I'm joined this morning by Professor Nicholas Burns, the Sultan of Amman, Professor of International Relations at the Kennedy School at Harvard University. Nick holds a range of positions. He's director of the Aspen Strategy Group, and he's on the board of a whole variety of eminent organizations. He was a career diplomat serving 27 years with the State Department and served as Under Secretary of State for Political Affairs under George W. Bush from 2005 to 2008. Nick, delighted to have you join us. Let's dive into the meat of your paper. You start out by noting that the pivot, or if you like, the rebalancing of U.S. strategic posture represents an important turning point in the evolution of the U.S.-Australia alliance. In what ways do you think this turning point might affect the nature of the alliance, the dynamics of the alliance, if you like? Well, Andrew, thank you very much. It's a pleasure to be with you. I only regret that I can't be with all of you in Canberra in person, but I hope to do that in the future and visit the University of Sydney and ANU. I would just say this, Andrew. I do think that this pivot, or the rebalancing now, as the Obama administration likes to put it, is perhaps the most important change that Barack Obama has made to American foreign policy in his first three years as President. And I think it will have a rather dramatic impact on the U.S.-Australia alliance, because as I reflect on that alliance, at least over the last 10 years, or 11 since 9-11, the U.S. has asked Australia to play really a global role with it in Afghanistan, certainly, in Iraq, and in many other ways in the battle against terrorist groups globally by rebalancing American attention to the Asia-Pacific region. I think the United States will begin to see Australia more in its true form as an Asia-Pacific country and begin to understand the role, perhaps more than we have in the past, that Australia plays in the Pacific, certainly, and in relation to China, given the very close economic relationship Australia has with China, as well as with some of the democratic countries in the region, like India and Singapore, where the U.S. as well as Australia is trying to augment its own security relationship. So I think there will be more of an Asian-Pacific character to our alliance and a focus on that part of the work we do together than perhaps we have seen at least in the last decade or so since 9-11. That will be a big change. I did say in my paper, and I thought I should add here, Andrew, that there is really no controversy in our country to speak of over this rebalancing. There is a very broad agreement, I think, in both of our political parties in the academic world where I currently am in the think tank world, in our non-profit institutions, that China is going to be the big relationship and the most complex relationship and difficult for us, and that our equities will be found more in the Asia-Pacific region than, say, in Europe, where the United States has had perhaps the majority of its equities at stake in the last 100 years or even 200 years, most of our history. And so I think that we'll get to a rebalancing, and you'll see the United States focusing more on the Asia-Pacific region, but not quite yet because, as I said in my paper, I won't belabor this point. There are a whole host of issues that at least for the next 5 or 10 years I think will keep us fundamentally engaged, unfortunately for many negative reasons, in the Middle East. Beginning with Iran, which I think is, without any question right now, the most serious vexing, difficult foreign policy concern that we have, it's a big, it's suddenly become a campaign issue. The Romney campaign has made it an issue in the last week or so. It'll be the biggest question that Obama or Romney as president have to face after November, and it's a big consequential decision. Are we going to go to war with Iran, and perhaps become entangled in a third land war in the Middle East since 9-11, or are we going to focus more on trying to negotiate our way out of this impasse with Iran? And if you add to that the real uncertainty about the future of Iraq, if you add to that the Israeli-Palestinian issue, and the problems between India and Pakistan and the unfinished business of how do we get out of Afghanistan, the Middle East and South Asia is going to occupy us. So the rebalancing and pivot to Asia makes sense. We may not see its fullest expression for another decade or so, unfortunately. Nick, thanks. As I read you, your core message is that we need to engage but hedge. Let's start with the engage element. What in your view should Australia and the United States be doing to deepen our collective engagement with China? Or to use the nice phrase that you've got in your paper, build habits of cooperation and trust that might over time create a more stable relationship? Yeah, I think that nice phrase comes from my time when I was following the Soviet Union and a newly liberated Russia from the end of the Soviet Union, and that's how we framed the issue back then at the end of the 80s and the early 90s. How do we develop a different quality, habits of cooperation, the trust that was clearly lacking in the Cold War with Russia? And I think we do face the same problem with China. And the reason I wanted to frame the issue in my paper of engage but hedge is that was the major take away I had from a conference I was at in Sydney in June 2011 sponsored by the University of Sydney. I was really struck by the argument in very live argument in Australia over whether or not the continued preeminence of our alliance was the right way to deal with China. Whether or not we should trim our sales and perhaps diminish the martial aspect of the alliance in an attempt to convince the Chinese that we were not to contain them. And this is a very tricky balance. Let's start with engagement as you said. I do think there's a lot more that we can do. And I'm speaking really from an American point of view. My guess is, my sense is that Australia in a way may have a deeper dialogue with the Chinese. And China, of course, doesn't see Australia perhaps quite in the same way it sees us as a future possible adversary. And Australia, of course, has a deeply engaged economic relationship with China. So what I'm struck by in the way that both President Obama and President Bush have dealt and Clinton too have dealt with the Chinese is that our rhetoric is good. We want friendship, partnership, some administrations have said strategic partnership with China, but our actions don't really correspond and fit with the rhetoric. So, for instance, I point out in my paper, an elementary step we could take would be to decide to spend more time with the Chinese leadership. It may not resolve the problems, it surely won't between us, but the patterns of cooperation, the habits of meeting, the continual conversations that a president can have to another president or a foreign minister to another foreign minister or a chairman of the joint chiefs to the top Chinese general in the PLA. You can't substitute for that. And right now we have an erratic pattern of high level contacts, dialogue with the Chinese leadership. Huzhun, Tao and Barack Obama might see each other a couple of times a year and they might spend a few hours together per year, one on one. That's simply not good enough given the stake we have in a better relationship with China and given China's role in the world. And correspondingly, you know, we still are stuck back in another age where American presidents spend a lot more time in Europe than they do in Asia and the Pacific region. So, you know, President Obama is going to see a lot of Angela Merkel this year and I'm sure they have a lot to talk about the Eurodeck crisis, right, the future of NATO. But we need to shift in how we prioritize our resources and our time and make a much more serious attempt to actually engage the leadership of China than we have in the past. That's an elementary thing. The second thing would be below the leadership, below President, Prime Minister, Foreign Minister, Minister of Defense. You know, you've got two big governments and particularly the military side. We did profit very much in the 80s and 90s from vastly increased military to military talks, junior officer training and exercises between the Soviet and then Russian military staff and the American military staff. And Australia participated in some of this. And you see the benefits 20 years later when senior officers actually had experiences as junior officers with their Soviet or Russian counterparts don't have that pattern of cooperation with China. It's very dangerous not to have it. At a time when our military, you know, the American military, as you well know, is forward deployed in Japan and South Korea. We're going to be forward deployed in Darwin. We're building up Anderson Air Force base. We're going to come into contact with Chinese military and hopefully we'll do it in a sophisticated way where we have some understanding of who they are and how they operate. And