1. Three-dimensional echocardiography in the clinical world Prof. JL Zamorano Director CV institute University Clinic SC, Madrid

2. Advantages of 3D.... additional advantages ?. A B How do you prefer to see a mitral prolapse?

3. Your preference A B

4. Modes of 3D-Echocardiography. Full volume. Cropping: every orientation of the planes is possible

5. Advantages of 3D. Spatial manipulation. Optimal alineation of structures. Views and planes impossible to get in 2D. Single acquisition, multiple information. Easy approach to complex problems. Volumes calculation. No geometrical assumption (Right ventricle). Precision  MRI, (but faster and cheaper).

6. J Am Coll Cardiol 2004;43: 2091–6

7. Evaluation of Mitral valve area MVA estimated by: MVA estimated by: 2D Echo : 2D Echo : PHT PHT Planimetry Planimetry PISA PISA 3D 3D Gorlin Gorlin Conclusions: Conclusions: 3D RT is very accurate in assessing MVA 3D RT is very accurate in assessing MVA 3D RT showed better agreement. 3D RT showed better agreement.

9. MV pre – post MVP Conclusion: 3D RT better correlation with Gorlin, after MVP

10. Mitral Valve. Mitral stenosis.

11. Mitral valve. Mitral stenosis. Anatomy of leaflets, comissures, subvalvular apparatus. Planimetry of oriffice: superior to 2D. Guide for balloon valvulotomy. Score. Oriffice post-valvuloplastia. Complications. 3D: Best diagnostic tool for structural mitral evaluation.

13. Mitral valve. Mitral regurgitation. Circulation, March 2003 Mechanism of Mi regurgitation

14. Mitral valve. Mitral regurgitation. Volumes quantification. 3D colour doppler quantification: promising perspectives. Mechanism of Mi regurgitation.

15. Lateral MR jets.

16. Real Time 3D. New perspective

17. 3D MVP. 3D Protocol: 4 steps 3D Protocol: 4 steps 1) P short axis + cutting planes 1) P short axis + cutting planesA3P3A3P3A2P2A2P2A1P1A1P1

18. 3D MV Prolapse 3D Protocol: 4 steps 3D Protocol: 4 steps 1) P Shurt axis guided cutting planes 1) P Shurt axis guided cutting planes 2) Apical + guided planes 2) Apical + guided planes 3) Full volume 3) Full volume 4) 3D color. MI. 4) 3D color. MI.

19. Agreement 3D vs TEE p< 0,0001 P2k = 1 A2k = 0.820 P3k = 0.934P1k = 0.876 A1k = 0.858A3k = 0.821 P2P2 A1-P1A1-P1 A3-P3A3-P3 1.- 100% P2 2.- False negative (anterolateral region) 3.- False positive (inferomedial region)

20. Volumes. 2D echo ?? 2D:Simpson Problems: ¿Optimal alignement ? Geometric asumptions Problems: ¿Optimal alignement ? Geometric asumptions

21. 3D: Volumes calculation Quantification of left ventricular volumes and ejection fraction using freehand transthoracic three-dimensional echocardiography: comparison with magnetic resonance imaging. Mannaerts HF, Van Der Heide JA, Kamp O, Papavassiliu T, Marcus JT, Beek A, Van Rossum AC, Twisk J, Visser CA. JASE 2003 Quantification of left ventricular volumes and ejection fraction using freehand transthoracic three-dimensional echocardiography: comparison with magnetic resonance imaging. Mannaerts HF, Van Der Heide JA, Kamp O, Papavassiliu T, Marcus JT, Beek A, Van Rossum AC, Twisk J, Visser CA. JASE 2003 3D underestimates volumes

23. 3D. Volumes 2D: Simpson biplane 3D (FV): 2 planes 4 planes 8 planes CMR: Simpson

24. RT3D: Semiautomated border detection Improved semiautomated quantification of LV volumes and EF using 3D echocardiography with a full matrix-array transducer: comparison with magnetic resonance imaging. Caiani EG, Corsi C, Zamorano JL, Sugeng L, MacEneaney P, Weinert L, Battani R, Gutiérrez-Chico JL, Koch R, Pérez de Isla L, Mor-Avi V, Lang RM. JASE 2005 Aug Improved semiautomated quantification of LV volumes and EF using 3D echocardiography with a full matrix-array transducer: comparison with magnetic resonance imaging. Caiani EG, Corsi C, Zamorano JL, Sugeng L, MacEneaney P, Weinert L, Battani R, Gutiérrez-Chico JL, Koch R, Pérez de Isla L, Mor-Avi V, Lang RM. JASE 2005 Aug

25. Volúmenes 3D Volumes calculation – Slice view Direct comparison with gold standard Volumes calculation – Slice view Direct comparison with gold standard

26. Aortic area with RT 3D echo ?

27. Aortic stenosis: Continuity equation Cumulative error in several parameters Depending on good parasternal & apical acoustic windows A Ao = π ( ) 2 D TSVI IVT TSVI 2 IVT Ao TSVITSVI IVT TSVI IVT TSVI

28. Aortic stenosis: Continuity equation Cumulative error in several parameters Depending on good parasternal & apical acoustic windows A Ao = π ( ) 2 D TSVI IVT TSVI 2 IVT Ao TSVITSVI IVT TSVI IVT TSVI STROKE VOLUME

29. Aortic stenosis: Continuity equation Cumulative error in several parameters Depending on good parasternal & apical acoustic windows A Ao = SV IVT Ao TSVITSVI IVT TSVI IVT TSVI STROKE VOLUME

30. Aortic area: RT3D-Doppler hybrid approach

31. Aortic area: Invasive: Gorlin Hakki Echo: Continuity equation Volumetric Simpson RT 3D

32. Correlation (linear association):Pearson r Absolute agreement: ICCa (Intraclass correlation coefficient – absolute) Lin’s coefficient Aortic area with RT3D: Results

41. Limitations of 3D. Quantification off-line ??. Time-consuming. Full-volume mode: breath- hold. Image definition does not improve respect to 2D. Lower frame-rate.

42. Conclusions 3D is the best imaging for Mitral valve. New approach to mitral anatomy and mitral prolapse. 3D planimetry: Best non-invasive methode for Mi stenosis. Mechanism of Mi regurgitation.. Best option for complex problems, MVP, surgical repair. 3D colour Doppler: promising perspectives for quantification of valvular regurgitations. Volume estimation… similar to MRI

43. 3 is the number ! Exécutif Législatif Judiciaire 3D !!!