 Hello. I'd like to thank the organizers for inviting me to give this talk on common errors, challenges, and pitfalls of TE guidance for structural heart disease interventions. Here are my disclosures. The objectives of this talk are to first review novel techniques to improve procedural visualization and communication, and to then present some challenging cases. So visualization of 3D cardiac structures has greatly been improved by the use of 3D echocardiography because it allows us, particularly for mitral valve to see structures on fast and in a kind of 3D space. However, the problem with current visualization of 3D structures is predominantly using these artificial colors, these separate schemes. So there have been developments that are coming down that allow us to actually see structures in a more real life way. They call this photorealism. So here if you look on the top left, you can see how we would normally see a mitral valve now with the sort of yellowy sepia tones. And then you look on the right, that's the matching image. But now the valve is made to look more real like with this sort of salmon color tint. And then you can actually see that they've used a light. So it almost looks like you're looking at a true anatomic specimen. And this helps with looking at structures such as a pacemaker wire. So the middle of that photorealism line is a apical view showing a pacemaker going through the right ventricle. And then there's a close-up view looking from the ventricular aspect at an ICD lead going through the trichuspid valve. And on the bottom, you can see on the bottom left corner is how we normally would visualize a mechanical mitral valve with a paravial leak. But here if you look on the right, if you take that photorealism and then you take the light that's shining on it and you put it up on the ventricular side, it shines through the perforation or the perforation of the paravial leak. And you could actually really appreciate the location and extent of it. The other thing that's going to be improving to help our communication with surgeons and interventionists is this development of this visualization of something called the glass mode where the tissues then are now rendered transparent. And you can have different layers of transparency. But the biggest advantage of this is that you can actually see where jets are coming from with the underlying structure in place. And so for catheter procedures, this is where you could place your clip, you can see both the tissue without dropping out the mitral valve tissue as well as the clip. But all of these sort of developments, what they're really trying to do is make this 2D screen that we're looking at, the picture on it look more 3D like, because we've really acquired a 3D structure, we've acquired a 3D dataset, but then we present it on a 2D screen. Well, there are methods now to try and address some of that. Some of these are not so new, like the stereoglasses. Maybe Pritching now has been around for a couple of years, but other things like holographic display are being worked up by companies as well as stereo monitors. But what's a bit more interesting has been this development of augmented reality and virtual reality. So in augmented reality, what you're doing is you're taking your 3D structure and just putting it in your own environment. And then you see the advantage to this is that you could rotate it. And there are companies that are developing this where you can do this augmented reality in the operating room with the patient. The other technique is virtual reality. In virtual reality, you go into this virtual environment with your 3D structure of interest. So if you look on the left, the person who's operating this 3D structure is wearing a set of goggles, and they're in the room by themselves and they're just rotating this mechanical mitral valve on the right, and you can see that this is someone who has got a mitral valve. Once again, it looks like it's a prosthetic valve, and they're going to cut in this virtual space. You can see how the video is playing, how they're doing measurements as well as cutting down on the valve, and then rotating it to see. They're really manipulating it in 3D space. Another thing that we have an issue with is not just presenting the information, but how do we share this information with the interventionist? Right now, I have the 3D data on my echo machine, and then we project it onto the screen. But if you look, this is what the interventionist sees. They have their sort of hemodynamic monitoring on the top right corner monitor. They have their floral image on the left, and then they have the 3D echo image. And somehow, they have to merge the 3D echo image with the floral image to make it make sense when they're doing the procedure. Well, the cath labs of the future are going to be these hybrid or fusion labs, just like how in the ORs now we have CT, and you can have MRIs in the ORs. Well, with echo, we can actually take it a step further and fuse the echo image with the floral image. So here is an example of the navigator system by Philips, and it's very simple. There's, with the most recent versions, you just need your cart to be compatible with the cath lab. And then if you look on the cath lab screen, you have the 3D image on the left of the screen, and then you have the fused image with the floral with the 3D overlaid and segmented to match on the right. So here's an example from our own lab of fusion imaging. So this is a left atrial appendage device. What we did was we created a model of the left side of the heart using TE data. You can see the left ventricles traced out on the left image. You can