 Greetings and welcome. My name is Annette Vegas. I would like to thank the organizers for the kind invitation to speak today on the topic of 3D, TEE, Mitral Valve Acquisition, Manipulation, and Quantitative Measurement. I have no conflict of interest. Over the course of this session, we will review Mitral Valve 3D datasets, describing the acquisition, optimization, display, manipulation, and measurements. Specifically, we will look at the many ways to analyze 3D Mitral Valve datasets, including presenting angled views, 3D live, multi-planar reconstruction, I-slice, and Mitral Valve models. Since its introduction into everyday clinical practice in 2008, 3D echocardiography has become easier to use, often with single-button acquisition and streamlined workflows. Previously, when using 2D to image the Mitral Valve, mostly we had to reconstruct multiple planes in our head to create a 3D model of the patient's pathology. Now life has become simplified as we can image the Mitral Valve in a single display in real time. We can add color with better temporal resolution. We can present large datasets with alternative imaging display to appear more realistic. We can use 3D valve models to quantify annular dynamics and changes in annular shape to better define pathology and guide treatment. One basic question to ask is what additional information does 3D TEE add to assessing the Mitral Valve? It is well established that 3D has deepened our fundamental understanding of anatomy and function of normal and pathological Mitral Valves. It helps to improve diagnostic accuracy of lesion localization, such as prolapse and collapse, identify mechanisms of Mitral Regurgitation, and quantify severity of Mitral Stenosis and Regurgitation. 3D parametric maps measure new parameters, quantifying Mitral Valve annular, leaflet, and subvalvular geometry throughout the cardiac cycle. It is indispensable in the guidance of percutaneous Mitral Valve procedures and post-operative assessment. There are many ways to manipulate a 3D Mitral Valve dataset, and it's not just about showing the Mitral Valve in the on-fast view. Some techniques are specialized software and take a bit of time, while others do not. It is important to understand some of the differences in acquisition, display, and cropping of these datasets, including the on-fast view and angled views. Specialized software permits multi-planar reconstruction or extrapolation of cuts from the 3D datasets using I-slice and creation of Mitral Valve models. Perioperative Mitral Valve assessment is evolving from a qualitative to a more precise quantitative approach for anatomic structure and function. Can you spot the difference with these trio of 3D Mitral Valve datasets of the same valve? These are different options for acquiring a 3D Mitral Valve dataset, live, zoom, or full volume. Each is chosen to optimize spatial or temporal resolution. Improving temporal resolution may require multi-beat acquisition. Live previously provided only a small volume, but recent software can expand to image the entire valve, but with poor temporal resolution. Zoom is often used to image the Mitral Valve as it can be centered around the region of interest with multi-beat acquisition to provide good spatial and temporal resolution. Full volume provides the largest dataset and requires multi-beat acquisition. Stitch artifacts are common. Optimizing the display of the 3D datasets involves commonly adjusting parameters. Good 3D images begin with good 2D images, so optimize the 2D image first. Gain of which overgain in particular is represented by an increase in brown speckles and undergain a loss of tissue. Overall brightness or smoothing of how coarse the image appears. Vision or the shades of color used to display 3D anatomy. More recently, one vendor can display the Mitral Valve with even more realistic tissue. Generally speaking, the Mitral Valve often fills the display with 2D imaging and also with 3D imaging. Cropping may be useful to eliminate near-field clutter in the left adrium. Choose an option and learn how to optimize the dataset. Thus cropping of the Mitral Valve may involve options such as OtterCrop Reset, which crops the dataset in half. A box crop using predefined planes or plane crop is an independently mobile plane. An eye crop, which uses a cube to alter the size of the dataset. Contrary to 2DTE, 3DTE shows the entire Mitral Valve in a single display. By convention, the Mitral Valve is often shown from the left atrial perspective in the on-fast view. This is probably the view that most seduced echocardiographers to 3D echocardiography. The Mitral Valve can be acquired from any 2D midisoft gel Mitral Valve view. It is always helpful to include a surrounding structure such as the aortic valve or left-atrial appendage to help orientate the 3D dataset in space. The Mitral Valve can also be displayed from the left ventricular perspective and simultaneously on-screen with the on-fast view, which may be helpful in identifying pathology. Angled views is a simple concept developed at our institution, which suggests Z rotation of the 3D volume from the on-fast view through 360 degrees to look at different portions of the Mitral Valve. This does not use any additional analysis software. Counter-clockwise rotation by 90-degree increments shows the posterior commissure, then the scallop view of the posterior leaflet, and finally the anterior commissure. Another technique that can be used is the live mode to obtain a 3D dataset of the Mitral Valve at zero degrees in a four-chamber view. The elevational size is adjusted to show the entire valve or more or less of the Mitral Valve. Rotating the image slightly upwards cuts through the Mitral Valve in a sagittal plane to determine leaflet motion in relation to the Mitral Analysts, shown here are cuts through A3, P3, A2, P2, and A1, P1. Multiplanar reconstruction uses the end systolic frame of the 3D dataset to look at a leaflet motion in relation to the annulus. The workflow varies with each vendor. Options exist to automatically extract four-chamber, Mitral Commissure, and Aortic Valve long-axis views. Alternatively, specialized software can dissect the 3D dataset to obtain a multitude of planes. Using Phillips software, this is done by positioning the blue lines representing