 much more anatomical view, we have more spatial resolution, we have less temporal resolution, but this is the most current imaging technique that we have. With this, we can see all the structures of the heart. You will see later on how we acquire as this is 2D, and of course the heart is 3D. We have to use the integration of different imaging views that we will see later on. But as I have said, the heart is a moving target, and there is tissue, which is made by the myocardium and the pericardium and the valves, but also we have fluid inside, which is the blood. So we can also have information for the echoes that are reflected by the moving particles within the blood, which are the red blood cells or the white blood cells. So we have information also applying the Doppler principle. We have also information about the speed of the motion of this blood within the heart. And for that, we have different modalities of Doppler, what we call the pulse Doppler and the continuous wave Doppler. You may know better than me, but pulse wave Doppler means that you send a pulse and you wait to have the echoes back. So you can scan fluids with low velocities, typically less than 1.5 meters per second, but you can localize very well where is that flow moving. On the other hand, we have continuous wave Doppler, which means that the transducer is sending and receiving at the same time, ultrasounds on the reflected echoes. So that means that you can evaluate high velocity flows, but you are not, this is not good to locate where is exactly the flow. And these two techniques or these two modalities are useful to evaluate velocities of flow inside the heart. We can also, we will, later on we will talk about the application of the Doppler to the tissues also. And what do we use this for? For example, we can use this pulse wave Doppler to see how fast or how slow the blood enters the left ventricle. And this gives us a lot, a lot of information because as Bart explained previously, we have an early passive feeling of the heart. So just looking at the velocity of this wave and also particularly at the speed of the deceleration of this wave, meaning how this accelerates, we can imply from here lots of information on how the stiffness of the ventricle and how is the flow if it is overloaded or not or under filled. Also, there is another part of feeling which is due to actual contraction. And this is what we call the A wave. And this gives a lot of information again of how is not only ventricular conditions like stiffness or compliance, but also about actual function or actual contraction. Continuous wave Doppler is mainly applied to look at flows with high velocities. Flows with high velocities is what we got when we have narrowed valves, for example, in valve stenosis. So there are some diseases that cause narrowing of the valves or other abnormal malformation, congenital abnormalities that do narrowing of the place where the flow should go out. And for those we have velocities of flow that go beyond three meters per second. So we need continuous wave Doppler to scan those flows. These applications are really, really important because before Doppler cardiography came in, we had to put a catheter inside the heart to evaluate these diseases. Now we do that non-invasively, just applying a trans thoracic echocardiography which is cheap, easily available and an expensive test. So this was really a revolution in the field of cardiac imaging and in the field of cardiology. Another modality or derived from pulse wave Doppler is color Doppler. I always tell my medicine students, this is echo for doctors who are less smart than engineers. So they put colors to us so we can understand it better. So this is another way to depict velocities of the blood. And by agreement, we just, as you know, the normal flow within the heart is laminar. So mainly we see velocities, similar velocities in laminar flow. And by agreement, we say that it is red when it goes towards the transducer, which is here. So, and it is blue when it goes away from the transducer. So this is a normal flow across the mitral valve, which is when the valve, mitral valve, which is this one opens, the flow gets into from the left atrium to the left ventricle. And as we have the transducer here, we see depicted in red color, okay? If we could stop, we could see that that is exactly in diastole after the exact moment in the cardiac cycle. When we have abnormal flows, this flow becomes turbulent. And we have no more laminarity. The flow increases velocity and it goes beyond what the pulse wave Doppler can do, which is, as I told you, is usually around one meter second. So it happens this thing that, you know, better than me, that is aliasing and the machine depicts it as a mosaic of colors. And this is the thing that we have to look at. The mouse doesn't work. Okay, we have a pointer. So we have this mosaic colors here that depict that there is a turbulent flow. Looking at when it happens during the cardiac cycle, this is systole, my eye is drained, so I can see it systole, and it goes from the right ventricle to the right atria. So this means that this is an incompetence of the tricuspid valve that doesn't close adequately during systole and then flow goes from the right ventricle to the atria, to the right atria. So this is how we diagnose regurgitations or abnormal flows. Just taking advantage of this Nyquist effect, and of, thank you, and of the appearance of this turbulent flow here in a moment of the cardiac cycle. We also have now, and with some more technical progress, we will have more and more. As I have said, we have a three-dimensional structure which is the heart that we evaluate with two-dimensional echo. That's our main clinical tool in daily clinical routine practice. But currently we have, in many systems, we have also the advent of 3D echocardiography. This is an example of trans thoracic, three-dimensional echocardiography. So with the use of transducers that have many crystals in a matricial disposition, we can take a whole volume of the heart, and even