see the left ventricles traced out. The mitral valve is traced, left atrium is, and so is the left atrial appendage. Now the left atrial appendage is a little bit truncated because the data set couldn't include all of it. So these left atrial appendages tend to look a little bit truncated, and you can see there's a catheter going across from the septum into left atrial appendage, but it seems to go beyond it, but that's because the left atrial appendage is a little bit truncated. And then on the right image, you can see now we've got the catheter in and we're actually injecting dye into the appendage. And you can see we've marked the orifice, the opening of the appendage, and we've taken away the ventricle structure just to make it a little bit more clear. So let's see how we can use some of these imaging techniques for some of the cases. So here's a case of left atrial appendage device, the closure device that we're going to place. Now the first step of all of these devices is that we need to get across the septum. Now the septal puncture for all the left side of procedures is very important. Where you place your puncture, it determines how much room you have to maneuver. So for the mitral clip, we want to be at least four centimeters from the mitral canal, so we have enough height, but we don't want to be too high that we don't have enough room on our guide to go down. The other thing is for a pair of alveolar leaks, you may not necessarily want to be at the same place you're doing your puncture for the mitral alveolar because of the leak may be more septal or maybe more lateral. And so you want to be able to maneuver your catheter to where the site of the leak is. So here on the left, for the left atrial appendage, we want to be, you see on the left image, so we use biplane because we want to make sure in two planes where we want to be. So the left is a bicable view, so we want to be right between the SVC and the IBC. On the biplane image, we have the, usually the aortic root at about the three o'clock position here. And this is where we want to know if we're anterior or posterior. So the bicable view tells us if you're superior or inferior, and the aortic view tells us if we're anterior or posterior. So here we're right in the middle between the superior and inferior vena cava, and we're right in the middle between the aorta, or so we're not too anterior, and we're right between the anterior and posterior position. Now, what happens when you have abnormalities in your anterior septum? Though that causes a lot of problems when we're trying to cross because we have very little control over sometimes on where the puncture happens unless you're doing with some radiofrequency ablation catheter. So here you can see this is an aneurysmal interatrial septum. It's very distorted. There is a shunt through it. So this is going to be a little bit more trickier for us to get where we want to go. So in this case, we're in this patient, and we've got our catheter tip. You can see now we're using fusion. So on the right is what we see on our TE machine. On the left is where we see our TE machine. And then on the right, you can see it's a fused image with the TE image interposed. I don't know if you can see the little red dot right directly down past the catheter, straight down from the TE probe. So that's where we actually want to puncture. We want to be inferior and central in our puncture because if you look, that gives you a straight trajectory up into the left atrial appendage, which is the circle on the screen. But you see that the catheter is actually above that because we kept sliding up because the aneurysm. Now this is the puncture that happened. As you can see, it's not where we want to be. We are inferior, but we are very posterior here. So there's a little too far from where we want to aim for. So because of that, the interventionist didn't have a straight shot into left atrial appendage and we couldn't actually find him because usually we go from the short axis aortic valve view and we roll over to show the left atrial appendage and the left upper pulmonary vein. However, when we went to that view, we couldn't find him. So what we did was we turned on the 3D and on the 3D, we saw that he was quite low and we directed him into the left atrial appendage. You can see the wire here directed him into the left atrial appendage using 3D. Now this is what it looked like on the fusion image for him. So here he's actually into left atrial appendage, but he was actually hitting the valve and so what we had to do is have him pulled back a little bit and redirect upward to get into the left atrial appendage. Now this is a different case. Here we have a patient with a large ASD with a single tissue bridge right between the two. You can see the 2D image with the color going mainly left to right and then on the right image you can actually see the 3D of it with the huge ASD with the single tissue bridge. Now we've used this case together. So the little off once again is that 3D of the atrial septal defect. On the right you can see the fluoroscopic image with the probe and then you can actually see the catheter coming in and we actually now have a clear visualization of what or the interventions of the clear visualization of what of the sides of the atrial septal defect they've entered in if you look at that catheter coming up. Now here we are with the sizing balloon across the catheter and we're checking to see if there's any color leak around it so you can see on the left is what we normally see with on a TE probe. On the right we've got the fused image showing the overlay with the fluoro. Now here we actually tried