 Good morning everyone. Sorry for the noise. Thank you for having me again and I'm a little bit emotional because I just left a few months ago and I'm back here and this time from Leipzig so the layout of my slides has changed but a lot of the contents and it's actually come from all I've learned and done here in Toronto and so I want to congratulate Jacobo for putting together the course. He thanked me but I haven't really done much. He said I have this idea and I just said yeah that's a good idea. You should do it and and it's done all of the work so I shouldn't take much of a credit. So the idea of this talk was just to go over the so you've heard about the basic 3d technology and the image acquisition model from Dr. Tsieng. So I'd like to talk about what can be done to make our 3d images a little bit better and what can we done with the 3d images so I don't have any disclosure on this topic and as you heard already so one of the main one of the things that make echo in general sometimes a little bit confusing and 3d even more so is the proprietary strings that go through the different vendors why because when some vendors comes up with a new technology or a new mode they give it a name and they trademark it so now that name cannot be used by anybody else so when something similar another company makes something similar then they have to use a different name so often when you go across platforms you will notice that there are so many different names but at the end of the day they do something that's a little different but it's not so different so that is one of the things and one of the things that I always find funny and a bit confusing is that actually when you go we are talking about 3d we all agree 3d 3d but then if you go to some of the platform you look for a 3d button there's not 3d button so the only button that you find it has 4d so some of the vendors call it 4d as they mean that it's a 3d image that moves over time what it's what it's what it eventually comes down to as we heard and I think Wendy did a wonderful job at trying to keep everything as vendor independent as possible is that there's three steps to the image acquisition so one is the data acquisition then there's a processing and then that's how we display that's how we summarized it in a paper I wrote many years ago with Annette and that's when you display what happened with 2d images where all were used to is that once you have a 2d image then there's not much you can do so you have a 2d image you can play you can look at it you can save it store it put in your presentation but then you can pause it and you can freeze you can take measurements both for 2d images as well as the but that's it if this is a bad image it's a bad image too bad so you can't go really back to the patient and do anything when for 3d it's different because what we do is we actually now scan a 3d space and of that 3d space we know all the characteristics of the tissue as Wendy mentioned the resolution is not exactly the same in all planes and there's one of the three planes where the resolution is not as good but we know the characteristics of the tissue so we now have voxels and what we can do is we can then once we know that we have a data set so we have a block we know everything that's inside the block then we can still do a lot of stuff with the block and normally what we do is we try to display this block in a way that looks like something that three-dimensional and to do that like the machines as we saw before use technology that's sort of being taken from many many years ago this is a painting Italian painting from the 17th century and what they did is they used shining lights on this block and used different shades of different colors to keep the the filling of depth of this block so I developed thanks to the support of the Peter MacCardic Foundation and the help of some of the people here one of them was Wendy these a few little videos that are posted online and on on the echo website which I'd like to use here to just go over some of the things that we can do with our 3d data sets once they are acquired so I obviously I have two videos for two separate vendors and now there's no point of hiding names and one is phillips so we're starting with the phillips with the phillips system and this what you see here right now is something that you can go home and actually watch on on on your own if it's again what I did is here you see your data set which we have acquired it's in the machine and now here is the the screen with the with the with the all the buttons that we can touch and here we have something that moves and looks like it's a three-dimensional object so and one of the first thing that you can do once you have something now this is the image that we don't only have a picture like a playing 2d image now we have something that we can play with we can still do stuff so and one of the very basic first thing that we can do and we sort of saw it at the top is we can actually rotate whenever we have something new in our hands or something that's three-dimensional or we can do that's good we can just take it and move it around and see what's inside so that's simple I know all you figure it out so and with a trackball usually you can move this box into different into different orientation and and so we can sort of see what's inside see what from different orientations we can understand things a little bit better this is the mitral valve we looked at it from the our side now we flipped it we looked from the ventricular side now we put it again unfast so we have the structure we're interested in this is the mitral valve it's looking at us and also something that's kind of useful is the rotation like a clock so in that's what we call dead plane so that allow us to keep the object parallel to the screen and rotate it clockwise and counterclockwise also there's an option where here now you can see we're looking at the subject from the top so we look at the mitral valve from the atrial side of the mitral valve but there is a feature that allow us to actually every time we get lost to go back to where the block started or to where the block was presented to us that's the the actually the home so what else can we do so again instead we can look at this block from the top we have the possibility to look at this same block from two perspectives at the same time and this is called dual volume layout so here we see the mitral valve from the off from the atrial side and at the same time we can look at the same structure from the ventricular side we just take the block and flip it and we can display it simultaneously sometimes gives us the opportunity to sort of store more data at the same time but we can just take it and flip it as we want without this feature but it's a cool feature that actually it's especially nice for the when we save this image and put it in our record we sort of save one step and one image something that I find that it's uh it's been very useful to me is uh the fact that sometimes especially when we go we have acquired the 3d block we store it and now maybe a couple of days later or later in the day we go back and we look at this 3d block and we're wondering and say what is this and you look at outside from this block and you