the blue pane along the Mitral Valve annulus in the red and green pane. The blue pane is now the Mitral Valve short-axis view. The red pane is then adjusted to be the Mitral Valve commissural view by rotating the 3D volume. The green pane can then be scrolled along the short-axis view to precisely identify individual segments in the green pane, shown here is A1 and P1. Another option using specialized software permits aligning predefined cuts perpendicular through the Mitral Valve, similar to CT scan cuts. This results in a display of multiple sagittal cuts through the Mitral Valve, each of which can be examined for pathology. Using IceLice, the on-fast 3D dataset can be displayed on-screen to localize individual segments. Remember, though, that pathology is identified using these 2D cuts extracted from the 3D dataset. Specific analysis software can create static or dynamic Mitral Valve models from 3D datasets. Most software is semi-automated, which reduces the analysis time, but does introduce error from inaccurate tracking. The Mitral Valve NAI software, or QLab, gives a static and systolic model. The Easy Valve software yields a dynamic systolic and diastolic model of both the Mitral Valve and aortic route. The TomTech and new 4D Mitral Valve Q software from GE gives dynamic systolic models. The newer Phillips machine have TomTech software in place of the Mitral Valve N software. Models can access individual patient's pathology, but importantly they demonstrate normal Mitral Valve shape and function. In order to better understand pathology, you need to appreciate what is normal and how even slight arrangements can have profound effects on Valve function. The complex annular shape is underappreciated on 2D imaging, which tends to simplify the annulus as a planar ring. It is best seen using 3D models, either dynamic or static. The annulus is not in a single plane, but rather saddle shape, like a wringled chip. The highest points are in the mid-portion of the anterior posterior annulus. The nators are the commissures. The posterior annulus is flatter than the anterior annulus, which is elevated as it attaches to the aortic route at the aortomitral curtain. The saddle-shaped annulus undergoes conformational change, which is crucial for normal function. Annular height and motion plays an important role in reducing leaflet stress. The saddle, for example, dynamic Mitral Valve models nicely demonstrate how the Mitral annulus moves, continuously through the cardiac cycle, deepening our understanding of valve anatomy and function. These movements include translation up and down motion, circumferential inwards motion, counterclockwise rotation, and folding along the anterior posterior and inter-commissural axes to increase annulus height and planarity. The largest area is during diastole, when the annulus is wider and shorter. During systole, the annulus is smaller by 25% and has an elliptical shape. It is narrower and taller. During systole, this change improves leaflet apposition by becoming taller with folding and smaller in area by AP contraction. An advantage of these 3D models is the automatic generation of robust quantitative information. Common measurements can be classified into 3 groups, linear, volume area, and annulus. We will explore these in the next couple of slides. Other measures of annular shape include annulus height, saddle shape, the ratio of annular height to inter-commissural distance, and the angles. Annulus height is the length between planes at the highest and lowest point of the annulus. The ratio of mitral annular height to the commissural width describes leaflet stress. This is lowest when the ratio is greater than 0.2. Leaflet stress increases when this ratio is less than 15% and is associated with moderate to severe mitral regurgitation. Aorta mitral angle is between the mitral and aortic annulus and is normally around 100 degrees. The non-planarity angle between the anterior and posterior leaflets at the commissures becomes more acute during systole and correlates well with the annular height commissural width. The smaller the non-planarity angle, the more non-planar the angle, the annulus. 3D models allow for more accurate determination of leaflet length or height, leaflet area, mitral valve area. The surface area of mitral leaflets may enlarge in pathology from prolapse or adaptation to chronic tethering second to left ventricular remodeling. 3D models allow for accurate determination of leaflet length, leaflet area, mitral valve area. The surface area of mitral valve leaflets may enlarge in pathology from prolapse or tethering. It is important to remember that 2D and 3D measurements are often different. 3D mitral valve imaging has become an important tool in accurately measuring the mitral valve area and is the goal standard for the plenimetry of the area in mitral valve stenosis. This is done from a 3D dataset using multi-planar reconstruction, aligning the planes through the smallest orifice in diastole and tracing the area in the short axis view. Similarly, the annulus may change dimensions throughout the cardiac cycle and vary in shape during diastole. Accurate measurements of annular dimensions can be obtained using NPR. More recently, data has shown that color Doppler can help to localize the origin of mitral regurgitation jets. Analysis using NPR can accurately trace the vena contracta area. This still has a problem of adequate temporal resolution, which is improving. Nonetheless, guidelines now include vena contracta area as a measure of MR severity with a value greater than 0.4 centimeter squared indicating severe mitral regurgitation. As we will see, specific quantitative measures can help predict the success of mitral valve repair. In addition to specific measures as shown here, may guide the surgeon into the type of repair in the presence of primary or secondary mitral regurgitation. Perhaps we are starting to transition from the art of mitral valve repair to the science of mitral valve repair. So in summary, mitral valve data sets are easy to obtain and optimize. There are many analysis options beyond just examining the on-pass view. Creation of mitral valve models provides some quantitative information that can better define pathology and help to guide treatment. Thank you very much.