with this first device and you can see the placement of the device. We've got the 3D image so you can see where the holes are and we're pulling back the device and you can see that both sides of the device come up. We haven't released it and we can see over where the device is on the fluoroscopic image and if you look very closely you can see the TE image and then underneath that the fluoroscopic device markings. Now if you look on the left here we've switched to a different device because there was a leak on that first one and once again we have this newer device here you can see the overlay of the image right on top of the device and then you can see we put color on and the interventions can appreciate the color and where the leaks are coming on their fluoro image. This is a different case here so this is a complication that sometimes occurs. We can see clots develop on the catheters either on the left atrial side or the right atrial side so here we had our wire crossed and as we were waiting for the device to be prepped a clot started to form the heparin was given but the clot continued to get larger and so we took quite a couple of images here and then the solution for this was actually to not move anything but to actually get a device and section of the clot towards the end the section is moving up and the clot is moving into the device if you look at the right image you can see the end of the clot being sectioned into the retrieval device so this is my final case here so this is a left atrial appendage that we looked at it's got almost like a claw-like shape if you look at the left you can see the multiple big deep lobes the right we're bi-planning through and these are very large lobes and then on the right image here's a device that we've placed we're cutting through with the bi-plane to check the placement the device doesn't look like a helmet it doesn't look very squeezed it looks like it's very in place and deep on the 3D images look on the above you can see that we pull and there's no movement of this device so it looks like it's actually a very good place unfortunately the next day the pre-discharge trans thoracic study was performed to look for pericardial fusions and unfortunately we see the device is dislodged and it's actually stuck against that mitral valve and the patient's actually getting some arrhythmias here so this was obviously the patient was not going to be discharged this day so we called the interventionalist and we emergently took him into the cath lab here are the floral edges I'm going to present these so you understand the steps that went through and then I'm going to show some of the TE images that match this so on image A you can see that there's the device floating on the mitral valve by itself on image B you can see that we've actually captured it and we brought it to a catheter there are two different catheters in to help us on the third image you can see the wire is slowly being tightened across the other a nub of the device because that's the device that that's the side that lets us retrieve it back into it and then on image D you can see we're releasing the cinch across the device so that lets us let go of it and then on image E we're rotating it so that the side that lets us pull it back into the catheter is facing the catheter and then on image F the device has now been completely retrieved from the atrium now the problem with this the location of this device if it had gone into a left ventricle it would have been easier to retrieve because it would then be a retrograde approach through the aorta if it was in the aorta that also would be easier to retrieve but because it was in left atrium we had to cross the septum again and come up with a lasso to grab it so what do we see on the TE so here on the initial image you can see that the device is actually stuck against the mitral valve there are hooks on the device so that's why it's probably stuck there we have a couple of 3D images one on the middle we're looking at the atrium down but the aorta is located at your 6 o'clock position the right atrium is about 9 o'clock the catheter is very faint but you can see where it's crossing the interatrial septum between the device and the word catheter and then you have the device stuck on the mitral valve moving back and forth we've taken this 3D image on the rightmost image we've taken that and we've rotated a little bit I've marked where the interatrial septum is and then you can see the catheter coming through going across the device and the device is stuck on that mitral valve and you can see where the anterior oratoric structure is located now here the device now has been dislodged off if you look at the leftmost image the device is dislodged now it's free-floating in the atrium there is the retrievable catheter sitting across the interatrial septum there's not a lot of room in this atrium now on the middle image we've actually grabbed the device and we're pulling it towards the catheter here and then on the rightmost image you can see here we've got the device being suctioned into the catheter now this is the final image so I had a mentor who once told me that Dishonor valve disease always gives you the finger so this is a patient we recently did where we did the mitral clip procedure now there are two clips that have been placed and as you can see the valve is giving us the finger between these two devices and there's a residual leak that's coming from between there so there are many new methods to integrate true 3D visualization into clinical practices a lot of them are very useful for improving communication as well as procedural guidance thank you for listening