 Good morning, everyone. In this video, we are going to be talking about the 3D image optimization. I have no disclosures to discuss with the audience. We are going to talk a little bit on how to display and how to optimize the 3D images that are set for the Philips EPIC 7 and the GE BB9. I really recommend you to go to this web page. It's part of the University of Toronto, the PIMED site. And there, if you go to the 3DTE, you will be able to actually work on the manipulation and optimization on 3D images. The page is for free and anyone can access it anytime. So, to start with this specific presentation, the most important part in 3D echo optimization is to understand that this is going to be dependent in three main things. Spatial resolution, which is the ability of an ultrason system to distinguish between two points at a particular depth. And it's going to be dependent into the longitudinal resolution, the lateral resolution and the line density. Temporal resolution, which is dependent on the frame rate and sector size, which is going to be dependent in the size of the image. You can't have the three of them. If you get too much temporal resolution, you're going to lose a spatial resolution on sector size. If you get too much size, you're going to lose a spatial and temporal resolution. So, understanding that, we are going to start with the display and optimization in the Philips EPIC 7. So, the next step is going to be to optimize your 2D image. And for that, we are going to start setting the focus. When we set the focus, the focal point in the ultrason plane is the one that is going to provide the highest lateral resolution. We can do that by adjusting the focus knob. And then you are going to focus in the structure of interest, in this example, the mitre valve or the left ventricle. The next thing that we need to do is to set the game. When we are setting the game, optimal game settings will display blot as black and tissues of shades of gray. One way to adjust the 2D game is to set the overall game using the game knob on the control panel. The first display that we are going to show is this example, which is a left ventricle trans-castrix or axis view. You try to put the left ventricle in the middle. You are going to press the X plane function, and this is how the image is going to populate. An image on the left, which is the short axis, and the next image on the right is at 90 degrees. The next mode is the live 3D. So the live 3D acquisition produces a small size 3D volumes allowing for mid-spatial resolution and high temporal resolution, although it might be insufficient to contain an entire structure of interest. For example, a left ventricle or a right ventricle because they are too big. These modalities are often used only for 3D image tests and to guide the placement of wires. And the live 3D modes like generates a 60 degrees of lateral width and a 30 degrees of elevation width, with a height that is equivalent to the 90% of the 2D plane. The next mode is the full volume. So those are different ways of displaying a full volume display. The layout can be the three images where you can see the top images, the 3D generated image, and the two bottom images are the 2D generated image, which are called planes of references. You can choose a single picture like the example on the right where you are only going to be able to see your 3D image. So the recommendation is you start with a triple setup on the left and then from there you go to the one and then you can manipulate your image. This is an example of a full volume display, which will include the four bulbs of the heart. So you start with this image. This is a four chamber view. You are getting a 90 per 90 3D data set. And from there what we are going to do is we are going to change the layout from 3 to 1. Because we have only the 3D image in our screen, we are going to press an function, which is called reset cropping. And then in the previous image, we were only being the posterior part of the heart. So you can see the heart and then now it's going to appear the anterior two. So you're not going to be able because you're only going to be able to see the surface of the heart. But then by tracking down your trackball using the 3D rotate version, you are going to expose the heart from the closest picture to the TE probe. And then in this case, you are showing the posterior part of the heart, the anterior part of the heart, and the four bulbs, including the mitral bulb, tracaspid, pulmonic and our thick bulb. The next mode that we are going to display is the 3D zoom with two different layouts. So the first one on the left side is going to be three pictures layout, where you have the first upper image is the 3D dataset. And the ones that are below it is going to be the one on the left, the 2D plane of origin and the one on the right, the 90 degrees perpendicular plane to this image. When you have the anterior and the posterior part in this case of the mitral bulb. If you select the image that we have on the right, which is the layout with four little icons, there you're going to have exactly the same three images that we were having before, but we are adding a fourth plane. This fourth plane is a