 Good afternoon everyone and thank you for being here for this presentation in how to use 3DT for clinical applications when assessing the left and right ventricles. I have no disclosures to discuss with the audience in regards of this presentation. The main objectives of these talks are to learn how to use the 3D data sets to assess the right and left ventricles using the Philips EPIC 7 and the GEBID E9 machines. We are going to start with the Philips EPIC 7. Using X-Plane we can assess simultaneously four walls of the left ventricle starting at the four chamber view. So in this example in the left side of the screen we are showing the left ventricle for chamber view where we have the inferior septum and the anterior lateral wall. And by doing X-Plane over this view we are going to generate a 90 degrees plane which is the one on the right side of the screen which is going to be the equivalent to your LB to chamber view where we are exposing the anterior and inferior wall. Both views are going to be simultaneously assessed and they are going to be separated by 90 degrees. Using X-Plane again if we go to the trans-gastric structure view of the left ventricle as in this example on the left side of the screen we can do the same thing. We place the X-Plane into the middle of the LB and then what we are going to be able to assess is simultaneously six walls of the left ventricle. In the example of the trans-gastric suraxis on the left side of the screen we have the anterior and inferior septum and lateral walls. And then in the right side of the screen you generate a plane that is 90 degrees more where you can see the anterior and inferior walls. The same thing can be done with the right ventricle. The parting from the modified four chamber view as we can see here on the left side of the screen we can see the septum and lateral or free wall of the right ventricle. When we place the X-Plane in the middle of the right ventricle we are generating a picture on the right side which is 90 degrees separated from it and you can simultaneously assess your infundibular wall. So in a single view you can definitely assess a lot of the function of the RV. From the trans-gastric suraxis modified view over the right ventricle the same thing can be done. So if we look at the left side of the screen we see the right ventricle trans-gastric suraxis. We put the X-Plane in the middle of the right ventricle and then we generate an image which is 90 degrees differentiating from the previous one. In the trans-gastric suraxis we can be the anterior, the posterior, the septum and the lateral or free wall of the right ventricle. While in the trans-gastric view at 90 degrees from the suraxis we can see the anterior and posterior walls of the right ventricle. So now using a 3D data set that includes the whole left ventricle avoiding the LBOT we can calculate the 3D left ventricle ejection fraction by using the function 3D advance. So once you use this function of 3D advance we are going to generate the image that we are showing you here in the example and four panels will show. So the first left upper panel represents the 2D image of the 4-chamber view of the left ventricle which was the original image where the 3D data set was acquired. So this is going to be named as Green Plane. As you pay attention there are a couple of lines on the Green Plane and we will be talking about those lines in a second. The second upper right part of the screen is showing what we call the red plane which will be equivalent to a 2-chamber view of the left ventricle with the anterior and the inferior wall. If we go to the bottom of the screen to the left side we are going to be generated the blue plane. The blue plane has a main difference between the green and red planes. Green and red planes are 2D images generated from a 3D data set. The blue plane is software generated from reconstructions from those multiple planes acquired with the matrix array and it's a view from the apex towards the atrium of the left ventricle. And in this example you can access the left ventricle because it's where we are going to be interested and you can see how the right ventricle is on the left side of the screen. Remember if you need to do measurements which is not the case of the EF I would recommend you to always do those measurements in the 4-chamber and the 2-chamber view because this blue plane is software generated. So it's never going to be as accurate as doing the measurements in the 4-chamber and the 2-chamber view which will be the green and the red planes. Finally on the bottom right side of the screen we are showing the 3D display of the LB which shows the 17 segments of the LB. So the first thing that we are going to be doing is in the green plane you need to select your red line which is the kivalent 2D chamber into the middle of the LB from the co-optation point of the mitrebal to the apex. The blue line needs to go to the middle of the LB crossing the right ventricle in the middle to get a perfect orientation. The same process is going to be repeated on the red plane. You want the green line which is going to be the kivalent to your 4-chamber view going from the center of the ventricle towards the apex and you want the blue line at the mid-level of the ventricle. Finally you are going to repeat the same process in the blue plane. In the blue plane you want to get the red line which is the kivalent to our 2-chamber view just from the anterior to the inferior wall in the middle and you want the green line crossing which is your 4-chamber view plane into the middle of the LB. When the planes are properly situated you will be selecting the end diastolic frame and it's normally automatically detected by the ECG but you need to be sure that you are appropriately situated. You can use the curves in the bottom part of the screen to rein yourself between the end diastole and end system. After that you will be asked to place the reference points in all the planes and we are going to start with the septum and lateral for the green plane. We are going to continue with the anterior and inferior with the red plane and finally we are going to ask you to position the apex. The apex can be positioned in the 4-chamber view in the 2-chamber view. There is no difference. The only recommendation that we get from the vendor is to be very consistent. If you select the apex in the 4-chamber view or the green plane in this example for end diastole do the same thing because next we are going to analyze the end systolic frame. If you selected in the red plane the apex over there then we consistent and in the end systolic use the same. So once finished with the end diastolic frame you are going to be prompt to select the end systolic frame. Once selected you will repeat the same process. You will be placed the reference points in the green plane septum and lateral and you will place the reference points in the red plane inferior and anterior. And the last part it will be the apex because in this example we select the apex in the green plane. We are consistent and we are selecting the plane at end systolic frame in the same green plane. Once all this is done you have the opportunity to select segmental analysis. And the software will automatically calculate for you