 Good afternoon everybody. Welcome to this 3DTE course. First of all I want to thank organizing committee for inviting me and especially from Victor Moreno that gave me this chance and the topic that Victor Moreno gave it to me is a 3D acquisition theory order structure. I asked him what are the order structure. He told me okay the valves are covered by other speakers and you concentrate mainly on interritorial septum. So I'm going to talk about 3DTE acquisition for interritorial septum, SVC, IVC, pulmonary veins, coronary sinus and maybe a little bit left atrial appendage. This is the diagrammatic representation of interritorial septum and this is the diagram that we can use a lot during our 3D acquisition. Here in this part you can see the septum from the right side and from the right side when you see you see mainly the septum secondum and fossa ovales and this coronary sinus and this oestation valve and you can see the SVC at the top and left and aorta at the top and right. So SVC is like 11 o'clock here. So we use this landmark when we display the 3D from the right side. This is the interritorial septum from the left side and as you see from left side you see mainly the septum primum fused with the septum secondum fossa ovales. You see a little bit part of the septum secondum from the top and in this view you see that SVC is around like 12 to 1 o'clock and pulmonary vein you are not seeing here the right pulmonary vein is around 1 o'clock and again we use that one the pulmonary vein as our landmark when we show the interritorial septum from the left side. This is again another diagram just showing the interritorial septum and how when the between septum primum and septum secondum they are not fused together you will see the PFO. This is again like a 3D image of the heart this is from cadaver and you can see all chambers and how is the orientation of the interritorial septum this is the IVC and IVC is the most posterior structure of the heart so IVC is a landmark for anything that we are looking for posterior like a posterior fluid of the tricuspid valve should be beside the IVC. This is orientation between mitral valve and tricuspid valve and again interritorial septum here you can see it and you can see the aorta is wedged between two valve. So this anatomic feature of the heart is very important to do the tea and to learn the tea so a good 3D tea person should be a good anatomist. For acquisition of interritorial septum 3D of that first we do our 2D tea picture in bicable view so SVC is in our right side IVC is our left side LA is at top and you can see the interritorial septum. If we use the 3D zoom in this view we can see the septum we like to get the septum 3D we'd like to acquire it at 90 degree that's the view that we are perpendicular to the interritorial septum and we have a better resolution also you can acquire it in zero degree and rotate the picture but I believe and many people and the guide I believe that we should do that 90 degree to have a better special resolution for interritorial septum. So this is a either zoom acquisition or full volume this is a full volume this is old machine this is 3D that I did in 2012 so you can see the SVC here you can see the RA you can see the trackers with valve down you see part of the IVC and LA and right PA here and you might see the polymer vein here it is very important to notice that SVC and IVC they are not exactly in the same plane as I told at the beginning SVC is more anterior and IVC is more posterior this is very important to know that in bicable view when you do the 3D if you have a ASD in this area you might not see the rim of the IVC properly it doesn't mean that the rim is not there that you don't just don't don't see it because IVC is more posterior so it's very difficult to bring IVC and IVC and SVC in the same view that's the reason that many interventions especially they prefer to use intracardioch echo to see the for example atrial septum to do intervention on the ASD because by intracardioch you can see the IVC better the view that I showed you at the beginning is mainly a echo view but this is the surgical view the way that the surgeon will see the intracardial septum is this way IVC is in the right side of the surgeon and SVC in the left side of the surgeon left atrium is down and this is the right atrium so this is the surgeon's view of the intracardial septum you can rotate the picture and see it in a different way so the first guideline of 3D acquisition and display of the 3D TE picture came in 2012 also we were doing 3D TE before that I actually started to do 3D TE from 2008 so this guideline was published in 2012 you can see all the big names and pioneer of the 3D there like Dr. Lang from Chicago that we learned everything about 3D in North America especially from him Dr. Luigi Bodano from Europe now is in Milan and he is the main pioneer of 3D in the Europe and you can see Dr. Tasang Vendi that we are very lucky to have her with us now I think she was fellow in that time probably and so we are lucky to have Vendi beside us and David Adams is a cardiac surgeon he was the president of WTS last year he's from Monsigny and here you can see my friend Dr. Francesco Fallettro he's from Switzerland and I took lots of images that I'm talking now from him so the first 3D TE probe came in the market in 2008 and in that year Dr. Roberto Lang had two workshops in Chicago to introduce the 3D and with Dr. Lisa Segang and I attended both of these two workshops so one of this I remember was from live war so in 2008 and we bought the probe in Saudi Arabia we had good money at that time and we started to do 3D in 2008 from that time and gradually I gained more experience also I always learned from Dr. Lang and Dr. Bodano in different meetings but I tried to upgrade my knowledge in 3D from 2008 in Saudi Arabia mainly by our surgeon Dr. Hanim Najem he's in Cleveland now we did lots of work together we did lots of dissection on the ship heart in the camel heart to learn to learn the orientation of the valves and to make everything surgically oriented we made a very good collection and I published like a five six chapters in different textbooks of echo all about 3D so this is the displaying the intertile septum based on the recommendation of amicus site of echo when we show it from the right side our SVC should be at 11 o'clock and when we show from left side our pulmonary vein right upper pulmonary vein should be at 1 o'clock this is short animation showing the same displaying the intertile septum this patient has a large second dome AST as well so you see this