 So when we're planning this course, we had discussed having a wet-lap heart dissection, which are always quite popular. But the few limitations to the picklap, aside from the logistics and the fact that it would have taken at least twice as much time, so cutting into our hands-on practice time, that I find that heart dissections are good for illustrating the detailed valve anatomy and seeing the leaflets. But it's not as, for that 3D morphology of the heart, they're not as good because you're cutting open the heart and it's flat and floppy. And we thought that it might be more useful to actually do this with 3D models. It's the first time we're actually running it this way. So in the feedback, if you can actually give us some comments about what you thought worked and didn't work comparing this to a wet-lap, we'd really appreciate that. Also, any feedback can provide us on the phantoms that we're using the hands-on, because that's a prototype that we're developing further. So any feedback you can give us on how to improve them would be appreciated. And my apologies also for the small size of the room. This was due to my miscounting of how many registrants we had. So I'm not to Hikoba. And so with that, we'll get started. So I have no conflict of interest with respect to the content here. So the overall purpose of this presentation is for you to develop a mental model of the heart in 3D. So be able to both the morphology of the heart and how it's oriented in the body. So by the end of this talk, hopefully everybody can just close their eyes and actually picture this model in three dimensions, properly positioned in a chest, and be able to build the entire rest of the heart around the model of the heart base. So we'll start with the heart base, then we'll build the rest of the heart around it. And finally, we'll go through some 3D echo views that we'll try to interpret using the heart base as our compass. So I'll take you step by step in terms of how to make this mental model in your head. So we're looking at the heart base roughly from the atrial or the side of the atria and the great vessels and looking towards the apex of the heart. So we have two small circles, one in the middle, one in front. So that's the aortic valve, the pulmonic valve, tricuspid valve, and then a jelly bean for the mitral valve. So if you draw that shape and mark the centers of the circles, and then you connect them, and then you divide each circle into equal thirds. At the mitral commagery, it's relatively easy to remember. But once you do this, then it's pretty easy to figure out what all the leaflets are. And it was pointed out to me a little bit like a clown face if you make the aortic valve the nose, so that's another good mnemonic. But once you have left and right are in quotations obviously because these terms are based on what's called the valentine projection of the heart, which assumes that the heart is sitting in your chest like that, which it isn't, my heart would be like this. But if we use these for naming the cusps, you can try to just think for yourselves what the cusps are. So for the pulmonic valve, that would be the anterior, right, left. So similarly, right coronary cusp, left coronary cusp, and non anterior, posterior, and septal. And here there's an anatomic view looking from the correct side. So right is right, left is left, and top is anterior. So now try to picture where the interatrial septum would be in this diagram. So we'll be cutting from the non coronary cusps, where we're used to seeing it between the two AV valves. So that would be the interatrial septum. The left atrial appendage, so it would be here. The right atrial appendage on the opposite side. And the coronary sinus would follow the back. So if we add those in, and these are the two sort of fibers trigones that are the main structural foundation of the fiber skeleton. Have the interatrial septum, the AV node passes very close to here. The coronary sinus follows behind the mitral annulus into the right atrium, which would be overlying the tricuspid valve and the two atrial appendages. Everyone's following so far? Just stop me if I lose you. So now try to picture where the outline of the RV and the LV would be from this view. So remember we're looking from the top towards the apex. So the LV would look like a circle, and the RV would look like a croissant. So try to picture where the circle and the croissant would go. So again, you're looking, so the left ventricle has the inflow and the outflow very closely associated. The right ventricle has them far apart. So this is fairly crude to make it a little bit more accurate in terms of the contours of the valves. The tricuspid valve is obviously not a circular. The septal posterior commissure is marked by the presence of the coronary sinus. The antroposterior commissure varies very significantly across individuals. And the dilation usually occurs in this axis. So the valve would extend out this way. The circumflex follows the coronary sinus. And I've also marked the cut planes for a four chamber and a long axis view. So you can see in the four chamber, they're cutting across the mitral valve, the entreatural septum, the tricuspid valve going down. And then you can use the left hand rule. So that's the little