Role of Echocardiography in Intervention | TAVR | MitraClip

This is going to be a quite a long presentation. essentially focusing on the interventions and surgery and how Echo plays a major role in these situations when you look at the Echo in terms of trans thoracic, there's always this restriction because it is a caged organ. it is inside. And then it is surrounded by the lungs on either side and this has a problem in terms of good imaging and this can be a problem many times when it comes to interventions or surgery when either in the assessment or in the during the procedural or even post operative you always been a dependent and you're always used the traditional tools of two color doctor and the spectrum doctor and over a period of time, this has been the foundation now for all. As far as echoes in addition to that. has given additional support and provided incremental. information and in terms of the help it can provide when the interventions are being done. now with the advent of new applications like threed, it has made the. life a little more easier in terms of how we can look at these lesions and. The way the interventions are happening is that more and more difficult lesions are now being addressed and then successfully being accomplished and this is where Echo plays a big role both in surgery and in interventions. the other area where the how emerging his of a great helpers in a new area, which has been there for some time but not really sort of made a big head because it's still restricted to some areas. This is a threed print. And this threed printing is mainly used, especially in the pediatric. specialty where the congenital defects and are very well sort of made out when the the images are threatened to the sprinter and then that gets converted into images and then you have the specialized threed printer, which comes out with it and with this one is able to plan surgeries one is able to plant interventions to a large very institutions, but it has been a successful journey wherever it is. Established apart from the surgical side the intervention also has seen a big boost in terms of the hybrid imaging. so this is an area where it has been very helpful when it comes to complex interventions and this is the fusion of the flop, which is primarily a one dimensional one. So when you fuse the threed matching with the poco this can be very very helpful for the intent and even for the person who's from the eco side who can provide much better information so this will hybrid emerging the fusion. 

As it is called is now expanding and it is becoming more and more sophisticated and hopefully it will reach a much more sort of people rather than being confined to a few areas because it's still a very niche sort of software and hardware, but hopefully this will expand in the years to come and make the interventions and surgeries, especially the interventions much more easier now when it comes to the assessment for these procedures, which are. being looked into one can. If you go into how the pediatric is sort of been always under the shadow of diagnostic errors because it is one of the most difficult imaging techniques, which is there and there is a lot of pain and dismay and sometimes can lead to disastrous consequences and this is one study, which has looked into the diagnostic errors and it is a very interesting study. so this is just sort of curiosity which I have sort of highlighted. So this is an institution which looked at. Acres over a period of close to 3 years and then they found eighty-seven errors so when they look at these errors, they were sort of looking into how what is the percentage which sort of made a difference in terms of an adverse. so 70% had a problem and one third of these errors were preventable and about another two thirds of moderate in terms of preventable errors. So it is a big sort of a chunk of the number may be small, but when it comes to the percentage and then the risk that is exposed to. To these children, it is quite high, so this is something which we have to keep in mind. So diagnostics are a big challenge, which we always sort of face when doing pediatric Echo and there are areas where they have been highlighted and how we can sort of look at it. This is the classification they've used over it is nothing but a classification so they've looked at administrative or data. So this is where generally some. entry of data into the I. On the machine, so that is where a problem happens when the wrong patient is picked up. So this is this can happen. We shouldn't be sort of more confident to say that you know it doesn't affect us, but it can once in a while it it will be so it's very important to enter the right data of the patient. next is looking at the background of these. patients and when you're doing this, it's important that you have some understanding of the. 

And then the imaging environment also makes a lot of difference, so it is very important as I suggested last time that we have to have a reasonable environment a good machine and the right knowledge and that sort of is conducive to good outcome in terms of information and the other era is the communication when we not able to assimilate the patient's history the background, that means which we are not looking at the patient's clinical history and we're collecting it and adding to our knowledge that can be a problem and. We are not able to access prior studies for comparison, it can be a problem and when we do see a critical finding and for some reason, we're not sort of conveying it to the right person at the right time, It can be a problem for the patient. so this is a communication error Next is cognitive errors, so this is something very inherent to individual persons, so it is very important that we have to have a good knowledge base and then you have to have good technical skills so if any of these can be problems now the next. Despite having knowledge despite having technical, if you're not able to synthesize this properly, if you're not able to coordinate and collect this information and then process it properly, this can be a problem so it is also important that how you sort of take this knowledge and process it and then how you sort of utilize it then again we have these technical factors. This is more issues so these are the various ways one can go wrong in terms of how the errors can happen. Let us look at the techniques and how they can sort of have their advantages and limitations in terms of interventions and surgery. So here we have the thoracic and then we have the plants especial and then the. in so when it comes to trans thoracic, it is very easy to use no problem said. But then we have these problems so it can be a problem and especially when it comes to the Cath lab or the OT. There's always this area where it is off. it is off limits and we are not sort of having any access to it and this can be a. So there is a restriction in terms of the imaging area, but it can be useful when it is a balloons in terms of cardio synthesis. no problems at all but fantastic emerging and it can be used in any procedure. The problem here is that it requires logistics. It is semi invasive and then you need to have this support of anesthesia and it required a general anesthesia and then the intra not going to that. but then again that can also be a. That you can. sort of has been shown to have some use, but it is expensive and very sort of limited use. and that is something which we are not looking into now. Let's look at how 3D Echo can be used when it comes to these device and then surgeries and what are the suggested TT windows If you do have the 3D facility so one is the subs so subs is the ideal sort of one where it gives you the highest. Of emerging windows and the quality of images next is the passes and some even the short access is not so good and when you look at the structures, you have the ASD and then you have the AV junction and then the epstein's anomaly. 