a lot of that comes from just going to staff columns together and having rudimentary naval exercises together or air exercises of the type that adversaries never had. But, you know, countries like us have to have in this kind of world. So that's another rudimentary suggestion and easy fix. I'm really suggesting that we take China more seriously than we have. And we have actually a strategic ambition to give this kind of diplomacy a chance of on the margins at least establishing a better atmosphere environment and framework for the way we have to deal with each other. That's part of the engagement that I'm talking about. Nick, let's shift from engagement to hedging. You underscore the importance of the U.S. and its democratic allies striving to retain preeminence in military power. Let's focus first on the U.S. itself. What in your view does the U.S. need to be doing on that score? Well, the first thing we have to do is pay attention to our economic issues at home. Because I think it's a truism that has been widely discussed here that our most important foreign policy challenge is our economy. And then if we're not able to rebalance our economy and dig out of the hole we've created for ourselves and make some decisions in Washington across the partisan divide, if we can't get our tax and budgetary policies in balance, we're not going to have the resources to be forward deployed in the way that we have been over the last 60 to 70 years since the close of the Second World War.  And it'll be the real test of our two-party system after the elections when we face this fiscal cliff. But I'd start there. If we're going to have a hedging strategy that means anything, if we're going to be able to sustain American power in the Pacific and in Asia, we're going to have to have a more healthy economy. Now, Leon Panetta, in a recent trip to Vietnam, did say very specifically, as President Obama had in his Canberra speech, the looming cuts, there will be quite substantial cuts in our military budget, at least half a trillion dollars over 10 years, but maybe more, maybe a trillion, if sequestration takes place. Obama and Panetta have both said none of the cuts will come out of our forces in the Pacific. And as you know, we're now going to alter the historic post-1945 ratio, balance of our air-enabled forces, Atlantic Pacific, to favor the Pacific. 60% of our forces in the Pacific, 40% in the Atlantic. But I wonder if we can sustain that pledge, because let's say we can't cope with our budgetary problems. If we go into sequestration, if we begin to slashing the budget, really in not a very rational way, but that could happen, that's what the sequestration law would have us do, then I think it might be hard to resist the kind of budget cuts in the Pacific that would really make it difficult for us to sustain the kind of power that we've had in the past. And that's really part and parcel of our alliance with you, with Australia. So I really worry about that set of issues first in terms of our ability to hedge. The second factor that I worry about, having been a practicing diplomat for a long time, is will we have the sophistication and the attentiveness in the way that we meet this very careful balance between engaging China and remaining part of this big alliance, Democratic alliance in Asia? Will we have the ability to actually hedge in a way that doesn't become a self-fulfilling prophecy, i.e. drive China into believing that we're really out to get them and contain them and at some point defeat them? And so I worry about our ability from one administration to another, say from a more conservative to a more liberal, from an experienced president to an inexperienced president to get to keep that balance right. And there, and I mean this in the most sincere way, having allies that speak truth to us and that remind us of what it takes to balance and hedge appropriately in Japan and South Korea and Australia in particular is going to be very important. So an alliance of equals where we remind each other of when to be aggressive and when to pull back. That hedging is going to be extremely difficult at a time when the Chinese are feeling certainly expressing a more muscular sense of Chinese foreign policy in the South China Sea for instance and not rising to every provocation is going to be important. And third Andrew, and forgive the rather long winter, but the third factor that I put in the paper is can we then create the types of institutions or use existing institutions to diminish conflict and to resolve and compromise in crises in a way that does not lead to war but leads to some kind of practical resolution. And I made the comparison because I served for a long time as a diplomat in Europe and on European issues. We were very fortunate in the Cold War and the post-Cold War era to have these overlapping and overlapping labyrinth of institutions in Europe and we could turn to any number of institutions and throw problems at them and have them resolve issues quite serious ones with the Soviets or Russians. We don't really have that overlapping set of institutions in Asia yet. We need to create them and that would be a common project with the Chinese. That's a nice segue to the next set of issues I wanted to explore. Again pursuing the theme of hedging but shifting the spotlight to Australia if you like. What do you think Australia from where you sit needs to be doing to support the hedging side of the equation? Both on its own terms unilaterally and in alliance with Washington. What would you have Australia do? I guess I'd say two things Andrew. The first is quite obvious. Having Australia sustain its own military capacity, particularly its expeditionary capacity. Both to take the lead as Australia has done in East Timor in the past, in Fiji and places where the US maybe is not in a position to do so. That's enormously beneficial to an alliance. Secondly to be the kind of first rate naval and air power that it is. Keeping that capacity will require continued political will. It will require quite difficult national conversation. I was part of it for a few days in Sydney last year. It was really struck by the passion on both sides of that argument in Australia. One would hope from an American perspective, if you agree with an engaged but hedged strategy, that the Australians would stay focused on that mission with us and having the capacity to do so. And second, as I said before, the kind of dialogue and honest conversation with the Americans that allows Australian Prime Ministers and Foreign Ministers to be able to say to give frank advice and to, since you do live in the region permanently in the way that we do not really, to give us a sense of what's manageable and what's not, what's possible and what's not, when to pull back, when to be aggressive. I think that what we've managed in the US-Australia alliance, as I've participated in government, we've managed to be frank with each other. Michael Estrange, I thought, put it very well. We had this brief meeting at the hotel. You remember, after the conference in January at the Australian Ambassador's residence, and Michael said, we're not going to have an identical worldview. We're going to have a complementarity of views. I think it was the way he put it. It was what I wrote down in my notes. And it's sometimes important for the Americans to realize, in an alliance situation, that it has to be an alliance of equals and the door has to be open to disagreement on tactics and strategy. We don't manage that as well with some of the others in Asia. I think we manage it pretty well with you and I think Americans are open to frank advice when we're not succeeding or not making the right calls. And I think that's really an important quality to the US-Australia alliance that I would never want to see disappear. Nick, I'm watching the clock, but let me broaden the conversation a little to one of, I think, the most interesting themes in your paper. And that is the need for both the United States and Australia to be building strategic and military cooperation with other democracies around the region. Can I draw you out on that a little? Sure. And this comes out of my own experience in the Bush administration when we had a discussion and Michael participated in it. I remember this. He and I were partners in it. Trying to figure out what is the architecture, formal and informal, for how democratic countries coalesce on military and security terms. Some of us are allies, so we have treaty commitments to each other, like Australia and the US, so that's easier. It's more difficult when it comes to India, Singapore, Malaysia, Indonesia, Vietnam. All of those countries are seeking a more pronounced security relationship with the US and Australia. And yet they have to be careful and perhaps limited in what we can do because they don't want to stoke opposition by China. They live next door to China, some of them. And then it was difficult for us when I served in government to get some of the architecture right. Well, do you have formal meetings? We