now in one bit, we can have the whole volume at least of a normal ventricle. And this is useful mainly to look for better spatial relationships, and also to estimate volumes of the left, of the heart cavities, ventricles, and also atria. This is still not so used in clinical routine practice. Why? Because technology is still not so good, and we still have limited spatial resolution, and of course very limited temporal resolution. So we can use that for research. We may use in clinical, in few patients, where we have good, we know with good images, but this is not really still a state of the art clinical routine practice. We also have it with applied to another modality that we will talk, which is transesophageal echocardiography. So with transesophageal echocardiography, we are closer to the heart, so we can have a better visualization of the cardiac structures. And then we use, this is where 3D is really, really useful to look precisely at the valves, and also to help interventionists to treat these valves. This is what we do in the OR, for example, helping cardiac surgeons to see if the repair in the valves they have done works appropriately or not, and particularly, this is really, really useful in the cath lab where cardiologists with catheters try to put things around the valves and they try to fix valves without opening the chest of the patient just by the use of catheters. And one limitation that we had, for example, when we used to the echocardiography is that it's very important to look where is the tip of the catheter they use. This was really, really difficult to do with 2D echocardiography while with 3D. I'm sorry that I don't have an image here, but we can see it very nicely. So you can see here, for example, this is a mitral valve. This is a segment of the mitral valve, which is prolapsing, and as you can see, there are two lines which are not any artifact. These are cordia tendine that rupture. So the definition with transophageal echocardiography is pretty good to see particularly the tip of these linear structures the same way that we see the catheters. And of course, with these volumes of data, you can do a lot of processing that you love to do and that probably Mathieu will develop tomorrow. Another modality that we use, and we also use in clinical routine practice, not as much as we should, but we already use, is the application of the Doppler principle. As we said, we use that for calculating velocities of the flow or the blood flow, but we can also changing the settings of the machine, and this is already a preset that comes with every machine. We can evaluate the velocities of the myocardium, because as I have said, the heart is a moving organ. So we can evaluate the velocities with which the myocardium moves. So we know the velocities that the myocardium moves in regards to the transducer, and we can do that mainly applying the Doppler. As I have said, this is what we call Doppler tissue imaging. And typically we can have pulse wave Doppler that we use usually to evaluate the annular velocities that gives us an idea of the global longitudinal of the formation of the heart, which is a surrogate of the ventricle of the function, of the contractile function of the heart, as Bart already mentioned, but we can also use these acquisitions where we have color coded velocities of the myocardium, and from here we can later on post process with the specific softwares, and from here we can have different sample volumes in the different regions of the myocardium and look and how the heart, how fast or what's the velocity of the myocardium moving across the cardiac cycle. So typically we have this motion in systole towards the apex, and then we have the two waves, the E wave and the A wave, the same thing that we look for filling. So we have the early relaxation of the ventricle and then the atrial contraction that also makes the heart to move away from the transducer which is here. From these Doppler imaging, color imaging, we can also have velocity as I have said, this is the raw data, but from this we can derive other parameters which is displacement and particularly strain rate. Bart already went to the concept of what is the velocity of the formation of the myocardium and also we can have a strain and global strain. DTI mainly we use clinically to analyze the velocities of the annulus, and sometimes we use to evaluate the strain and the strain rate particularly for hypertrophic myocardial disease. But as I have said, the main application is for looking at velocities of the annulus. More recently, another modality to evaluate the myocardial deformation of the heart was developed, this, as somebody says, this is kind of easier for doctors or for physicians, but it's probably less accurate because it has less temporal resolution than tissue Doppler, but this is definitely more friendly to use for physicians despite not so precise from the engineering point of view or the technical point of view. So here what we do or what the machine, the software does is track the nature of speckles that we have in the myocardium when you insulate it. You have these bright points within the myocardium. The system tracks them across cardiac cycles and it gives you the longitudinal deformation, also the circumferential deformation in another view, in another transversal view of the heart and from this to provide you the radial deformation of the heart, which are, as mentioned in the previous talk, the three directions on which the heart is moving through across the cardiac cycle. So from this, we can calculate the global deformation of the left ventricle, also of the atria on the right. We can estimate the regional deformation of each segment and what is more interesting for us is we can look at the pattern of this deformation, not only at the amount of the formation but also how it deforms across the cardiac cycle. As I have said, this is measuring the formation is something that we still do a lot for research and less for clinical practice despite we should incorporate it more and more for clinical