So these are the areas where it is useful but when it comes to. threed T, this is where the real sort of. scoring happens where it is very very valuable. So. Is excellent in terms of what it can provide next is how do we look at threed normal cardiac connections So here you have the HL septum and then you have the. value of this so the Arial symptom that is a high recommendations valve high recommendation mitral Valve recommendation Ventricular system is also septum is also quite high on the list and also looking at the LB OT and then the Arctic. so these are the structures where the utility in terms of threed, but when it comes to the aortic the RV, the OT and then the valve so these are areas. Are not so three different when it comes to abnormal cardiac connections. you have the a VST and then you have the discord connections, which are of high utility high recommendation and then the TGS are also good to not so good and then you have the trunks and then the double outlet where the utilities high so the threed can be useful in these select areas. and then so that is how you should be able to utilize it next is looking at the three DRV ones so the threed RV volumes are again excellent in terms of how it has been. Recorded as far as data is concerned, and you can see that there are many adults Many children's feasibility studies have been done and in most of the children where the visibility has been done, the percentage has been pretty high, except for a few, it is almost around eighty-five here and then you have another 90.1 here and then only in this that was around fifty-two, but then you have again with 100% 9800%. So so you have a lot of studies which shows that 3D. When it is done in the right way, it can be very accurate so three RVs should be sort of considered whenever you have the facilitate access to it now let us come to the very sort of to a point which we are here looking at the patient and how we assess so one can assist these patients in terms of three very procedural and post procedure. so. people will be pathology looking at what the pathologist and then once pathology is identified what is the anatomy and then the next is it suitable for any sort of. Dimension in terms of the size in terms of the hems measurements, so this is something that we have to go through for every. patient who is considered for any intervention then based on this our demise or a surgery is made and then afterwards the Echo is helpful in terms of guidance and in terms of monitoring so it is an essential support and and then of chlorophyll. also and we have these various options. 2D threed thoracic and T, which is there. And let's look at interventions in interventions. It is very important that we have the right selection of patients so when you sort of not sort of don't plan it properly, it can lead to a lot of disasters and we know that we have seen enough of these disasters when the right planning has not happened so we have to be very careful in choosing the right patient so it is important that the interventionist. should see the Echo when they are doing the procedure and then based on that type of device can be selected and then they have a better understanding of lesion and the interventionist takes a look at the A better outcomes will be there so. The procedure becomes much more easy less complications and of course, the procedure time, and the full time also comes down. So this is where seeing an echo the pathology before doing an intervention or surgery. It is very helpful for either the surgeon or for the interventionist now let's go disease by disease in terms of the closure in terms of the defects so starting with the ad one, it has to go through the sequences of looking at it's anatomy. So what is it? What is it? is it a very dynamic sort of and notifies that means we have to be careful in terms of the sizing. Where is it located so it helps us to get the right technique in terms of approaching that with the the device and what is the maximum diameter? So that is very important so that we don't want too much of residual off. We don't want actually no and then again the number of defects and how to sort of tackle this and then important is to look at the rims the sides and then again to look at the total length so that the length of the the size of the device has to be considered and what is it? Terms of the fact from the structure so if the device is going to be put in, is it going to cause any problems in terms of affecting the function of adjoining structures or sort of coming in the way of a flow, which is coming in. so this is something that you have to look at and also the Eustachian valve The Chiari network also has to be looked into so the illustration valve can be less of a problem, but when it was very expensive when it was very big, it can be a problem now the text is to look at the aneurysm to. The administrations and any maligned septum so these are these are abdominals, which makes the. the procedure a little more challenging, which is a little more difficult and of course the veins if there is a PA pvc, it is definitely something that you don't want to put a device now if you want to call an osteen a SDS complex. What are the definitions? What are the terminology that I need to be looked at so if it is man it is a complex ostrom. There are multiple effects more than thirty millimeters in size. That means a large defect when there is an aneurism when there are demonstrations and a lot of floppy tissues that especially in the posterior the IV serums when the IOT is absent, so not necessarily a deficient, but this is an absent trim So then again it is something which we need to consider and then any post will locate the ASD again will be sort of high risk and then any associated lesions, which are there which we have to take into account when there is closure next. The defects so the or if it was there, we choose the largest and then we try to sort of approach that and see how we can use the single device and how we can close the adjustment in one or we need to take additional steps or additional devices next is to take a look at the bridging tissue so the breeding issue many of times in our institution when the thickness is not that much of the sort of tend to put a balloon and ruptured the tissue and make the two defects into a single tissue and then they put a single device so the bridging tissue is helpful in such cases. residents of. Much of a can be a problem post it it can be a it can be a problem so it is important that we quantify the amount of MR that is a free device Closure. IV serum is the most important room and then if it is deficient, then you know that it is not possible and among the rims they are Mi and we are the most consistent rims. These are the ones which are least likely to have problems and so they are the most stable ones is the one which is most often deficient, but it is least important but. Absent can be a problem when it can lead to erosion so that can be an issue and we have to look at the Est rate and not to mistake it for it. So let's start to look at some images so these are still images So here one is to look at the size. What is the size of the defect? and then what is the length of the total length and then the size of the reps? So these are the three important measurements which any ASD assessment is included. If you're doing a drastic looking at the shorts, so this will provide a here and this is a posterior and then the size in this. view in this cut we take it and then we take another size here in this for chamber view and then again, this is the or the AB room and then this is a superior, the postural superior rim and then the size again is taken care of this is a little bit of a difficult one. So this is a subtle so most of the time it is doable and the pediatric population. Issue so it is very important that we visualize the SPC here and then once the SPC this becomes the SPC rim here and then if you look at the IVC here, then this becomes the IVC and this gives you the length so if it is not doable, then we have to look at additional ones and especially in the older age children that we can look at as a possible option in case of a subconscious issues Next, let's look at how to look at the sizing of the rims as well as the size of the defects. This is in terms of. so this is where the real value is in terms of difficulty lesions. So one is the fortune that is at the 0° and this is the poster at the top and the EV of the at the lower one here and then you have