 structures. So, who of you does 3D regular in UR? Who of you does look at coronary sign as regular in 3D pulmonary reeds? No one. We also don't do that. But, because it's the topic of the talk together with Professor Mineri, we did a lot of video recording and all that. I have to apologize, I cannot show any GE pictures. But, of course, GE or Siemens, it doesn't matter. I'll do 3D. And these are the publications where all my slides are built on for the 2D. And as you have heard that several times, without a good 2D image, you will not be able to get a 3D image, of course. And that is, mitral valve is nice. So, and you gave fantastic talk and you showed beautiful pictures, that's great. Whenever you come to all the other structures, it's really painful, at least for me. And maybe it's also for you. So, you have to have really excellent image quality. And you have to admit that you cannot see any, every structure in every patient. So, don't waste time too much if it's not really for a clinical purpose. And all of these structures, I think, have some clinical purpose, but not much. One of them is tricuspid valve. Yes, for tricuspid valve, you know all these, the new procedures with the clipping and all that, tricuspid visualization of the tricuspid valve is key for all the transcended procedures. And what I realized when we started with that, that I don't have any clue which leaflet I see with the 2D on the tricuspid. Everyone knows about the mitral, anterior mitral, anterior and posterior leaflet, but with a tricuspid? I don't know. You all know these four images, how you can display it with 2D. And then that is from the guidelines of recommendation that the interateral septum should be at 6 o'clock p.m., at 6 o'clock position. So, then you may have the septal, the anterior and the posterior. The more patient with tricuspid valve you visualize, the more you will see that the tricuspid valve is not tricuspid at all in a lot of patients. So, that is a picture of the tricuspid where you have here the septum. Here you have the aorta, the mitral valve. So, it's 6 o'clock position. So, that means that is the septal leaflet. From here to there is the anterior leaflet and that is the posterior. And you see in the anterior leaflet here a cleft or whatever, which is quite common. That is, I think, quite a nice picture of the tricuspid valve. You won't get it in every patient due to the fact that the ultrasound beams are not perpendicular. So, when you have a septum there and if the aortic valve is a little bit calcified or whatever, you will struggle with that, of course. What I love in clinical practice is so that when you start with the 4th gen of you and then you switch to that live 3D. That live 3D, that should, you know, the live 3D starting from that is if you press the bottom elevation post, that is your cutting plane from the 2D image and you have the elevation post here to that cutting plane. So, that will give you a little bit more spatial orientation. And then, why doesn't it work? It should just give me a second. It should work automatically. But I did it, but in fact I didn't. So, now it should run. Yeah. So, you start with the 4th genver, then you press the live 3D. That is your 2D image. And with that elevation and then you tilt the image and then you see this is your cutting plane from the 2D. Then you notice, okay, that is the septal leaflet, that is the interior leaflet. You see that? And that is the posterior. So, that means if you want to visualize the posterior leaflet for whatever reasons, what do you have to do? Just insert the probe a little bit and then you see until that cutting image is crossing the posterior leaflet. And then you switch back to 2D to have a higher frame rate and then you know exactly which part of the tricuspid valve you visualize on 2D. Okay? And that is, I think, for us really a good thing to do with the tricuspid. So, you have that on the PDF file how you do that as well. Another thing what you can do is you can use iCrop. I don't know what's the name in GE. Okay. So, that means you have that 3D which you have seen already and 2D images. And then you define that blue line is where you look at the tricuspid. You have the lateral width and you have that elevation width. And you see in that image right now, lateral width is fine but elevation is not fine. So, that means you hardly see the whole tricuspid. Then you can adjust. So, you can increase increase the elevation width and then you have the tricuspid valve well here. Okay? That is what you can do practically. So, remember, of course, that if you want to have such an image you have to rotate that image 90 degrees in the set axis. So, that your septum is at 6 o'clock. Here is it at 9 o'clock position. But that is it what you can do afterwards. I don't know exactly why they want to have it in the 6 o'clock position but it's in the guidelines. Because for some reasons, first for some procedures it's good to have the septal in the 9 o'clock position but that is what they want. So, that is the tricuspid. So, one structure gone. Pulmonary valve, that is short. That is the theory. The theory is you start with the middles vigil or upper as a vigil 90 degrees where you see the pulmonary valve. Hardly to see in 2D in most of the patients and then you tilt and rotate the picture and then you have the pulmonary valve here. I'm lucky to present you this picture where you see that is live 3D again. So, based on the 2D image and then you just press the live 3D, you have the cutting plane. That is quite nice where you see the pulmonary artery main stem, you see the valve here and then you can crop and you can tilt it around and you see the 3 leaflets of the pulmonary valve. I worked for years to show you that image. I tell you. So, daily life looks like that. You have no image on the aortic arch. You