eSie PISA™ Volume Analysis 5.1 software release-US

Welcome to the Siemens Healthineers eSie PISA™ volume analysis tutorial. Before we begin, I would like to introduce myself. I will be your guide to help you understand the information presented in this tutorial.  During the course, I will be giving you a lot of detailed information. This tutorial has more information in the form of links placed on the page. To successfully complete this course, please view all available content. We hope you enjoy our tutorial. Click on the right ► to continue.   Upon completion of this tutorial, you will be able to:   Understand the PISA calculation   See the advantages of using 4D volume imaging for PISA   Apply the workflow for eSie PISA analysis Within this tutorial I will help you understand how and why the use of the eSie PISA analysis is useful.    eSie PISA analysis uses four-dimensional (4D) volume imaging and color volume data sets. This use of 4D volume imaging removes all geometric assumptions that are inherent in the 2D PISA method.    eSie PISA is used with either a 4D volume imaging Volume transthoracic echocardiogram (TTE), or transesophageal echocardiogram (TEE) dataset. Proximal Isovelocity Surface Area or PISA calculation allows measurement of the effective regurgitant orifice area (EROA). This group of measurements estimates the functional size of the perforation(s) in the valve. The PISA calculation can be used on any valve that has regurgitant flow but is commonly used with the mitral valve (MV) for evaluation of mitral regurgitation (MR) severity.    Learn more on how traditional PISA calculations are derived by clicking on the icon below. Traditional PISA Calculation Learn More about PISA Calculations Tab TitleTextContinuous Wave (CW) DopplerA  CW Doppler signal displaying peak mitral regurgitation (MR) wave form. Measure the velocity time integral (VTI).   ​Measure the max velocity of MR (Vmax). ​​Ensure measurement is in alignment of peak MR flow for highest velocities. Color Doppler Display the color Doppler flow image at the peak flow convergence.   Using this method is more effective for central regurgitant jets.   ​The flow convergence area appears as a hemispherical dome.  There is an assumption with this 2D PISA method that the flow convergence is hemispherical in shape.  This can often overestimate or underestimate the effective regurgitant orifice area (EROA) calculation, especially during secondary MR where the flow convergence area can appear crescent shaped.                                         Adjusting the Color Velocity Scale Once the ideal frame is found; (displaying the largest flow convergence), shift the color flow velocity baseline towards the flow of the regurgitant jet. Move the color flow velocity bar to approximately 30 cm/s down below the baseline for TTE and up approximately 30 cm/s above the baseline for TEE - In the direction of regurgitant flow. This technique will help define the flow convergence as a hemispherical shape.  At this point measure the radius of the flow convergence from leaflet coaptation to the top of the sphere.   As seen in the examples below, the flow convergence is easier to identify after the color velocity baseline is shifted. ​          Color velocity baseline shift defines flow convergence    Formulas PISA Calculation VFR = 2 *  π  * r2  * Vr       VFR units mL/s ERO = VFR / Vmax            ERO units mm2 RVol = ERO * VTI        RVol units mL   The following is a very simplified explanation of hemodynamics and pressures within the heart. The hemodynamic transference of blood from the left atrium, (LA) through the MV and into left ventricle (LV) will be referred to as the load or the volume of oxygenated blood that is available to be pushed out to the body through the left ventricle outflow tract (LVOT). A perforation or a lesion that occurs in the MV, allows oxygenated blood to flow back into the LA as the pressures change between ED and ES cycles, reducing the amount of new oxygenated blood allowed to enter into the LA during the diastolic phase.  This reduces the volume of oxygenated blood delivered to the LV and out to the body through the LVOT.  To compensate for this occurrence, the heart increases pressure to try to compensate for the reduction of oxygenated load available to the body. As the pressure is increased in the LA, the appearance of a flow convergence is seen with color Doppler on the opposite side of the regurgitant jet. Systolic Phase Systolic Phase Systolic Phase:  There are two systolic phases within the heart:  atrial systole and ventricle systole.                             In atrial systole the pressure rises in the LA from the entry of oxygenated blood from the pulmonary veins, the atrial muscles contract from the superior portion toward the atrioventricular septum.  Pressure rises within the LA and the MV opens, (represented by the E wave).  At the start of atrial systole, the LV normally fills approximately 70-80%.  Atrial contraction then occurs (represented by the A wave) and contributes to the remaining 20-30% of LV filling.   The AO valve is closed at this time.   In ventricular systole: the LV pressure raises, but not enough to open the AO valve.  