the defect number so one looks at the rim is it thick is a floppy is it mobile and what is the status of the issue here Next? Is we take a look at the size of the different and then we also measure the size of. Rim so the rim is measured in this and then this is documented so you can see that this is the 0° in this drawing at the top and the threed, which is there, which gives you the slice where it is packed Next is we go to 50° fifty plus minus and this gives you the short so in the short time you get to see the Arctic grip and then this is a posterior. So again the same thing we look at the thickness and the mobility and then whether it is absent or whether it is. Deficient and then again look at the cultivators made here and then the size of the defect again is documented here and then the length of the rims are looked into shape. so we go to the same sequence in this view also next would be the the really sort of important one where we look at the IV serum and then there's three serum. So this is the. the white cable view and this is around 90° and then you get the IVC here and the SPC and then again the same thickness. Thermo and then you look at the size of the different and the length of the rims here. So now you have three FS and this sort of sums up and tells you at this point or whether it is advisable or whether it is not. now when one is mentioning. so it is important that we mention the size of the defect, especially when you don't have a threed. so we really have to do a mental reconstruction based on these measurements. So, for example, here you have to get this from all the views and then give the signs and then how dynamic is it so that. Tell us how thin or the amount of floppy, which is there and? that that's how the description is going to be so next would be to look at the length of the receptor. so this is generally done in the cable view, so you have to do some multiple measurements. make sure that you get the right one and then you sort of average it out when you have these multiple measurements and take the best left here And then there is the AP dime meter. So this also tells us what would be the size of that can be sort of pushed. Terms of the sizing of the device misconception, so this is the AP, So one is the cable and the other one is the AP. So now let's look at some images here. So here we have different types of your images so you have a one from the a side a large different and then you have a single defect here so this is difficult in terms of making a corporation so this can be a problem in terms of of a device is going to be so it's a question of again if you're going to look at the size and whether they're single device can covers so that. Can be looked into so these are other examples of how they can be so this is a very very thin floppy tissue with one large effect on the very sort of bad floppy tissue with one triple penetrations here. So this is going to be a lot of problem in terms of the device here and this again is a very floppy tissue almost like an issue, large effect a lot of penetrations and again. the same thing is so this is from the using the twod so you can see that again of it. Floppy here and all three views so this is one can look at it from the TV and when you're doing the it is important that you look at the illustration that so even in the thoracic so many times the illustrations are solid piece of tissue here can hide the the. IV serum here and this can be mistaken for an IV serum and it can cause a problem here. so we have to be careful. so this is another example of how you have any. And the IV serum at the back here so that would be something that we should be careful and this is again most of the times on thoracic, it can can be difficult. You may have a suspicion or maybe even the window is excellent. You might even sort of get a good diagnosis, but when it is not the key is sort of really provides the information as to these multiple pens that you can see that there is one which is very close to the IBC, so that is going to be difficult in terms of the device closure, then you have the. So again, this is a defect and then you have the here This is towards the right atrium and then you have these multiple sort of flows, which tells you that it is administrative defect that and then you have the sinus menos. This is the other type. So obviously this is not advisable one though there's a new approach, which is sort of being introduced. It is still a sort of not widespread. so we're. a device can be sort of. In terms of the strength and then when you have a sinus spins of course, we have to look at the PPA PVC also and this is in terms of the Austrian primer. so this is how you can assist please surgery. so looking at the Austin Prima ASD and this is an image of an interracial pouch and this is something which has sort of gained some prominence because we are not able to understand it and see it much better and now that the trans. procedures are much more so these pouches are a lot more sort of a highlight. And looked into so you have the septic pouch here so and this can be a puncture problem but this is an area which is all together, but it will be good if you can provide information. to the interventionist or not now the procedure. so now you're in the Cath lab and then or you're looking at the the device being put in so it is important that you look at the color during balloon information. is there a little flow that is happening so that the dimension gets. Idea of what would be the sizing of the device that is being taken and once the right device is taken, the disc is deployed and when the disc is there in the left, it should be free in the it should not be when it is out of the sheet. It should not be in the vein or the appendage or the close to the microwave that can be a problem so it should be very clearly seen and the my also should be seen on the left lateral disc is deployed so that the disc is not it should not be coming towards the microbial. if there is any contact can lead to a problem later on in terms of. Where there's cooperation the next is the RE, which is deployed and then they should not sort of cause any problems in terms of the SPC or sometimes even the sinus also and once the deployment has taken place and. before sort of releasing it. so check all the limbs and make sure the positioning is good and then the interventionist does the wiggle test so just to look at the stability of the device and once you are happy and then the answer is happy and it does not causing any interfere. And the devices and then afterwards, it is a question of looking for a new, also if it is the small residues through the device will be there and even some tiny but we do not worry about too much. so we can sort of ignore it but anything more than 5.5 millimeters We have to seriously think that it is going to be a significant which can affect the. which can be a problem later on. So this is an example of how sort of. Can be helpful in the catalog so this is AT again here. so this was a large VST ASD, which was being considered so there was a high risk so the the approach was whether it was possible or not so it was because the patient was very keen on a device so all the risks were told that it can be a failure. Also. So this is where where the Echo is helpful to the interventionist so as the devices being sort of brought into the RA and it has been sort of opened up here. And you can see that there is the device, which is sort of not really positioned itself, and it does not really sort of you know the right size. The the The difference is too big and it's sort of didn't really work out here, but this is how one should be looking to help the interventions and this procedure. and once the device is deployed. so then the positioning takes place so everyone can look at the short access here in terms of the 50° or if you're doing thoracic. The shorts will sort of give you a good sort of. view that it is in place or not so this alignment has to be sort of equally on both sides and it should be an alignment with the then. You know that the devices in the right plane and it's sitting very nicely and of course, the t sort of is very helpful. It gives you multiple pains you don't have an undefeated view and looking at how it is being well Classes here So that is where the T is going to be used. And, of course, the three DT is definitely helpful in terms of I mean on farms so you can see where it is sitting and how close it is to a structure and then also if there is