3d application in practice...2017/10/11 · 10/8/2017 1 3d application in practice wendy tsang, md...
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10/8/2017
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3D Application in Practice
Wendy Tsang, MD
Toronto General Hospital
University of Toronto
Recommended
LV Volumes
MV anatomy
MV Stenosis
Guidance of Transcatheter
Procedures
+ Tricuspid Valve
Anatomy
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Techniques for Integration
3DE
Integration
CroppingMulti-planar
Reconstruction
Automated Analysis
Programs
Techniques
Case
• 21 year old male
• Admitted with peripheral edema, weight gain and a 3-month history of SOBOE
• Prior to admission, he had been seen at another hospital and was noted to be in atrial fibrillation
– Rate controlled and anticoagulated
– After multiple visits, electrically cardioverted
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Case
Case
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What is this?
a) Cor triatriatum
b) Supramitral ring
c) ASD
d) a and c
e) b and c
What is this?
a) Cor triatriatum
b) Supramitral ring
c) ASD
d) a and c
e) b and c
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Case
Which is a true 4-chamber view?
A B C
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Which is a true 4-chamber view?
A B C
LV Function Assessment
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Tomographic SlicesLV Function Assessment
Tomographic SlicesLV Function Assessment
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Tomographic SlicesLV Function Assessment
Tomographic SlicesLV Function Assessment
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Multi-planar ReconstructionRV Size Assessment
MPR RV Size AssessmentIncreases Consistency
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Normal or Abnormal?
Normal or Abnormal?
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Normal or Abnormal?
a) Normal
b) Abnormal
Normal or Abnormal?
a) Normal
b) Abnormal
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What EF would you report? 2D LVEF
What EF would you report? 3D LVEF
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What LVEF Would You Report
a) 2D
b) 3D
What LVEF Would You Report
a) 2D
b) 3D
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LVEF
EDV ESV EF
2D 113 57 50
3D 116 62 46
MRI 118 65 45
Normal or Abnormal?
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Normal or Abnormal?
Normal or Abnormal?
a) Normal
b) Abnormal
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Normal or Abnormal?
a) Normal
b) Abnormal
2D LVEF
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3D LVEF
3D LVEF
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LVEF
EDV ESV EF
2D 136 60 56
3D 139 73 48
MRI 157 80 49
True 3D LV VolumesIncreased Accuracy
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Heart 2008;94:440–445.
3DE Changes 2DE Categorization
Thavendiranathan P
et al JACC Imaging
2012;5:239-51
y = 6.8+0.88x
r = 0.86
y = 0.3+0.99x
r=0.97y = 4.9+0.85x
r = 0.93
y = 16.0+0.76x
r=0.92
y = 36.9+0.69x
r = 0.88
y = 21.0+0.78x
r=0.85
Bias = -10.7
LOA = 17.5Bias = -25.7
LOA = 32.7
Bias = -4.1
LOA = 6.1Bias = -16.2
LOA = 24
Bias = -2%
LOA = 2.4%Bias = -0.5%
LOA = 2.5%
y = 29.1+0.7x, r=0.90 y = 0.68+0.98x, r=0.98y = 9.2+0.8x, r=0.96
Bias = -17.6, LOA = 26.7 Bias = -9.8 LOA = 17.9 Bias = -3%, LOA = 2.5%
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Rheumatic Mitral Stenosis
Left Atrial Perspective Left Ventricular Perspective
What MVA would you report?
3D 1.44 cm2
BA
2D 1.66 cm2
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What MVA would you report?
3D 1.44 cm2
BA
2D 1.66 cm2
MVA Planimetry by MPR
• 2D echo planimetryoverestimates MVA
• 3D echo improves identification of the narrowest part of the MV orifice due to better alignment of the image plane at the mitral tips
Wunderlich, NC. JACC: Cardiovasc Imag. 2013;6(11):1191-205.
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Accurate 3D MV Area Planimetry
A1=1.06 cm2
Mitral Valve Quantification
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Mitral Valvuloplasty Scoring Wilkins <8
• Semi-quantitative
• Subject to observer variability
• Less reliable in classifying patients with scores within the mid-range
• Fibrosis vs calcification
• Uneven distribution of pathology
• Underestimates subvalvedisease
http://www.csecho.ca/wp-content/themes/twentyeleven-csecho/cardiomath/?eqnHD=echo&eqnDisp=mvsmgh
Mitral Valvuloplasty Scoring
• Commissural morphology not assess – Post-procedural MR
– important predictor of long-term outcome
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Anwar AM et al. J Am Soc Echocardiogr 2010;23:13-22.
3DE Score
<8 Mild
8-13 Moderate
> 14 Severe
A2-P2
A3-P3A1-P1
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Subvalvular Assessment
Anwar AM et al. J Am Soc Echocardiogr 2010;23:13-22.
• Feasible
• Reproducible
• Good intra- and inter-observer variability
• Better detection of calcification and commissural splitting
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Balloon Valvuloplasty
PBMV in Mitral Stenosis
PRE PBMV POST PBMV
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Nunes MCP, et al. J Am Coll Cardiol Img 2014;7:453–61
Nunes MCP, et al. J Am Coll Cardiol Img 2014;7:453–61
LAV at LV end-systolic
Hypothetical spherical volume= 4/3πr3
r
LA Shape Index
LA Shape Index=
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“Easy” Applications
Technique Application
Cropping• Display and understand the anatomy
• Tricuspid valve• Mitral valve
Multi-planar reconstruction
• Improve measurements• MV planimetry• LVOT
• Improves LV and RV assessment
Automated Analysis Programs
• LV volumes• LA volumes• RV volumes• SV measurement• MV
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