The increase of pressure causes blood to flow back toward the atria causing the MV to close.  As the ventricular enters into the second phase of ventricular ejection, the LV muscle contracts to raise the pressure within the ventricle.  The AO valve opens and oxygenated blood pumps out the LVOT to the body.  The difference between the blood expelled from the LV and the blood remaining after contraction is called the stroke volume (SV).                       Diastolic Phase Diastolic Phase As with systole there are two diastolic phases between the ventricles and atriums.    In ventricle diastole the LV muscle relaxes and pressure begins to drop.  The AO valve closes to prevent backflow of blood into the LV.  With the valves closed there is no change in the volume of blood in the LV.     As with systole there are two diastolic phases between the ventricles and atriums.  In ventricle diastole the LV muscle relaxes and pressure begins to drop. The AO valve closes to prevent backflow of blood into the LV. With the valves closed, there is no change in the volume of blood in the LV. In late ventricular diastole, the LV muscle relaxes and pressure within the ventricle drops. Eventually, the LV pressure drops below the arterial pressure. As pressure drops within the ventricles, blood flows from the pulmonary veins into the relaxed atria. This is considered atria diastole phase.   Flow Convergence Flow Convergence Note that while the MV is closed in this TEE volume image, the MV leaflets do not fully coapt.  There is a formation of a flow convergence into the LV. The flow convergence is an area of increased flow velocity before the regurgitant orifice.  This appearance of the flow convergence occurs at the maximum velocity of the regurgitant flow. Summary Summary With the changes between systolic and diastolic cardiac phases, it is important that the maximum amount of oxygenated blood is delivered to the body.  Within the normal heart cycle, a normal SV delivers approximately 70-80 mL of blood from the LV. In the event there is a perforation or a lesion in the MV, it will allow blood to leak back into the LA from the LV.  This reduces the amount of area in the LA for newly oxygenated blood from the pulmonary veins, and reduces the SV from the LV. Example: Example of Flow Convergence An example of this increased velocity can be represented by narrowing the opening on a garden hose output with your thumb. The velocity of water coming out of the hose will increase in velocity, but the amount of water traveling through the narrowed opening is reduced as the hose opening is narrowed.  The water behind this narrowed area builds pressure, slows and becomes turbulent.  Similarly, the size of flow convergence corresponds with the size of the regurgitant orifice.  This is the principle behind using the flow convergence size to quantify the severity of regurgitation. The convergence is the slowing of blood before a pressurized leak back into the LA through the regurgitate orifice of the closed MV. The blood slows at the narrowed opening and creates the domed appearance of the flow convergence along the surface of the valve at the orifice. As the flow convergence area increases so does the severity of regurgitation. The use of the eSie PISA analysis tool can simplify obtaining this group of complicated measurements as well as deliver more accurate results. There are two acquisitions needed to complete the eSie PISA analysis package. The acquisition of the peak MR with CW Doppler and a 4D volume imaging with color volume dataset acquired in real-time (single beat).   The volume rates and volume size often are acquired with one click on the ACUSON SC2000 PRIME ultrasound system.  The advantages of this practice is: A volume data set will remove all geometric assumptions that can be made using 2D imaging. The whole LV and LA are acquired with color Doppler so the need for multiple views is eliminated. Eccentric and/or multiple jets location and severity can be more readily captured and evaluated within the volume data set. The eSie PISA analysis tool is available with both TTE and TEE imaging utilizing both color flow volume and tissue volume acquisition. The eSie Measure™ Analysis package can be used to measure one, two or three spectral wave forms. Volume Acquisition Volume Acquisition While this tutorial does not address the technique of acquiring a 4D volume data set, there are other tutorials available that do . While the ACUSON SC2000 PRIME™ ultrasound system does simplify 4D volume acquisition, there are other tools that are useful. Please look for other tutorials that will cover 4D volume acquisition as well as Job Aids and other applications that may help simplify a departmental workflow. TEE is an exceptional and accurate tool to evaluate patients that are hard to image, or need further planning for future surgical interventional procedures.  The Z6Ms True Volume TEE transducer allows the use of the eSie PISA volume analysis tool during the TEE examination.   The calculation of PISA is the same regardless of acquisition methods, (i.e. TEE or TTE); however there are often variations in results between those completed with 4D volume imaging Volume TTE and those completed with 4D volume TEE.  