because it provides you a lot of information. One of the limitations of not using this in clinical practice is that we don't have this available in all the machines, you have to transfer this to a workstation and analyze later on and physicians are always very busy, they have like 50 patients waiting to do an echo. So you have to rush to do echocaryography and just keep it to ejection fraction. Indeed, this is something that we do wrong. We have these tools and we should take more advantage of them. Another limitation of this is that sometimes these are concepts difficult to understand for busy physicians, but this is why to the strain which is our spectral striking strain has been more successful than DTI because it has less artifacts, it's kind we have a lot of smoothing in this post-processing and this is why it's more friendly for us and this is why we are now using a little bit more than the tissue Doppler was used for. Okay, how do we do this? How do we get echocaryography? As you know, the main access is trans-terracea echocaryography, we just put a transducer on top of the chest and we look at the heart and for that we have a standardization of different views and different approaches and from that we reconstruct from 2D images but we also incorporate all these techniques M-mode pulse wave Doppler, continuous wave Doppler, Doppler echocaryography, tissue Doppler, 3D, we have 3D or other things as you will see, we incorporate all of these techniques in the different views. So we know in each view what we are looking for, what we want to scan in each view and typically same structure we look at from different views in order to make the 3D reconstruction in our head to complete the evaluation of the heart. So typically we start with a parasternal view here and then we go to the apical view and from here with our hand or with the hand of the sonographer, we change the cutting planes and we see the different structures. For example, this is a parasternal long axis view, what we call, we can see here the left ventricle, the aorta and the outflow of the right ventricle just by turning the transducer 90 degrees, we have transversal views of the left ventricle and the right ventricle and also depending on the tilting that we give to the probe, we have different cuts at different levels. This is an example of an apical view, the four chamber apical view, this is kind of the most anatomical one and the easier to understand for those who are not familiar with this and also we have here the left ventricle, typically larger than the right ventricle in the adult and the atria here with the mitral and the tricuspid valves. Also by turning the probe, we can have a cut across the left cavities with the left ventricle and the left atrium and this is important because we see different segments of the left ventricle which is in cardiology kind of the most important, the spider right ventricle is also important. The left ventricle is the most involved in most of the pathologies at least in the adult because the most prevalent one is chemically hard disease which mainly involves the left ventricle and it's important to see in all the walls of the left ventricle because we have three coronary arteries and the three coronary arteries irrigate different aspects or different parts of the whole left ventricle. So it's important to do this reconstruction of this view of all the parts of the left ventricle but that also applies to the mitral valve and indeed to all the structures in the heart. So what do we do when the heart is not really nicely seen with trans thoracic cardiography because you know we have the lungs in the middle and you know ER is not a good conductor for the ultrasound so sometimes we face patients who have a bad window what we call a bad acoustic window and we have something to see better the heart. So in that case we have two options keeping it with echo so we can give what we call echo contrast. Contrast for your choreography has nothing to do with other contrast used for other imaging techniques such as radiology or CTs or MRI. What we use is micro bubbles and we have several types of macro bubbles depending on the size of the bubble. So if we have big bubbles these bubbles if you inject them in the vein when these bubbles will reach the lungs they will be stopped there and they will be destroyed and expirated as air but if you have very very small micro bubbles they will pass the pulmonary pulmonary membranes and they will go through the left circulation so they will arrive to the left atrium and the left ventricle and what they will do they will empower the transmission of ultrasound so you will see like this the left ventricular cavity and this has helped a lot us to diagnose and to evaluate LV motion and also LV morphology. Indeed this was a side effect of something that they invented to look at myocardial perfusion. They invented contrast to look at myocardial perfusion but this has not really been a very successful story. This is one of the big pitfalls of the ocariography. We are not so able to really accurately and reproducibly see myocardial perfusion with ocariography giving contrast. We can see some perfusion here but there's a lot of work to do to improve this but we use it routinely, clinically to evaluate LV cavity in patients with bad acoustic windows and also we use the big bubbles the ones that are stopped in the lung to look at intracardial chance. For example patients who have a patent for amenovale which is a congenital structure that typically the two layers of the intracardial septum are closed during fetal life or in the very first days after birth and in some people they keep separated. That can be related to some problems particularly when you are diving. So typically if we inject big bubbles in a peripheral vein they go to the right cavities and they don't pass to the left ventricle. In these patients as they have a permanent hole here and you put a lot of pressure here when you inject the contrast, the bubbles they pass through the left cavity. So that makes