 Hello once again from Leipzig, this virtually, and in my second lecture, we will talk about clinical applications. You see my sclerosis, the same as in my first talk, some consulting honorees, and we are referenced customer from Philips. And I will talk about the peri-operative use of 3D imaging of the audit valve and the peri-procedural use of 3D imaging of the audit valve during trans-catheter AV procedures, especially then focus on the basilica procedure. There are two publications which I want to mention. The first one is the last year publication from the Quara and colleagues and where Professor Vegas from your institution is also one of the co-authors about the guidelines for the use of TE in the surgical decision making in the OR. And the next is an article from Alabaribi, published 2019 about the systemic audiographic assessment of the audit valve. What should the surgeon know for audit valve repair? And if we go to the guidelines, there are three key points for resurgical assessment of audit valve. One is evaluate AV anatomy, of course, with 3D, especially for the cost of the co-op patient height and the diameters. The limitation is, of course, spatial and temporal resolution, which I addressed in my previous talk. The next one is identifying the coronary artery osteos, also with 3D. Once again, spatial and temporal resolution might be a problem and post-processing is required. And then evaluate AV functions, especially the 3D audit valve area, planimetry, and the use of color dot. Now, all the other things you can see here is 3D not mentioned. So starting with the evaluation of AV anatomy publication, you see in the image, in the 3D image display, you can rotate your image of the audit valve at 45 degrees and then you can display it like a surgical view. It's the same for the metal valve where you have a surgical view of the eye rotating your AV short axis image at 45 degrees, you will get surgical view of the right coronary cusp here, the non-currentary cusp there, the left coronary here. That is also where the anesthesiologist will see the audit valve if they look from ahead of the patient. And with 3D, sometimes you can really detect small raffle like here, which was mentioned in the article from Airbnb, which you of course cannot see in the AV short axis view because of the lacking elevation. And this is an example from our institution where you may detect something which was not so good visible in 2D. And this is the patient for coming for a redo, optic valve replacement, where of course, it was a history of infection one year ago and he came now to our institution with optic life regurgitation and you see here the explanted valve, bioprosthesis with a hole here in the right coronary cusp, and with 3D, you really can visualize that hole here. And if you tilt that image a little bit and have it insistently, you see that hole also here on the right coronary cusp. That is really sometimes an advantage over 2D. Do you see that here? Playing. Another advantage was the alignment of the non-coronary cusp and the left coronary cusp, which I showed you in one of the last slides in my previous talk. You can do that with multi-planar reconstruction of course, where you set your image and plane here crossing from the right coronary 2D, right coronary and non-coronary cusp, and here to the left coronary. So that you can do with post-processing processing, for example using, with that 3D, you can also measure the LVOT diameter in the area. That is a view which you never get with 2D, but with 3D and MPR. It's easily, you measure the LVOT diameter, and here it's an example of measuring the diameter. Another thing which you can do with 3D in the piece of the orbit valve is you measure each individual cusp of the orbit valve, and you measure the co-operation height, which is the height where two of the cusps really que up, and the effective height, which is the height from the tip of the cusps to the orbit analyst in biosome. Geometric height is this one here, where you have it from the analyst, from the hinge point to the tip. You can measure that, of course, by using either multi-view here, and you can measure that life. Adjusting the planes here, back here, just rotating that, and you do the short axis, and you turn it here, and you can do that, or you can use the multi-planar reconstruction of the previous one. And here it is, here is just the MPR once again, and the red one here is enlarged, and you measure from the analyst the effective height and the co-operation height here, and you can do that with all of the three cusps, by just adjusting that red plane from the middle of your right coronary cusp to the opposite commissure. You can measure effective and co-operation height of the right coronary cusp. You turn it to the non-coronary cusp, and then you can measure it here again, co-operation height and effective height, and last but not least, by turning that, you see it also from the left corner. That is not possible without 3D, so that is really a good advantage if the surgeon listened to that. And here are the recommendations and the parameters which you can use for guidelines, for the effect of what to do, what are the surgical implications, and I won't go into that in detail. But patient height should be after repair, if possible, more than 5 millimeters in each of the cases. Identifying the coronary arteries with 3D, you can do that, which I'll show you here. So once again, we use the MPR mode, and then you look for the left coronary oceum, which is typically here and here, and then you go to the right coronary cusp, very nicely you can see the right coronary artery here arising from the optic sinus. That is again using MPR, or you can use it with multiple view. You can also