debated whether we should have a quadrilateral group, Japan, Australia, India and the United States. We went back and forth. As the years changed in Tokyo, Delhi and Washington, we had different views as to whether we could meet formally or informally or declare that we were meeting or not meeting. And I think getting that pattern of cooperation among the democracies right in a way that satisfies the national needs of all of us is tricky but not impossible. And as I do point out in the paper, I think the India equation is more difficult because India, if you go into Delhi, I visit several times a year, and you ask Indian officials or academics what do you worry about the most? To a person, they say China, the nuclear weapons modernization, the military buildup of the PLA, the lack of transparency in the PLA, the fact that China seems to be constructing a web of relationships in the Indian Ocean that are designed to ham in India. So the Indians are quite concerned strategically. In fact, I've noticed in Delhi these days, China is issue one, two, and three, and Pakistan is issue four and five, which is a big reversal from, say, 10 years ago or 20 years ago. But the Indians very much want much more enhanced naval and air cooperation, particularly with Australia, Japan, Singapore, the U.S. but they don't want any kind of formality to it. And they don't want to be part of a league. And they don't want to be part of an association much less a treaty because, first of all, they have their own relationship with China to think about. They've got their non-blind status, which is still very much a part of how India sees its role in the world. In fact, there's a renewed debate called India 2.0 about modernizing the concept of non-alignment. I thought non-alignment was dead after the end of the Cold War, but it's not. And so I think a tricky part of this diplomatically for Australia and the United States is actually having better cooperation among the democracies, but in a way it's sensitive to the political concerns of all those countries. One last question, Nick. One of your closing messages is that a positive articulation of China's role in the region and China's role in the world will be an important part of what we all need to do. I'd like to draw you out on that. As part of that, get your take on the Obama speech in Canberra. How would you characterize that speech in that context? Right, and I read that speech closely, as I'm sure you did. My sense is that President Obama has been a very careful, sensitive articulator of this balance that we need to have in how we talk about China. I mentioned this in the paper because I'm concerned about the American domestic discussion about China. It is increasingly shrill. It is increasingly friend and foe. Excuse me, not friend. It is increasingly China as foe. It is increasingly focusing on the areas where China is delinquent in its international responsibilities. And there's a lot one can criticize about modern China and its policies. But we've got to get the narrative right over the long term in how we Americans talk about China and how they talk about us. So, for instance, President Clinton said something very important. I can't remember the exact quote. Others perhaps will around the table. But President Clinton said, in effect, our strategic problem is going to be with a weak China, not a strong China. And given the degree of interdependence between us, which is very different from the Cold War with Mao's China or Stalin's Soviet Union, we better hope that China succeeds economically. And therefore, I think this really is incumbent upon the Americans first and foremost, we have to establish a narrative of our own about China that treats China with a certain degree of respect and that speaks about the importance of China's role in the world. And here I give credit to John Eikenberry, and I really admire the way he thinks about this. And in his most recent book published last year, Eikenberry says essentially, you know, China is not a rebel in the international system the way that Mao was, Stalin was. China is actually a fully paid up member of the international system. We can quibble about whether it's the kind of stakeholder, as Bob Zellick put it, that we would wish it to be. We would ask China to do more to manage the international system, but it's part of the system. It's not rebelling against it. And it's an extraordinary economic rise that has come within the system that we have built together, Australia, the US, Britain, Germany, Japan, South Korea. And keeping China as a member of that system and giving it leadership roles in the system is extraordinarily important, as opposed to the rhetoric that one might see in political campaigns that China is the enemy or the reincarnation of the Soviet threat. I mean, that is not the mainstream American view and I'm not sure it's not in Australia either, but you do hear that. And the majority of our public leadership dialogue about China focuses on the problems. We very rarely focus on what we might be able to achieve together if we are able to maintain a peace with China and encourage a more responsible Chinese government, say in the South China Sea. So I do think getting that narrative right is going to be important. There will be some limits, obviously, domestic political limits on you and us and how we phrase, how we articulate our relationship with China. There will be times when we have to be quite, have to disagree and be quite tough. But there's got to be a positive element of how we, of that narrative is what the point I was trying to make at the end of the paper. If we fail to do that, then how do you establish common ground with the Chinese leadership in such a way that secures a peace and helps us keep the economies of the world growing and helps us work out very difficult problems like the South China Sea problem that's at the forefront today?


much more anatomical view, we have more spatial resolution, we have less temporal resolution, but this is the most current imaging technique that we have. With this, we can see all the structures of the heart. You will see later on how we acquire as this is 2D, and of course the heart is 3D. We have to use the integration of different imaging views that we will see later on. But as I have said, the heart is a moving target, and there is tissue, which is made by the myocardium and the pericardium and the valves, but also we have fluid inside, which is the blood. So we can also have information for the echoes that are reflected by the moving particles within the blood, which are the red blood cells or the white blood cells. So we have information also applying the Doppler principle. We have also information about the speed of the motion of this blood within the heart. And for that, we have different modalities of Doppler, what we call the pulse Doppler and the continuous wave Doppler. You may know better than me, but pulse wave Doppler means that you send a pulse and you wait to have the echoes back. So you can scan fluids with low velocities, typically less than 1.5 meters per second, but you can localize very well where is that flow moving. On the other hand, we have continuous wave Doppler, which means that the transducer is sending and receiving at the same time, ultrasounds on the reflected echoes. So that means that you can evaluate high velocity flows, but you are not, this is not good to locate where is exactly the flow. And these two techniques or these two modalities are useful to evaluate velocities of flow inside the heart. We can also, we will, later on we will talk about the application of the Doppler to the tissues also. And what do we use this for? For example, we can use this pulse wave Doppler to see how fast or how slow the blood enters the left ventricle. And this gives us a lot, a lot of information because as Bart explained previously, we have an early passive feeling of the heart. So just looking at the velocity of this wave and also particularly at the speed of the deceleration of this wave, meaning how this accelerates, we can imply from here lots of information on how the stiffness of the ventricle and how is the flow if it is overloaded or not or under filled. Also, there is another part of feeling which is due to actual contraction. And this is what we call the A wave. And this gives a lot of information again of how is not only ventricular conditions like stiffness or compliance, but also about actual function or actual contraction. Continuous wave Doppler is mainly applied to look at flows with high velocities. Flows with high velocities is what we got when we have narrowed valves, for example, in valve stenosis. So there are some diseases that cause narrowing of the valves or other abnormal malformation, congenital abnormalities that do narrowing of the place where the flow should go out. And for those we have velocities of flow that go beyond three meters per second. So we need continuous wave Doppler to scan those flows. These applications are really, really important because before Doppler