the diagnosis of intracardial chant. Other patients have the chant in the lungs such as those athletes that Lagerge studied in the slide of the previous talk and you see also contrast appearing lately big bubbles appearing lately in the left cavities. So we use contrast for two things for detecting chance and also to enhance the intracardial border of the left ventricle to look at its motion and also at its shape. Another thing is to use transasophageal cartography. This is amassed in patients who cannot be performed transasophageal cartography like those who are in the operating room. They have the open chest during cardiac surgery so you cannot do echo, definitely. This is why we use the transophageal approach. We also use the transophageal approach when we need to be very precise to look at small structures that are not seen in the transasophageal way. Like looking for example at the left atrial appendage if we want to see there are clothes inside we cannot see that accurately with transasophageal cartography so we use transasophageal cartography and transasophageal cartography is nothing else than an endoscope that it's put in the sofagus with a probe in its tip. And we put that in the sofagus because the sofagus goes just behind the left atrium so we can image the heart very nicely from this position. The problem of course that is a little bit more uncomfortable for the patient so we usually have to give some superficial anesthesia because it's not so nice to swallow an endoscope. But we use that very every day, every day in ICUs, in the OR or even in the outpatient in the echo lab we use that for specific diagnosis of cardiac pathology. Again in transasophageal cartography we mainly use two-dimensional cartography and we use different views again instead of looking about the apical or the parasternal we talk about degrees but we have the same more or less terminology for chamber, longitudinal or aortic view so more or less we have the same terminology but our guide here is the angle with what you move the crystal of the transducer of the endoscope. Here we can also apply all the other modalities like color, like chemo, pulse wave, continuous wave and also three-dimensional echo cartography. So what do we use in clinical routine echo cartography for? As I have said this is our main standing they say it's going to substitute the endoscope, the stethoscope and it has been really replacing it quite a lot. So as I have said we use this for everything and any patient with suspected involvement of the heart. So we can measure cardiac dimensions and motion. It's the technique of, imaging technique of choice involved disease so the other techniques as we will see can do very well evaluating dimensions and motion of the heart but there is no other technique as good as echo cartography to look for valve disease. We also use it to look at pericardial effusion and some pericardial diseases. It can be the first imaging tool to detect intracardial masses. We also use it, sorry it's intracavitary thanks to the Doppler application and the potential conversion into pressure from velocities applying a very simplified Bernoulli equation that we do we can estimate intracavitary pressures and this is very important as I said before because we used to do that with a catheter. We had to put a catheter to estimate pressures across an arrow or stenotic valve and now we can do that with echo cartography. We also, as I have said, using contrasts we use echo cartography to diagnose intracardial shans. We also use echo cartography at least as a first approach to evaluate thoracic aortic disease. Also abdominal but typically thoracic aortic disease is evaluated with echo cartography. How do we evaluate motion? As I have said left ventricle is our big star in cardiology. The right ventricle is also important but the big star is the left ventricle and how do we evaluate its function? In reality we do it very badly but this is how we do. What we do is how the left ventricle moves across the cardiac cycle. So typically we see how it moves and we see the shape of the left ventricle, the dimension and we evaluate if the motion is uniform across all the segments of the left ventricle. This is a normal heart and this, of course, is a very, very abnormal heart. It becomes a spherical, it becomes big and the motion here becomes weird because it has something else which is a LBVD, left bundle branch rock and has this septal flash but if you look at this wall this is moving very, very few, very little motion as compared to this one. So we talk about normal motion, very reduced motion and from here what we typically do we trace volumes from here with an estimation of an ellipsoid and we calculate ejection fraction or we just visually in train eyes we visually say okay this has an ejection fraction around 60%, this guy has an ejection fraction around 20%. We also have a look at segmental motion and let me point your view, your attention here so if you look the septum is still moving a little bit not very normally but a little bit but if you compare the free wall of the right ventricle and you compare to the lateral wall of the left ventricle this is completely akinetic, okay? So this was a patient with a big infarction in the circumflex artery which gives flow to this area of muscle in the left ventricle. So he had a lateral infarction and this is how we detect this abnormal motion segmental abnormal motion of the ventricle. As I have said we can also estimate pressures and the most typical thing that we do we estimate gradients across asthenotic valves when you have asthenotic valve the flow increases velocity and that means that there is a gradient of pressures between the two cavities that are communicated by the valve. So if you have for example aortic stenosis the left ventricle has to increase the pressure a lot above the normal values to open an asthenotic valve, okay? So then you have through the whole systole you have a big gradient between the left ventricle and the aortic valve. That's the main use of continuous wave