Towards Patient Specific Mitral Valve Modelling via Dynamic 3D Transesophageal Echocardiography

Mitral valve disease is a common pathologic problem occurring increasingly in an aging population, and many patients suffering from mitral valve disease require surgical intervention. Planning an interventional approach from diagnostic imaging alone remains a significant clinical challenge. Transesophageal echocardiography (TEE) is the primary imaging modality used diagnostically, it has limitations in image quality and field-of-view. Recently, developments have been made towards modelling patient-specific deformable mitral valves from TEE imaging, however, a major barrier to producing accurate valve models is the need to derive the leaflet geometry through segmentation of diagnostic TEE imaging. This work explores the development of volume compounding and automated image analysis to more accurately and quickly capture the relevant valve geometry needed to produce patient-specific mitral valve models. Volume compounding enables multiple ultrasound acquisitions from different orientations and locations to be aligned and blended to form a single volume with improved resolution and field-of-view. A series of overlapping transgastric views are acquired that are then registered together with the standard en-face image and are combined using a blending function. The resulting compounded ultrasound volumes allow the visualization of a wider range of anatomical features within the left heart, enhancing the capabilities of a standard TEE probe. In this thesis, I first describe a semi-automatic segmentation algorithm based on active contours designed to produce segmentations from end-diastole suitable for deriving 3D printable molds. Subsequently I describe the development of DeepMitral, a fully automatic segmentation pipeline which leverages deep learning to produce very accurate segmentations with a runtime of less than ten seconds. DeepMitral is the first reported method using convolutional neural networks (CNNs) on 3D TEE for mitral valve segmentations. The results demonstrate very accurate leaflet segmentations, and a reduction in the time and complexity to produce a patient-specific mitral valve replica. Finally, a real-time annulus tracking system using CNNs to predict the annulus coordinates in the spatial frequency domain was developed. This method facilitates the use of mitral annulus tracking in real-time guidance systems, and further simplifies mitral valve modelling through the automatic detection of the annulus, which is a key structure for valve quantification, and reproducing accurate leaflet dynamics

Fusion of interventional ultrasound & X-ray

In einer immer älter werdenden Bevölkerung wird die Behandlung von strukturellen Herzkrankheiten zunehmend wichtiger. Verbesserte medizinische Bildgebung und die Einführung neuer Kathetertechnologien führten dazu, dass immer mehr herkömmliche chirurgische Eingriffe am offenen Herzen durch minimal invasive Methoden abgelöst werden. Diese modernen Interventionen müssen durch verschiedenste Bildgebungsverfahren navigiert werden. Hierzu werden hauptsächlich Röntgenfluoroskopie und transösophageale Echokardiografie (TEE) eingesetzt. Röntgen bietet eine gute Visualisierung der eingeführten Katheter, was essentiell für eine gute Navigation ist. TEE hingegen bietet die Möglichkeit der Weichteilgewebedarstellung und kann damit vor allem zur Darstellung von anatomischen Strukturen, wie z.B. Herzklappen, genutzt werden. Beide Modalitäten erzeugen Bilder in Echtzeit und werden für die erfolgreiche Durchführung minimal invasiver Herzchirurgie zwingend benötigt. Üblicherweise sind beide Systeme eigenständig und nicht miteinander verbunden. Es ist anzunehmen, dass eine Bildfusion beider Welten einen großen Vorteil für die behandelnden Operateure erzeugen kann, vor allem eine verbesserte Kommunikation im Behandlungsteam. Ebenso können sich aus der Anwendung heraus neue chirurgische Worfklows ergeben. Eine direkte Fusion beider Systeme scheint nicht möglich, da die Bilddaten eine zu unterschiedliche Charakteristik aufweisen. Daher kommt in dieser Arbeit eine indirekte Registriermethode zum Einsatz. Die TEE-Sonde ist während der Intervention ständig im Fluoroskopiebild sichtbar. Dadurch wird es möglich, die Sonde im Röntgenbild zu registrieren und daraus die 3D Position abzuleiten. Der Zusammenhang zwischen Ultraschallbild und Ultraschallsonde wird durch eine Kalibrierung bestimmt. In dieser Arbeit wurde die Methode der 2D-3D Registrierung gewählt, um die TEE Sonde auf 2D Röntgenbildern zu erkennen. Es werden verschiedene Beiträge präsentiert, welche einen herkömmlichen 2D-3D Registrieralgorithmus verbessern. Nicht nur im Bereich der Ultraschall-Röntgen-Fusion, sondern auch im Hinblick auf allgemeine Registrierprobleme. Eine eingeführte Methode ist die der planaren Parameter. Diese verbessert die Robustheit und die Registriergeschwindigkeit, vor allem während der Registrierung eines Objekts aus zwei nicht-orthogonalen Richtungen. Ein weiterer Ansatz ist der Austausch der herkömmlichen Erzeugung von sogenannten digital reconstructed radiographs. Diese sind zwar ein integraler Bestandteil einer 2D-3D Registrierung aber gleichzeitig sehr zeitaufwendig zu berechnen. Es führt zu einem erheblichen Geschwindigkeitsgewinn die herkömmliche Methode durch schnelles Rendering von Dreiecksnetzen zu ersetzen. Ebenso wird gezeigt, dass eine Kombination von schnellen lernbasierten Detektionsalgorithmen und 2D-3D Registrierung die Genauigkeit und die Registrierreichweite verbessert. Zum Abschluss werden die ersten Ergebnisse eines klinischen Prototypen präsentiert, welcher die zuvor genannten Methoden verwendet.Today, in an elderly community, the treatment of structural heart disease will become more and more important. Constant improvements of medical imaging technologies and the introduction of new catheter devices caused the trend to replace conventional open heart surgery by minimal invasive interventions. These advanced interventions need to be guided by different medical imaging modalities. The two main imaging systems here are X-ray fluoroscopy and Transesophageal  Echocardiography (TEE). While X-ray provides a good visualization of inserted catheters, which is essential for catheter navigation, TEE can display soft tissues, especially anatomical structures like heart valves. Both modalities provide real-time imaging and are necessary to lead minimal invasive heart surgery to success. Usually, the two systems are detached and not connected. It is conceivable that a fusion of both worlds can create a strong benefit for the physicians. It can lead to a better communication within the clinical team and can probably enable new surgical workflows. Because of the completely different characteristics of the image data, a direct fusion seems to be impossible. Therefore, an indirect registration of Ultrasound and X-ray images is used. The TEE probe is usually visible in the X-ray image during the described minimal-invasive interventions. Thereby, it becomes possible to register the TEE probe in the fluoroscopic images and to establish its 3D position. The relationship of the Ultrasound image to the Ultrasound probe is known by calibration. To register the TEE probe on 2D X-ray images, a 2D-3D registration approach is chosen in this thesis. Several contributions are presented, which are improving the common 2D-3D registration algorithm for the task of Ultrasound and X-ray fusion, but also for general 2D-3D registration problems. One presented approach is the introduction of planar parameters that increase robustness and speed during the registration of an object on two non-orthogonal views. Another approach is to replace the conventional generation of digital reconstructedradiographs, which is an integral part of 2D-3D registration but also a performance bottleneck, with fast triangular mesh rendering. This will result in a significant performance speed-up. It is also shown that a combination of fast learning-based detection algorithms with 2D-3D registration will increase the accuracy and the capture range, instead of employing them solely to the  registration/detection of a TEE probe. Finally, a first clinical prototype is presented which employs the presented approaches and first clinical results are shown