These differences are due to both physiologic and technical factors.    Anytime there are serial measurements using eSie PISA it is recommended to perform them with the same transducer and with the patient in the same physiologic state. TEE and TTE Results Understanding the Differences Tab TitleTextTechnical TEE transducers use higher imaging frequencies than TTE.  This changes the pulse repetition frequency (PFR) and the signal strength. Higher resolution and closer proximity to the MV make MR evaluations easier. The TEE examination is favored to evaluate MR severity in patients in whom TTE is inconclusive or technically difficult. Physiologic Patient Stress is a large factor in hemodynamics. During the TTE examination the patient has many stress factors added to the examination, (i.e. multiple exams for the day, walking and traveling to the facility). Blood pressure should be documented for exam results to identify physiologic changes in the patient. PISA results change with beat to beat variances (i.e., atrial fibrillation, irregular rhythm). The eSie Measure package for Doppler allows multiple spectral waveforms to be measured.  The resulting calculation is an average of the output instead of an instantaneous velocity of one of the varying spectral wave forms.Sedation versus Non-sedation The physical state of the patient between TEE and TTE examinations can change the results. During the TTE examination the patient is fully awake and non-sedated.  This environmental exertion can change the hemodynamics giving varying results. During the TEE examination the patient/s environment is much different.  Patients are moderately to heavily sedated, which in turns changes their hemodynamics.  This change can give lower PISA results when compared to the TTE examination. Summary With these challenges in mind, the user needs to appreciate the variances in hemodynamic load factors and why there may be variation in results.  Some of these factors are differences between equipment used as well as the environmental factors exerted on the patient. So, now that you understand the fundamentals of traditional PISA analysis, let's discuss how you can utilize the eSie PISA analysis package.   The MR measurement can be obtained from an image in review, or taken during acquisition of that image during the exam.  Both methods work.  Following your standard protocol to quantify MR, optimize the CW Doppler sweep.   Press Freeze Bring the active pointer within the spectral Doppler or image area.  Press the Next Control (right click) to bring up the eSie Measure™ workflow acceleration package. Using the active arrow point to MR Flow from the measurement list and press the Select control. The MR VTI and the VMax will be measured automatically.  Results will be displayed in the calculation list and entered into the report page. Press Image Capture. ​Click on the Measurement of MR control to view a video of these steps. Measurement of MR Example Measurement of MR Example Instructions:Flash File:/content/generator/Course_90021207/ESIEMEASDOPPpg9.mp4HTML5 File:/content/generator/Course_90021207/ESIEMEASDOPPpg9.mp4PDF File: The 4D color volume data set can be obtained real time, reactivated from thumbnails, or from Review. After choosing the 4D color volume data set to be used, proceed to these steps. Press the Next (right click) Control.   ​Choose PISA from the menu and press Select   ​ Volume is opened in review mode.    On the right side of the screen is a complete set of instructions to perform the PISA calculations.                                      ​Click on Activating the eSie PISA package example to see these steps. ​ Activating the eSie PISA package Activating the eSie PISA package Instructions:Flash File:/content/generator/Course_90021207/ActivatingeSiePISApg10.zipHTML5 File:/content/generator/Course_90021207/ActivatingeSiePISApg10/ActivatingeSiePISApg10.mp4PDF File: Congratulations.  You have completed the eSie PISA™ Volume Analysis, 5.1 software release Online Training course.  Listed below are the key points that have been presented.  Take time to review the material before you proceed to the final quiz.  Here are some key learning points: Understand the PISA calculation   The advantages of using 4D volume imaging for PISA   Apply the workflow for eSie PISA analysis   The differences in results derived between TEE and TTE. Select the link below to print your review material before proceeding to the final quiz. eSie PISA Course Review If you have enjoyed this Online Training course, look for other technical review tutorials for more courses similar to this one. PISA - Proximal Isovelocity Surface Area MV – Mitral Valve MR – Mitral Regurgitation CW – Continuous Wave Doppler PW – Pulse Wave Doppler CDI – Color Doppler Imaging EROA - Effective Regurgitant Orifice Area 3D – 3 Dimensional Imaging 4D – 4 Dimensional Imaging – real time volume imaging TEE – Transesophageal Echocardiogram TTE - Transthoracic Echocardiogram PRF – Pulse Repetition Frequency LV – Left Ventricle LA – Left Atrium MPR - Multiplanar Rendering RVol – Regurgitant Volume Further reading for your reference on PISA