Expansion over the last decade of minimally invasive and catheter-based therapies for cardiac disease has resulted in the creation of a multidisciplinary “heart team.” Functioning within this team, the peri-operative echocardiographer’s role has also evolved from providing monitoring services to the salient role of guiding interventions. This evolution combined with growing pressure for increased efficiency has fostered innovation in perioperative echocardiography. A few novel technologies recently attracting attention include: 1) the co-registration of multi-modality imaging, 2) stereolithography, and 3) the use of artificial intelligence platforms to sharpen accuracy while increasing precision of interpretations as well as improving work-flow.
Fusion Technology
Specifically, three-dimensional transesophageal echocardiography has assumed the role of a vital procedural adjunct. Due to the “open” nature of a traditional cardiac surgical procedure, every echocardiographic “finding” reported by the echocardiographer is visually confirmed by the surgeon. With limited or no access to the intra-cardiac structures, 3D imaging is used to assess suitability, for procedural guidance, confirm success, and exclude procedure-related complications. The quickly evolving percutaneous interventions for structural heart disease are largely driven by improvements in 3D cardiac imaging. Flouroscopic imaging is devoid of depth perception, and interventionalists depend upon the simultaneous display of 3D echocardiographic and fluoroscopy for real-time guidance. Real-time guidance required during percutaneous interventions is at the crossroads of these imaging techniques. Fusion imaging that is based on co-registration of anatomical landmarks results in simultaneous and overlaid echocardiographic and fluoroscopic images. This is likely to simplify spatial orientation and enhance communication during procedural guidance.
Stereolithography
The technique of stereolithography (STL) and fusion deposition modeling more commonly referred to as “3D printing” has the potential to significantly improve operator performance and techniques. In addition to CT and MRI, 3D echocardiographic data have also been used to generate high fidelity patient specific models of cardiac anatomy. These 3D models are “tangible” and superior to digital projections of 3D anatomy on a flat surface that are devoid of any haptic perception. Such patient specific anatomical models can be used as “task trainers” prior to the procedure and be used for de-briefing and practicing the observed surgical procedure. With no risk to the patient and no consequences of failure, a procedure can be practiced multiple times by trainees. This technology holds promise for procedural planning in a variety of clinical contexts such as myectomies and mitral-clips.
Artificial Intelligence
With the ever-increasing constraint for resources, the importance of efficiency and focus on workflow has grown. Artificial intelligence platforms now assist the user in the quantification and interpretation of images allowing users to complete their exams not only more quickly, but also with greater consistency between users and possibly greater accuracy. No longer is it necessary to trace spectral tracing by hand. Platforms now can trace and average multiple spectral tracings measuring velocity time integrals and peak gradients instantaneously. For more complex structures such as the mitral valve, artificial intelligence packages now allow for largely automated real time 3D models and dynamic analysis of these models in the time sensitive environment of the operating room where this was not previously possible. This has become particularly important useful in sizing mitral valve rings during mitral repairs and measuring aortic valve annular areas. Artificial intelligence has also been applied to largely automated quantification of flow and regurgitant volumes by 3D color Doppler.
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