an update on 3d echo: advances in...

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)

Lang et al. JASE 2012; 25: 3-46

Lang et al. JASE 2015; 28: 1-39

2015;28:1-39

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!

Real-time3D

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

TomTec approach ~1992

Which Is a Lot Easier Than the First Way…

Breburda et al., JACC 1998;32:432-7

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

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

3D Volume/Function Validation Study

March, 2000 JACC

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0.3

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0.5

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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)

Presenter

Presentation Notes

Relationship of left ventricular ejection fractions obtained by real-time 3D echocardiography and MRI.

Semiautomated Methods Have Been Around for a While

Severe 4+ AR with Dilated LV

Nine-Plane Visualization of 3D Echo

Quantitation similar to MRI

3DE vs 2DE for LV EDVMRI Comparison

Qin et al. JACC 2000; 36: 900-7

Better with 3D but still underestimate MRI volumes

3DE and MRI Handle Trabeculae Differently

Mor-Avi et al. JACCi 2008;1:413–23But very similar if trabeculae handle the same

Lang et al. JASE 2015; 28: 1-39

Normal 3D LV Volumes

Barbosa et al. Int J CV Img 2013; 29: 309-16

B-spline explicit active surfaces

Barbosa et al. Int J CV Img 2013; 29: 309-16

Excellent Agreement with Manual Measurements

24 pts comparing BEAS with manual contours

Anthropomorphic heart phantom

Biplane from 3D dataset Method of discs from 3D dataset

Full auto EDV/ESV edits All-frame edits

Biplane Method of discs

• 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

Decomposing cardiac motion into 3 principal components

PLoS One 2014; 9 (1): e86896

Muraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press

Alignment of LV and RV LandmarksSubsequent Automated Contouring

Muraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press

Checking RV Endocardium at End-Diastole and End-Systole

Opportunity for manual editingEHJ-CVI 2015

Final Check of Endocardial Tracking

Generation of 3D RV modelMuraru et al. EHJ-CVI 2015; on-line 12/8/15 ahead of press

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

EDV

ESV

EF

Automated RV Volume Reasonable, Better with Editing

Muraru et al. EHJ-CVI 2015; on-line

Mesh Export of 4D Structure

Can be used for finite element modeling

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

Thavendiranathan et al. JASE 2012; 25: 56-65

Automated 3D Flow More Accurate Than 2D

What’s New in MR Quantification?

3D PISA Analysis!

Proximal Isovelocity Surface Area

Thavendiranathan et al, JACC Cardiovascular Imaging, 2012, 5(11):1161-75.Thavendiranathan et al, JACC 2012, 60(16): 1470-83

Quantification of Mitral RegurgitationAutomated Identification and Modeling of PFCR

Courtesy of Dinesh Thavendiranathan

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?

3D-Reconstruction of ValvularStructure and Function

Calleja A et al. Circ Cardiovasc Imaging. 2013;6:99-108

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

Presenter

Presentation Notes

Noack T, Kiefer P, Ionasec R, Voigt I, Mansi T, Vollroth M, Hoebartner M, Misfeld M, Mohr F-W, Seeburger J. New concepts for mitral valve imaging. Annals of Cardiothoracic Surgery. 2013;2:787-795

Calleja A et al. JASE on-line 5/27/15

Annulus Circumference vs Annuloplasty Band Size

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!

Presenter

Presentation Notes

So we’ve seen how poorly medically treated patients fare with severe aortic stenosis. So an important question is how often is AS inoperable. The Euro Heart Survey was published in 2003. This goal of this survey was to quantify the amount of valvular heart disease seen in Europe, and to see how patients were being treated. In included 92 centers in 25 countries in Europe over a 3 month period in 2001. 1197 patients had severe AS. 809 had single valve disease with severe AS. 9.8% of patients with guideline indications for AVR did not have surgery. Reasons often cited were surgical risk factors of: old age, COPD, renal failure, short life expectancy. Or operations were not done as symptoms decreased with medical treatment (although we know what the prognosis of this is unchanged).

New Rendering Tools for 3DTEE

Depth coloring Shadows Reflections High Dynamic Range

Presenter

Presentation Notes

On the Vivid E95 we have implemented HDLive which is a new real time volume visualization algorithm. Some of you may havev seen the beatiful fetal images from the Womens Health ultrasound systems created using the HDLive algorithm. We have now adopted this algorithm to cardiology. Since cardiac imaging has many additional challenges and requirements we had to do quite a bit of development to make this work for cardiac. This slides describes most of the basic features of HDLive for cardiac. Depth coloring is not new, this is something you know well from existing systems Depth coloring is used to better perceive depth. With HDLive we add both sharp and soft shadows based on a light source that the user can easily rotate with a rotary. In addition to shadows we have added light reflections which helps perceiving the shape of the structures. Finally we have added local contrast enhancement. This works a bit similar to the HDR function you can find on the Iphone and it greatly improves local contrast in the image. The end result is images that both look more realistic, enhances depth perception and which can also reveal more details. So cSound has been a big investment for the business and we plan to further captialize on this investment going fortward. Based on activity that we have in the lab right now I expect us to make it even easiert to scan difficult to scan patients. I also expect that we will be able to increase volume rates still with excellent spatial resolution. Finally, I expect that we will be able to accerate reserach both internally and with out external research partners which eventually will end up as improvedments in the products.

MitraClip guidance

Percutaneous Closure of Paravalvular MVR

Transseptal lasso catheter capturing retrograde wire through leak

Watchman guidance

Fusion ImagingCo-Registration of Echo and Fluoro

Guiding transeptal puncture

Fusion ImagingCo-Registration of Echo and Fluoro

Providing a target for mitral clipping

Fusion of TEE and Fluoroscopy for Mitral Application

Fusion ImagingIntegrating Mitral Modeling

How Can We Afford to Provide Guidance?

Approved for 6.38 RVUs in 11/14

Thanks!

an update on 3d echo: advances in...

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