calculations. *W. A. Zoghbi M. Enriquez-Sarano E. Foster P. A. Grayburn C. D. Kraft R. A. LevineP. Nihoyannopoulos C. M. Otto M. A. Quinones H. Rakowski , American Society of Echocardiography: recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography, W. J. Stewart A. WaggonerN. J. Weissman *de Agustin, J. A., Viliani, D., Vieira, C., Islas, F., Marcos-Alberca, P., Gomez de Diego, J. J., .Perez de Isla, L. (2013).Proximal isovelocity surface area by single-beat three-dimensional color Doppler echocardiography applied for tricuspid regurgitation quantification. J Am Soc Echocardiogr, 26(9), 1063-1072. doi:10.1016/j.echo.2013.06.006   *Grady L, D. S., Kutter O, Duong C, Wein W, Little SH, Igo SR, Liu S, Vannan M. Regurgitation quantification using 3D PISA in volume echocardiography. Med Image Comput Comput Assist Interv.   *Kato, A., Sandoval, J. P., Mroczek, D., Chaturvedi, R., Houle, H., Georgescu, B., . . . Lee, K. J. (2018). Automated 3-Dimensional Single-Beat Real-Time Volume Colour Flow Doppler Echocardiography in Children: A Validation Study of Right and Left Heart Flows. Can J Cardiol, 34(6), 726-735. doi:10.1016/j.cjca.2018.03.001   *Sampaio, F., Ladeiras-Lopes, R., Almeida, J., Fonseca, P., Fontes-Carvalho, R., Ribeiro, J., & Gama, V. (2017). Three-dimensional proximal flow convergence automatic calculation for determining mitral valve area in rheumatic mitral stenosis. Echocardiography, 34(7), 1002-1009. doi:10.1111/echo.13558   *Sidhu, R. S., Tyrrell, B. D., Welsh, R. C., Meyer, S. R., Shanks, M., & Bainey, K. R. (2018). Transcatheter Mitral Valve Intervention for Chronic Mitral Regurgitation: A Plethora of Different Technologies. Can J Cardiol, 34(9), 1200-1209. doi:10.1016/j.cjca.2018.04.034   *Thavendiranathan, P., Phelan, D., Thomas, J. D., Flamm, S. D., & Marwick, T. H. (2012). Quantitative assessment of mitral regurgitation: validation of new methods. J Am Coll Cardiol, 60(16), 1470-1483. doi:10.1016/j.jacc.2012.05.048   Thavendiranathan, P., Liu S., Datta S., Rajagoalan S., Ryan T., Igo S., Jackson M., Little S., Michelis N., Vannan M.(2013). Quantification of Chronic Functional Mitral Regurgitation by Automated 3-Dimensional Peak and Integrated Proximal Isovelocity Surface Area and Stroke Volume Techniques Using Real-Time 3-Dimensional Volume Color Doppler Echocardiography In Vitro and Clinical Validation. Cardiovasc Imaging.  Doi:10.1161/CIRCIMAGING.112.980383. Please note that the learning material is for training purposes only!   For the proper use of the software or hardware, please always use the Operator Manual or Instructions for Use (hereinafter collectively “Operator Manual”) issued by Siemens Healthineers. This material is to be used as training material only and shall by no means substitute the Operator Manual. Any material used in this training will not be updated on a regular basis and does not necessarily reflect the latest version of the software and hardware available at the time of the training.   The Operator's Manual shall be used as your main reference, in particular for relevant safety information like warnings and cautions.   Note:  Some functions shown in this material are optional and might not be part of your system.   Certain products, product related claims or functionalities (hereinafter collectively “Functionality”) may not (yet) be commercially available in your country.  Due to regulatory requirements, the future availability of said Functionalities in any specific country is not guaranteed. Please contact your local Siemens Healthineers sales representative for the most current information.   The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority. Offenders will be liable for damages.   All names and data of patients, parameters and configuration dependent designations are fictional and examples only.   All rights, including rights created by patent grant or registration of a utility model or design, are reserved.  The reproduction, transmission or distribution of this training or its contents is not permitted without express written authority.  Offenders will be liable for damages. All names and data of patients, parameters and configuration dependent designations are fictional and examples only. All rights including rights created by patent grant or registration of a utility model or design, are reserved. ACUSON SC2000™ PRIME ultrasound systems, eSie PISA™ volume analysis and eSie Measure™ workflow acceleration package are trademarks of Siemens Medical Solutions USA, Inc. Copyright © Siemens Healthcare GmbH 2019 Selecting the ► continues this course and confirms you have read and understand this disclaimer.   …………………………………………………… Siemens Healthineers Headquarters Siemens Healthcare GmbH Henkestr. 127 91052 Erlangen, Germany Telephone: +49 9131 84-0 siemens.com/healthineers Over the next several pages we will review function and controls covering Image Menu, Cine and Pan, Seed Point placement and PISA Analysis.   eSie PISA Workflow Image Menu Example Instructions:Flash File:/content/generator/Course_90021207/PISAactivateBaselinepg(1).mp4HTML5 File:/content/generator/Course_90021207/PISAactivateBaselinepg(1).mp4PDF File: Image Menu Learn more about the Image Menu Tab TitleTextImage Menu On the Image Menu; (located on the left side of the screen), there are tabs.  