an update on 3d echo: advances in...
TRANSCRIPT
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An Update on 3D Echo: Advances in Technology
James D. Thomas, MD, FACC, FASEDirector, Center for Heart Valve DiseaseBluhm Cardiovascular InstituteProfessor of Medicine, Feinberg School of Medicine, Northwestern UniversityChicago, Illinois
Conflicts of interest: GE, Abbott, Edwards (honoraria)
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Lang et al. JASE 2012; 25: 3-46
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Lang et al. JASE 2015; 28: 1-39
2015;28:1-39
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Bob Levine, Mark Handschumacher, MGH ~1986-9
3D Echo Has Come a Long Way…
Q: Does this reconstruction take minutes, hours, or days?
A: Months!
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Real-time3D
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Electronics neededfor 2500 Elements
>150
Fro
nt E
nd B
oard
s
Further compressed intoTEE Tip
Higher density electronicsNew micro-beamforming architectureNovel interconnect scheme
Compressed intoTransducer Housing
Real-Time 3D by TEEShrinking Beamforming Electronics
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TomTec approach ~1992
Which Is a Lot Easier Than the First Way…
Breburda et al., JACC 1998;32:432-7
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Critical Benefits of 3D Echo
• Quantification of cardiac chamber volumes and function– Cardiomyopathy, cardio-oncology,
valvular heart disease
• Improved visualization of nonplanar structures within the heart
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Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
interventional procedures
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3D Volume/Function Validation Study
March, 2000 JACC
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0
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0.7
0.8
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7
EF by MRI
EF
by 3
D
y = 0.98 x + 0.01r = 0.98p < 0.0001SEE = 0.04
3DE vs MRI (EF)
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Semiautomated Methods Have Been Around for a While
Severe 4+ AR with Dilated LV
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Nine-Plane Visualization of 3D Echo
Quantitation similar to MRI
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3DE vs 2DE for LV EDVMRI Comparison
Qin et al. JACC 2000; 36: 900-7
Better with 3D but still underestimate MRI volumes
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3DE and MRI Handle Trabeculae Differently
Mor-Avi et al. JACCi 2008;1:413–23But very similar if trabeculae handle the same
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Lang et al. JASE 2015; 28: 1-39
Normal 3D LV Volumes
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Barbosa et al. Int J CV Img 2013; 29: 309-16
B-spline explicit active surfaces
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Barbosa et al. Int J CV Img 2013; 29: 309-16
Excellent Agreement with Manual Measurements
24 pts comparing BEAS with manual contours
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Anthropomorphic heart phantom
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Biplane from 3D dataset Method of discs from 3D dataset
Full auto EDV/ESV edits All-frame edits
Biplane Method of discs
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• In Greek mythology, Procrustes was a bandit who forced his victims to fit his bed by either stretching them or cutting off limbs
• Procrustean analysis stretches structures to a template to determine their size and shape
PLoS One 2014; 9 (1): e86896
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Decomposing cardiac motion into 3 principal components
PLoS One 2014; 9 (1): e86896
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Muraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press
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Alignment of LV and RV LandmarksSubsequent Automated Contouring
Muraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press
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Checking RV Endocardium at End-Diastole and End-Systole
Opportunity for manual editingEHJ-CVI 2015
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Final Check of Endocardial Tracking
Generation of 3D RV modelMuraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press
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Calculations of RV Volumes and Ejection Fraction
Time course of RV volumesMuraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press
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EDV
ESV
EF
Automated RV Volume Reasonable, Better with Editing
Muraru et al. EHJ-CVI 2015; on-line
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Mesh Export of 4D Structure
Can be used for finite element modeling
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Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
interventional procedures
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Region of Interest
SV = π∫ ∫ r v(r,t) dr dtApical Long-Axis View
Distance
Velo
city
Profile
Automated Calculation of Cardiac Output
Sun et al, Circulation 1997; 95: 932-939
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Thavendiranathan et al. JASE 2012; 25: 56-65
Automated 3D Flow More Accurate Than 2D
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What’s New in MR Quantification?
3D PISA Analysis!
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Proximal Isovelocity Surface Area
Thavendiranathan et al, JACC Cardiovascular Imaging, 2012, 5(11):1161-75.Thavendiranathan et al, JACC 2012, 60(16): 1470-83
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Quantification of Mitral RegurgitationAutomated Identification and Modeling of PFCR
Courtesy of Dinesh Thavendiranathan
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Thavendiranathan et al. Circulation cardiovascular imaging 2013, 6(1): 125-33
De Augustin JA et al, J Am SocEchocardiogr. 2012 Aug;25(8):815-23
Proximal Isovelocity Surface Area
Biblical degree of accuracy?
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Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
interventional procedures
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3D-Reconstruction of ValvularStructure and Function
Calleja A et al. Circ Cardiovasc Imaging. 2013;6:99-108
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MV Dynamic Modeling
Noack T, Kiefer P, Ionasec R, et al.. New concepts for mitral valve imaging. Annals of Cardiothoracic Surgery. 2013;2:787-795
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Calleja A et al. JASE on-line 5/27/15
Annulus Circumference vs Annuloplasty Band Size
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Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
interventional procedures
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Guidance of Interventions• Transcatheter aortic valve replacement (TAVR)• Percutaneous mitral valve repair• Paravalvular leak closure• ASD/PFO/VSD closure• Left atrial appendage closure• Coming soon…
– Percutaneous mitral valve replacement– Percutaneous tricuspid valve repair
Excellent visualization is critical!
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New Rendering Tools for 3DTEE
Depth coloring Shadows Reflections High Dynamic Range
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MitraClip guidance
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Percutaneous Closure of Paravalvular MVR
Transseptal lasso catheter capturing retrograde wire through leak
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Watchman guidance
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Fusion ImagingCo-Registration of Echo and Fluoro
Guiding transeptal puncture
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Fusion ImagingCo-Registration of Echo and Fluoro
Providing a target for mitral clipping
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Fusion of TEE and Fluoroscopy for Mitral Application
Fusion ImagingIntegrating Mitral Modeling
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How Can We Afford to Provide Guidance?
Approved for 6.38 RVUs in 11/14
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Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
interventional procedures
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Thanks!