Statement

This study design was approved by the appropriate ethics review board (2019PS327K). Informed consent was obtained from all individual participants included in the study. The authors affirm that human research participants provided informed consent for publication of their medical imaging.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supplementary Video 1 Transesophageal echocardiographic TrueVue Glass imaging shows a normal aortic valve with the cardiac cycle.

Supplementary Video 2 TrueVue Glass imaging shows the spatial configuration of a fibrous stent in a normal human heart undergoing transesophageal echocardiography

Supplementary Video 3 Multiple, leafy cauliflower‐shaped left atrial appendages observed using transesophageal echocardiographic TrueVue Glass imaging.

Supplementary Video 4 Transthoracic echocardiographic TrueVue Glass plus color imaging used in patients with complete pulmonary vein ectopic drainage (supracardiac type) to observe the entirety of the ectopic drainage vessel.

Supplementary Video 5 Transesophageal echocardiographic TrueVue light imaging in patients with atrial fibrillation shows cloudy echogenicity in left atrium owing to hypercoagulable state.

Supplementary Video 6 After prosthetic metal mitral valve replacement, transesophageal echocardiographic TrueVue Light imaging shows the morphology of the prosthetic valve from the left ventricle and left atrium aspect.

Supplementary Video 7 Transthoracic echocardiographic TrueVue Glass plus color imaging shows severe regurgitation of the aortic valve from the perspective of the left ventricular outflow tract.

Supplementary Video 8 The morphology and boundary of the trabeculae and muscle columns found in the left ventricular cavity in patients with incomplete myocardial compaction observed using transthoracic echocardiographic TrueVue Glass imaging.

Data Availability Statement

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.