cardiography came in, we had to put a catheter inside the heart to evaluate these diseases. Now we do that non-invasively, just applying a trans thoracic echocardiography which is cheap, easily available and an expensive test. So this was really a revolution in the field of cardiac imaging and in the field of cardiology. Another modality or derived from pulse wave Doppler is color Doppler. I always tell my medicine students, this is echo for doctors who are less smart than engineers. So they put colors to us so we can understand it better. So this is another way to depict velocities of the blood. And by agreement, we just, as you know, the normal flow within the heart is laminar. So mainly we see velocities, similar velocities in laminar flow. And by agreement, we say that it is red when it goes towards the transducer, which is here. So, and it is blue when it goes away from the transducer. So this is a normal flow across the mitral valve, which is when the valve, mitral valve, which is this one opens, the flow gets into from the left atrium to the left ventricle. And as we have the transducer here, we see depicted in red color, okay? If we could stop, we could see that that is exactly in diastole after the exact moment in the cardiac cycle. When we have abnormal flows, this flow becomes turbulent. And we have no more laminarity. The flow increases velocity and it goes beyond what the pulse wave Doppler can do, which is, as I told you, is usually around one meter second. So it happens this thing that, you know, better than me, that is aliasing and the machine depicts it as a mosaic of colors. And this is the thing that we have to look at. The mouse doesn't work. Okay, we have a pointer. So we have this mosaic colors here that depict that there is a turbulent flow. Looking at when it happens during the cardiac cycle, this is systole, my eye is drained, so I can see it systole, and it goes from the right ventricle to the right atria. So this means that this is an incompetence of the tricuspid valve that doesn't close adequately during systole and then flow goes from the right ventricle to the atria, to the right atria. So this is how we diagnose regurgitations or abnormal flows. Just taking advantage of this Nyquist effect, and of, thank you, and of the appearance of this turbulent flow here in a moment of the cardiac cycle. We also have now, and with some more technical progress, we will have more and more. As I have said, we have a three-dimensional structure which is the heart that we evaluate with two-dimensional echo. That's our main clinical tool in daily clinical routine practice. But currently we have, in many systems, we have also the advent of 3D echocardiography. This is an example of trans thoracic, three-dimensional echocardiography. So with the use of transducers that have many crystals in a matricial disposition, we can take a whole volume of the heart, and even now in one bit, we can have the whole volume at least of a normal ventricle. And this is useful mainly to look for better spatial relationships, and also to estimate volumes of the left, of the heart cavities, ventricles, and also atria. This is still not so used in clinical routine practice. Why? Because technology is still not so good, and we still have limited spatial resolution, and of course very limited temporal resolution. So we can use that for research. We may use in clinical, in few patients, where we have good, we know with good images, but this is not really still a state of the art clinical routine practice. We also have it with applied to another modality that we will talk, which is transesophageal echocardiography. So with transesophageal echocardiography, we are closer to the heart, so we can have a better visualization of the cardiac structures. And then we use, this is where 3D is really, really useful to look precisely at the valves, and also to help interventionists to treat these valves. This is what we do in the OR, for example, helping cardiac surgeons to see if the repair in the valves they have done works appropriately or not, and particularly, this is really, really useful in the cath lab where cardiologists with catheters try to put things around the valves and they try to fix valves without opening the chest of the patient just by the use of catheters. And one limitation that we had, for example, when we used to the echocardiography is that it's very important to look where is the tip of the catheter they use. This was really, really difficult to do with 2D echocardiography while with 3D. I'm sorry that I don't have an image here, but we can see it very nicely. So you can see here, for example, this is a mitral valve. This is a segment of the mitral valve, which is prolapsing, and as you can see, there are two lines which are not any artifact. These are cordia tendine that rupture. So the definition with transophageal echocardiography is pretty good to see particularly the tip of these linear structures the same way that we see the catheters. And of course, with these volumes of data, you can do a lot of processing that you love to do and that probably Mathieu will develop tomorrow. Another modality that we use, and we also use in clinical routine practice, not as much as we should, but we already use, is the application of the Doppler principle. As we said, we use that for calculating velocities of the flow or the blood flow, but we can also changing the settings of the machine, and this is already a preset that comes with every machine. We can evaluate the velocities of the myocardium, because as I have said, the heart is a moving organ. So we can evaluate the velocities with which the myocardium moves. So we know the velocities that the myocardium moves in regards to the transducer, and we can do that mainly applying the Doppler. As I have said, this is what we call Doppler tissue imaging. And typically we can have pulse wave Doppler that we use usually to evaluate the annular velocities that gives us an idea of the global longitudinal of the formation of the heart, which is a surrogate of the ventricle of the function, of the contractile function of the heart, as Bart already mentioned, but we can also use these acquisitions where we have color coded velocities of the myocardium, and from here we can later on post process with the specific softwares, and from here we can have different sample volumes in the different regions of the myocardium and look and how the heart, how fast or what's the velocity of the myocardium moving across the cardiac cycle. So typically we have this motion in systole towards the apex, and then we have the two waves, the E wave and the A wave, the same thing that we look for filling. So we have the early relaxation of the ventricle and then the atrial contraction that also makes the heart to move away from the transducer which is here. From these Doppler imaging, color imaging, we can also have velocity as I have said, this is the raw data, but from this we can derive other parameters which is displacement and particularly strain rate. Bart already went to the concept of what is the velocity of the formation of the myocardium and also we can have a strain and global strain. DTI mainly we use clinically to analyze the velocities of the annulus, and sometimes we use to evaluate the strain and the strain rate particularly for hypertrophic myocardial disease. But as I have said, the main application is for looking at velocities of the annulus. More recently, another modality to evaluate the myocardial deformation of the heart was developed, this, as somebody says, this is kind of easier for doctors or for physicians, but it's probably less accurate because it has less temporal resolution than tissue Doppler, but this is definitely more friendly to use for physicians despite not so precise from the engineering point of view or the technical point of view. So here what we do or what the machine, the software does is track the nature of speckles that we have in the myocardium when you insulate it. You have these bright points within the myocardium. The system tracks them across cardiac cycles and it gives you the longitudinal deformation, also the circumferential deformation in another view, in another transversal view of the heart and from this to provide you the radial deformation of the heart, which are, as mentioned in the previous talk, the three directions on which the heart is moving through across the cardiac cycle. So from this, we can calculate the global deformation of the left ventricle, also of the atria on the right. We can estimate the regional deformation of each segment and what is more interesting for us is we can look at the pattern of this deformation, not only at the amount of the formation but also how it deforms across the cardiac cycle. As I have said, this is measuring the formation is something that we still do a lot for research and less for clinical practice despite we should incorporate it more and more for clinical because it provides you a lot of information. One of the limitations of not using this in clinical