any flow which is coming, You can also identify if there's any residue of a which direction it is coming so you can whether it's coming at the top or below and this is where you can sort of tell the interventionist like this is a problem area or it is something that can be ignored so three DT is really really helpful. Now next, let us look at Bst so in BST the diagnosis is made by the thoracic, but when it comes to a device closures the general preference that it is sort of you know older age group. It is better that it is a key that is that so here again, so the anatomy is looked at where is it located? Is it a high sort of BS or ADHD and then are there any additional defects and then the sizing is done and. The fact is identified, does it have what are the sort of what is the exit on the RV side? Is it a multiple channels and if there are multiple channels, a particular channel is chosen for the device, you know from the left, which will take that particular rule, which will go on to the RV site and then you have the distance of the different from the adjacent structures. Also, so we have to make sure that the device does not interfere with the functioning of the other structures. So what to look for in a BST device placement. so the To the so it should be more than two millimeters, so, at least some tissue should be there. If it's too close, it can be a problem. then it will start touching the aortic valve and then it can lead to a regurgitation later on. So this is where the high VS DS can be an area where we have to be especially be careful and then also in terms of what is it's positioning in terms of I like a Is it coming in the way of the and is it going to be a problem and when? That is in the news in terms of the membrane membrane vs so or is it is it there and if it was there, how many are there? So this is again helpful to the interventions and the size of the BST preferably should be less than eight millimeters. So that is where it is really sort of the outcome is going to be successful and the size of the BST As I mentioned in the early one, it has to be measured on both the BDR. We decided to make sure that it is that sort of a well-planned and well thought of before. Devices put in place so again, this is primarily from the parcel views so you can see the flow here and then there is a small. membrane a membrane here and then looking at it from the short. So this gives you an idea as to what is the anatomy and how it is and how to spread over and where it is located and how far is it from the commissions? So this is something which should be short. tells you and is close to sometimes the coronary osteo. Then are there any multiples so this again we have to make sure that we don't miss out on these additional PST and lastly to look at the aortic regurgitation. So this is something which is very very important so any significant a regurgitation. It is not a good idea to put in a device because we know that the AR will become a problem and later on this will require some surgery so we don't want to sort of unnecessary cause any unwanted interventions at this point. The ideal one is that you have a clear look of the defect and then, for example, I've taken a more difficult one which is very close to the aortic valve here and then to get a very clear idea of where the floor is and then one can zoom it and. look at the size here and then once the sizing is printed. so then one can look at the closure. so you're doing the closure. We have to make sure that what the size was earlier is a is a good one, and if there's been any sizing mismatch, how have you has been undersized? it can be a problem. Then during the deployment, the disc is deployed and during the deployment it has to be visualized so that is it in the correct location within the LV and sometimes it can get the device can get trapped in the app, so it is very important that we keep a close watch where the devices and whether it is affecting the app, especially the the muscular Bts. then they are. we discussed the point once it is satisfied on the left side. And then the nexus look at whether the septum is Classes properly or not and then when it is high vs how much is it affecting the Arctic so after the deployment, so then the residual is there or not and if there are any additional defects should we look at the additional devices so this is something and also a procedural complications like a fusion or other problems related to the. procedures that should be looked at so this again is an area where you can see that this is the device, which is seen over here and then you have the. There also so just an example of how a successful one, so this is an older one and all the lady, but then again, this is something which is very useful in terms of how we can go and look at it. In the tea, so if you have an older child and then the BST is being planned for so these are the views so the white view the at the LVOT level. So this is one area where the deer has to be looked into. then you have the short axis where you can get to see the the fact that how close it is to be. and. as you can see here, it is a sort of like a here and then looking at it from the the long axis. Zoomed up view here so that these are the three views for the BS DS and again to look at the out of here in the agitation then there are the other available sort of threed sort of. viewing emerging the windows, which are there and this can give you some really good sort of views and this is you know the better ones. it may not be successful in many of the BST, but to a large extent it can be done if provided with this, you have. Good sort of a machine and then you do it the right way, so you can see that there's a difference here, which is sort of clearly visible here and you can you can see that if this is on the RV side and this is from the this is the LB here so you can see it from both the sides here and this is in the short axis and what you see actually from the short axis is. you can see just a flow which is coming but when you look at it from the threed view, you can see that the defective is a little lower down and this defect is in connection to the. The family. so I'll be on this side here so both sides you can be able to look at it so so we've we've decided to put an offer and then during the release. So this is where the device is in place here and you can see that the way the device is placed and then at this point is it coming in sort of a close to the commission and is it going to affect the leaflets. So at this point we should. It's a participation had a little bit of a so we were really concerned, is it going to increase on because we are very close to the competitions here. So we kept a close watch on the we kept looking at it for some time, nothing really happened and we kept looking at it both the with the wild close and open so nothing really happened over there and then the department happened so you can see that again during the Department of Sort of helpful, it is so you can see that the angle is different before release and once it is released. And changes and the because this angle changes what happens is the device is pulled down and it will sort of booster away from the Arabic back. so this gave us the confidence that it will not be touching the Arabic valve and that is how we went ahead and put the device in this particular patient. So we are the cat pictures I will skip this so with the post device again, it look great so everything was in place and then so you can see that the device. It's not really. Of Eco-friendly in terms of weeding, so but you definitely can see the designs are over there They are continuing to be the same and nothing can go across the device. The itself. There was no. and again this is from the ROI. and I'm sorry. This is something where I know that the images may not be so very clear, but this sort of give a clear idea as to. sort of the device is not very close to there to and this is some. Which was confirmed by you can see that the the device, which is there is very sort of away from the Arctic and it was not really coming into contact or not causing any problems to the top. So this is the advantage of threed when it was done in the right way and again you can look at additional views in terms of. in terms of the gastric and when it comes to. tea now next is let us look at the PD so in terms of the PDA, Clos. So here we have the measurement of the diameter and the a side and at the end and then we have to make repeated measurements to