Doppler but there is another use which is estimating the pressure of the pulmonary artery pressure and as again we used to put a catheter into the pulmonary artery pressure to measure that now we estimate with echocardiography and we do that because we can have the peak velocities of flows you can calculate that, you can determine that using continuous wave Doppler and from that we make a transformation because we use a simplified Bernoulli equation you can discuss later on if this simplification is good enough or not but it works not so bad in clinical practice and if we have the difference between the right we have the difference in pressure of the gradients between the right ventricle and the right atrium if we add the pressure of the right atrium to that that in the absence of an stenotic pulmonic valve is exactly the same than the pressure in the pulmonary artery in systole so this is something that we do routinely all the machines have a bottom where you put maximum peak velocity of the tricuspid regurgitation and then it calculates the estimation or it estimates pulmonary artery pressure this is something that we do routinely and indeed most of the cardiologists use it without knowing where is it based on so this is how clinical work works or shouldn't it work with why do we use this? because most of us have a slight degree of tricuspid regurgitation so we take advantage of this signal and we estimate pulmonary artery pressure we can do that at rest or at exercise because we can also do exercise echo in some of these patients as I have said we use echo mainly for valve function with echo we can evaluate the morphology this is an example of an aortic valve which is by caspit instead of the typical one which is the most common one in the population which is tricuspid we can see how it opens and how is the flow across it if it has high velocities because it is stenotic or it has regurgitations because we see the color Doppler and this is exactly what we do we look at the opening this is a mitral valve of a patient who had rheumatic fever and has some degree of stenosis of the mitral valve which is abnormal look at this leaflet it doesn't move at all this one is thickened and it opens restrictively so this is mitral stenosis this is another example of a aortic valve we are cutting the aortic valve transversally so this should be three valves opening in systole and closing in diastole and as you can see there's a lot of white which is calcium and there is no motion almost no motion maybe one leaflet is moving a little bit but this is a very very stenotic aortic valve we look at the gradients as I have said using continuous wave Doppler and we look at color looking is if there is any regurgitation and this is most of the clinical echo we do we look at this area of regurgitation how big it is how large is it within the the receiving chamber in this case the right atrium and with this we first say regurgitation yes or no and secondly we semi-quantitate how large or how big is this amount of regurgitation we have other methods to try to quantify but indeed for regurgitation we don't have perfect methods to quantify regurgitation we can also evaluate valve prosthesis this is an example of three-dimensional aquariography this was a patient with mitral valve disease who had replaced his mitral valve and they put a mechanical prosthesis which is made but a stent of titanium and then two ME discs that move across this hinge point opens and closes in systole you can see nicely the sutures of the surgeon made so you can check if he did it a good job or not we can also apply color and this is really useful to look where the abnormal flows come from so for example here we have this regurgitation which is completely normal in a mechanical prosthesis and we also can evaluate pathology for example here we see a prosthesis in the mitral position two ME discs we see one ME disc moving here but the other is fixed by a mass here so we can diagnose problems also with the valve with the prosthetic valve here what we are not good with the echo is that telling okay what is this mass so we can say this is a mass but we can we are not good at saying what is this mass made of so is this thrombus is this a tumor is this infection and we have poorly material here we are not good with echocardiography at looking at the tissue at the characterization of tissue there has been some attempts to do that using backscatter techniques but really it doesn't work very well with echocardiography so what we rely on to say this must be thrombus this must be infection is on the clinical presentation of the patient on the clinical records and also on the morphology on the aspect but really looking at this this is more bright less bright this must be that is not good with echocardiography similar what we can what we use very much echocardiography and really we don't have any other technique so precise to that is in endocarditis endocarditis as said is an infection of the valves of the heart valves or other devices that are in the heart like electrodes for example there can be infection of intracardial structures and endocarditis is an infection starting on the valves typically that can destroy the tissue of the valves which is the case this is the aortic valve so this aortic valve was destroyed and even it can extend to the anulus and destroy the anulus so this aortic valve was kind of being dissected from the content of the of the aortic wall and having very very important complications with the aortic regurgitation and some dissection or the sense of the valve here so what is used to look at these small structures which are called vegetations vegetations are made of purulent material consequence of the infection of the valves and this is one of the points for the diagnosis of endocarditis again we cannot say for sure this is infectious material because we don't have this tissue characterization but again the clinical context and the clinical presentation of the patients support the diagnosis that we made with echoreography and finally