practice is that we don't have this available in all the machines, you have to transfer this to a workstation and analyze later on and physicians are always very busy, they have like 50 patients waiting to do an echo. So you have to rush to do echocaryography and just keep it to ejection fraction. Indeed, this is something that we do wrong. We have these tools and we should take more advantage of them. Another limitation of this is that sometimes these are concepts difficult to understand for busy physicians, but this is why to the strain which is our spectral striking strain has been more successful than DTI because it has less artifacts, it's kind we have a lot of smoothing in this post-processing and this is why it's more friendly for us and this is why we are now using a little bit more than the tissue Doppler was used for. Okay, how do we do this? How do we get echocaryography? As you know, the main access is trans-terracea echocaryography, we just put a transducer on top of the chest and we look at the heart and for that we have a standardization of different views and different approaches and from that we reconstruct from 2D images but we also incorporate all these techniques M-mode pulse wave Doppler, continuous wave Doppler, Doppler echocaryography, tissue Doppler, 3D, we have 3D or other things as you will see, we incorporate all of these techniques in the different views. So we know in each view what we are looking for, what we want to scan in each view and typically same structure we look at from different views in order to make the 3D reconstruction in our head to complete the evaluation of the heart. So typically we start with a parasternal view here and then we go to the apical view and from here with our hand or with the hand of the sonographer, we change the cutting planes and we see the different structures. For example, this is a parasternal long axis view, what we call, we can see here the left ventricle, the aorta and the outflow of the right ventricle just by turning the transducer 90 degrees, we have transversal views of the left ventricle and the right ventricle and also depending on the tilting that we give to the probe, we have different cuts at different levels. This is an example of an apical view, the four chamber apical view, this is kind of the most anatomical one and the easier to understand for those who are not familiar with this and also we have here the left ventricle, typically larger than the right ventricle in the adult and the atria here with the mitral and the tricuspid valves. Also by turning the probe, we can have a cut across the left cavities with the left ventricle and the left atrium and this is important because we see different segments of the left ventricle which is in cardiology kind of the most important, the spider right ventricle is also important. The left ventricle is the most involved in most of the pathologies at least in the adult because the most prevalent one is chemically hard disease which mainly involves the left ventricle and it's important to see in all the walls of the left ventricle because we have three coronary arteries and the three coronary arteries irrigate different aspects or different parts of the whole left ventricle. So it's important to do this reconstruction of this view of all the parts of the left ventricle but that also applies to the mitral valve and indeed to all the structures in the heart. So what do we do when the heart is not really nicely seen with trans thoracic cardiography because you know we have the lungs in the middle and you know ER is not a good conductor for the ultrasound so sometimes we face patients who have a bad window what we call a bad acoustic window and we have something to see better the heart. So in that case we have two options keeping it with echo so we can give what we call echo contrast. Contrast for your choreography has nothing to do with other contrast used for other imaging techniques such as radiology or CTs or MRI. What we use is micro bubbles and we have several types of macro bubbles depending on the size of the bubble. So if we have big bubbles these bubbles if you inject them in the vein when these bubbles will reach the lungs they will be stopped there and they will be destroyed and expirated as air but if you have very very small micro bubbles they will pass the pulmonary pulmonary membranes and they will go through the left circulation so they will arrive to the left atrium and the left ventricle and what they will do they will empower the transmission of ultrasound so you will see like this the left ventricular cavity and this has helped a lot us to diagnose and to evaluate LV motion and also LV morphology. Indeed this was a side effect of something that they invented to look at myocardial perfusion. They invented contrast to look at myocardial perfusion but this has not really been a very successful story. This is one of the big pitfalls of the ocariography. We are not so able to really accurately and reproducibly see myocardial perfusion with ocariography giving contrast. We can see some perfusion here but there's a lot of work to do to improve this but we use it routinely, clinically to evaluate LV cavity in patients with bad acoustic windows and also we use the big bubbles the ones that are stopped in the lung to look at intracardial chance. For example patients who have a patent for amenovale which is a congenital structure that typically the two layers of the intracardial septum are closed during fetal life or in the very first days after birth and in some people they keep separated. That can be related to some problems particularly when you are diving. So typically if we inject big bubbles in a peripheral vein they go to the right cavities and they don't pass to the left ventricle. In these patients as they have a permanent hole here and you put a lot of pressure here when you inject the contrast, the bubbles they pass through the left cavity. So that makes the diagnosis of intracardial chant. Other patients have the chant in the lungs such as those athletes that Lagerge studied in the slide of the previous talk and you see also contrast appearing lately big bubbles appearing lately in the left cavities. So we use contrast for two things for detecting chance and also to enhance the intracardial border of the left ventricle to look at its motion and also at its shape. Another thing is to use transasophageal cartography. This is amassed in patients who cannot be performed transasophageal cartography like those who are in the operating room. They have the open chest during cardiac surgery so you cannot do echo, definitely. This is why we use the transophageal approach. We also use the transophageal approach when we need to be very precise to look at small structures that are not seen in the transasophageal way. Like looking for example at the left atrial appendage if we want to see there are clothes inside we cannot see that accurately with transasophageal cartography so we use transasophageal cartography and transasophageal cartography is nothing else than an endoscope that it's put in the sofagus with a probe in its tip. And we put that in the sofagus because the sofagus goes just behind the left atrium so we can image the heart very nicely from this position. The problem of course that is a little bit more uncomfortable for the patient so we usually have to give some superficial anesthesia because it's not so nice to swallow an endoscope. But we use that very every day, every day in ICUs, in the OR or even in the outpatient in the echo lab we use that for specific diagnosis of cardiac pathology. Again in transasophageal cartography we mainly use two-dimensional cartography and we use different views again instead of looking about the apical or the parasternal we talk about degrees but we have the same more or less terminology for chamber, longitudinal or aortic view so more or less we have the same terminology but our guide here is the angle with what you move the crystal of the transducer of the endoscope. Here we can also apply all the other modalities like color, like chemo, pulse wave, continuous wave and also three-dimensional echo cartography. So what do we use in clinical routine echo cartography for? As I have said this is our main standing they say it's going to substitute the endoscope, the stethoscope and it has been really replacing it quite a lot. So as I have said we use this for everything and any patient with suspected involvement of the heart. So we can measure cardiac dimensions and motion. It's the technique of, imaging technique of choice involved disease so the other techniques as we will see can do very well evaluating dimensions and motion of the heart but there is no other technique as good as echo cartography to look for valve disease. We also use it to look at pericardial effusion and some pericardial diseases. It can be the first imaging tool to detect intracardial masses. We also use it, sorry it's intracavitary thanks to the Doppler application and the potential conversion into pressure from velocities