subword generated plane that is seen from the ventricone up into the atrium. And in this example, we have the mitral bulb and the aortic bulb and the anterior-aposterior relationship with the heart. If we select the 3D image, how do you want to present this 3D zoom in this example for the mitral bulb is an emphase view, where the mitral bulb is below and the aortic bulb is on top. And the other structures can be perfectly recognized. The left atrial appendix, the tracaspid bulb and the pulmonary bulb. So here you're going to differentiate the different scallops of the mitral bulb. And in the example that we are actually selecting here is a P2 prolapse that can be very well appreciated in this picture. So to be able to determine this, we are going to start with the 3D image selecting the layout of a single picture. And then here you're going to have the mitral bulb and the aortic bulb from the side. So the moment that we use the track bulb with the 3D rotate function, we bring it down. So the mitral bulb is going to be exposed. The next step is going to decrease a little bit the gain. You normally want to have a gain between 45-50% not to decrease so much the gain, because then you are going to under gain and then you're going to see holes where they don't have. Okay, and that's the image that is going to be generated with the scallops of the mitral bulb and the aortic bulb in the anterior part. So after decreasing the gain, the next step is you're going to use the rotate set clockwise function and then is when you're going to be able to position the mitral bulb in the end phase view and show this image to your surgeon. Other options when we are selecting the 3D zoom display, it's the function that we call dual volume layout. When you use that, the picture on the left is going to be seen from the e-tron. The picture in your right is going to be seen from your ventricle. So now in the next part of our talk, we are going to be talking about the 3D optimization in the epic queue, not the display now. So to optimize the 3D image again, we actually mentioned it before, you need to adjust your gain. So when you do that, the example that we are showing on the left part of the screen is how you increase your gain. So you don't want to over gain, but then you definitely want to decrease a little bit until you achieve 50 to 45%. And then you can start to see your mitral bulb. Again, you don't want to under gain too much because then you can actually start to see holes in the image that they are not there. So compression. So what is compression? Compression optimizes the ratio of lights and darks, which is like the white sun and blacks in your fiber optic would be exactly the same thing. Okay, it's normally set around like 30, and then you can go up and down and just adjust the image to get a better quality image. Another thing that we can use is what we call vision. So what is vision? It goes from A to H, and by default, we start at H. So it can be found in the secondary tactile screen. Okay, and it normally goes rotating counter-wise on the knob. Each letter has a different shades of colors to give a sense of depth. H is the most commonly used and is made of a combination of brown, which is closer to the screen, gel, white, and blue as it goes farther away from the screen. And it's a way to actually help you understand, help you actually optimize how deep you can actually percept the image. Another feature from the EPIC is the use of ChromaMap. What is the ChromaMap? So it's the intensity and combination of the color use to give us a sense of depth changes. The most commonly used is the ChromaMap 2, but you have up to seven different planes. But this is the one that most of the people cannot appreciate better. The brightness is another setting that we need to, that we can actually use in the EPIC. And for brightness, we normally start around like 40%. And you can see in this example, when we increase the brightness, you can see like better, like summer structures. But if you over-bright, it's going to be too bright for you. And in the right side of the screen is a decrease in the brightness where you can make the picture a little bit darker to appreciate better the contrast. The next feature that we can use with the EPIC is a smoothing. So for that, you need to press on the brightness knob and then you can adjust the smoothing. And it's like making like smooth the details. A higher smoothing will prevent you from appreciating fine details on the image. It goes from zero to six. So in this next part, we're going to talk about the GE BB9 and we are going to start with display and optimization. So as we did in the Philips with the GE, you first need to optimize it to the images. We are going to actually start with the focus here. And to set the focus, the first step, again, you need to actually use the focal point in the ultrasound to provide the highest lateral resolution. The focus is just normally using the focus knob. And the focal point should be actually adjusted to the depth of the structure of the image. When we are setting the game, again, you want to have an optimal tissue blow differentiation. And you can change the overall game by using the active mode and