 My name is Ergender and I'm the head of department of anesthesiology and intensive care medicine. The next 15 to 20 minutes. I want to talk about the 3d acquisition of the article. Before I start my talk I want to thank the organizers for inviting me. So during the talk I will talk about the 2d standard views for the challenges of 3d acquisition, especially for the article. And if you send tricks how to optimize 3d image. My hospital receives big consulting honorary on behalf of mine from other events life science with a lot. And we are reference customers from Phillips. So if you look at the 2d standard views you know that we have four views in the middle of the jail position for the audit valve. And we have two views for the transfer. Basic principle challenges of the imaging of the audit valve is that you see that here that the relatively thin and less equitable tasks of the normal are surrounding surrounded by relatively thick and equitable issue of the audit route. And no matter which position you have in the middle of the deal position of the probe, you will always have to pass that I could dance structure. That is in contrast to the module of where the middle of the deal position here. The trans users here and you have a good view of the my talk. So Arctic valve is much more challenging. And you know, the basic principles of duty is a cross sectional view. And you see, even if that is the tissue of the office as thick and equitable as here to do you really can see different. You see that here, especially if you look at the anatomical display here. It's hardly hard to see the right coronary cast left coronary coronary cast here. And if you look at the duty views here, which are simultaneously displayed in this video. You nicely see the cast like in the 2D 3D imaging of the love is a little bit. I would just thought that video. Just to concentrate on that. You see that here would be that position. Turn the image. Set turn, set turn. Now you have the short axis. This is the short axis in the 3D image with a two dimensional display like I'm here. Another problem for 3D imaging is dropouts due to classification. Dropouts in duty. So here by shadowing and also in the long axis. And of course, you have the dropouts in 3D because 3D is based on 2D imaging. If the image is not good, or has dropouts, then you will have the dropouts as well in 3D image. You can increase the gain so that you hardly see anything of love. If you decrease the gain like in this image, you see a lot of holes here, which are caused by dropouts due to the calcification. So in some times, in some patients, you can get beautiful. Here, example, 3D dry cascaded optic valve. This is an image of a monocuspid optic valve here in the full volume. And here, this is the frame. So you can get beautiful images. So basic for 3D acquisition, as I mentioned before, is good 2D image point. Second, good 2D image point. Third, good 2D image point. That is the main thing you should focus on before you activate one of the 3D images. So basic for 2D, I'm pretty sure you know that, that's just a repetition, is the structure of interest should be centered. If we look at the midisovigil views of the optic valve, the optic valve is centered in the midisovigil long axis and in the short axis. It's not centered in the 5th chamber and the long axis. For sure, you can modify the 5th chamber view by turning the probe a little bit more to the right. So that you have your optic valve here in the center like this. The next thing is to do the machine settings. So that means you adjust the depth. And you really don't have too much depth which you need. You have to look at the focus. The focus is really at the level of your mouth. And of course, you should have a frequency of midisovigil views. Normally you have to test on teeth. It's in the general mode. In the trans-casual views, the same thing, the same principle, machine settings should be correct. And you see, if, like in this case, the optic valve is not really very centered, you can do a flex probe to the left. Always more at the apex of left ventricle and to see the optic valve more or less. And then the focus again, of course, in the panacea. Despite all these 2D imaging improvements of quality of the image, trans-casual views are not good views for three-dimensional display of the optic valve because the depth can change. So it's always relatively low in 3D image. That means that the quality of the 3D image is not good. And if you look at the technical aspects during data acquisitions, that was touched by the previous speakers. Of course, you have real-time life 3D, either in narrow-sector or in sub-mode, or you have a multi-plane, or for the Philips thing, they explain this plate of two-dimensional images. And you have EKG-tricked multiple-beat acquisition, either with or without. And the clue for image optimization is, you have to test the game, of course, so void over game. If possible, avoid under game, but in this patient, which I showed you also before, you cannot have a good optimization. So sometimes it's not really possible. Then, if you do good recording with multiple beats, you should avoid stitch artifacts. Stitch artifacts can be rhythm artifacts, or it can be respiratory. Respiratory artifacts are easy to treat for us as cardiac anesthesiologists. You just have to stop ventilating. Respiratory artifacts can be charged, and I will tell you that. Poor resolution. That is, of course, if your area of interest is not in the right plane, so not orthogonal. And if the death, as I mentioned in the transcripts we use, is too low. So you always have to balance between MPRO versus spatial resolution and the EKG. So you see on the lower display of your epic, we have that where you can change the relationship between resolution and speed on time, temporal resolution. I would recommend not to change anything, because in my mind, it isn't really helpful to change that. Maybe you can discuss that with other speakers. My preference is not to change that. Of course, to work with multiple beats acquisition. And for that, I find really helpful to change your display, not only to 3D, but also to this note, where you have 3D volume here. And the psychostasis, and the coronary, and the transverse, and so painlessly, so that you really see if there's a stitch artifact. If you look here, then you can see here, the structure is not really very good here. Here you have a step between this tissue. So that is a stitch artifact due to an intervention. This is a stitch artifact, as you can see here on the EKG, due to extra system, which is even more pronounced. This indicates that you have a stitch artifact. And that is a perfect 4B acquisition. You can see also in the 2D images, there is no interruption in the image. So just forth. Look at that. So you see that here in the movie. This is a stitch artifact here. This is the stitch artifact. Excessively. And this is perfect. No stitch artifact because this recorded with breath home and patient. So the solution between 2D and 3D with the, let's say older 720. See that here. 53 Hertz in 2D. And you have one beat acquisition, 20 Hertz volume rates in by using the one beat acquisition with the seven. And if you use a beat acquisition, you end up with 77. Which is even higher resolution than the two. This is for one beat acquisition matters before. If you use these eight to be close to the newer one, then you get much higher. One beat 26. 