An Update on 3D Echo: Advances in Technology James D. Thomas, MD, FACC, FASE Director, Center for Heart Valve Disease Bluhm Cardiovascular Institute Professor of Medicine, Feinberg School of Medicine, Northwestern University Chicago, Illinois Conflicts of interest: GE, Abbott, Edwards (honoraria)
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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)
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 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
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
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?
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-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
Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of
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
Emerging Trends in 3D Echo
• Automated chamber quantification• Quantitation of 3D Doppler• Extracting anatomic models of cardiac
structures • Improved visualization and guidance of