make sure that the our measurements are consistent and we take the maximum diameter and again the sizing base on this, I want to look at the coil or the and I want to make a choice based on that. so looking at the views itself, so one can look at the personal views and then you have the tactile view and then you have the supposed to. views also so. You know, it's important that you get this floor here and then. to utilize the simultaneous or the pellets so you can look at the two piece separately and you can look at the floor here and then you can have an idea of how the anatomy is on the TV side and do the measurements. so this is at the side and this is the. looking at the aortic side. so this the site at which the the size of the idiotic and is also. Measurable and that is how it should be approached so we have the the the para and then you have the and then we have the ducts and those are the views which you should be looking into and then you can do the topper. Also the top and look at the peak gradient and look at the the direction of the and what is the IVs also at this point once the device is in place, so one has to look. Any residual look at the position of the device and is there any sort of a turbulence so if there is a turbulence so then we could there be any possibility of. stenosis a brass which was there and it has been unmasked or is there a small residual, which is also there so that it is very important that we look at this area very very closely in terms of turbulence. So this is the easy one and then at the Arctic when looking at the abductor so look at it from both sides. Get any issues of that and then in the long term, so how well the sort of? affect the closure has been in terms of the LED remodeling. So once the Lord has been taken them, they'll we should start to decrease in sales and over a period of time you should be monitoring this apart from the PPE. so related issues. the other devices the cooperation of the aorta. so here is the is is an accepted method. So here are the sort of limited to some it is mainly the other modalities and during the car that is more of the flu, which is from the. Helpful so what we are has to be sort of going to be contributing, making sure that there are other pathologists are wounded out so that they are not in place and they should not be sort of ignored in terms of significantly diagnosis or is there a PD along with this? So then we approach changes along with the ad and is it a long segment if it is possible, it can be difficult and is there an action mode so in these situations, PDS and Hypnosis and the long segments so. avoided or sometimes it can be done but with a lot of challenges. then the two per se looking at the aortic root are primarily looking at the ay itself and then any other associated anomalies and looking at the significance all sort of the LB looking at the LV function looking at the doctor in terms of the art the color flow descending IO. The ingredients so it can be more color and the ingredients and also to look at the abdominal layer to also to see if any additional information is obtained from there. so it's important to realize that when it comes to cooperation, the gradient is not a reflection of severity so it can be affected by the length of the. defects can affect the. the gradient the cardiac output can affect it and even the compliance of the a also will be. attractive so it is. Apart from looking at the peak peak gradient, it is also important to look at the diatonic velocity and looking at the especially the dias. so the more the dias flow the more the dias spillage as it is called the more the velocity that is the number, which is given here is roughly around two meters or more. That means that the competition is quite severe. so just don't go by the gradient itself and during the deployment, so it is more like a look. At any position or any other positional complications and also if any aortic heart issues are there, which one can contribute if it is not been properly and then during the follow up, there is no other way except to look at the gradient so gradients should be looked at and then also has there been any sort of autism, which has developed a period of time and also improvement in LV function And then we also that is the one which should be looked into then next, let's look at the. So a tendency to rupture the rights rights and is more and more and where the approach is not sort of feasible is that when there is a BST and there is a membrane significantly well when there has been vegetation in the previous endocrine has been there and vegetarians have seen in that place and there when there are multiple ruptured sites and you know that we're sealing one. We're not really sort of be helpful and then if the size is quite big, it is. Feasible so looking at where the floors and this is a game from the view here and looking at where it is sort of rupturing it to and then one can look at the sizes the signs should be seen by the end as well as the ruptured and also the largest diameter is taken and based on that the the devices is decided so what the minimum and the maximum should be measured. And also it's important to measure the length of the cord. So this gives an idea as to what is the approach the interns to do and also whenever possible. What is the distance from the coronary OS? So the ISO is there so how far is it from the Austria so that the device should not come and play in the way of an osteo sort of obstruction. then again in this, especially in difficult RST would be better but to even thoracic also should be okay. During the time of the deployment is it positioned properly Is it stable so stability is shared so that is how the approach should be and is there any AR or TR has a device causing problems in terms of aortic valve in the valve and the arteries so as every function change or there's one motion of normality, so that is again something that we need to be looked into and then transfers it again to look for any resolution or a period of time and also to look at any aquatic vegetation. and these are the. Alas, so not go too much into this so. it's mainly for Congenital stenosis and most of the times TPT should suffice, though, would be better, but as it should be okay and it's important that the patient has to be selected in the right way so the valve morphology the valve. the regurgitation the valve size has to be sort of looked into the hand side, so a lot of things have to be looked into and the masses on the should be looked into so here. Acupuncture is made and then the balloon is positioned and then there is a dilation and the efficacy of the procedure is primarily looking at how well the is open so in terms of looking at Viva, so it can be looking at direct visualization or looking at Doppler calculations or looking at the ingredients themselves and has the representation increased. Have you cause more problems after the procedure so this again should be followed up, You know just like any other procedure. Precision complications also have been observed for so the the last one is the in terms of intervention. You have the balloons me so here you have the frequently performed one in terms of when it comes to a guidance is the example of being a PG so the primary aim is to before the sassy has has done is to look at the anatomy look at the location of where it is the and how inadequate it is in terms of its size and here. Would be sort of a reasonably okay in terms of how one can look at it, and then the costs of you would be the preferred one with focused on the septum and if the subconscious is not good, one can ship to the chamber que So here is this applies to me is being done. There is constant visualization and guiding the interventions as the balloons the wires going in and once it goes to the left side and then again with and then you have the invasion done. And then again check whether the floor is good and repeatedly it is not pulling it out again to sort of. making sure that the right. has been created the right size, so there will be a sort of frequent pulse back and forth left to right and. this is how it is done. so the advantage of this is that there's no radiation because it is done in the bedside and the difficult part is it's a very small area, especially when it comes to small. The risk of contamination is very high because you're working in very small areas. So this is a really big problem and of course the windows again going to be a problem. So this is something which is sort