 Good afternoon everyone, and thanks for listening to this presentation in how to use 3D transesophageal echocardiography to assess parabalgural leaks in clinical scenarios. As you know, I have no disclosures to discuss with the audience regarding this presentation. The two main objectives of this presentation are going to be to learn how to use 3D technology to assess mitral and prosthetic bulbs to evaluate parabalgural leaks in real cases. The first case that we are going to be presenting is a 70 year old female coming for aortic bulb replacement due to severe aortic stenosis with ascending aorta repair due to ascending aorta dilatation. This lady had only one comorbidity with hypothyroidism. The bioprostatic bulb inserted by the surgeon was a magneis 23 millimeters with an ascending aorta 28 millimeters Dachron graft. So to understand how to assess an aortic bulb prosthesis is important to remember the anatomical plates. In this representation, I presented this from an auricular view into the banter course. We are just removing the atrons from the heart and we are looking down to the banter course and it would represent the different cutting planes to expose the aortic bulb during TE at 45 degrees. We can see the midisophageal short axis B of the aortic bulb where the left coronary casp is next to the pulmonary valve and the right and non-coronary casp are going to be close to the tracaspid valve. At 130 degrees as shown here, we can see the midisophageal long axis B of the aortic valve where the right coronary casp is below and the upper casps can be either the non or the left. The more the angle, the more possibilities that is going to be the left, the less the angle, the more possibilities that is going to be the known. Finally, to assess for parababular licks, we will be using the clock number description to guide our surgeon. And as Wendy pointed out in her lecture, we will see 12 will be on top of the right coronary casp and six will be between the left and non-coronary casp, three into the left coronary casp and nine into the non-coronary casp. This clock guidance was defined by Al-Huli and colleagues for prosthesis and by Pivarotan colleagues for Tavars or Tavis. If we start with the short axis B of the aortic bulb at 45 degrees, as we can see here, this will be equivalent to the parasterne on short axis by trans thoracic and the casp will be presented. As you can see right now, the 12 o'clock position is going to be where the right coronary casp is and the six o'clock position is going to be between the non and the left. To translate that into 3D, you will be looking from the short axis B and those are the positions equivalent in 3D. When we do it from the aortic bulb long axis view, as we can see here at 130 degrees, this will be equivalent to the parasterne on long axis view by trans thoracic and the o'clock position for six and eight will be situated on the top and from 11 to 2 at the bottom of the aortic bulb and that's the equivalent image. So when we came off pump, we went into the trans thoracic long axis view to visualize our new bioprosthetic aortic bulb replacement, which in this case was like a magnized 23 millimeters. We put the colorful Doppler that you can see on the right side of the screen and in this case, we can see a mylic coming from the 12 to 2 o'clock position just there. Magnify it, there it is, which is equivalent to the position between the right and left coronary casp. And again, remember, the incidence of parababular licks in aortic bulb replacements is between 2 and 10 percent, much less than in mitral bulbs and is most commonly located along the non coronary or right coronary casp and the small jets or discrete jets are more difficult to assess. So this following table has been modified from reads and colleagues with the most important quantitative parameters to assess parababular licks in prosthetic aortic bulbs. The quantifications of these parameters that can better be estimated by 3D rather than with 2D are the following, which is going to be your benacontracted with jet to LBOT ratio and the circumferential extent. For those of you that are not familiar with the circumferential extent, this can be calculated as the sum of the parababular lick-jack circumference divided by the bulb circumference and is considered mild when it's less than 10 percent and severe when it's more than 30 percent. From a 3D perspective, exposing the new bioprosthetic aortic valve, the o-clock positions are displayed as you can see now. So if we focus in the version between 12 and 2 o'clock, we will be able to see the very mild lick. To assess the parababular lick, we can use multi-plane reconstruction by selecting in this example the 3D Q function from the Philips. Then in the green plane on the upper left section of the screen, you should align the red line which is the corresponding line to the red plane perpendicular to the jet benacontracted with and the blue line parallel to the jet benacontracted with in the middle of it. You then look to the red plane which is in the upper right side part of the of the screen and this red plane will be equivalent in this example to the short axis view of your aortic valve prosthesis. And you should have the green line and the blue line intersecting both of them in the middle of the parababular lick-jacked cross-sectional area. The cross-sectional area of the 3D benacontracted with will then display in the red plane as follows. So if you select the red plane display along to get a better view on the screen, this can be improved a little bit more and better by using the magnifying tool and you can increase up to 200% to be able to see the area a little bit better. Then you use the basic measurements tool which is shown here and after using that you trace the 3D benacontracted with by clicking in the right side of the now of the trackball until finished and then you click in the left side now. The software will automatically calculate the area for you and display it into the right upper part of the screen. In this example it was measured as 0.09 centimeters to the square which is consistent with mild regurgitation. And again remember to calculate the circumference at a stand you need to divide the parababular lick jet circumference by the valve circumference and the quantification will be mild if it's less