for echoreography we can as I have said we can use it to look at the aortic thoracic aorta diseases particularly dissection in dissection the inner part of the aorta which is called the advantage the intima is separated from the rest of the wall of the aorta and we have a typical image which is called this flap here which is the intima the broken intima of the aortic wall and this makes even with holes that connect what we call the true lumen of the aorta within the false lumen we can see this very nicely with echoreography we can also see that with MRI and CT as we will see but in some emergency settings this is the image that we we choose of choice and particularly for the ascending aorta we use that to see if this dissection is involving the valve or not which is important in terms you have to operate the patient you need to know the surgeon needs to know if the valve is working or not so we have many applications of echoreography but the most important thing is that echoreography can be performed at the bedside of the patient and this is really really important because we have other techniques that we will see now with much nicer images with much more three dimensional information but they cannot be done at the bedside of the patient and this is important because echoreography is being more and more used in ICUs in EOS and it's the imaging tool of choice to help other physicians to perform the treatments like surgeons cardiac surgeons or any surgery that may pose the heart into trouble like long digestive surgeries or as I have said before in the interventional laboratory either for electrophysiology procedures or either for valve procedures which need somebody who guides him within the heart also we have this very very miniaturized so this is what we call pocket echo these are still limited machines so they cannot do all the modalities that we have been discussing they do color Doppler and B dimensional Doppler but this is really useful in clinical practice because you have the patient there in one shot you can tell a lot of things to your patient if this is performed in the wood hands we also use that for a screening of some patients for example for aortic aneurysm a screening family doctors are being trained to look at it very easy things with a really really small machine that can provide you lots of information another modality as very quickly that we use in cardiography is to look at the heart under different conditions and the main conditions that we use for the heart are to stress the heart okay what happens to the heart if I stress and how do we stress the heart we have two ways of stressing the heart indeed we give drugs that stress the heart or we do exercise the main objective in most of the patients is to look for ischemia you know ischemia can be provoked and this is the most prevalent disease this is the main indication of stress eukaryography but we are using more and more to evaluate patients with valve disease with shorten of breath even athletes so what we do is we provoke stress to the heart and then we see how it responds we have pharmacological stress eukaryography and this is an example the typical drug that we use is the butamine the butamine does several effects on the heart it increases heart rate and it increases contractility so the normal response of a heart of a normal heart to the butamine would be to increase its heart rate and to increase its contractility and this is what happens in this patient this is baseline this is a really high dose and you can see how the the heart increases the heart rate but also increases contractility so the cavity collapses during systole in this case we added contrast to improve visualization of the endocardium another example is the stress exercise eukaryography these are images sorry these are images that addressed and after exercise I hope it doesn't stop but you can see that here the apex should close and it's persist open a kinetic indeed so this patient started to run on the treadmill and said my chest is pain I have pain on my chest the ECG show some very important changes on the ECG and we saw this abnormal segmental motion of the apex so we suspected this patient had important coronary artery disease which was confirmed on the coronary and geography so in summary eukaryography before going quickly to the other techniques is a quick easy available technique imaging technique we need to improve some things some artifacts we have no time to go very much on some artifacts that we get particularly for mechanical devices prosthesis or even the bobi that we use in the world they do a lot of artifacts on ultrasound and that doesn't allow us to make an accurate evaluation we need to improve a spatial resolution particularly when we are using three-dimensional echo temporal resolution is quite good as compared to other techniques but if we want to study very very quick things that happen in the myocardial cycle like myocardial deformation we need to improve it also we need to improve a little bit on the measurement of intracardial pressures and dynamics we have the information there for example we have color Doppler within the left ventricle we could indeed calculate how pressures within the left ventricle are and there are some research studies made on that but still it's very far away from clinical practice we have a big limitation with tissue characterization and a big limitation also with myocardial perfusion so for this we have other methods other techniques that we don't use so much in clinical routine these techniques have our cardiac CT and MRI they have the big advantage that they have a high spatial resolution so pictures look great but they still have lower temporal resolution and also our big limitation is availability and portability so you have to send your very sick patient to the city which is typically downstairs in radiology or to the MRI and I do an echo in five minutes the MRI takes if we are going quick at least 30 minutes and if you have a very very sick patient intubated, ventilated it's difficult to do