compass rose up here. For the long axis, you see the mitral valve cut in half across the anatomic center, you see the aortic valve cut in half in the long axis. So this is still imprecise because we're still flattening the whole thing out. So obviously it's not flat. So now adding the third dimension, it's a famous diagram from Netter. The main thing to notice is that the aortic valve and the pulmonary valve are not coaxial. So the long axis of the two valves, so we take your model and you picture the long axis coming out of each one. You can see they're roughly at 90 degrees. So if you picture a line coming straight out of the aortic valve, one coming straight out of the pulmonary valve, they're almost perpendicular. And you can kind of see that in the diagram there. And you can see it a little better here. This is a famous diagram by Zimmerman. I've been trying to figure out exactly how this diagram was created, whether it was based on a pathologic model or it was actually artificially built. Because it seems that these things don't actually exist fully in most patients. But in the center here you have the crown shaped support of the aortic leaflets. In the distance in the back you have the pulmonic valve, and then you have the two fibrous trigones here. So the AV node passes here, interatural septum would be here. And you have the right and left AV grooves. So these are not the true annuals of the multilevel intraocuspid valve. They're actually more accurately marking the atrial ventricular groove, the boundary. Because the annuals of the intravalve valve is more saddle shaped, in normal cases. And for the tricuspid as well, but it's not planar. And on the right is the projection of this model in the same position as this. And if you actually scan the QR code, you'll get a 3D viewer online. Because these models are all online, and they can be downloaded freely. It may be a bit slow to load up, but it should work. And you can spend that around on your device. So now that's the 3D version lined up as close as possible to our 2D. I'll just leave that up for a moment, just to, are there any questions at this point? And all these slides will be online as well, as well as the diagrams. So now looking at the orientation of it. So if you can just pick up your model there, and picture the long axis of the aortic valve. So imagine a long line running through the center of the aortic valve. Perpendicular to the, to the annular plane of it. That line, if this is your heart base, would go from your right humeral head to your PMI, to a point of maximal impulse, just close to your apex. So if you orient it that way, you can actually hold it the way your heart base would be. So for me, it would be roughly this way. So this is the anterior view. And then you just rotate it so that the bottom is roughly flat. And the aortic valve would be right behind the sternum. And the pulmonic valve is in the front, and some of you have it backwards. So this is mine, so yours would be flipped over. So the pulmonic valve would be in the front, I think it would be like this for you. So this line would go from your, yeah. So this part is very important, so make sure you get this part, because then the rest of it will be hard to follow without this. So again, picture the long axis of the aortic valve, going from your right shoulder to the apex of your heart. And then once you have that, then it can rotate about that axis. So for you, it would be like that, yeah. So from most of you, it should be, from your perspective, it should be like something like this. So that's the view from the right. And we've also, for this patient, modeled the esophagus as well. So you can see where the path of the TE probe would be. And obviously, there are very individual variations in the shape of the esophagus. So things aren't exactly like this for everyone, but for this individual they were. So that's from the right-sided view. So again, so for this patient, the humeral head would be here, down to the long axis, down towards the apex, that's somewhere near the back wall of this image. And now this is the most important view. This is the posterior view from the perspective of the TE probe. So that's going to be coming down the esophagus. So down here is our metasophageal window, because the left atrium is going to be right behind the mitral valve. So these hearts actually come apart. So here we have this, and the left atrium is here. And the esophagus is passing right behind it. So if we do this with the whole heart, the heart, the whole heart would be in this position. So that's the left atrium. And you can see again, so at about zero degrees, you're going to go through the interatrial septum, the mitral valve and the tricuspid valve. And you can actually see why in many patients to get the proper four chamber is not quite at zero. Sometimes you have to add about 10 degrees or so. And this patient illustrates why that happens often. Because if you do exactly zero, you're either going to get the coronary sinus back here. And if you move it up to get the middle of the mitral valve, you're going to have too much erotic valve in your view. And then the upper esophageal window be up here. The airways are passing in between. So the heart models you have in front of you, I think