than 10% and severe if it's more than 30%. Anything in between is considered moderate. Now we are going to follow with our second case. In this case we are going to be presenting a 78-year-old male coming for redo AVR and mitral valve replacement due to severe MS and a severe bioprostatic artery valve stenosis which was previously inserted in 2013. The patient had important comorbidities too as OSA and fissema chronic kidney disease diabetes and severe left-sided carotid stenosis with the challenging case. The surgeon performed a redo tissue AVR with a 25 magnase and a tissue mitral valve replacement with a 27 magnase and the reconstruction of the intervabular fibrous body plus one auto coronary bypass. When we need to assess a mitral valve prosthesis using 3D imaging it's always good to understand the anatomical reference to not get lost or disoriented. Disrepresentation again is presented from an auricular perspective into the ventricles, representing the different cutting planes to expose the mitral valve during trances of argilego. The location of the parababular licks in mitral valve prosthesis will be described as per the mitral valve's colors. The o-clock reference can also be used for the mitral valve prosthesis as we can see now. Remember that for our tick valve prosthesis though the three and nine o'clock positions are embedded compared to the mitral valve prosthesis to assess parababular licks. To report a mitral valve prosthesis parababular licks location we will use the extrapolation of the carpenter mitral valve classification. When we use 3D color flow in a prosthetic mitral valve the position of the mitral valve scallops will be used to locate the leak. In this example you can see here the leak is between A3 and P3. If this was a mitral peri-prosthetic transcutator leak reduction the o-clock reference can be used as per Machuva and colleagues. And remember that up to 27% of the patients where you are able to find one leak they may have more than one leak so it's better to look well before you miss one. In this case we started by examining the new bioprosthetic mitral valve. At the mitral valve commissural view we could see a parababular leak then we perform a quantitative assessment of the parababular leak. Quantifying the leak as mild. We did then color continuous weight doctor assessment to assess for possible patient prosthesis mismatch but the velocity and main gradient of the mitral new mitral valve prosthesis were normal. The velocity less than 2.5 and main gradient less than 5. In our case here we can see a clear parababular leak coming from the A3 and P3 or at 3 o'clock as shown here. The parameters that can be used to better quantify the degree of parababular leak by using 3D when compared to 2D are summarized in the following table which are then a contractor with and circumferential stand for mitral valve prosthesis. This table from recent colleagues has been modified with the most important quantitative parameters to assess parababular leaks in the prosthetic mitral valves. To better assess the degree of a parababular leak in a new mitral valve prosthesis with 3D we can use two multiplane reconstruction as we are going to show next. So to be able to use multiplane reconstructions from the phillips q-lab again you will need to go to 3Dq. Then in the green plane which is equivalent in this case to the midisophageal mitral commissural view in Te dual line the red line perpendicular to the benacontracta of the parababular leak regurgitan jet. Followed by the alignment of the blue line parallel to the benacontracta of the parababular leak regurgitan jet. Then you look into the red plane on the top right side of the screen which is 90 degrees apart and you want to see that the green and blue lines are intersecting at the benacontract at the middle of the benacontracta width of the parababular leak regurgitan jet 2. Finally the cross-sectional area of the 3D benacontracta width will be then displayed in this particular case in the blue plane with the green and red lines intersecting in the middle which is at the bottom left part of the screen. By selecting the blue plane display we will then use the basic measurement tool again to trace the 3D benacontracta width and the software will calculate the area for you. In our case it measures 0.11 centimeters to the square which is consistent with mild degree and again to calculate the circumference understand you will need to divide the parababular leak jet circumference by the wave by the bulk circumference and this classification this quantification will be mild if it's less than 10% and severe if it's more than 30%. Anything in between it will be considered as moderate. Finally in this multiball prosthesis instead of using multiplayer reconstructions we can use something which is simpler and still a 3D tool which is explain and by using explain you can explain color flow Doppler and you can assess in real-time you now have a replacement in the long axis view and short axis view. As you can see here we can see a mild leak at 8 o'clock with the jet detected towards 6 o'clock. So always remember that if you use explain from the long axis view the 90 degrees perpendicular image generated to the right side of the screen will pass 180 degrees and as you can see on top it says 250 and minus 11. So it will give you an inverted image of where is your leak. You can avoid that by using writing birth. If you press the writing birth function in the tactile screen so the right side image that is generated will be 90 degrees less from the left from the long axis view of the arctic valve. So it will be 125 minus 90 which in this case will be 35 degrees as you can see here and then in this view the parababular leak will be generated from opposite size that when we were seeing first. So my recommendation if you don't want to get lost when assessing a parababular leak I would recommend you to start from the short axis view and go into the long axis view and from the short axis view to explain on the short axis view and then get the long axis view but you can always use the writing birth function to get both at the same time the long axis and the short axis view of the arctic valve and that is where we are. Thank you very much for your attention and I will be happy to answer all your questions in the Q&A session.