applying a very simplified Bernoulli equation that we do we can estimate intracavitary pressures and this is very important as I said before because we used to do that with a catheter. We had to put a catheter to estimate pressures across an arrow or stenotic valve and now we can do that with echo cartography. We also, as I have said, using contrasts we use echo cartography to diagnose intracardial shans. We also use echo cartography at least as a first approach to evaluate thoracic aortic disease. Also abdominal but typically thoracic aortic disease is evaluated with echo cartography. How do we evaluate motion? As I have said left ventricle is our big star in cardiology. The right ventricle is also important but the big star is the left ventricle and how do we evaluate its function? In reality we do it very badly but this is how we do. What we do is how the left ventricle moves across the cardiac cycle. So typically we see how it moves and we see the shape of the left ventricle, the dimension and we evaluate if the motion is uniform across all the segments of the left ventricle. This is a normal heart and this, of course, is a very, very abnormal heart. It becomes a spherical, it becomes big and the motion here becomes weird because it has something else which is a LBVD, left bundle branch rock and has this septal flash but if you look at this wall this is moving very, very few, very little motion as compared to this one. So we talk about normal motion, very reduced motion and from here what we typically do we trace volumes from here with an estimation of an ellipsoid and we calculate ejection fraction or we just visually in train eyes we visually say okay this has an ejection fraction around 60%, this guy has an ejection fraction around 20%. We also have a look at segmental motion and let me point your view, your attention here so if you look the septum is still moving a little bit not very normally but a little bit but if you compare the free wall of the right ventricle and you compare to the lateral wall of the left ventricle this is completely akinetic, okay? So this was a patient with a big infarction in the circumflex artery which gives flow to this area of muscle in the left ventricle. So he had a lateral infarction and this is how we detect this abnormal motion segmental abnormal motion of the ventricle. As I have said we can also estimate pressures and the most typical thing that we do we estimate gradients across asthenotic valves when you have asthenotic valve the flow increases velocity and that means that there is a gradient of pressures between the two cavities that are communicated by the valve. So if you have for example aortic stenosis the left ventricle has to increase the pressure a lot above the normal values to open an asthenotic valve, okay? So then you have through the whole systole you have a big gradient between the left ventricle and the aortic valve. That's the main use of continuous wave Doppler but there is another use which is estimating the pressure of the pulmonary artery pressure and as again we used to put a catheter into the pulmonary artery pressure to measure that now we estimate with echocardiography and we do that because we can have the peak velocities of flows you can calculate that, you can determine that using continuous wave Doppler and from that we make a transformation because we use a simplified Bernoulli equation you can discuss later on if this simplification is good enough or not but it works not so bad in clinical practice and if we have the difference between the right we have the difference in pressure of the gradients between the right ventricle and the right atrium if we add the pressure of the right atrium to that that in the absence of an stenotic pulmonic valve is exactly the same than the pressure in the pulmonary artery in systole so this is something that we do routinely all the machines have a bottom where you put maximum peak velocity of the tricuspid regurgitation and then it calculates the estimation or it estimates pulmonary artery pressure this is something that we do routinely and indeed most of the cardiologists use it without knowing where is it based on so this is how clinical work works or shouldn't it work with why do we use this? because most of us have a slight degree of tricuspid regurgitation so we take advantage of this signal and we estimate pulmonary artery pressure we can do that at rest or at exercise because we can also do exercise echo in some of these patients as I have said we use echo mainly for valve function with echo we can evaluate the morphology this is an example of an aortic valve which is by caspit instead of the typical one which is the most common one in the population which is tricuspid we can see how it opens and how is the flow across it if it has high velocities because it is stenotic or it has regurgitations because we see the color Doppler and this is exactly what we do we look at the opening this is a mitral valve of a patient who had rheumatic fever and has some degree of stenosis of the mitral valve which is abnormal look at this leaflet it doesn't move at all this one is thickened and it opens restrictively so this is mitral stenosis this is another example of a aortic valve we are cutting the aortic valve transversally so this should be three valves opening in systole and closing in diastole and as you can see there's a lot of white which is calcium and there is no motion almost no motion maybe one leaflet is moving a little bit but this is a very very stenotic aortic valve we look at the gradients as I have said using continuous wave Doppler and we look at color looking is if there is any regurgitation and this is most of the clinical echo we do we look at this area of regurgitation how big it is how large is it within the the receiving chamber in this case the right atrium and with this we first say regurgitation yes or no and secondly we semi-quantitate how large or how big is this amount of regurgitation we have other methods to try to quantify but indeed for regurgitation we don't have perfect methods to quantify regurgitation we can also evaluate valve prosthesis this is an example of three-dimensional aquariography this was a patient with mitral valve disease who had replaced his mitral valve and they put a mechanical prosthesis which is made but a stent of titanium and then two ME discs that move across this hinge point opens and closes in systole you can see nicely the sutures of the surgeon made so you can check if he did it a good job or not we can also apply color and this is really useful to look where the abnormal flows come from so for example here we have this regurgitation which is completely normal in a mechanical prosthesis and we also can evaluate pathology for example here we see a prosthesis in the mitral position two ME discs we see one ME disc moving here but the other is fixed by a mass here so we can diagnose problems also with the valve with the prosthetic valve here what we are not good with the echo is that telling okay what is this mass so we can say this is a mass but we can we are not good at saying what is this mass made of so is this thrombus is this a tumor is this infection and we have poorly material here we are not good with echocardiography at looking at the tissue at the characterization of tissue there has been some attempts to do that using backscatter techniques but really it doesn't work very well with echocardiography so what we rely on to say this must be thrombus this must be infection is on the clinical presentation of the patient on the clinical records and also on the morphology on the aspect but really looking at this this is more bright less bright this must be that is not good with echocardiography similar what we can what we use very much echocardiography and really we don't have any other technique so precise to that is in endocarditis endocarditis as said is an infection of the valves of the heart valves or other devices that are in the heart like electrodes for example there can be infection of intracardial structures and endocarditis is an infection starting on the valves typically that can destroy the tissue of the valves which is the case this is the aortic valve so this aortic valve was destroyed and even it can extend to the anulus and destroy the anulus so this aortic valve was kind of being dissected from the content of the of the aortic wall and having very very important complications with the aortic regurgitation and some dissection or the sense of the valve here so what is used to look at these small structures which are called vegetations vegetations are made of purulent material consequence of the infection of the valves and this is one of the points for the diagnosis of endocarditis again we cannot say for sure this is infectious material because we don't have this tissue characterization but again the clinical context and the clinical presentation of the patients support the diagnosis that we made with echoreography and finally for echoreography we can as I have said we can use