most of you have the regular scale one. The front one is the one that's double scale. Unfortunately, we didn't have enough of these for each person. But you can take them apart. And what I recommend is actually take them apart now and try to position them around the heart base. These models are not from the same patient. So it doesn't sound an exact fit. But you can kind of picture where each chamber goes in relationship to the heart base. So some of the joints are a little bit on the stiff side. So you can put it back together. You can put it back together. And you can kind of picture where it goes in relationship to the full size. So this is easier with this way. For example, like this would be your right atrium. So you can work out slowly. This set is missing the left atrium, unfortunately, which is kind of important. But we have a tetralogy of fellow model here as well. Well, it's anatomically, it's normal morphology, general orientation. So it's just the developer bit stenotic. But it has the right chambers and the right orientation. That one's not coming up. There is one that is glued. This one is not glued. But that one's OK. But this ring would be the tricuspid ring there. So we want us to put this one between. No, just kind of picture. I would take each chamber one at a time and position it where it would be. So like the left atrium. I mean, this one, this is a double scale heart. This is a single scale. So you have a bit of a mismatch. You can't actually put it together. You can't actually put it together. You can't actually assemble it with the base, because especially if your base is the half scale. But you can kind of position each one. So this one would be there. So the aortic outflow and the mitral inflow. Oh, you don't have a. Sorry? It doesn't actually fit. It's more yet. You can sort of do the chambers one at a time. We're going to make another version that does fit together. And I should acknowledge an important debt here. This diagram is actually inspired by probably one of the most used illustrations in echo teaching at Yuf in Toronto by Dr. Armran, which was his map of the mitral valve model and the heart base. So what's our finish time? Because you need 20 minutes? 15? OK. It's the muscle, I guess. So with that one, you have to look at where the appendage is to figure out which way to orient it. Yeah, no, you need 25 minutes. 14, 15, 10 minutes? OK. 15 minutes. 15 minutes, OK. Do you want to give people a hand? Just look around and see if people are lost or anything. Very good. Oh, thank you. How are you developing? They're going to be able to. It took me a long time to manage this segment, this one, a CT scan. But it's been, oh, thank you. Oh, yeah, yeah, yeah, yeah. Yeah. Oh, very, very good. Thank you. So I will look up where the pulmonary veins are. They're going to be able to orient the appendage. They're going to be able to orient it. And do you want to give them a hand? I'm sorry. OK. OK. I'm going to give them a hand. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. OK. relationship to the IVC and SVC. You can see whether you have a sinus venosis, ASDs, and while you have to go past the bicable, you keep turning to get the right pulmonary veins. So you go to 90 degrees, and then you keep rotating, and then these come to view, because your kind of bicable is there, and then you keep turning right, rotating right to catch the pulmonary veins. For those of you whose hearts have a, this is from a different model, you can kind of roughly hold it in that position. So because this one is missing the left atrial appendage as well, oh, this is here, so I think it's, yeah, that's the left atrial appendage, so it would be kind of like that. And notice where the pulmonary veins are in relation to the IVC and SVC. Less clear in your TET model, but in the, yeah. And this model is also, you can look at that 3D viewer on your device as well for this one. So you have the viewer, you can download the 3D file, which you have to use the separate 3D viewer to view. So you can save it, but the viewer right now that we're using it can't be saved, but it's not ours. It's on a third-party site. We are developing our own viewer that you can download completely and view. This is on Sketchfab right now, yeah. No, no, outside you can, yeah, as long as you're online. But if you download it, it'll just download the 3D data for this, which won't have, you need a viewer. You can download the 3D printer for yourself. Yeah, so all these models are, we do sell them, but they're also available for download and for your own use for free, if you have your own printer. So you're here for us to keep or not? Yeah, so you got to keep your heart base. The full hearts we need right now, we don't have enough of them. But yeah, but you got to keep your heart base so you can, as long as you can reach consensus about who gets the full size one or who gets the half size one. So you're welcome to keep going with the hearts, but for those of you who are bored with that part, we have a few 3D data sets. So I'll put them up one at a time and try to orient your heart base to match what you're seeing on the screen. So for example, for this one, this is a mitral valve. And if there's appears to be a valve in front of it, that's presumably