 Okay, good afternoon again, and I hope you enjoyed from this meeting so far. So my second lecture is about 3DT clinical applications, and again I'm going to talk about 3DT clinical application in relation with inter-HR septum. This is the anatomy of the heart when we open the right atrium, and we look at the inter-HR septum from the right side. It shows the different type of the ASD. So the most common type of ASD is the second-dom ASD, is in that of Fosau-Valis. It's about 75 to 80 percent of all ASDs. The second most common is Primome ASD, is about 10 to 15 percent of all ASD, and that Primome ASD can be a part of AVST or AV canal, we used to say, in all time. Sinus venous ASD, it can be SVC type, it can be IVC type. IVC type is rare, we had only four or five cases in the last three years, but SVC type is about overall like five percent of all ASDs. Unroofed conicinous ASD is very rare, I am going to show you one case. If you look at this anatomy, you see the SVC is at the top, and aorta beside that. SVC is in the right side of the aorta, right side of the body, and it's a little bit more posterior compared to the aorta. Aorta is anterior, SVC is posterior. IVC is the most posterior structure of the heart. The case number one is not actually ASD, by definition, is a PFO. It's a patient, 44-year-old male, presented with two episodes of stroke. That is the PFO, as you see, the shunt is from left to right. Shunt of PFO is from left to right always, except the right side pressure increased, like during valsalval, or coughing, or pulmonary hypertension, anything happens. So that's the PFO, you can see it by color. You can see it by 3D nicely, I will show you better now. You can see the gap of the PFO is a tunnel shape, but this gap during the inspiration will increase, and this is a large PFO. If you open this PFO in the OR, maybe it's like a 1 centimeter. So that PFO is from LA side. If you make it bigger, it's about, we measured about 0.6, multiplied by 0.8 centimeter, or 6 by 8 millimeter. But as I said, usually this size PFO in the OR is much, much bigger than this. So this patient had an indication to be closed by device, by all guidelines, had a two stroke already. This is an amplizer PFO device, that the right side disk is bigger than left side, and here the amplizer device is in place. The case number two is a 52-year-old male, presented with palpitations. You can see there is a second of ASD, it's like a moderate size. So this is the 3D of that ASD, showing the ASD from RA. This is the SVC, should be at 11 o'clock, and this is a part of the station valve that you can see it. This is the ASD from LA side, and SVC is down again, the IVC is down, SVC is around 12 to 1 o'clock, and right upper movement should be at 1 o'clock, that we are not seeing here. And this is the measurement of the ASD. And this patient had a device, you can see the amplizer device, is sandwiching the two rims very well, and you can see the device nicely sitting in the LA side. We have to always be sure that device is not pushing the ortho, it's not pushing any permanent vein, and there is a talk about this tomorrow. The case number three is a 26-year-old female, presented with palpitations. As you see it in transters, you see very large RV, and very large RA, and big second-dom ASD. You can see it by the color as well. And when we do TE, you see the ASD is very big. Here, we are trying to see the IVC rim, and aortic rim as well. There's no rim here, and no rim IVC. Just for aortic rim, we know that it's not a problem during the device closure. We can use a bigger device and overlap under the ortho, but IVC rim is very important. So we have to be sure that there is or there is no IVC rim. Many times, there is IVC rim, but we don't see it, because IVC and SVC, they are not at the same level. To see the IVC rim, you have to do a retrograde flexion of the probe, like this one. We did a retrograde or retroflexion of the TE probe. Now, you can see the rim better. So anytime you don't see the IVC rim, it doesn't mean it's not there. It might be there, and we are not seeing, because we didn't do retroflexion of the probe. And the reason is IVC and SVC, they are not in the same plane. IVC is more posterior, and SVC is a little bit anterior. So to look at the IVC, you have to do a retroflexion, or look at the posterior. When we did the 3D, we were able to bring the IVC rim as well. This is IVC rim, but it is small. It may be four, five millimeter. That's enough to, is not enough to hold the device. So the size of the defect is 4.3 by three centimeters, very large. The largest device that we have, I think is 36. So this AST was big by the size, and IVC rim was there, but was not enough. So this is surgical view of that AST. Look at the right side of the RA, right atum. This is the SVC, the IVC, and this is the SVC, and the Aorta. Surgeon is standing here. So IVC is in the right hand of the surgeon. SVC is in the left hand of the surgeon. Aorta is more anterior. That's all. So this is Dr. Al-Khaldi in our center. He opened the right atum. You can see the large defect here, and he's showing me the rim. So that's a rim in the IVC side. There is a rim, but it's not big. This is the IVC canola. This is the SVC canola. So he's closing this AST by a precardial patch. Some surgeons, they treat the precardial patch in the OR with growth or height, and some surgeons, they just use the fresh precardial patch. So this is a fresh precardial patch, and he's closing the defect by the surgeon. It is very good to wash the surgery all the time when you are doing tea in the water, if you have time, because watching the actual surgery, it will enable us to look at the post-stop repair much, much better. So this is a patch in post-stop echo. You can see the patch is pushing from LA to RA, and you can see the patch from the right side. This is the patch from the right side. The whole size of the patch, you can see it, and this is a patch from left side. You can see the patch in left side is a little bit deep down, because left side pressure is more than right. It will push the precardial patch down towards the RA. Case number four is a 60-year-old female presented with shortness of breath. Here in this case, you can see a multiple AST. This is at least two AST by color. When we do the saline contrast, you can see the saline is injecting in the arm, going to the RA, and you will see the negative effect of contrast. Two negative effects. Shantis from LA to RA, but you see the two negative effects. Here is this very nice 3D of this two defect, larger AST, a smaller AST, and you see that there is a tissue, remnant tissue between these two AST. This remnant