hardly see the pulmonary valve here because it's calcified. Then you press 3D. What you see very nicely is your right ventricle but no leaflet of pulmonary valve. That is at least our German experience. I don't know if Canadian looks different but German. So, I would say and not only me, there's currently no evidence for 3D imaging of the pulmonary valve. It doesn't make sense. It's a waste of time. If you want to do a lecture and you need one, just don't don't agree to the lecture before you have at least one year of time to get that. So, then the left atrial appendage. That is who of you are involved in left atrial appendage closer or something like that? Procedures? Doing anesthesia or doing also the TE? Anesthesia. Okay. So, the nice thing in 3D for left atrial appendage is of course that you can measure all the things that the interventionalists need to decide which size of closure. So, you have the length of that. You have the circumference and you have the diameter. So, the thing is you have to center your pulmonary, your left atrial appendage in 2D and then you can do either a live 3D or you do a zoom mode and that is a publication which I would recommend to you from Nina Wunderlich. She's in Frankfurt and there are nice pictures showing you the anatomy of that. So, how do you do that practically? You just center, try to center the left atrial appendage, then you press. That is live the 3D zoom where you have that region of interest to define and then you see that here. For all that structures except of the tricuspid, my recommendation is that you use a lot the brightness and the smoothing button because otherwise you won't get really good images. I hardly use the smoothing button for the mitral valve but for all that structures, left atrial appendage, pulmonary veins, I use that a lot. So, the smoothing usually at least in the machines we use is between 2 and 3 and for these things I increase it up to 8 and 9. So, that is your 3D and you know that it's anatomically so you don't see anything. Then you tilt around and you still don't see a lot. Here you can see something, here you see something. The difficult thing, at least for me at the beginning, was really these are pictures you won't see in 2DT, not at all, these imaging planes. For the mitral we see that, for all these structures you don't see that. So, it's really good to have an idea of the anatomy and for acquiring the image if you set the region of interest here. This up there, that creates this artifact. So, if you decrease a little bit the the region of interest, that would help you a lot. So, and then you tilt again and turn around already, so go to that. So, just stop here and not increase it up to there, then you don't have to crop. That is one thing. It's still, it's over now, hopefully not. So, you see the left atrial appendage, you see the coumadine ridge here and then you adjust that, press the bottom and then turn it around and that's gone. Sorry for that. Okay, you can also do it from here. So, it's a five-jamber where you have it and then what was also mentioned for orientation, it's quite good to have the simultaneous 2D pictures as well. So, you see the mitral valve here with a lot of smoothing, then you know that the left atrial appendage should be over there and that is your aortic valve. So, and then if you want to look into the left atrial appendage, you do that cropping and then you can cut through the left atrial appendage here. That is quite nice, but I think for the clinical thing it doesn't make a big difference compared to 2D. So, again, do that and then you crop away these things. We come to the LA closure in the last slides if I have enough time for that. So, that is, so coming to the left atrial appendage, then it's cropped here. So, you have, please include really structures where you can orientate on. So, this is part of the mitral. That is the anterior valve. That is the left atrial appendage. Okay, so if you tilt your 3D a little bit more, then you see the cumidine ridge and you have the left upper pulmonary wing. Okay, you have it here again, just even more tilted mitral valve, left atrial appendage and then you have the left upper pulmonary wing here together with the left atrial appendage. I think my computer is still in jet jet lag. Okay, so you can see a lot of patients have just one osteome where you have the left upper and the left lower pulmonary wing here. Then, and if you don't have that smoothing thing, then you will see terrible pictures coming to the coronary sinus, like that. You see that? Here the smoothing is not really good. Again, it's from the fourth gender view. Then you press the live 3D. You have a 2D cutting plane here with a little bit more elevation. Then you do the brightness and the smoothing. So that is without. That is smoothing and you see that the tissue looks smoother. So what you do is you reduce the spatial resolution. So and where is the coronary sinus? What would you do? You have to turn it on. So the coronary sinus should be there above the tricuspid valve. So what you do is just rotate it along the z-axis and then you see the coronary sinus. And again, these are pictures which you don't see in 2D. So you have to really figure out what you have to do. Another thing what you can do is you use the 3D zoom. So for that, I would with the 3D zoom, you always have that explained. So the two simultaneous 2D images. And then you see, okay, coronary sinus is in here. Then you have the 3D zoom. Just for quick orientation. That is optic valve, mitral valve and tricuspid. So then you do the cropping. I prefer that free plane cropping. Maybe because I started with that because that was the only option available. So then you crop into that and then you turn with the trackball and you see the coronary valve. By the way, what is that? So that is the right atrial. We