the aortic valve. So the heart base would be something like this. And once you picture that, then you can quickly figure out what these dimples are and what's going on there. Because once you get comfortable doing this, whenever you get your 3D data set and if your probe happens to move and you lose your mitral valve, you don't have to go back to 2D to come back. You can actually figure out which way I need to turn the probe to get the rest of my mitral valve back while it's still in 3D, which would really speed you up in the OR. In the five minutes you have to get a full study done. So this is a very similar data set, similar position. They're gonna try to picture where the heart base, how we positioned here. And for example, which way you would have to rotate the probe to see the tricuspid valve. Almost the same as the last one. A bit more challenging. So this is a bicuspid aortic valve that we're looking at almost on fast, but it's not in the standard view. And we have the mitral valve in the back. So again, if you position the heart base, so the right atrial appendage is here, the left atrial appendage is here. So what we're seeing here is the right atrial appendage and the tricuspid valve is behind it. We can press the time for this workshop to leave more time for the hands-on, but all these slides will be available online. So yeah, a similar view. This one's a 3D model based on the data sets. This is more of an on-fast view. So which cusps are fused? Nonetheless, this actually matches your short axis view. Again, if you can picture the heart base in there. And again, this part is sort of behind, but that's the orientation. Okay, I'm gonna hand it over to Max to tell us sort of a few more. So my part will look awful compared to what I thought has done so far. But I just wanted to add a few more pictures. So what we did just now was to see if from 3D models can understand a bit more of the anatomy of the valve. And so I start with this slide very quickly just to highlight something that adds to the confusion and complexity. And I'm glad Wendy Tsang is here and she's one of the authors of these guidelines. But something that's a little bit confusing is the fact that I think at minimum right now, pretty much everybody can recognize a mitral valve in 3D. And pretty much everybody has understood that how we can show and display a 3D mitral valve. How do we display it in the surgical view? So surgical orientation on-fast view, which basically means that we show it to the surgeon the same way the surgeon will see it when he opens the heart. That means the posterior leaflet is at the bottom and anterior leaflet is at the top. So then before these guidelines came out when we, with a net in 2010, wrote a review on 3D for anesthesia and algeasia, we wanted to display the 3D data sets. We went to our surgeon and asked, how do you see this structure? How do you see this other structure? And try to present the 3D block just like the surgeon sees them. Because we thought that the surgical orientation was the correct one. Unfortunately, what you will notice in these guidelines here and actually Professor Ender has mentioned it earlier today is that not all of the structures are actually supposed to be displayed in the same orientation as the surgeon see them. Also probably because there's no surgeons. I don't think there was any surgeons in the panel that wrote these guidelines. But I think there's still something that people sort of, I think it's underestimated is how much of the three-dimensional cardiac anatomy have we learned and I'm better understood and being finally able to show our student with 3D echocardiography. And this is sort of, I just put together a series of slides using an example from a porcine heart. This is a porcine heart. That's what we were supposed to, initially what we thought we were gonna do. And you can recognize the structure. This is the base of the heart. And then again, you can use the model that you just got and the Arctic valve of label them. These are all of the structure. And this is the dataset of the heart base. And actually we can take this dataset and rotate it around. And here we can see that there's a perfect match from this model here with the mitral valve here. Here's the mitral valve in the surgical view. And actually when you orient the big dataset what I find because, and you can see on the structures. So Azad used the Arctic valve as the center of your block. But it is difficult when you see the Arctic valve alone to understand which casps is which, right? So you can, if you see a little piece of interraterial septum, you understand that one is non-coronary sinus. But if you look at the casps or the root alone, they are symmetrical, so they're all pretty much the same. But that doesn't apply, and the tricuspid valve, if we see it, then it's also very difficult to orient. Something that it's easier to orient, definitely is the mitral valve because it's a smiley, right? So the commissure is open upward, right? So if we orient the mitral valve in unfast looking upward, then the other structure sort of will come into the same sort of surgical orientation. And in this case, actually, when it comes to the Arctic valve, you see this is the interraterial septum. That's a non-coronary