 With some examples about how to use 3d for the for the Arctic valve and SNR is where we actually do Tavis, which I think it's It's actually a good way to actually get introduced as I mentioned before I don't have any disclosures here And again, I think at that point we have actually been Really really involved in how to orient ourselves. So for this specific clinical cases, I think To get the right the right casp is very important to orient or self Again, you have the models you can use the web page as we mentioned you before But I think this is what I have in my brain every single time that I'm doing Transes of agile echo. Okay, so in the short axis view of the Arctic valve again We are going to have the non-coronane casp, which is always the reference between the inter-artial septum Okay, the left and the right and that's how we are actually going to orient ourselves compared to those structures here, okay? so If we go to the long axis What we are going to be able to see and that's what I always tell everyone so we have This cap here that everyone know what it is now at that point The right what about this one It's difficult know and that's when the things come in no between the known and the left what I can't tell you is you increase your Angle up to a hundred and forty you have higher chance to actually pick the left if you decrease a little bit your angle to 110 so you most likely will actually get the known so 110 So we are like that and then we are increasing to 120 So a little bit decrease non-coronane and a little bit increase the left That's another way to actually try to get the view. Okay? So that's the first example, and I wanted to point that out We we consistently talk about that you need to add something that will help you So what I will normally do is I will take a bigger box sample To orient myself put it when I like it and the presentation that I like it And then I will crop it and then mark the structures even on the 3d that I said So you can actually when you go back in because you can see the internal septum here But you need to know that you are there Okay, so for that you need to be able to actually see the rest of the Structures and that's the 2d picture. This is an example of abicast Casp with a raffi in between the left and the and the right, okay? So we have it actually over there. So the same thing with with 3d Okay, so another thing that I would like to point is the fact of the LBOT diameter Okay, we always assess our tecestanosis when we are in the or we are under anesthesia conditions Can actually be very variable So one of the things that you can definitely do and based on the findings that the LBOT is actually not circular Is actually elliptic you can really take a 3d picture of the of the LBOT track and As an example here the LBOT diameter by 2d again, it's difficult sometimes the article is very Classified so it's 2.3 and we got an article by area of 1.3. No, so in this same example We go to the picture that we did before and this is a phillips example You go to multi plane reconstruction You are very sure that you are cutting a sacri where you have your structure You're happy with all the images you aligned your planes Okay, and you want to bring it to the LBOT diameter. Okay, so you go there and you can actually measure two things You can get Your diameter which in this case it can be seen very well here That's is 2.02, which is a little bit of a difference or you can even get the area and it's your cross-sectional area Calculation you can actually use it and it's going to be actually more accurate even but the diameter is going to change too So if you use those calculations with 3d your area is really pointing Okay, so it is another point That is actually important when we are using that technology. Okay So our taking sufficiency so I Normally go to the long axis. I try to optimize my image. I have say that before in the hands-on I always try to go to for example if we are using phillips HBR Okay, the high volume rate you try to mobilize when you're happy with the image that you are getting You stop the vent you try to get as much as you can to get the best resolution for your image After that you can actually crop it and then to show the image that you want with that. What can we do? So this is an example for example We were able to calculate by pizza the effective requisite an orifice So one thing that we can do with 3d is you can go there Go to multi-plane reconstruction freeze the freeze the image and get This window here, so long axis of the article short axis as you can see I'm narrowing the sector to get the maximum frame rate and then here which is actually seen from From from above so you can actually have your effective regurgitan orifice area and you can You can multiply that by your BTI on your a matter of which it and yet and get an estimation on how much is your regurgitan volume Okay, and then you can compare one on the other which is another thing that you can definitely use that technology for okay so I Wanted to put an example of hypertrophic obstructive calloderma your body, so This is a an image of there the other thing It's how to measure for example the interventicular septum So you know exactly where you are cutting the septum and then I think it's actually good too because sometimes you can see When you have this LBOT acceleration flow how so that's the image that we are getting So that's not the way that we are supposed to actually looking at no So we change it and then that's the view from the surgeon So the surgeon as max mentioned is going to pull from the vicarinic gas It's going to go down it's going to do the the septum myectomy over there And that's the view that he's actually going to have the opposite that we were actually having there no so One of the other things that we can do is before the myectomy You can actually estimate your smaller like the minimal area the minimal area of the LBOT Diameter you can do it by 3d choose trace you get the measurement You know pre myectomy and after myectomy you measure from the annulus up to the minimal area What was the distance you apply the same distance here and then you measure it again And you can tell the surgeon your barbaria went from 2.5 to 3.05 Which is another way of absolutely telling him let the myectomy is good It's opening there is no laminar flow But you can give him an objective measurement on the LBOT area the minimum LBOT area is actually increased But at least 0.5 centimeters, okay, which is pretty good on top of doing the gradient So I apologize for that, but that's happening since I did the system too So the first case for Tavar. I think I always will recommend To go with the X plane because it gives you a lot of information in both planes So I just wanted to put an example here of an aortic An aortic stenosis that was actually going with a Tavar with a little finding in the TECO that was Actually pretty interesting so this case What the cardiologist saw we give a little annular plane and again You can do it into D or you can go to 3d know exactly where you are and give a full area and you give them What's the full area? Okay, you go to X plane and you can actually see both structures in both planes Which I think it's really really important for us when we are doing that and then What happened here is? They before deploying the the Tavar they actually normally do like a little Balboulo plastic and after the Balboulo plastic what we were able to see is that flap here Which I saw there so again if you want to know there what's involved You really don't know so you go to your X plane you cut there And you can certainly see that there was a little dissection of their non-coronautic cast with the balloon Dilatation okay, so what they did is they decided to go ahead and deploy the sapiens valve And after the sapien was was actually deployed they were able to actually fix that just with the with the valve and there was no received one Which I think is another Good example on how to assess those those things so This is another case so this one was like a very long day and extremely long day in the or so We have a patient that has a previous So that they came to actually get a Tavar for an aortic stenosis So they try to actually deploy a core valve and as you can see the shape of the core valve It's completely different from the sapiens those are the main valves that we actually use here sapiens 3 and the core valve and the core valve the head should be situated in between the annulus and this should actually go up So we don't occlude the coronaries The only difference basically with the sapiens and with this one this one tends to embolize a little bit more and The other one tends to actually occlude a little bit more the coronaries when we actually deploy them Okay, so in this situation on the problem that we have is this after the deployment What do you think is happening here? So the the the valve might greater a little bit higher than it's supposed to be as you can see in the image this part here should This part here should be actually at this level and then the crown should actually start here and not over there So really with that we can't really do anything. So what they decide to do is go with the sapiens deploy the valve in the annulus and try to actually fish the core back the core valve down and We try for several several hours The problem that we got is that Okay, when we were trying to fish in and out in and out in and out so at the end on the Descending out we get like a little flap we get like a distal dissection Was not a happy day We were not never able to actually fish the ball and we end up requiring to do a turaco to me for rescue that Balvin, but again this explain for these Cases I think it's one of the the best things to have because you can at the same time that things are happening You cannot end yourself in two planes and you are giving real information in real time to the to the surgeons Okay any question