tissue looks very fragile, and it looks like it cannot hold any device. For example, if you want to put two devices side by side, maybe it's not able to hold it. But in real life, when you open the patient in the RA, this tissue is good. It's strong. That's one of the pitfalls of 3D. This 3D, because it doesn't have a good, special resolution, will show the tissue a little bit weaker than actual RA. Here you will see it in the RA. I will show you in a minute. You see it has a good tissue. Anyway, we decided to close it by surgically, because this T is done in 2012, and we were not very good to put two devices together, or one large device. That's two devices together, two AC together, maybe like 3.6, so it's big. Again, this is another view showing the two AC together from the right side, and you can see the coronary sinus here, beside the septal difference of the tricuspid valve. This case is in the war now. This is Dr. Arifi, our surgeon in my previous center in Riyaz. He's opening the RA, and he's going to show us the EST. This is the RA, and then you can see the camera is more close now. You can see the large defect here. That's a larger defect close to the SVC side, and this is a smaller defect that we saw it in 3D. So this is exactly like a 3D. The only difference is this tissue between these two EST and 3D, we look at that it was very loose and fragile tissue, but here you think it's a very strong tissue. So that is one of the problems of the 3D. So this is our case number 5, 65-year-old male investigated for severe permahypertension. This is a TEE. We did the transplants, we got first, we didn't see an EST, this is TEE, the first view. Again, we are not seeing any secondoma EST. And then when we look at the upper part of the SVC, you see that sinus venous as EST. This is sinus venous as EST in 3D. So you see this is the LA and SVC is behind. So the defect is between SVC and LA. That's a defect. This is a good image compared to the year that I did it in 2011. This is that zero degree. You can see the communication between LA and SVC through the sinus venous as EST. And again, you can see the defect by 3D. And you can see here in the OR, the rim of that defect, sinus venous as defect between SVC, SVC is here. This is SVC cannula. And this is IVC cannula. So this defect is between SVC and LA. LA is in the back. This is a defect. LA is the place that this suction is there. That's a post-stop. You see the patch here, especially when they use the single patch, you're seeing that SVC is compressed by the patch, but many times SVC is open totally. But it's better to check it, especially with 3D, to see that SVC is open or not. And you might even check by color. Should not be a turbulent velocity. Should not be more than 1.2 meter per second. And you can do even bubble study to see how the bubble goes inside the RA. These are techniques of sinus venous as EST closure, SVC type. This is the actual defect with pulmonary vein draining to the SVC. This is single patch technique, closing the ASD and redirecting the pulmonary vein towards the LA that is in the back. Two-patch technique or double-patch technique. When they close the ASD, just to check that SVC is open enough, you might augment the SVC. So augmentation, use another patch. That's the reason they call it double-patch technique. But sometimes the pulmonary vein is draining very high up to the SVC. The surgeon cannot reach from here, from the partitioning the SVC, cannot reach the pulmonary vein. So they have to cut the SVC from the top, above the connection of anomalous pulmonary vein, and direct the flow of the pulmonary vein, throw this SVC to the LA, close this defect, and then the rest of the SVC can be connected to the RA appendage. So the flow of the SVC comes from RA appendage to the RA. The flow of these two pulmonary, anomalous pulmonary vein through the previous SVC goes to the LA. This is case number six. 47 year old female presented this palpitation. You can see this patient has a primal ASD. Primal ASD is a part of the AVST. We used to call it AV canal when we were medical students. Now we call it AVST. And this valve is called left side valve, right side valve. Both of these valves are leaking. This is the 3D. This is the tricuspid valve, mitral valve. See, they are side by side, and aorta is not wedged at the middle. It's unwedged. This is one of the criteria of AVST. Aorta is unwedged. It's outside of tricuspid and mitral. You can see the cleft mitral valve here. You can see the cleft mitral valve nicely. Look at this cleft. It's looking to the tricuspid valve. But if the patient has isolated cleft mitral valve, that cleft is looking to the aorta. So this is the cleft that we see it as a part of the AVST. That's after the repair. There's no MR. We have to always be careful. No MS. This is an example of coronary sinus ASD. As I told you, it's very rare. I've seen maybe three, four cases only. And that kind of coronary sinus ASD has unroofed coronary sinus. So if you do a bubble study from left arm, the bubble comes to the LA at first, then coronary sinus, and then RA. So LA, coronary sinus, RA. And this is unroofed coronary sinus. I don't have 3D of this example. So I'm not very good in publication of the papers, but I'm very good in writing books. This is three textbook of Echo. And in all these three textbook, the chapter of the 3DTE and 3DTE in OR is written by me. It's not advertised for books because the money doesn't go to me. But if you want to look at the many example of nice 3D and especially the surgical clips, you can look at this book has lots of DVD. So in summary, majority of second-dom ASDs can be closed by percutaneous devices. 3DTE has a great impact on selection of cases and monitoring of the procedures. There is a recent interest in nonsurgical correction of SVC-type sinus venous ASD by covered stents. Patient selection is currently based on advanced imaging and 3D printing technology as we do it in sectional hospital. T and 3DTE with balloon interrogation can confirm the complete occlusion of the defect which is unobstructed for my veins draining to the LA. In the UK, especially Shaquille Oreschi team that he, I think he was the first person to close the sinus venous ASD by device, he did lots of cases only by 3DTE in the cat lab, not by CT. In patients with large second-dom ASDs or ASD with infrapostero extension, that is very difficult to see the IVC, primal ASD and non-eligible sinus venous ASD who are surgical candidates. Pre- and post-op 3DTEs are the major player in decision-making in the cardiac OR. So, thank you very much for listening to this lecture. I hope you enjoy from the rest of the lectures.