casp. The one at the top is gonna be the right coronary casp. And when the surgeons open the aorta and look in, what comes at the top? And we all know, as cardiac anesthesiologists, very well, that's the top is the right coronary casp. And that's where the air would go at the end of the cardiopulmonary bypass if we don't the air the heart properly. But then if you look at the guidelines, the way the aortic valve is supposed to be displaced is actually upside down. But that's sort of one of the things. So here is, again, it's one of the things that before I always use these images and this dissection because this is something that helped me a lot as a trainee to understand caracanatomy is that the aortic and the pulmonic valve are perpendicular to each other, are 90 degrees to each other. What does it mean that when I see one in short axis, the other one is long axis and so on? So in here, you can see it very clearly in this dissection. So here we see the aortic valve is at the top. This is the pulmonic valve. So here we look into the aortic valve. Here we have the interatrial septum that comes here. That's then at the bottom will be the right coronary casp. Yeah, left coronary casp and none. And here on the side, you can see that you don't see it because it comes this way. You have the pulmonic valve. And now to further demonstrate what we just said, as soon as I get a picture, okay? So if I take this block that I had and I rotate it on the other way, so I look inside the pulmonic valve. Here I can see I look inside the pulmonic valve. This is now unfast for the pulmonic valve and this is the aortic valve in the other direction. So here I can see look into the pulmonic valve and the aortic valve comes on this side. So this is another feature that we can easily appreciate from 3D echocardiography. And so we can clearly see here coming up there. So it's very nice. And the casps of the pulmonic valve, this is the case where, yeah, we need a lot of imagination to see them. But if we could ever see them, then they are named basically based on the adjacent aortic casps. So the most anterior is anterior and then we have right and left casps. They are just next to the right and the left casps of the aortic valve, yeah? So when it comes to tracaspid valve, tracaspid valve here on this big heart, usually because there's stagnant blood and clots, it's never so clear, but we always struggle a little bit to identify and figure out which leaflets are which. And I think what Azad just pointed out is with the model that was brilliant is you can see clearly that the adjacent structures are the coronary sinus and the aortic valve. So the coronary sinus is brilliant because it comes right at the commissure between septal and posterior leaflets, the coronary sinus. And then the aortic valve is here at the top that comes adjacent or close to the commissure between anterior and septal leaflet, yeah? And so then when we have a data set, the other thing that sometimes it's helped or relatively helpful in these 3D data sets is when we have patients with pacemaker. So here is the pacemaker wire that comes in. So you can see in 2D where the pacemaker is and that would help you orient yourself. So in here, if we orient ourselves in a sort of the same view as here, which is sort of a surgical view with the aortic valve at the top, then we have the aortic valve here. This is the interrational septum. The coronary sinus here kind of comes and goes. So then here we can appreciate this is septal, this is anterior, and this is posterior. So this coronary, this pacemaker cable as often happens it's sitting in the commissure between the posterior and the septal leaflet. So this is actually pretty nice. And then like last but not the least, the mitral valve everybody knows. So and as Dr. Tseng was mentioned in this morning, it's always important when we take a block, we need to try to keep the block as small as possible because that gives us the higher temporal and spatial resolution. But we also need to have a little bit of something else that allows us to orient our block. Because otherwise we look at something, we don't know what it is and how to orient it. And obviously for the aortic mitral valve, the reference is always to the left, is the left ather appendage and at the top is the aortic valve. So when we have a block, a 3D block with the mitral valve, then it becomes pretty easy to orient. And here we can clearly see this is a left ather appendage to the left, this is the aortic valve at the top, and this is the interraterial septum here. And here we can clearly see the two sort of commissure of the aortic valve. And next to the commissure on the side of the aortic valve are the two trigons of the heart, which are two structures. They are cartilaginous structures that the surgeons like very much because they are very solid and they can suture stuff too, but we don't normally see them on echo. You can feel them in a porcine heart, but you don't really actually see them on echo. So that was pretty much it. I think, yeah. So just when you have 3D data set, just look at them, play with them. And I think I've learned and I continue to learn a lot of stuff every day just by looking around and appreciating the different geometry of the different structures.