In the last decade three dimensional echocardiography (3DE) technology has evolved significantly, and the advance of matrix transducers has made its use commonplace in daily clinical practice.1 Currently, it is possible to acquire real-time 3DE images for appropriate visualisation of valvular anatomy and proper quantification of valvular heart disease (VHD). However, 3DE quality depends of a number of factors, including the intrinsic quality of the ultrasound images, the number of heart beats used to reconstruct each 3DE image, and the ability to limit motion artefacts with adequate electrocardiographic and respiratory gating.2 The latter is particularly challenging when using systems requiring electrocardiographically triggered multiple heartbeats for volume rendering analysis. The acquisition of 3DE images can be performed in most ultrasound systems using the ‘live’ mode, by one single heartbeat, ‘full volume’ mode, composed of gated subvolumes, and ‘3D zoom’, ideally with the ultrasound beam aligned perpendicular to the structure under investigation. The decision is dependent on the target structure of the study and the balance between frame rate, volume size, and image resolution, as the improvement of one item is reliant on the other two.1 For the study of VHD the ‘3D zoom’ and ‘live’ modes are the most conventionally used, giving priority to frame rate and imaging resolution.

At the present time 3DE complements 2DE and it is incorporated into clinical practice in numerous centres worldwide. It is already recognised as an important clinical tool, and has been shown to be superior to 2D echocardiography in a variety of VHD scenarios. The ability to orientate a structure from the axial direction of the beam allows new perspectives of the valvular structures, on its face view (‘surgeon's view’) and on its ventricular view, providing a better understanding of the morphology and spatial relation among the intracardiac structures. This …