you will see the characteristics of the surface. So once you have set the focus on the structure of interest and set the game, so different modes can be displayed. The first one that we're going to be talking about is the multi-D display. This is going to be equivalent to the X-plane on the Philips. So this is a multi-dimension or multi-D mode. And simultaneously it can display like two deep lanes, which are perpendicular one to the other. And the reference place is 90 degrees to the primary plane. The second mode that we can display with the G is the bird's view display. That's an example of a right ventricle bird's view display. It produces a small size narrow 3D volume data sets that has highest fashion and temporal resolution, but it's insufficient to contain a medium or large structure. It's often used, again, equivalent to the live 3D on the Philips to test and guide the placement of wires or devices. And the default volume that is generated is 50 degrees for lateral width and 10 degrees for elevation of depth. When we change to a new mode, this is an example of the medium and large volume display. So in this mode, the reference plane shows a line cutting the left ventricle in half, where the 3D image is displayed. And then the yellow arrows will show from where we are looking at the 3D data set in the reference planes. And then if we press clear, we are going to reset the cropping and get a full image like we did with the epic. So an option that you have when you're using medium and large volume display is to use the laser lines. So here's where we can find the laser lines option. And when you do it, you have a white line, which is the reference plane in this example for the four chamber view and a green line, which is the perpendicular plane, which will be equivalent to the two chamber view. These lines cannot be moved, but it gives you an idea on where your image is positioned in 3D so you can orient yourself a little bit better. And in this example, we are exposing the four valves of the heart. Another option that G gives us with the medium and large volume is the option of rotate set. This is exactly the same option that we have with the epic. And then what you want is to use this to rotate the 3D data set parallel to the screen. So you can, for example, in this example, show the monitor valve in an face view. Another option that we can use with the medium and large volume display is the up and down function, which is located in the second page of the panel, which allows you to see the image from the bottom and from the top with only a click. Another option that we can use with the G is the 4D zoom display. This is equivalent to the 3D zoom in Philips. And the 4D zoom is used for the assessment of individual valves and the small structures. It allows to define a 3D block and orient it automatically to provide an face view of a specific structure. It's mostly used for mitral valve, aortic valve or intraartic septum, intraartial septum. You need to press the 4D zoom preparer to actually obtain that picture. And you choose the region of interest to show this picture. In this example on the left side is, without color, on the right side is with color and both of them are examples of mitral valves in the face view. So if we want to optimize the GE image, we are going to talk about different things. We are going to start to talk about 3D gain. And you can see here an example how we over game and how we actually decrease the grain progressively. And this can be used with this node show on the left side of the screen. You can use active mode, which is to highlight the characteristics of the surface and it's considered like 3D compression. And you have the active mode node to be able to do that as shown in the left side of the screen. You can use the function UD clarity, which is able to provide a better depth of perception. By default it's at 1, you can go to 0 or to 2. When you increase it to 2, it enhances the shades and gets a better sense of depth. When you decrease it to 0, it's for a smoother appearance. You can use deep and color map optimization. The deep and color map, it gives you a darker brown close to the cream and a darker blue far away to the screen to again get a better impression. There are very different colors that goes from copper blue to gray to map, as you can see in this example. Another option that G offers us is a stereo vision, but to appreciate this, you need 3D glasses and you will be able to get, like in the cinema, a really 3D image of the mitra valve, in this case. You can use smoothness for getting a better smoothing of the image. You can increase it, like we are showing here, or the crescent. There are very subtle changes. You can use gamma, which is the ratio of dark and light shades. And on the left side of the screen is where you can find the knob. And finally, you can use tissue transparency. As you see in this example, you can increase the tissue transparency, make it thinner, or you can decrease it. You don't want to decrease it too much, but you will lose the possibility of appreciator structures. This is the end of the presentation. Thank you very much for listening, and I will be happy to answer your questions.