These tabs help the user to navigate quickly to the function needed.       Volume Review Image Format is located under the Volume Review Tab, first icon.  Choose the image format needed. The second icon will activate the axis markers on the MPRs. The X, Y & Z planes can quickly be aligned by centering the axis markers on the location of the flow convergence.  This can be quickly accomplished by pointing to the flow convergence area on the MPR with the active arrow and pressing Select.  This quickly aligns the MPR plains with the flow convergence.  The individual planes can be angled to align with the MR Flow if needed. This alignment can assist with eccentric jets.                                                                             Initialization Under the Initialization Tab, use the drop down menu to identify which valve you are performing the eSie PISA package on.  Choose MV from the drop down menu on the Initialization Tab if not already active. The Color velocity baseline can be shifted from this tab, or on the control panel of the ACUSON SC2000 PRIME ultrasound system. Use the up or down arrows to adjust baseline accordingly.                                                                  The icons on this page continue the eSie PISA workflow.  There are video examples for each function. Cine & Pan eSie PISA Workflow Continued Sample IntroTitleTextCine & PanTab TitleTextCine & Pan Use the Cine control to select the frame that shows the flow convergence at its largest.  The movie controls will stop or start the Cine loop.                                                                                                                                     Activate the pan tool by pressing Select when active arrow is within the volume image.  ​This will allow panning through the volume with the scroll wheel to find the flow convergence at its largest.  This can help with accuracy of modeling. Seed PointTab TitleTextSetting the Seed PointSet the seed point on the volume image (this step is automatically ready and is indicated by the arrow displaying as a green dot when the active arrow is moved over the volume image).   Set the first point at leaflet coaptation by pressing the Select control. Pull or draw the arrow in direction of regurgitant jet using the trackball. Use zoom if needed.   Seed Points can be edited if needed by continuing to press the Select control to toggle between set point and direction.    ​Color overlay can be removed to see leaflet tips clearly. ​ Shift the Color Baseline in the direction of the regurgitant jet if this step is not completed yet. (Down for TTE and up for TEE.) PISA AnalysisTab TitleTextPISA AnalysisWith these steps achieved you are ready to activate the PISA Analysis, located on bottom of the Image Menu.   Analysis results are displayed as well as the multiplanar rendering (MPR) images and the volume.  Choose the Color Cut Plane icon to display the flow convergence in green on all of the MPR’s as well as the flow convergence cast on the volume. This image can be enlarged to view the flow convergence cast modeling better. See PISA Analysis Example 2 for this example. Cine & Pan Example Cine & Pan Example Instructions:Flash File:/content/generator/Course_90021207/PISAcinepg10/PISAcinepg10.mp4HTML5 File:/content/generator/Course_90021207/PISAcinepg10/PISAcinepg10.mp4PDF File: Seed Point Example Setting the Seed Point Example Instructions:Flash File:/content/generator/Course_90021207/SeedPoint.mp4HTML5 File:/content/generator/Course_90021207/SeedPoint.mp4PDF File: PISA Analysis PISA Analysis Example 1 Instructions:Flash File:/content/generator/Course_90021207/PISAanalysis.mp4HTML5 File:/content/generator/Course_90021207/PISAanalysis.mp4PDF File: PISA Analysis Example PISA Analysis Example 2 Instructions:Flash File:/content/generator/Course_90021207/PISflowconv.mp4HTML5 File:/content/generator/Course_90021207/PISflowconv.mp4PDF File: Editing the size of the flow convergence cast is available. Note that editing the size of the flow convergence cast will change the calculation results.  To activate this tool: Edit - Add Tool Click the PISA mesh icon. Select the Add Tool.  The Add Tool has different sizes for precise editing. To activate click anywhere inside of the green flow convergence cast area.  The size of Add Tool can be changed as needed by using the sizing icons.   Edit - Erase Tool The Erase Tool will remove any mistakes or corrections needed when editing the shape of the flow convergence or remove overestimation of flow convergence. To activate click the active icon anywhere outside of the green flow convergence area and the Erase Tool will become active. These tools are controlled with the trackball and Select control. Choose PISA Analysis tab and press Select to update and view results. User can acquire an image of this page; information will be updated on the report pages, or can be exported onto a USB. Edit Tools Editing Tools Example Instructions:Flash File:/content/generator/Course_90021207/EditToolAddpg.mp4HTML5 File:/content/generator/Course_90021207/EditToolAddpg.mp4PDF File: