 Good morning. My name is Azad Mishare. I'm one of the anesthesiologists here at TGH. I want to start off by thanking Hecobo for all the work that he's put into putting this course together, and not just this course, but all the previous years. He's really been a pillar of our cooperative echo group and has made major contributions both to our education work and our research, and he'll be very sorely missed. Fortunately, he's not going very far away and will continue to collaborate on this kind of work in the future. We're going to start off the day by talking about a review of critic anatomy, specifically for 3D Echo. All the content here is under Creative Commons license. I'm opposed to link in the chat. These are my disclosures. I'm going to rely pretty heavily here on the powerful 3D visualizing abilities of our brains. My goal here is to help you memorize and visualize the structure of the heart base in three dimensions, and to use it to rapidly orient yourself when looking at echo images, especially 3D datasets. We'll start with a drawing exercise that'll help you visualize the position of all the cusps, leaflets, and some key adjacent structures. Then we'll look at the morphology of the heart base in 3D and its position in the chest. Next, we'll use the heart base as an anchor, and we'll build all the cardiac chambers and grade vessels around it. Then we'll add the airway, the esophagus in the stomach, which will determine our transcephalodial windows, and finally, we'll practice using the whole thing as a compass to orient our way around 3D datasets. So here we have a dissection of the heart base. We see the aortic valve in the middle. You can see the right and the left coronary cusps. The non-coronary sinus of alfalfa is here, closely associated with the interatrial septum. We have the right atrium here with the right atrial appendage, the tricuspid valve deep inside with the anterior posterior and septal leaflets. We have the left atrium here with the left atrial appendage opened up, the mitral valve inside. The coronary sinus is buried underneath behind the posterior mitral annulus and comes out into the right atrium at the junction of the posterior and septal leaflets of the tricuspid valve. And out of the front here, we have the pulmonic root and the pulmonic valve. You can see the anterior and the left cusp of the pulmonic valve here. And on the right here we have the schematic diagram that by the end of the stock hopefully you'll be able to draw from memory. The heart base corresponds roughly to the fibrous skeleton of the heart illustrated here. This structure is clinically important because it forms strong anchor points for sutures. It includes the crown shape support structures of the aortic and the pulmonic valves. It includes these two denser areas of fibrous tissue called the trigones, the lateral trigon and the medial trigon. The medial trigon also includes the AV nodes with a very sensitive structure. In addition, you have these fibrous partial rings that extend around the tricuspid and mitral valve annuli, but they're often incomplete, unlike what is illustrated here. On the right, you see a 3D model based on a cardiac CT from the same vantage point. Okay, so let's start our drawing exercise. I suggest you follow along with a pencil and paper if you haven't done this before. I've included this orientation markers here to remind us in scare quotes that we're talking about cardiology orientation terms and not standard anatomical terms. So right means right heart, left means left heart and so on. So we begin by drawing three circles and a jelly bean like so to represent the valves and we mark out the centers of the circles. Next, we connect the centers of the circles like so and this gives us landmarks that will let us figure out exactly where all the commasures are and all the custom leaflets. So for the next step, we divide each circle into thirds. Like so. We're shooting a jelly with a tricuspid valve because we haven't made it even thirds and this commasures fairly horizontal. For the mitral valve, we just draw the little smile. This is another mnemonic. So again, to review, we set up by drawing three circles and a jelly bean. We marked out the centers of the circles. We connected them with straight lines and then we divided the circles into equal thirds. So from here, it's pretty straightforward to label all the leaflets and cusps. So the harmonic valve here has the anterior leaflet, the right leaflet, sorry, the anterior cusp, the right cusp and the left cusp. The aortic valve has a right coronary, left coronary and non coronary cusps. The tricuspid valve has the anterior posterior and septal leaflets. The mitral valve has the anterior and posterior leaflets. So now with this structure, try to visualize where the interatural septum would go, where the right and left atrial appendages go, and where the coronary sinus goes. So here they are. I've put in these triangles to mark the lateral and medial tricones. So this is where the AV node would be. We have the