really have not much of an idea so and one of the features that I find useful is that when we look at the 3d block we can look at it as a rendered picture as you can see here that is like this pyramid that like some feature tries to make it as full as possible or as realistic as possible but also we can look at the same block with two perpendicular planes that are cut into the block in 2d so for example so this is the plane where the image acquisition started comes in the center and it's playing near perpendicular so we can display the 3d block as a 3d block or a 3d block plus 2d images what I personally find is that especially for all of us who have done we've learned 3d they haven't started we haven't started with 3d when we look at these blocks sometimes we say no idea but then we look at 2d images that cut through it oh that's the micro block so we're actually used to it so that's one of the feature and depending on the system we can display there's two perpendicular images at the top or three perpendicular images that's the plane of origin the perpendicular plane and the plane that cuts through it or now there's also something that's got in the different vendors have different ways of this was from a previous version of the software where these planes are perpendicular to each other they're cutting in the center you can change the angle now you can actually change the angle so finally as I said for 2d images there's not much we can do but for 3d images there's still a lot we can do once we have the image and one of the things that we can do that I initially thought it was very cool is that you can actually change some of the settings even though the patient is gone and the image was taken time before when you do this so the first thing that we can change and we are all encouraged to do is is the game so normally for 2d images once the image is acquired it's over game it's over game so there's not much we can do but with 3d images we can still change the game and here at the top of the screen here you can see that this was the original game at which the image was acquired and this is the new game you can see that as we increase the game the tissue becomes less transparent but we also then when we over game in 3d we have this fog that prevents us from seeing anything and actually as we practice on on the models later normally what we need to do is not increase the game but actually decrease the game when we go from 2d to 3d the other thing is when we decrease the game with 3d you can see it's very easy to make things transparent so what is the optimal game and is this the real gap or is it under game so what we are looking for and it's part of the exam that has 2d images so what we see that has to make sense in 2d as well as in 3d depending on what we're interested in for example as who came for the earlier talk we were talking about a perpendicular procedure when we do microclips and the clip is over the valve we want to see the clip and the leaflet when the clips goes under the valve we want to see the clip and we can make the leaflet transparent so in that case we decrease the game to purposely make the clip transparent as you saw here one of the things that we could do we can also change the compression so similarly to what you do you can actually change the compression and the compression would allow you to sort of increase the contrast of the different colors that are used and the shape that are using this image and it's something that can further be done to optimize your image so finally um we can this is sort of we can change the we can change the the the the combination of colors that are used to display this image and this is sort of the standard combination of colors that most of us use and find useful and we need to interpret this image but can be changed so here we've just changed the different settings so using just one color and different shades so and as you saw from Dr. Ten the presentation now with the philip system you also have the option to make it look like a real tissue which is called TrueView and I'm sure the software is loaded on the new machine and you'll be able to do it with the system that we have here then the last sort of setting that I found I find useful to optimize the image is something that's called smoothing so smoothing is is a feature that basically allows us to make the surface of this block that we have a little bit as as it says as the word says smoother or less smooth this was sorry we were changing the brightness so we can make it brighter or less bright and then finally this is the smoothing which is this feature as you can see with increasing the smoothing you see how the surface of our tissue becomes sort of more homogeneous as you can see here it's more homogeneous which sometimes depends on what we're looking for sometimes it helps to present to the surgeon or our colleagues a better image but also when we increase the smoothing too much then we lose the sum of the tissue characteristics that are seen in the original clip. So I've used this as an example and this was using the one of the two system and so similarly to what you saw for the philip system this is something that can also be done with the with the g-system and although the names of the bottom side are a little bit different because what is for one vendor called gain for gg is called active model 2d but again this was just an example how we have a big pyramid with a big data set with a whole ventricle and the lentatrio for looking inside the mitral valve and then again we have this block we can try to make it nicer and this will decrease the gain and we've made this valve tissue transparent or we can increase the gain to make it just right and while for 2d images what's the right game this is something that I couldn't really find in any books but it's something I learned from a net that there's blood is black so we need to we see the blood is back if we see the 2d image together with a 3d image then we can use that to help us but otherwise we have to use our sort of cleaning talent common sense and judgment in order to set the right gain so we can see the structures the way they are supposed to be one of the features of all of the vendors have tried different ways of actually making the blocks as three-dimensional as possible and one of them that sort of unique feature about GE is the fact that we can use something that actually no one else has that's called stereo vision and stereo vision gives us this kind of block that with like naked eye it looks a bit weird but if we had 3d got 3d glasses with red and blue then we would see this structure popping out of the screen so and that applies that word for 3d images so for the 3d block the tissue itself as well as with the color so I think I'll probably stop here you can obviously review this video and other videos that we've created and they are posted on the website I'd like to thank Hakobo again for inviting me and I'd like to congratulate him and all of the team here in Toronto who put together this course I hope you'll enjoy and we'll spend more time together here and we always take the opportunity to invite you to visit us in Leipzig and this would be a good opportunity is the AACTA ECO conference that's coming up next June