it to look at the aortic thoracic aorta diseases particularly dissection in dissection the inner part of the aorta which is called the advantage the intima is separated from the rest of the wall of the aorta and we have a typical image which is called this flap here which is the intima the broken intima of the aortic wall and this makes even with holes that connect what we call the true lumen of the aorta within the false lumen we can see this very nicely with echoreography we can also see that with MRI and CT as we will see but in some emergency settings this is the image that we we choose of choice and particularly for the ascending aorta we use that to see if this dissection is involving the valve or not which is important in terms you have to operate the patient you need to know the surgeon needs to know if the valve is working or not so we have many applications of echoreography but the most important thing is that echoreography can be performed at the bedside of the patient and this is really really important because we have other techniques that we will see now with much nicer images with much more three dimensional information but they cannot be done at the bedside of the patient and this is important because echoreography is being more and more used in ICUs in EOS and it's the imaging tool of choice to help other physicians to perform the treatments like surgeons cardiac surgeons or any surgery that may pose the heart into trouble like long digestive surgeries or as I have said before in the interventional laboratory either for electrophysiology procedures or either for valve procedures which need somebody who guides him within the heart also we have this very very miniaturized so this is what we call pocket echo these are still limited machines so they cannot do all the modalities that we have been discussing they do color Doppler and B dimensional Doppler but this is really useful in clinical practice because you have the patient there in one shot you can tell a lot of things to your patient if this is performed in the wood hands we also use that for a screening of some patients for example for aortic aneurysm a screening family doctors are being trained to look at it very easy things with a really really small machine that can provide you lots of information another modality as very quickly that we use in cardiography is to look at the heart under different conditions and the main conditions that we use for the heart are to stress the heart okay what happens to the heart if I stress and how do we stress the heart we have two ways of stressing the heart indeed we give drugs that stress the heart or we do exercise the main objective in most of the patients is to look for ischemia you know ischemia can be provoked and this is the most prevalent disease this is the main indication of stress eukaryography but we are using more and more to evaluate patients with valve disease with shorten of breath even athletes so what we do is we provoke stress to the heart and then we see how it responds we have pharmacological stress eukaryography and this is an example the typical drug that we use is the butamine the butamine does several effects on the heart it increases heart rate and it increases contractility so the normal response of a heart of a normal heart to the butamine would be to increase its heart rate and to increase its contractility and this is what happens in this patient this is baseline this is a really high dose and you can see how the the heart increases the heart rate but also increases contractility so the cavity collapses during systole in this case we added contrast to improve visualization of the endocardium another example is the stress exercise eukaryography these are images sorry these are images that addressed and after exercise I hope it doesn't stop but you can see that here the apex should close and it's persist open a kinetic indeed so this patient started to run on the treadmill and said my chest is pain I have pain on my chest the ECG show some very important changes on the ECG and we saw this abnormal segmental motion of the apex so we suspected this patient had important coronary artery disease which was confirmed on the coronary and geography so in summary eukaryography before going quickly to the other techniques is a quick easy available technique imaging technique we need to improve some things some artifacts we have no time to go very much on some artifacts that we get particularly for mechanical devices prosthesis or even the bobi that we use in the world they do a lot of artifacts on ultrasound and that doesn't allow us to make an accurate evaluation we need to improve a spatial resolution particularly when we are using three-dimensional echo temporal resolution is quite good as compared to other techniques but if we want to study very very quick things that happen in the myocardial cycle like myocardial deformation we need to improve it also we need to improve a little bit on the measurement of intracardial pressures and dynamics we have the information there for example we have color Doppler within the left ventricle we could indeed calculate how pressures within the left ventricle are and there are some research studies made on that but still it's very far away from clinical practice we have a big limitation with tissue characterization and a big limitation also with myocardial perfusion so for this we have other methods other techniques that we don't use so much in clinical routine these techniques have our cardiac CT and MRI they have the big advantage that they have a high spatial resolution so pictures look great but they still have lower temporal resolution and also our big limitation is availability and portability so you have to send your very sick patient to the city which is typically downstairs in radiology or to the MRI and I do an echo in five minutes the MRI takes if we are going quick at least 30 minutes and if you have a very very sick patient intubated, ventilated it's difficult to do that and also we have the problem of radiation for cardiac CT what do we use these techniques for mainly for aortic pathology so we can see very nice the aorta in all its extension all the thoracic aorta and also abdominal we use particularly MRI for the right ventric evaluation right ventricle is in a structure that it's difficult to evaluate because it has a complex geometry with two parts and it's difficult to see it either with 2D and 3D echo we use MRI particularly is our imaging of is to evaluate tissue characterization is good at detecting scar looking at fibrosis and it's getting better and better to look not only at cicatricial or replacement fibrosis but also interstitial fibrosis and it's also good to differentiate fat from thrombus or other other tissues we use CT for non-invasive coronary angiography and we also use MRI particularly some work starting with CT but particularly MRI for myocardial perfusion so we combine MRI with stress here we use mainly drugs we use adenosine and we look at myocardial perfusion with specific sequences for MRI so these are examples of aortic disease you can see here the flap of the dissection of a patient with an aortic aneurysm we can evaluate right ventricle right ventricle motion morphology very nicely with left with MRI and also of course the left ventricle it's difficult to have this definition of these aneurysms here in the interlateral wall of the left ventricle with your cardiography we can have a hint but definitely the definition or the spatial resolution is much better with MRI and of course as we have 3D volume data sets we are much better quantifying data from MRI than from echocardiography CT is also very good that is based on X-rays it's very good to depict calcification this is important for example when we have to operate a patient and we want to see how is his aorta or we have doubts about the aortic valve disease severity for example we look at calcification and CT is the technique of choice for that as I have said MRI is very good at characterizing tissues particularly the left ventricle myocardium because it has enough thickness to be scanned we are working on the atria and on the right ventricle but definitely using contrast which is another contrast the gadolinium it's very good at looking at scars to see the extent of scars and also research is being done on trying to characterize the tissue within the scar also there are new sequences that not only look at the scar or replacement fibrosis that we call that they look at interstitial fibrosis which is a prior state of disease before sometimes even before left ventricular dysfunction or ventricular dysfunction occurs and finally coronary and geography typically we do that putting a catheter on the aorta in most of the patients we do this way invasively why because then we can put the catheter inside the coronary and put a stand or treat coronary stenosis but in those patients where we think we are not going to treat because we think very much that they are going to have normal arteries or we want to do a follow