The push to get 3D echo into the congenital operating room

3D TEE imaging comes of age in pediatric surgery

For years, preoperative planning was based on 2D or transthoracic imaging, Khoo explained. But pediatric 3D TEE probes now allow use of real-time 3D information in the operating room.

"There is nothing like seeing the structures of the heart in real three dimensions that really brings a whole different level of understanding. It definitely improves our communication with the surgeons, because they are very used to seeing anatomy. So it's much easier for them to adopt the technology, and what I find is that the champions of this technology usually are the surgical team. Surgeons don't put up with things that are going to waste their time. It's very rare now that we will take someone to the OR without a 3D echo as a preparation. That's where we're at," Khoo explained.

In the past, pediatric cardiologists relied on transthoracic echo for pre-surgical planning, only bringing echo into the OR when complications arose. But with the advent of miniaturized 3D TEE probes, teams like Khoo’s can now evaluate surgical repairs immediately, and adjust them before the chest is closed.

Over the last year, Khoo’s team has made 3D TEE a near-routine part of valve and defect repair surgeries. He said when something is not quite right, they can identify it instantly and provide the surgeon with precise information. That feedback loop lets them go back and correct the issue with much greater confidence, which is changing the way they work together.

The difference between 2D and 3D, Khoo said, is nothing short of “night and day.” Traditional 2D echocardiography requires expert interpretation to mentally reconstruct heart anatomy from slices and angles. But 3D imaging delivers an intuitive, anatomically accurate view, the same kind of visualization surgeons are accustomed to seeing directly.

“In the past, we might say, ‘It’s probably this,’” Khoo said. “Now we can say with certainty, ‘This is the problem.’ That level of precision completely changes the conversation in the OR.”

The technology has been particularly valuable for complex valve repairs and ventricular septal defect (VSD) surgeries, where anatomy can vary widely. “Congenital hearts are tiny, and the surgical field is incredibly small,” Khoo said. “3D pre-planning and intraoperative guidance make those repairs faster, more accurate, and ultimately safer.”

Surgeons trained at Stollery who move on to other hospitals are now requesting 3D TEE systems at their new institutions. “They know what they’re missing,” Khoo said. “That’s how change spreads.”

The challenged of proving the value of 3D TEE

As with many emerging technologies, one of the biggest hurdles is convincing administrators to invest in the new and more expensive technology. Khoo compared the transition to when color Doppler was introduced in echocardiography decades ago. “There was no paper proving its value — we just knew it made a difference,” he said. “It’s the same with 3D.”

Still, Khoo acknowledged that broader adoption will require new training standards. “We’re working with societies to define what level of 3D experience is needed and how to build that into fellowship programs,” he said.

Beyond surgery, pediatric 3D TEE is also finding a role in the cardiac catheterization lab, where it can guide interventions while reducing radiation exposure, a critical advantage in children. “That’s one area where the benefit is clear and measurable,” Khoo said. “It’s an easy case to make.”

He believes that in the next few years, 3D TEE will become a standard expectation in congenital heart surgery, much like it already is in adult cardiac imaging.

Khoo spoke with Cardiovascular Business at the 3D Echo Academy 2025: Beyond Pretty Pictures - Acquisition and Application of 3D Imaging in Congenital Heart Disease, hosted by the Ann & Robert H. Lurie Children’s Hospital of Chicago.