measure the distance from the optic cusp to the coronary oceum, which is very crucial for the harvest of acilica procedures, which I will highlight at the end of my talk, and what we have discussed, the LVOT dimensions, or the diameters. And you see that this has a good correlation with CT scan. That was a publication from 2010. The distance between the left and the right coronary has to compare to the CT. For the left coronary, it was significantly different in that publication, not significantly different for the right coronary. We did the same few years ago, and we could show that there is no difference between measurements of left coronary or right coronary oceum compared using 3DT or CT scan. It was a very excellent correlation. Then coming to the evaluation of the AV function, with using animetry of the orthophotomy area, or with the other gap, or with all degree precipitation, you see that here, you can really exactly identify the jets, and you can do a planimetry of that. Here again, example from our center, so here you have that patient with a degree precipitation with the MPR. We really can adjust the plane at the vena contracta, and here you have the vena contracta area, looking from the left one to the outflow tract view, where that is the anterior micro leaflet here, that is very good. And then you can also measure that here, and with MPR you can measure the IMD area, which is here in Germany, so when you measure that in the still frame, and you really can adjust the orthographic rotation, see that here in MPR, and then measure either the vena contracta or the vena contracta area. As mentioned before, of course, you can measure the orthographic opening area, and with that green voice, you really can adjust, yeah, sure that you are on the top of the process, then you measure the area. These are the guidelines for the adulation of orthographic rotation after perpopenia valve repair, so for replacement, that means after tarver, and you see for tarvers, as you all know, not many centers still do tarvers under general anesthesia, even in Canada or in North America, most of the centers switch to monoclonal anesthesia care, which makes the use of tea really difficult. And one possible advantage of using PE in these procedures is to evaluate the residual paravvalval leakage vena contracta area, and then you can really measure the area of in case there are multiple paravvalval leaks of all of the leakage, and then sum it up. This is again an image from our center, and you see here at the date, that is really years ago, when we used 3DTE for evaluating the paravvalval leakage. And here is the grading, so always use the relationship of the whole circumference, and then the circumference of the vena contracta area down that here. I don't think that this really makes a theory method, or it's an argument to do general anesthesia for tarvers. Where you need general anesthesia and where 3DTE, especially the explained mode, is really crucial is during the basilica procedure with this high prosthetic or native or skeletal intentional laceration to prevent adrogenic coronary artery obstruction. And this was published this year by one of my senior consultants. That is the basilica animation. So you see that in case that you fear that during tarver coronary ostin gets obstructed, you use catheter here and beating heart to slice the test so that you have a reform, and that should be in the direction of the left coronary ostin. And then after tarver and transplantation, you see that after basilica, there's no risk of obstruction of the coronary artery after that. And how do you do that? It's mainly focused on the multi-plane method or the explained method, where you see at the first step the positioning of the snare system, here you see the otter, here's the LVT, the optic valve, the native or the bioproceses. That is your catheter here, that is the left coronary ostin. And you see that that this snare catheter should be here, like here in that scheme, should perforate your cast really at the bottom of the native optic analyst or really close to the bioprocedic ring, if in case that is a bioproceses in place. So then you catch the catheters and just confirm that your traversed catheter is really at traversing the optic cast at the bottom of the ring of the bioproceses string and confirm, I can explain, you see here, that is your sector, here the left main and here you have the tip of the catheter really next to your coronary ostin. So and then you can see that the traversal catheter has crossed that pass is positioned in the LVT and not in the left atrium, which can happen. It's rare, but you should have to execute that, because otherwise if you then do really the slicing, you would slice the optic route that you're going to do this. And with 3D visualization, yes, you can do that. Sometimes you see here the coronary ostin, you see here the tip of the catheter and the struts. But again, for daily practice, I would say we use 90% of the time explained. So to conclude, 3D imaging of the optic valve allows unique imaging things. It provides helpful measurements, especially of the optic valve for optic valve repair. It allows quantification of residual or degree of agitation after optic valve repair and accurate measurements of venocontractor and venocontractor area after carbon and after, of course, surgical optic valve replacement, sorry, and explain as usual useful for guidance in basilica procedure. And as I mentioned in my first talk, next year we plan to have a live transmission also from the basilica procedure where you can see TE masters how they do the echo very operatively, how they do the nobilities and which images will result after a perfect nobilage. So thank you once again for your attention.