of shown here. So I'm not sort of really sort of being familiar with this just to give you an idea of this now. The next is looking at the perio synthesis. so this is a procedure. This is a complication which is there in every. Where there is interventions and that this is something that you should be fully aware and we should be knowing when to sort of see it and as soon as you see it what to do and how to identify so typically a pre isn't is the intervention that is happening and then you see that there is an infusion which is there and then once the fusion it is the RPO, which is more susceptible in terms of the pressure so the pressure goes up and then this causes the first compression here. so always keep a close. watch on the. Whenever it is possible whether it's a PT or the P and that gives you an idea as to what's the status of the human dynamics, you can see that during nicely there is. compression here. so there's a chamber compression, which is there so this already actually collapsed tells you that there is a pending and then suitable steps have to be taken place. Of course. If there's time we can look at the respective variations and sort of look at the IBC So this is a patient. Happened just last week where we were doing the. deployment. for for it was a defect and you can see that there is no infusion here and over a period of time as a device was put in place, you can start to see that there's a fusion which is starting to happen here so and then the shows that there is. a fusion of that so that this it is very important that you. Close but in every interventional procedures and then looking at the apart from looking at the compression of the RV, no one can also look at the RA collapse. Also, so this is another one which tells you that there is a tampon and issues related to that now coming to the last bit of it. I know that this is a very extensive topic, so I have focus mainly on the interventions and to a lesser extent of the cardiac surgery. so I'm just coming to the last few slides here. so let's look at cardiac surgery. Now when it comes to cardiac surgery, the this is how the image looks like to the surgeon and this is something which they expect whenever we give a diagnosis a pre surgery and we see that these are the findings and this is what they expect to see but generally many of times we are not able to convey the right sort of images right sort of the right sort of pathology and this is something which we sort of need to be aware of but most of the times in the many. Cardiac surgeries so now an important tool and we don't really have to look at other conditions now other investigations so this is something which looked at the reliability of Echo of a long time ago and I remember this is in the early 90s. So this is a study which. had patients from 1992 to 90.7 and they looked at a real mixed bag of diseases here P GS. And then you have the. DVD interrupted and then the trunk so it was a real mixed type of disease and then they look at these children so eighty-two. 82% of the children under went surgery and the number of errors were quite low so that at that time for the sort of found out that echo itself when it is done in the right manner with the right approach, it can be very reliable in terms of guiding. The surgeon and making sure that the errors are not going to be there and the surgical risk is minimized. So here the conclusion was and this is in 1999 that echocardiogram is an accurate tool for the pre operative diagnosis of major congenital heart defects in children undergoing primary complete repair. So this is an important statement and from there on the cat really has taken. a second place and this is where it's really sort of played a big role. and now I think. It has been sort of made our job much more easier. This is again a study, which looked at simple once again this study and this again same conclusion it can be accurately diagnosed here so again looking at a predominantly. less complex defects here but again, the conclusion was that it can be accurately diagnosed by eco. So the message is that Echo is capable of giving the right information to the most of the times. but now. Advent of modality So now it has become even more improved. so there is your hub City and so MRI, which is much more sort of complete now when it comes to cardiac surgery, so we have to make sure that whatever the defects in terms of on table and post-operative has the repair been adequate hasn't been good and are there any complications significant or non significant in terms of a lesion residue. And the mild moderate to significant has the reticular function improved or is it sort of reduced because of any coronary issues and even if they are there, the idea is like you do they sort of have any hedy consequences on cable are they causing any ironic consequences or the thinking would be as if five theaters left alone because of some constraints are not going any further in terms of surgery if it is left alone. Be a consequences later on or is it sort of going to close so based on this is going to be a tool which can sort of give information to be so and but the real problem is a post op is always the things can go wrong as the really tiny infant where the the the The window is very, very sort of limited, so it can be very difficult when you have these multiple lines, you have the chest tubes and you have the throttle extensive dressings, which sort of. Approach and this is where the balance has to be made and with the right information is being provided or not and time when you have been called for a card and hypertension the immediate clinical sort of suspicion, both from the surgeon side and from your side Post-operative is is there any cardiac time for that? so it should be sort of immediately be looked into and if there is AP, What is the location? What is the size and what is the extent and then can it be sort of? Needs to be exploited and so this is where Echo can be helpful if it is going to be tapped so eco can guide the synthesis. The real challenges and the assessment of when there is a problem with the culinary flow. so this is when the problem starts, and we're unable to sort of get the right information so looking at the flow and also to look at a function so RV function is a key sort of a parameter and sometimes we just don't get it right and we sort of get ourselves into trouble in in being unable to assist the RE function because it has its own challenges and also the dynamics if you have to be aware of the dynamics, the hems What happens post Operatory and also. Can be difficult when there is a distant obstruction which we are not able to see properly and when you have these arrhythmias, which are happening so you have to find out is it because of any coronary artery that is sort of having being sort of you know compromised or is there a line which is sort of causing this or is there a mass which is causing this? so I can be sort of helpful to flow can be difficult, but an item should be made and the line also can be difficult, but at least a mass in terms of. What what it is causing you so the mask is usually a. especially when you have a low flow in the heart. That means you have a low stroke volume and a low cardiac output, and if there's any localized, you know spaces, for example, if the chamber is dilated or if there is a localized spaces, then this can trigger a traumas and if it is there, it is going to get bigger and it will cause compression and it can cause it's own problems so in addition to that a patient can have not just these. No status and other triggers it can they can also have or they can have their own plotting disorders. so this one should be pre operative or during a surgically. maybe it might have been missed and if it comes then the formation is going to be quite there and then you have to be have a high sort of suspicion to look for a promise and what should be also be aware of where to look for it and if you do look at the mask, it has to be sort of a differentiated. If so many times, I know that it can be difficult so. Is it an artifact? or is it some normal radiance so normal radiance can be sort of confused and they can be sort of thought of as a mask and also echo can be useful when suddenly patient has some sort of a downward trend and then is there a PH which has happened on the hypertension, which is unanticipated so this can be a problem. then in ASD closure surgery so. for any residual and a sort of look at for contrast to see. Seen on the other side