52. And it's one of them, which is very, very good. With multiple beat records and acquisition. You have the risk for stitch. You can even be a six feet. Here you have the videos for beat six feet. You see that the temporary resolution is both are the same. Both have 100. And I turn it to, if you have a patient with really unstable. Is that you doing before acquisition, you change to high volume rate acquisition, which is, in fact, a one beat acquisition. But with a higher temporal, but with a lower spatial resolution. If you compare these three images, just take, take a second. This looks a little bit smoother. And that is due to the fact that spatial resolution here, in this case, is low. And that, so that is the highest resolution temporal and spatial, especially spatial. This is same temporal, but a little bit lowest. But for the clinical practice, six feet acquisitions really change, especially in the year. Because you need really six consecutive hard beats, which are regular. There's no touch on the patient, whatever, which can interfere with your KGC. It's always our wave trigger. So if you have a disturbance in your EKG here, we will end up with. So for us routinely, we aim in patients with stable rhythm for four feet acquisition. There's no comparison between seven and eight. So you see one beat acquisition 2026 will be to 77. So, I think it's worth to invest more money. If you adjust, if you apply color Doppler, this even worse. So you see that here with four beat acquisition, using the seven. And nine. It's a problem. End up with 35. 35 versus. It's a good temporary resolution where you hardly miss anything. So what is recommended. These are the guidelines standard. The acquisition of the mouth. The short axis, and the long axis and the use of the long axis you have to turn so that you have the audit. And with really so sure you can turn that image so that you have a look at the audit from the audit view or from the LBG. If you display the RCC in both views should be on the bottom of the six. So, and this is, if you start with a short axis, you immediately have the display. You start in the long axis or in that meant modified five to show you. You have to turn your image. See that here. You can see the audit. Otherwise, because it's anatomically like here, you won't see anything. So there is a rotation needed electronically for the audit of this. You do it clockwise for starting from the middle of the five gender. You have to rotate counter. I would recommend to use the best to debut of these three to start with AV. Acquisition of 3D images of the audit. So that if you start like here, it's really similar, you'll have to identify the origin of interest, and it should be big enough to visualize the structure, but it shouldn't be too big. Otherwise, because then if you really assume sectors to buy. Then the frame rate. You see that that size is maybe too low with that size here. It's good because you have the sign to be a junction and you have the last one would be too large. Then you have that lateral position. See that with the not position. Place here in short axis, the region of interest. Okay, and then you will have that. Center also in this case. So for this, I think the region of interest is large enough. Yeah, because you have the sign into the junction within the image and you have the. You can change the elevation persistent position on the lower panel panel of your system. You see, and you have three positions back, middle or fall. This is back position. And then, if you press the button, you have this middle position. And that is fun. If you put it in the back or in the front, you hardly get a whole lot of. So, please look in your machine settings, I would recommend that you always have the position in that elevation position to have a quick view of your path, and you can see it here in 3D zoom, you define your starting view, your viewpoint and then the direction where you look at, and then you see the object of the short axis here. You can also do that on the LVOT. If you want to look at the output of very quick on the LVOT here. You can do that, and then you have to turn it set. Here you have the entry of my truly set. No, they're actually, which is this example, not good to see, but we will come to that. There's in the newer machines, the so-called true view available. You can define both display of the object of which looks more like tissue. And with that true view, you can have a touch view as well. Touch view is that you have to start a flashlight. Here, and with my pressing your finger on the image here, you can change the position of the flashlight here and here. It should highlight any holes or degree of vegetation or whatever. My opinion doesn't have so much. There are other opinions. Be sure that if the 3D imaging is really not good. You can always use either the explain or multi-plane visualization where my positioning of your sector can change the displayed image from the right side, normally by 90 degrees. Especially for the optic valve, you see sector here right now is cutting through the right coronary and one coronary cast that is displayed here. And if you place your sector on the right side to the right and the left coronary cast, you see that. And of course that NPR motors can you always use also in your 3D acquisition. So how can you optimize. So here you have three, the same patient that was right after acquisition. And you see that here. At the audit mouth is hard to see. So that means you have away all that tissue, which is an obstacle to look really at, which is done here. So here you have to prop in and then you adjust the game and maybe a little bit smoothing and then you see. Right coronary, the left. Much better than at the beginning. So that needs a little bit training and it's hard to, to tell you that in an online lecture, I would be happy to go with you that with that. And when we have a personal meeting. But I hope it's convincing so first do the acquisition. You crop to visualize the structure. And then you adjust the game and maybe a little bit smoothing to have a good. But that quality in the 3D image doesn't have an influence if you go to the multiple plane you construction, which we will see in the next. So again, you see, you have seen that so it is sometimes in some patients really possible because beautiful images by optimizing the game by use cropping and smoothing. And we will have quite a good 3D imaging. So to conclude, 3D imaging offers unique imaging claims. The quality of the images of course depends on pretty quality of equipment was killed a choreographer and mainly of course processing. And due to the anatomical conditions for three images of your mouth are much harder to achieve. So if you want to see that life, then please come to like to next year, June 22. Either in person or virtually where we will have a lexic perioperative team masterclass with life transmission from the or the three cameras, one showing the choreographer and what he does with the pros. Simultaneously, you will see the resulting pictures and hide them high quality. And then the next camera, which is on the ultrasound machine which shows the manipulation of the nobologies to get the best images. So, looking forward to see you next year in my team. Thank you for your attention.