up what we can do is an uninvasive coronary and geography which is done with multi-slice CT you know it's CT with a lot of rows and we can have very nice images now of the coronary arteries non-invasive just to slide out nuclear scintigraphy nuclear scintigraphy is just the imaging that we have with a gamma camera in a patient that we have given a level particles that fix to the myocardium typically we use that for assessing ischemia of the heart for assessing perfusion and again we stress the heart with exercise or giving drugs the butamine or adenosine depending on the on the center and what we do is we compare the images at baseline and during exercise lately we can have also images gated with the ECG and we can have also motion so we can combine with this imaging technique motion and perfusion this is mainly used for perfusion despite MRI is gaining more and more fill in this indication because this has the problem again of radiation so we are using less and less but still use a lot for testing for ischemic heart disease another advantage of this is that we can or with other techniques that we can fuse to imaging modalities is an example or fusing CT coronary angiogram and perfusion imaging by nuclear but we use every day in the EP lab for example in the electrophysiological lab we fuse images from the MR and also from the navigator system this is non this is invasive imaging but these are other ways to work like fusing putting the good things of every house into a single shot so what we would like you to do indeed is that we got this perfect imaging tool that we still don't have as I have said the most useful or the one that we use routinely is a cardiography but has important limitations that are partially provided by the other ones particularly MRI for tissue characterization and for perfusion but still we need to improve we need ideally harmless which is widely available and inexpensive so these are conditions for a cardiography this is why it's so successful but we need to have high spatial resolution and high temporal resolution and a cardiography is not that good particularly at spatial resolution has to be able to characterize dynamics and tissue composition we are improving we are quite good at dynamics with the cardiography quite not perfect yet and quite good about tissue composition with MRI but we don't have in one technique we need it to be easy to quantify because we have many patients waiting many patients to be diagnosed and always busy cardiology departments we have to avoid artifacts and this is it so I hope you can work a lot and in some few years have this more advanced imaging modalities thank you very much for your attention Is this work? Thank you very much just a brief question because most of the engineers when we start working or talking to cardiologists we start to do modeling and things like that and we say like okay we obviously need a 3D MRI or 3D CT in order to do it because otherwise we cannot work and which percentage of patients do you think these are available in routine clinical practice? 5% so we need to work with ultrasound in reality so this was a very very clinical talk in the sense that this is our routine so if you see my talk was like 90% eukaryography and 10% CT and MR and this is reality this is real cardiology of course for research we do MRI and it will be more and more but also availability of MRI machines is not that good in all cardiac centers so you have to think that our big tool is echo of course we need to improve on MRI because we have to incorporate so many things with that but realities and maybe a bit more philosophical or practical question for some people in the room it's like say somebody develops a nice modeling tool and say like okay this is better than what you use will you buy it as a clinical cardiology? we do have money so how do you think we can get our tools at some point in clinical reality because in reality it's indeed you go to cardiologists they don't want to pay but how do you proceed? yeah I mean the thing is really that that we we work much together because it's the same thing that I was saying with the statisticians okay it's like the thing ejection fraction okay it doesn't work we know it has a lot of limitations but in the end this is what we use and it's okay so they need to we need to know what you are able to do and you need to know what we really need and you need to learn medicine that's it I mean it's important that you learn medicine and that you read and that you go to clinical sessions to really understand what are the real problems because unfortunately theory is here and practice is there and that's life I mean I think it's everywhere the same any other questions? question well it's a little bit of a follow up but if you're looking for a new tool is it a new tool or is it more likely that it might be a combination of tools that already exist mainly because of course the financial part you don't have to buy new equipment if it's already there would it be possible to combine not just in the analysis in retrospect but also just in a combination of different techniques at the same time to for example solve the temporal and spatial resolution something like that well I don't know exactly in terms of time I think that if you go from what you have and you improve what you have it's quicker if you want to go to unique tool that does everything I think that that's going to be tough I think I think but I mean there are many things to do with information we have for example intraventricular gradients is something that we have been talking a lot not so that in 2000 I was I remember some authors already writing papers on this and that's something that it seems easy but the companies were not interested in this because what does it what do they sell nice pictures and in the end okay these are nice pictures but what do you use it for no so it's a trade-off and this thing is going to be difficult to do if we do not interact more than we do and for that I mean we want to sell okay nice pictures will sell much better we know that but in the end we need useful things because we have lots of examples of nice pictures that haven't been there for like 3D volumes from eco I mean 3D volumes okay but in the end we don't use so much I guess integration of new things in the current clinical routine is I think the most important if you do something which is totally separate from clinical routine acceptance will be extremely low and add on there it will be much easier to get into some of these and also you need to make it it's you need to make it also easy to understand for example DTI was a nice example of something that can give you a lot of information but most of the physicians they don't understand and they don't pay attention to it so you need to find I mean we are simple people so we are always kind of saving lives so we need simple things and easy to use because if not it's going to be that again Hi first of all thank you for the talk very interesting my field is cardiopulmonary bypass so regarding monitoring of microemboly is echocardiography the best or the most most used tool or is there during surgery some atoms to use because during pulmonary cardiopulmonary bypass you can only use echo okay and there have been some atoms looking at myocardial perfusion with contrast but that's another field to work we are not sure if the bubbles are so harmless to the myocardium so but maybe something working on strain and myocardial deformation would be good cardiopulmonary bypass is the the status of the myocardium okay is that what you are working or not or in the pulmonary I'm starting more the optimization of the oxygenators okay okay I'm not so expert in lung perfusion and I'm not so aware on that but maybe I don't know there I know that has been some work maybe it's something that you can apply but I'm sorry I cannot help with the lung perfusion it's not my field okay thank you very much in the sake of time or was there still okay one last question hi again thank you for the presentation I have a question regarding modeling and image analysis because Bart was talking before about doing some kind of patient but how is it used really in the clinic so can you easily combine the two techniques and take images from the patients and do some kind of patient-specific modeling to better study the disease or is it not yet being used so indeed this is another example no so you have injuries coming saying okay I'm going to model this model so now what we are using modeling sometimes is to better understand pathophysiology and then translate that into clinical practice so the translation of modeling into clinical practice I think is still a little far away I mean we should do that to understand much more pathophysiology and this is how we usually work at least in cardiology I know other specialties like for example maxillor maxillor surgery they are very very ahead but in cardiology still it's still difficult okay thank you very much in the sake of time I think we continue thank you very much for coming