are now on the right, coronary sinus. So what is that? Superior vena cava, okay? We are coming on that. So then you do, you see, from the left to the right, I adjust the brightness and the smoothing. And I think the structure, at least from my eyes, is more visible. Also that vessel here, so the superior vena cava. And then you rotate because due to the guidelines, the superior vena cava has to be at the one o'clock position if you display that. Do you display, do you do that regularly? Yeah, but not for clinical purpose, huh? So okay, but that is what you do. And again, looking at, so the post-processing, I think, for these structures is really very, very helpful. So coming to the interatrial septum, again, coming from the bicable or whatever, what I recommend is that you really adjust your region of interest to cut through the superior vena cava. Not really take all the right atrial structure because then, at least I am lost because then you have to start cropping. So that is the picture you see after rotating. So you see, with that region of interest, cut through the superior vena cava. Not put it like here because then you will see a lot of tissues and you have to crop to visualize the superior vena cava. At least, that is my advice. So then you have the interatrial septum from the left atrium site, okay? So that is, what is that hole? What do you think? What is that? No, it's still from the left. What we did, it's just where you rotate now. But it's still from the left. It's the interatrial septum, but what is that? Pardon? If you look at that one, yeah, you see it's, maybe it's an interatrial atrial septum, septal aneurysma starts and that is because of the, of the poorer temporal resolution. That is your foziovalis, which can have the impression that it's an ASD, it's not. It's just the, the fast-moving foziovalis and here you have your right pulmonary vena, again at the six o'clock position. Have it like here, okay? Rotate counterclockwise and that is up there. So, and if you then turn that in that direction, you would not look from the left atrial side, but from the right atrial side, okay? Again, that is the foziovalis and that is not the right pulmonary vena, yeah, the superior vena keiva. We were lucky because we recorded that during insertion of the central vena catheter and that is the wire still. So, just for better orientation, that is, that is what we, I thought it's helpful to, to, to see the difference. That is the right pulmonary vena and if you switch, that is the wire of the superior vena keiva and of course you can also tilt it and you see here the superior vena keiva up there and down there the right pulmonary vena. So, you can look at a lot of different directions. I'm running out of time, sorry for that. So, for the intraatrial septum again, just a smooth of that and so that is what you see if you don't use the smoothing and the, the brightness. It looks terrible, I think. It looks as if it was a real hole everywhere and it's hard to see. So, please use these two buttons to, to create better pictures and for whatever reason. So, that is for, for the intraatrial septum repair. Again, you see without smoothing, without brightness on the right side, it's with adjustment and that is a picture of the ASD. You see that is a true ASD. You have a different, a membrane in between and of course you can also use the 2D and what was mentioned earlier for all that guidance, this biplane or multi-view is also 3D and that helps the interventionalists a lot because if you start, that is your otter here. So, that means that is anterior, posterior direction, perpendicular to that is superior, inferior. That helps the interventionalists to pass the ASD and then you pass it with your device of course and then you can also do that in 3D but our interventionalists really like that the multi-plane because the temporal resolution is higher. With the life 3D or 3D zoom you see 11 hertz, it's not a good thing to, to guide the procedure because it's too slow and then you can nicely see your device, the umbrella up there. You look here from the right atrial side, on the right side you just can control with color if the closure is successful and then you can look at that from the left atrial as well as from the right atrial view and see the, the device really closing that ASD. And the same for the left atrial appendage I promised to you I really love that explain or the the biplane view where you look at the left atrial appendage and then whoops here so you do the left atrial closure here you have the left atrial appendage with the pulmonary wing and now the computer stocks that was too fast. All the videos, sorry for that, he needs a break and just give me a second. What is that structure by the way until we hopefully you will, what is that structure? Left atrial appendage, what is that? Oh it's gone, okay so I need a break, sorry for that. So coming to the last one, so here just the last slides to show you, here you have that explain once again where you do all the measurements which I have mentioned from the article and you see the device coming into the left atrial appendage and then you see here the watchman device covering the left atrial appendage and finally you see it here where you have that is the left atrial appendage and the device covering all the ostium I don't find it very helpful in 3D I think because of the frame rate that is really very good and just the last slide for the auto because that is really easy for the for the auto you just take all these views and then you do the white sector the advantage for that I think is that you really see the amount of the atheromas in 3D but at least to my knowledge there's no other clinical advantage so sorry for having too much time used for that and thank you for the attention that's it and hope to see you in Leipzig