that and also we have the problem of radiation for cardiac CT what do we use these techniques for mainly for aortic pathology so we can see very nice the aorta in all its extension all the thoracic aorta and also abdominal we use particularly MRI for the right ventric evaluation right ventricle is in a structure that it's difficult to evaluate because it has a complex geometry with two parts and it's difficult to see it either with 2D and 3D echo we use MRI particularly is our imaging of is to evaluate tissue characterization is good at detecting scar looking at fibrosis and it's getting better and better to look not only at cicatricial or replacement fibrosis but also interstitial fibrosis and it's also good to differentiate fat from thrombus or other other tissues we use CT for non-invasive coronary angiography and we also use MRI particularly some work starting with CT but particularly MRI for myocardial perfusion so we combine MRI with stress here we use mainly drugs we use adenosine and we look at myocardial perfusion with specific sequences for MRI so these are examples of aortic disease you can see here the flap of the dissection of a patient with an aortic aneurysm we can evaluate right ventricle right ventricle motion morphology very nicely with left with MRI and also of course the left ventricle it's difficult to have this definition of these aneurysms here in the interlateral wall of the left ventricle with your cardiography we can have a hint but definitely the definition or the spatial resolution is much better with MRI and of course as we have 3D volume data sets we are much better quantifying data from MRI than from echocardiography CT is also very good that is based on X-rays it's very good to depict calcification this is important for example when we have to operate a patient and we want to see how is his aorta or we have doubts about the aortic valve disease severity for example we look at calcification and CT is the technique of choice for that as I have said MRI is very good at characterizing tissues particularly the left ventricle myocardium because it has enough thickness to be scanned we are working on the atria and on the right ventricle but definitely using contrast which is another contrast the gadolinium it's very good at looking at scars to see the extent of scars and also research is being done on trying to characterize the tissue within the scar also there are new sequences that not only look at the scar or replacement fibrosis that we call that they look at interstitial fibrosis which is a prior state of disease before sometimes even before left ventricular dysfunction or ventricular dysfunction occurs and finally coronary and geography typically we do that putting a catheter on the aorta in most of the patients we do this way invasively why because then we can put the catheter inside the coronary and put a stand or treat coronary stenosis but in those patients where we think we are not going to treat because we think very much that they are going to have normal arteries or we want to do a follow up what we can do is an uninvasive coronary and geography which is done with multi-slice CT you know it's CT with a lot of rows and we can have very nice images now of the coronary arteries non-invasive just to slide out nuclear scintigraphy nuclear scintigraphy is just the imaging that we have with a gamma camera in a patient that we have given a level particles that fix to the myocardium typically we use that for assessing ischemia of the heart for assessing perfusion and again we stress the heart with exercise or giving drugs the butamine or adenosine depending on the on the center and what we do is we compare the images at baseline and during exercise lately we can have also images gated with the ECG and we can have also motion so we can combine with this imaging technique motion and perfusion this is mainly used for perfusion despite MRI is gaining more and more fill in this indication because this has the problem again of radiation so we are using less and less but still use a lot for testing for ischemic heart disease another advantage of this is that we can or with other techniques that we can fuse to imaging modalities is an example or fusing CT coronary angiogram and perfusion imaging by nuclear but we use every day in the EP lab for example in the electrophysiological lab we fuse images from the MR and also from the navigator system this is non this is invasive imaging but these are other ways to work like fusing putting the good things of every house into a single shot so what we would like you to do indeed is that we got this perfect imaging tool that we still don't have as I have said the most useful or the one that we use routinely is a cardiography but has important limitations that are partially provided by the other ones particularly MRI for tissue characterization and for perfusion but still we need to improve we need ideally harmless which is widely available and inexpensive so these are conditions for a cardiography this is why it's so successful but we need to have high spatial resolution and high temporal resolution and a cardiography is not that good particularly at spatial resolution has to be able to characterize dynamics and tissue composition we are improving we are quite good at dynamics with the cardiography quite not perfect yet and quite good about tissue composition with MRI but we don't have in one technique we need it to be easy to quantify because we have many patients waiting many patients to be diagnosed and always busy cardiology departments we have to avoid artifacts and this is it so I hope you can work a lot and in some few years have this more advanced imaging modalities thank you very much for your attention Is this work? Thank you very much just a brief question because most of the engineers when we start working or talking to cardiologists we start to do modeling and things like that and we say like okay we obviously need a 3D MRI or 3D CT in order to do it because otherwise we cannot work and which percentage of patients do you think these are available in routine clinical practice? 