the 3D Levantical Ejection Faction. And it will show you on the 3D display the performance of the 17 segments. It's a good idea to have a look when the software is showing you that the tracing on the green, red and blue plane to be sure that the endocardium was well traced. If you see in the upper right part you will be able to see your end diastolic volume calculated by 3D and systolic and ejection fraction plus the stroke volume. If you see on the bottom right part of the screen where you have the 3D displays you can manipulate this jelly bean. Show it from the basal, showing from the apex, showing from the inferior part and you can go with a hand and touch any of the 17 segments which automatically will give you the name of the segment and you will see how this segment is performing. The same thing can be achieved by using a strain or the formation from an applied force using technology which is called a speckle tracking. The type of strain that we will be measuring is longitudinal strain which has a negative value due to that we are departing from a baseline length L0 and will shrink the heart to a smaller length L1. The normal value is 20% or less. This can be done by using the four chamber view of the left ventricle. As in this example, the two chamber view of the left ventricle and the long axis view of the left ventricle. Finally, the bull size will be shown with the 17 segments. Anything red represent shrinking of the segments which means normal function as in this example. Anything blue means not shrinking rather increasing in distance between the points which means the skinnesis of the affected walls. As in this example with an abnormal ejection fraction and you can see the zones that are affected in blue. Another possibility is using speckle tracking technology without a strain to determine the left ventricular ejection fraction. This is an example of a four chamber view of the LV. And then you can use the same technology and do it in the two chamber view and in the short axis view of the left ventricle from the trans-gastric view. And you can get a complete study by this technology. From a 3D data set, as we did with the LV, we can use the same technology to calculate your right ventricular ejection fraction. When you use this technology using the same 3DQ advanced, you will be prompt to place the same markers designed for the LV analysis. Starting with the end diastolic frame. The same thing will be actually done in the end systolic frame, positioned yourself and later on your anterior and inferior. Finally, what we will get is an EF that will be calculated by the software. It's important to remember that by using a dedicated LV software to analyze the right ventricular function, we are not analyzing the infundicular wall of the right ventricle. There are other platforms as TomTech that can perform re-unright ventricular assessment, having an account infundicular wall of the right ventricle. When those software are used, the right ventricular ejection fraction and volumes calculated by 3D are very closely related with the cardiopagnetic resonance. Around R0.56 for the right ventricle ejection fraction, R0.74 for the end diastolic volume, and R0.84 for the end systolic volumes. 3D string can also be used to assess right ventricular longitude in other state. From a modified 4-chamber view, we are going to select chamber motion quantification in the tactile screen of the machine, and then you will be asked to place three reference points. As we can see in this example, it's at the base of the right ventricle and at the apex of the right ventricle. Then the software will analyze the segments for you. If you agree with the tracing and the tracing looks good, you need to approve the analysis. Once the analysis is approved, this is what is going to be generated. So we will focus only in the basal, mid, and apical segments of the free wall of the right ventricle. The right ventricle global longitude to the understrength from those three segments produces the highest correlation with cardiac magnetic resonance right ventricle ejection fraction when compared to the 3D ejection fraction of the RV. And it's a good predictor of RV dysfunction with an R of minus 0.69, as per Lu and colleagues. And again, we can use a speckle tracking without a strain, and in this case, for the right ventricle to determine the fraction and area change. So now we are going to do the same thing, but using the GE-BBD E9. Using multi-D is going to be equivalent to X-plane. In this example, we use it over the right ventricle, and we can see simultaneously the same walls that we were able to use when we were using X-plane with the Phillips. To be able to calculate the 3D left ventricle ejection fraction with the BBD, we will need to acquire a 3D data set. From this 3D data set, we are going to use the software of the BBD to go ahead and then position the reference place following the instructions. First, in end diastole, from the 2-chamber, 4-chamber, long axis view and short axis view. Once the reference points are positioned, you will be asked the same thing in end systole. And when that task is done, once this is done, this is the image that the software is going to generate. And you will be able to obtain from this analysis LB ejection fraction, stroke volume, and cardiac output. So if we want to repeat the same process with the right ventricle, the same thing can be done. But this time, the advantage is that the BBD offers us a dedicated 3D software specifically for the right ventricle developed by TomTech. Where again, you will be able to ask the position of your reference points as per the instructions. So that's what they are going to request from you. Once the points are situated, this is the image that is going to be provided by the software in the machine. And it will calculate for you the 3D right ventricle ejection fraction, the TAP-C, and the fraction area change using 3D technology. So finally, we are going to use 3D longitudinal strength to assess the RV. In the GE, we will start from a modified 4-chamber view. And then from this view, you are going to go to measures. And then from measures, you are going to use the function AFI, which is Automated Function Imaging. Once you select AFI, you will be prompted to actually select the Parasternal Long Access View, which is the one that performs the best assessment. Because remember, we are using dedicated LB strength software to analyze the right ventricular strain, longitudinal strain. So when that's done, you want to place the reference points. The reference points are going to be at the base of the right ventricle and at the apex. Once this is done, the software will automatically calculate the longitudinal strength for you. And again, remember, you need to neglect the right ventricle septal wall and assess the average of the 3 segments of the free wall. This will provide you with a big segment on the strain map. And the average of those 3 segments is your average of your right ventricle longitudinal strain. And again, remember, in the right upper part of the screen of this example, we can also see the regional strain curves of each segment represented. Thank you very much for your attention and we were happy to answer your questions in the Q&A.