and more importantly to look at any function, which is affecting the mitral valve. so in terms of the especially the osteo primal meds. so what is the status of the MMR? has it reduced? Is it still there is it the residuals even if it is residual sort of should be ignored now, or is there a flaw obstruction if the repair has been done? has it been too sort of aggressive is the orifice to sort of small? So this is. In terms of the primary, and in the SVT, all the veins brought back into a without any problems is there any narrowing in terms of the itself or in terms of the SPC, which has become narrowed because of the railroad. So the flow can be turbulent by the sort of velocity can be a little high, but many of times this can sort of settle down post-operative so we have to be careful before. Sort of say that there is some sort of an obstruction you have to be following on today's and sometimes there is a patch when there is a high peer pressure. so they acts like a pop pop pop out well so this the savage what that is intentionally luck and whenever the pressure builds up, so this acts like a valve and it opens up and let's the pressure out of the chamber. So this is something that you should be aware of then you have. We as the closure so it's disclosure doctor for a shot and even if it is that is it acceptable so many times small VST flows respirators. We don't really bother. We know that we can sort of. clothes are shut out and if you think it is too significant definitely then the KPIs are looking at the blood analysis has to be made and if it is sort of quite significant where it is going to be a problem in terms of he dynamics, then it has to be explored and also one can look. The by the by the the BS checked so so looking at the graded and begin to look at the abs, whether it would be the. after the and then we have the reticular function, which has to be looked into a Cds. so the Austin primal defect. I'm looking at any PF force looking at any ad looking at any straddling cords the we've the right of the valves and then the cleft the. So this is pretty obvious assessment and then the functions and also the presence of LSPC, which is important to post operative can be a problem so that is again which should be mentioned. and of course, we're all very very well aware of what would be the type of the ABCD so the sergeant knows when he's taking it and post-operative as they've been a good closure. so I need a and even if there has been a part of the. how sort of how good is the floors. Stenosis is there any collapse is there any flame and this degree of education sort of alerts us and makes us look at it more closely and this is something we should be looking at and also look at the person and even function so my last few slides and I know that I'm sort of all my time. next is the top so nothing about the top of because you know we will have top is so most of the points here are in the top post office so here the real sort of pain and and the grief that happens is because the artery function so we have to look very closely when you're monitoring what. The systemic function and also the Dias function that can be multiply is why these things can happen and but we we should be alert to it and the moment we see it We should start looking at what is it possible and post offices and the PD again repeatedly look at it and especially when the pressures come down the it can start on a PBS DS and this is where it was helpful. So look at the look for BST repeatedly in the main sort of repair has been done and. To look at the RV of the obstruction also as the obstruction being delayed and the RV pressure if it is more than two thirds of the systemic, then one has to alert the surgeon and say that to the expiration is needed and. for me. sort of look at the conduit function and any PO and what is the direction of the flow again tells us what is happening to the dynamics and to look at the function. Also so the RTG is the DTG here closure of the ATVs and obstruction of the Arctic and osmosis. we're looking at the reticular function and marks and. A PVC is obviously the antes of the TV conference in the LA has to be sort of that's most of the time it seems to identify and again just like in PA, we see there can be pseudo obstruction so we have to be careful not to diagnose that something is wrong with the. here so and then to look at any sort of if there has been a proposal of the ASD and then look at PH and then also to look at the reticular functions. Closure conduit the valves, stenosis or regurgitation, and to look at the septum and then with function and also to look at flow. So this is how one can look at these various can come to a conclusion as to what would be happening at the time of the intervention or at the time of surgery and also post procedure. What are the problems and the procedure we've already looked at it in a way. I don't really focus on so. I'm sorry I apologize for sort of really all my time. Thank you for your kind patience. Thank you. Doctor Sosa for your enlightening and entertaining presentation on the right way. How to apply. for our PT. practice and clinical decision-making during our intervention as well as surgery and follow up now I request all respected finalists to make any comment on the topic. I shrunk there is some question you know. three questions are there so you can read these questions on behalf of the. participants. I'm out. the what is the type of device is ideal to close RSOV. The name is mentioned the name of question are also. This the type of device will depend upon how the sizing of the story is, and where it's location is so I really don't want to go into the interventional side of it, but I just want to focus mainly on the how one can look at it in terms of Echo so it is important that when you look at the RSO, what is the size and where is its location? and what is the distance it is in terms of the culinary A. And based on that the devices are decided and the size of the devices are looked into. so I think that would be a better way of looking at it rather than giving a very simplistic answer that this would be the device. An exclusion from the doctor. would you please focus on tagging and of different to and for you whenever the place is required. Could you I'm sorry? Could you please repeat that again? we focus on siding and of the different paths. Timber timber is required so this is which. disease which you are mentioning. probably the I think is of our LT. or Mi. The sizing is it is that what you yeah. Yeah. Okay. So then here again. it will be the based on the analysts sizing. That is how the whole process is and again how the how much the stenosis is and it ultimately comes down to the analytics. So if that is what you are trying to ask in terms of the vibes. Thank you for the excellent presentation. This is doctor at the. Would you please tell me the in case of VD with pulmonary hypertension in EC? Cardiogram? What are the factors we have to keep in mind whether the patient is operable or not that is without the cat. How can you guess it may be this patient that we can do the operation and we can come out of the surgery. into the hypertension or and again the hypertension. Want us to look at the traditional parameters? so of course, you can get a good alignment as far as the PSD is concerned so the gradient will be there so based on the peak gradient and the systemic systolic pressure so that will give you an idea of what is the RV systemic pressure is going to be and if that is not a, you know what sort of conducive in terms of the jet, then one can look at the Tris regurgitation. as. Secondary way of looking at in terms of the PSP and the other additional point, which one can look at in terms of it's not a quantitative tool, but it can be reasonably reliable is that one can look at the acceleration time where you can put a sample in the RBOT and look at the exhalation and anything sort of less than around 70 milliseconds. sort of tells you that the peer pressure is fine, You don't have any different number here but. That sort of tells you that the is quite high, so these are the three ways but. beyond this, it can be a little tricky. The others are all nonspecific in terms of looking at the RV size or the flattening of the spectrum. so those are quality areas where you know that it has advanced quite a lot. I would I think of civility doesn't work at all. It is not a very reliable one. I would be very hesitant to sort of to go by this one. The and the is quite big and then