is from the right side and here is the SVC at the top we'll go to like 11 o'clock okay and this is the large AST and when we rotate it to the to see from the left side our right upper pulmonary vein should go to the 1 o'clock this is a one full volume acquisition of intertile septum and SVC IVC and that's how we optimize the images use all the tips and tricks that Dr. Moreno talked about that this morning gain should not be too much high too much down compression brightness smoothing x-rays and I think Dr. Moreno talked about all of this and how we do cropping we can crop it from different aspect and we can see it in this RA this is IVC you can see the corneal sinus here this is a very nice paper from one of my friend Dr. Mahmood from Saudi Arabia about displaying the intertile septum and he used a special maneuver I saw some other people are using different maneuver he called it rattle 90 so this is the intertile septum take it as a box and then two times one time rotation one time tilting to show the SVC at the top and this is a short movie that he put it there and you can see that it will take the the septum as a zoom mode and the septum at the zoom mode and then acquire the full volume doesn't matter is the full volume or zoom mode one bit or four bits and then rotate the picture and make the SVC at the top so I believe is a good maneuver but the important is see the right septum from right side when the SVC is at the top there are some challenges to show the intertile septum one is the aneurysm of intertile septum when we have an aneurysm because our frame rate is low compared to the 2DTE we might see a hole here but this is not the real hole this is because of a low temporal resolution this is from RA side you see like a hole here but there's no ASD in this case this is an artifact drop out mainly because of low temporal resolution temporal resolution here is only 10 this is another challenge when we have a lipomatous hypertrophy of intertile septum so this lipomatous hypertrophy of the septum when we show it by explain you can see like a dumbbell shape appears of the septum the first oval is spared this is one of the challenge during the septal puncture because if the catheter might go inside this fatty part and if you use only one view we might not see it so always we should use explain to see the perpendicular image that shows that catheter is not going outside of the heart so this explain is very important and the second image of the explain is perpendicular to the first one and is right and left reversed we have to be careful about that one septal puncture is part of the many intervention in the left side so we have to be familiar how we do the puncture of the septum this is the catheter pushing the intertile septum tending and we can see this tending in a two view this the catheter came out the left side during the mitoclip i know Dr. Max is talking about mitoclip today so i show on the two series case about the septum so this is septal puncture septal puncture should be superior about four centimeter away from the closure of the mito valve and posterior away from the aorta about 2.5 centimeter so again explain is very very important so this one shows the catheter and the catheter should be around 1.5 to 2 centimeter inside there okay the best way to see the guiding catheter and the clip is using again the 3d and this the catheter clip is coming from r a to l a septal puncture during the left ethyl appendage closure again see it is very important to look at the anatomy of the appendage before the procedure appendage should be clean and this for example this is another patient has a smoke in the appendage so we should not do a puncture during that time the procedure this is another case with a large clot in the appendage this is a laminar clot in the left ethyl appendage the laminar clot sometimes is difficult to differentiate with pectin or muscle but and 3d and explain are very helpful how we do the septal puncture during the appendage closure we should be posterior but we don't need to go superior for like a mito valve clip so posterior and inferior goes directly to the appendage and this is after the device this is the washman is sitting in the appendage i know washman device is not very popular these days but it was very popular in the past a septal puncture during mitral balloon valve velocity again the valve velocity the septal puncture should be done from the fossa ovalis and this is the balloon is coming from ra to la and we are seeing as a live we do sometimes mitral balloon valve velocity by 3d live but many times the expert interventionist they do by fluoroscopy so this is a very nice inflation of the balloon and this is the fluoroscopy as i said many interventions they just use fluoroscopy this is an inoe balloon that is widely used especially in the middle east for rheumatic mitral stenosis anatomy of the pulmonary vein by 3d dr fletra is publishing lots of paper about this about different aspects of the 3d especially intraceptome and the pulmonary vein ablation in their center they use the live 3d to do ablation so that way that we can see the left upper pulmonary vein left lower the left upper pulmonary vein is just beside the appendage and there is a rich here we call it lateral rich or left lateral rich or we call it commodity rich that's a space here if this space is very big it means the patient has a left svc so this is the how we show the left upper pulmonary vein and left lower left lower is a little bit more difficult but still we can show it even we can show the long axis of the left upper and left lower they come like a y to the a and this is a right upper and right lower again we can show it very well by 3d this is how we show the coronary sinus by 3d and this is one of the real anatomy of the coronary sinus when we open the right atrium in a patient that has a tr so in summary the intraceptome is more than a simple partition dividing the two atria and 3d t enables consistent visualization of the intraceptome and surrounding atrial walls from both the left and right perspective spectacular accuracy of 3d images proved by equivalent displays of anatomic specimens and the clear definition of the border of the specimen of symptom should encourage its use during interventional procedures for left heart pathologies such as transcad and might of our repair or replacement definitely till appendage device closure and catheter based pulmonary vein operation thank you very much i hope i will show you more the intraceptome and ASD in my next talk that's mainly a surgical talk thank you very much