5% so we need to work with ultrasound in reality so this was a very very clinical talk in the sense that this is our routine so if you see my talk was like 90% eukaryography and 10% CT and MR and this is reality this is real cardiology of course for research we do MRI and it will be more and more but also availability of MRI machines is not that good in all cardiac centers so you have to think that our big tool is echo of course we need to improve on MRI because we have to incorporate so many things with that but realities and maybe a bit more philosophical or practical question for some people in the room it's like say somebody develops a nice modeling tool and say like okay this is better than what you use will you buy it as a clinical cardiology? we do have money so how do you think we can get our tools at some point in clinical reality because in reality it's indeed you go to cardiologists they don't want to pay but how do you proceed? yeah I mean the thing is really that that we we work much together because it's the same thing that I was saying with the statisticians okay it's like the thing ejection fraction okay it doesn't work we know it has a lot of limitations but in the end this is what we use and it's okay so they need to we need to know what you are able to do and you need to know what we really need and you need to learn medicine that's it I mean it's important that you learn medicine and that you read and that you go to clinical sessions to really understand what are the real problems because unfortunately theory is here and practice is there and that's life I mean I think it's everywhere the same any other questions? question well it's a little bit of a follow up but if you're looking for a new tool is it a new tool or is it more likely that it might be a combination of tools that already exist mainly because of course the financial part you don't have to buy new equipment if it's already there would it be possible to combine not just in the analysis in retrospect but also just in a combination of different techniques at the same time to for example solve the temporal and spatial resolution something like that well I don't know exactly in terms of time I think that if you go from what you have and you improve what you have it's quicker if you want to go to unique tool that does everything I think that that's going to be tough I think I think but I mean there are many things to do with information we have for example intraventricular gradients is something that we have been talking a lot not so that in 2000 I was I remember some authors already writing papers on this and that's something that it seems easy but the companies were not interested in this because what does it what do they sell nice pictures and in the end okay these are nice pictures but what do you use it for no so it's a trade-off and this thing is going to be difficult to do if we do not interact more than we do and for that I mean we want to sell okay nice pictures will sell much better we know that but in the end we need useful things because we have lots of examples of nice pictures that haven't been there for like 3D volumes from eco I mean 3D volumes okay but in the end we don't use so much I guess integration of new things in the current clinical routine is I think the most important if you do something which is totally separate from clinical routine acceptance will be extremely low and add on there it will be much easier to get into some of these and also you need to make it it's you need to make it also easy to understand for example DTI was a nice example of something that can give you a lot of information but most of the physicians they don't understand and they don't pay attention to it so you need to find I mean we are simple people so we are always kind of saving lives so we need simple things and easy to use because if not it's going to be that again Hi first of all thank you for the talk very interesting my field is cardiopulmonary bypass so regarding monitoring of microemboly is echocardiography the best or the most most used tool or is there during surgery some atoms to use because during pulmonary cardiopulmonary bypass you can only use echo okay and there have been some atoms looking at myocardial perfusion with contrast but that's another field to work we are not sure if the bubbles are so harmless to the myocardium so but maybe something working on strain and myocardial deformation would be good cardiopulmonary bypass is the the status of the myocardium okay is that what you are working or not or in the pulmonary I'm starting more the optimization of the oxygenators okay okay I'm not so expert in lung perfusion and I'm not so aware on that but maybe I don't know there I know that has been some work maybe it's something that you can apply but I'm sorry I cannot help with the lung perfusion it's not my field okay thank you very much in the sake of time or was there still okay one last question hi again thank you for the presentation I have a question regarding modeling and image analysis because Bart was talking before about doing some kind of patient but how is it used really in the clinic so can you easily combine the two techniques and take images from the patients and do some kind of patient-specific modeling to better study the disease or is it not yet being used so indeed this is another example no so you have injuries coming saying okay I'm going to model this model so now what we are using modeling sometimes is to better understand pathophysiology and then translate that into clinical practice so the translation of modeling into clinical practice I think is still a little far away I mean we should do that to understand much more pathophysiology and this is how we usually work at least in cardiology I know other specialties like for example maxillor maxillor surgery they are very very ahead but in cardiology still it's still difficult okay thank you very much in the sake of time I think we continue thank you very much for coming