Echocardiography

The book "Echocardiography - New Techniques" brings worldwide contributions from highly acclaimed clinical and imaging science investigators, and representatives from academic medical centers. Each chapter is designed and written to be accessible to those with a basic knowledge of echocardiography. Additionally, the chapters are meant to be stimulating and educational to the experts and investigators in the field of echocardiography. This book is aimed primarily at cardiology fellows on their basic echocardiography rotation, fellows in general internal medicine, radiology and emergency medicine, and experts in the arena of echocardiography. Over the last few decades, the rate of technological advancements has developed dramatically, resulting in new techniques and improved echocardiographic imaging. The authors of this book focused on presenting the most advanced techniques useful in today's research and in daily clinical practice. These advanced techniques are utilized in the detection of different cardiac pathologies in patients, in contributing to their clinical decision, as well as follow-up and outcome predictions. In addition to the advanced techniques covered, this book expounds upon several special pathologies with respect to the functions of echocardiography

Simultaneous Multiplane 2D-Echocardiography

Two-dimensional (2D) transthoracic echocardiography is one of the most frequently used techniques for diagnosis, management and follow-up of patients with any suspected or known cardiovascular disease. It is based on multiple single cardiac planes taken from standard positions on the chest wall. With the development of the matrix transducer, three-dimensional echocardiography (3D) can now be performed in the routine lab reducing the number of cross-sections needed for the information required. However, there are several challenges for the use of 3D echocardiography in daily clinical practice. The 3D transducer has a lower temporal resolution and the acquisition time is time-consuming often requiring offline analysis. Also as 3D echocardiography is a relatively new technique, it requires extra training and has a learning curve. Recently, a new generation 2D/3D matrix transducer has become available, overcoming some of these drawbacks and even introducing a new image modality called “Simultaneous Multiplane Imaging” (SMPI). This new modality permits the use of a full electronic rotation of 360° of the 2D image (iRotate) and a simultaneously adjustable biplane 2D image (xPlane). This thesis investigates the potential contributions of this new imaging modality to cardiovascular imaging and patient care. Firstly it concentrates on how this new imaging modality can be utilized on day-to-day bases in the echo laboratory cutting down the scanning time and making cross-sectional scanning more robust. The following section on congenital and valvular heart disease reveals that this imaging technique makes the diagnose of a secundum atrial septal defect less operator dependent but most importantly a diagnostic transesophageal echocardiography (TEE) will not always be necessary. With 2D xPlane imaging the MV can be assessed in a systematic manner and we could correctly diagnose the site and extent of a mitral valve prolapse. Most patients may thus be operated on without the need for an outpatient pre-operative TEE. In transcatheter aortic valve implantation (TAVI) iRotate echocardiography may it possible to study the whole circumference of the TAVI prosthesis f