interatural septum separating the left atrium overlying the mitral valve from the right atrium overlying the tricuspid valve. You can see the coronary sinus wrapping around behind the posterior mitral annulus, coming into that right atrium at the junction of the septal and posterior leaflets. The left atrial appendage lies close to the aortic valve and somewhere between the mitral annulus and the pulmonic valve annulus and the right atrial appendage is adjacent to the anterior tricuspid valve leaflet. So next, try to visualize the outline of the LV and the RV from this position. And here they are. So you can see the compact silhouette of the LV because of the close proximity of the inflow and the outflow valves and the elongated banana or croissant-shaped outline of the RV because of the distance between the inflow and the outflow. You can also see these two grooves, the anterior and posterior interventricular grooves, which have major vessels running through them. So the LAD runs along this groove and your PDA and posterior descending vein run along here. So now we're going to move into the third dimension. If you follow this link and we'll post a link in the chat as well, there's an interactive rendering of the heart base that you can rotate to help you with the exercises coming up. So the models we're using here are based on a cardiac CT. This model consists of blood volumes. We've removed all the sort of muscle and vessel walls to highlight all the connections and relationships between the chambers. You see the heart base in the middle. You see the right heart blood pool in blue, the red heart blood pool in red as well as the great vessels, a very faint ghost of the airways and lungs, as well as part of the chest wall with the sternal wires. Despite the abnormal anatomy, but he'd also undergone a coronary bypass. So you can see some sternal wires. You can see some vein graphs coming off the ascending aorta and part of a mobilized lima in the model as well. So here we have an interior and left lateral view of the heart base in the chest. In terms of positioning, you can notice that the aortic valve, which is the center of the heart base, is directly behind the sternum. The pulmonic valve is the most anterior structure and the planes of the tricuspid and mutual valves are essentially vertical. The blue and red lines mark the long axis of the aortic and the pulmonic valves. And you notice that they're not coplanar, unlike our 2D diagram, but that the long axis form about a 60 degree angle with each other. So here's a posterior view of the same for the vantage point of the esophagus, looking at the heart base. So again, we notice that the aortic valve is directly behind the sternum. The long axis of the aortic valve goes from the right shoulder to the apex and the long axis of the pulmonic valve lies pretty much along the mid sagittal plane and goes from the lower C spine to the xyphoid process. Again, you notice that the mitral and tricuspid valve planes are essentially vertical. So now we add in the left blood pool. So we have the left atrium, the left ventricle, the aortic root, the ascending aorta, the aortic arch and descending aorta, as well as the airway and the esophagus. You can see the left atrial appendage, the pulmonary veins coming into the left atrium, to the left atrium going through the mitral valve there in the base, the septal wall of the LV, the LV outflow tract, the free wall of the LV and the cavities for the papillary muscles, and the left atrial appendage, which again comes pretty close to the pulmonic valve. You can also see the right coronary and the stump of the left main coronary artery. So here we have the right blood pool. So you can see the right atrium here with the IVC that's unfortunately truncated in the model, the SVC, the coronary sinus coming into the right atrium, the right atrial appendage, tricuspid valve there, the RV free wall, the RV outflow tract, the RV septal surface. You can see the pulmonary artery, main PA in the branches and their relationship to the airway. So here we have everything put together, the right and the left sides. At first it looks like a pretty busy diagram, but if you go back to the previous views that we had, you can assemble it all around the heart base. So here's the same model in static images from all four directions. So this is from the vantage point of our echoprope behind the left atrium, the right and left lateral views and the anterior view. So coming up close, this is what the heart base looks like from the vantage point of the echoprope in the esophagus. You can see the proximity of the probe to the mitral and aortic valves, which is why these structures are much easier to image, generally, and the relatively greater distance of the pulmonic valve and the tricuspid valve, which makes imaging these structures more challenging. And this is the view of the stomach, so we're looking at the underside of the heart base now, from somewhere on the ventricular side. So we have the tricuspid valve now on this side, mitral valve, the aortic valve there, and the pulmonic valve out in the front. One of the great powers of 3D Echo is that it gives us the ability to spend the images around regardless of where we acquired them from. So our goal now is to visualize the heart base embedded in any 3D data set that has enough surrounding context. So we're not going to be using the heart base as a compass to orient us in any 3D data set that has enough context for us to be able to locate where we are. So here again is a full volume data set of the heart base, so you can see the aortic valve in the middle, just like our schematic. Tricuspid valve on the right, mitral valve on the left, and the distance, the pulmonic valve. Now try to visualize our 3D heart base embedded on the 3D data set. That's what it would look like. Of course this is just superimposed. Here's a standard short axis view of an aortic valve that happens to be bicuspid. So again try to visualize the base embedded in this rendering and identify the structures with question marks. Here it is. So we're looking at the aortic valve in the middle of the image, the pulmonic valve in front of the data set. The tricuspid valve is embedded inside the volume and the mitral valve. So here we're looking at the mitral valve and specifically the posterior mitral valve leaflet. And that structure there is part of the right atrial appendage. So here's another one. See if you can identify with this structure over here is. Not this one in the middle, but this one further out. At the base you see the aortic valve is there. Beyond the aortic valve you have the RV that spans the distance of the tricuspid valve to the pulmonic valve. So that is the RVOT. Here's another one with more vintage rendering. Again try to visualize the heart base embedded in the volume. And here we go. So that back there is a tricuspid valve that we're looking at. So another mitral valve image. Again try to visualize the heart base in a corresponding position and then visualize it embedded in the data set. So here it is, in a matching position. We'll just slide it over. So the last few minutes by way of illustration I just want to go through some of the standard presentations for 3D data sets and the guidelines and look at the corresponding projections of the heart base relying on the 2013 comprehensive TE guidelines and the 2012 3D guidelines. The standard presentations are going to be discussed in more detail in the upcoming talks. So here I'm just looking at one view from each valve. So the standard on- fast aortic valve view is positioned with the red coronary cusp at the bottom and the Mercedes-Benz logo oriented in the usual fashion. So we have the left coronary cusp there and the non-coronary cusp there. So here we have the mitral valve in the background, the tricuspid valve over here, the RV outflow tract and the pulmonic valve around there and the left atrial appendage. Here we see the heart base projection corresponding to the standard on-fast view of the mitral valve. So see if you can identify the marked structures. So this structure should be over here. It's a left atrial appendage. That structure there is part of the aortic valve and it's the left coronary cusp. So here's a slight variation on the mitral valve. It's a very dilated valve from a patient with a very severe MR. And you can see it's in the standard position with the aortic valve at 12 o'clock and this is the heart base projected over it. For the tricuspid valve the standard recommends having the septal leaflet at the bottom. So the interatrial septum is at the bottom and this is the corresponding projection of the heart base and the schematic diagram. So you can see we have the septal posterior and anterior leaflets, the right atrial appendage over here, the interatrial septum, the aortic valve and the mitral valve. And for the rarely imaged pulmonic valve, the recommended presentation is to have the anterior cusp at the top, the right on the right and left on the left. This is the corresponding projection of the heart base and the schematic diagram. Unfortunately the guidelines themselves do not quite follow the guidelines. So to summarize we learn how to draw the heart base starting with 3C steps, draw the circles, mark the centers, connect the centers, divide into roughly equal thirds. We then labeled all the cusps and leaflets of both valves, added some structures in two dimensions. We then moved on to three dimensions and looked at the morphology of the heart base in two dimensions and in particular the angulation between the aortic valve and the pulmonic valve. We reviewed the position of the heart base in the chest and how it's oriented. We then assembled the major cardiac chambers and vessels, the airway and the pathway for the echo probe in three dimensions. We set the left and right blood pools and finally we practiced using the heart base as a compass to help orient us in 3D datasets. Thank you very much for your time. All the content here is available at that link and we'll post that in the chat as well. Thank you.