the the size is high and the patient's symptoms are there so it the Echo can just give you a rough idea. but when the if you. it is so when you sort of feel that it is going to be quite tight, then it is not very good to rely purely on it and one is look at the cat as such as an alternator. Thank you. Doctor Abdul What is the matter? what is the majors? It's a child. the second floor of a deployment. which device would you be talking. So I think. a device. BST device after it is put in what would be the question again. Could it be repeated? I'm very sorry. It's there's a lot of noise here, which is coming so I'm not even here. Okay now you can see the chair. also by yourself. huh from you can see the mall. you can. click the more and you will see the question by yourself. Okay. I can see the chart here. yes, but I don't see the questions. here. Of the analysts again the you can look at the shorts or you can look at the pass and long access outflow of view, but again going to be useful in terms of the Arctic and the analyst and when it comes to nothing beats the view and since we expect the Highlanders to be eso so to. Measurements should be taken in terms of the vital analysts both in the long axis and in the chamber. so this is what the Mi well for the aortic district come back to the aortic, so this is going to be long axis One new, which is again not reliable, so I sort of try to use the or the view, which is there with the machine, which is a threed, and this gives me both sections. So this gives me both the and and that gives me. Sort of comfort that my sizing is quite okay, that is for the ionic and as I told you earlier so that is the one and. Now that that would be the sizing is that. anything else. another question. That is that. What? does measure? if the child developed first? 1.° or 2.° artwork, Of course, the TPI is always going to be there so we'll have to sort of relocate the size of the device or where the positioning of the devices happen and the if it's going to be a big problem in terms of the block. getting to be worse than the TPS has to be switched. But in in in terms of how we can sort of avoid that is to reposition or to relook at where the position of the devices, whether it is. Salvador, I think there's no question. and now I request the panelists if they can have any comment on that. It's not the I'm sorry if I can interrupt. I think there's one more question when do you ask the surgeon for alas, non of. Valve with severe TR? This again is something which has to be the band has to be measured in the chamber view that would be the one which is a lot of data and this is one measurement and then this has to be. this has to be spread to the body sufficient so based on that I don't exactly remember the number for the cut off but the full view and then the body surface area and based on the cut off one can say that either the patient is in favor needs. So I think that's all about the question answer. We are fasting doctor so so we have to break our fast. okay. I understand I am Yeah II would like to thanks everyone for participating just two sentences. I just want to add actually videography is the very important. investigation for purpose for like to see the indications of the intervention or surgery and in the. To see whether the operation of the intervention is going on properly or whether there is any. any complications is going on there and then in post-operative period is paying for the surgery and for the intervention so in preoperative period and post-operative period. is fine, but for the operative and interventional doctors. The fusion emerging with the with like. a fusion or some other things than Emma and and threed fourd ecard so all these are good for the operative assessment with the operation or the intervention is going on properly or not. but for the preoperative and for the post operative for seeing the indications and for seeing the result of the operation and for to see the complications of the operation. And interventions. is still very good and it is the gold standard. so and again indication is changing day by day when we started doing. BS. devices at that time, only muscular BSD was the indication. then we started doing PM DSD then we are now doing even committed and even with the pros we're doing some cases with the ups also so indication. Are changing every day before we are doing a closure for only for the second time. nowadays, people are doing sinus also so. the cardiologist they have to update them every day because the interventions are coming new surgical options are coming. It is the duty of the pediatric cardiologist actually to help the interventionist and also the sergeants. in the lab in the operation Theater so that they will be able to see whether there is any complications going on or where everything is going in right track or not So with this, I'll just want to conclude and if anybody want to say anything from the panelist can say thank you. Abdul Salam Greetings from Bangladesh and it is an excellent. delivery from you. It was crystal clear and Lucid and and illustrated and it was thought provoking also, as well as. you know first Lecture actually not for the beginners, which I think. really I like to thanks to the congenital hearts of deaths of Bangladesh. Particularly and as well as the health group India for arranging wonderful. webinar on congenital heart disease. you have nicely described many things very vast topics in a very concise and comprehensive way I really enjoyed the Lecture really illustration and other things. A small caution to you that is in case of failing font. circulation. How do you assist with eco the way the patient? may require a surgery or for go for heart transplant number one number two in case of power. eco. or else. Do you use the transit or sometimes you do ecard. In beating heart. And I'd like to know from you. Thank you yes for the failing Fontana right now the A modality is what we use as the MRI so. to a large extent the MRI sort of really tells us what is happening and because of it's excellent special resolution and the information that is provided so the dependency on MRI's quite right and that is a decision taken on that. And the second question is that about the EP. epileptic isn't it. That's what you ask me. and as far as it is. ecard. is open in yes. on feeding Heart. it is very very rarely used I. First, you've done it just you know twice and I don't remember when I last did it. Because most of the times we do have the trans. Echo, which can provide you, you know some really good information so use of. the PT. robe itself on an open chest. I would say it is quite limited at the most maybe one can look at it in terms of an aortic in terms of looking at the Arctic finals. the cancellation at that point of time, but. Is quite simple. It's quite useful, I would probably speak to that. it's particularly for revelation of. of. and are not. is. so in that case it is useful we used to use the probe in ecard. surface and we we do a versatile Heart. We're synchronizing with your hands. You're a wonderful option. Thank you. Thank you. Thank you very much. so you can sir what do you want to see in TEE? That is a chance? eco in technological surgery? So what do you want to see here? that we can be viewed by the P. as well as the primary. MPA. you can easily visualize As a result, you're going to see the disclosure whether it is optimal or not is there any chance? You can see. nicely and he's the SD. and there is a chance to the. very nicely. Yes, I am I wonder what you can see from that he that whenever the. was not available in my center in those era, sometimes we used to use the ipad or the very small baby, maybe two kilograms the teeth or we can't put in, but I think most of the. Nowadays by the Anyone can be used anyone can be used, according to the Asian size as the availability of the probe, as well as the options you are having your hand but you must appreciate the operative and post-operative. evaluation of cases for better outcome. That is the issue. Thank you. thank you that we have. that we have any comments to make in short. Thank you all thank you for participating. Thank you all. it's real pleasure interacting with you. Thank you very much. Kareem. thank you doctor. Thank you for your two lectures. Those are very interesting and we'll be very helpful for our fellows. It's really important. Thank you for giving your valuable time. Thank you. Thank you. Thank you. Thank you. Bye. thank you very much. Thank you very