ACUSON Sequoia 3.5 (VB30) UDFF Presentation

SIEMENS Healthineers SIEMENS Healthineers .. ACUSON Sequoia Ultrasound System Ultrasound Derived Fat Fraction (UDFF) 3.5 (VB30) 1 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Notes No. 1 SIEMENS Healthineers Objectives SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 2 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 2 SIEMENS Healthineers Overview SIEMENS . Healthineers ... • Ultrasound Derived Fat Fraction (UDFF) is a measurement tool to aid physicians in managing patients as part of an overall assessment of hepatic steatosis • Results are acquired in a user-defined region of interest using the same exam technique (not technology) as shear wave • The UDFF index is calculated using attenuation and backscatter information obtained from a region of interest (ROI) placed within the liver tissue and displayed in percent (%) • UDFF shows strong diagnostic performance for assessing severity of hepatic steatosis in adults and children. • Diagnostic performance indicates Area Under Receiver Operating Characteristic (AUROC ≥0.88) 3 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Ultrasound Derived Fat Fraction (UDFF) is a measurement tool to aid physicians in managing patients as part of an overall assessment of hepatic steatosis. UDFF uses the same exam technique, not technology, as shear wave elastography (SWE). It is calculated using attenuation and backscatter information and displayed as a percent. The UDFF index is an easy-to-understand cut-off value of 5%, that delivers a clinical utility similar to and benchmarked against Magnetic Resonance Imaging Proton Density Fat Fraction (MRI-PDFF) Image: HOOD05162003330011 Notes No. 3 SIEMENS Healthineers Objectives SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 4 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Notes No. 4 SIEMENS Healthineers What is a steatotic liver? SIEMENS . Healthineers ... Normal liver contains a Fat accumulation/deposition small amount of fat (less than 5%) Steatotic liver disease 2 classifications Metabolic dysfunction associated Metabolic dysfunction associated liver disease with increased alcohol liver disease* (MASLD) intake (MetALD) 2 categories Metabolic dysfunction associated Steatotic liver disease (SLD) steatohepatitis (MASH) • Simple steatosis • Greater fat accumulation • Reversible • Inflammation, constant damage Considered benign and repair of liver cells, scar tissue • • Minimal risk of progression • Progressive – can lead to cirrhosis, liver cancer and/or liver failure * https://www.aasld.org/news/multinational-liver-societies-announce-new-fatty-liver-disease- *MASLD is now considered the most common cause of chronic liver disease worldwide 5 nomenclature-affirmative-and Unrestricted © Siemens Healthineers 2024 Speaker Notes: We encounter fatty liver everyday in ultrasound – everyone is familiar with what it looks like, how it affects our image and what we can do to try and accommodate it…but do we really know what it is? Fatty liver is a multi-faceted disease that is classed in the liver when the amount of fat contained within the liver tissues exceeds 5%. A normal liver contains less than 5% fat in total. There are two main types of steatotic liver disease (SLD) that are classed based on contributing factors. The first, metabolic dysfunction associated liver disease with increased alcohol intake or MetALD, is the result of excessive alcohol use. The other, metabolic dysfunction associated liver disease or MASLD, results of factors outside of alcohol use. Out of the two, MASLD is the most worrisome, as it is the most common cause of chronic liver disease worldwide. SLD was chosen as an overarching term to encompass the various aetiologies of steatosis. The term steatohepatitis was felt to be an important pathophysiological concept that should be retained. Nonalcoholic fatty liver disease (NAFLD) will now be metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD encompasses patients who have hepatic steatosis and have at least one of five cardiometabolic risk factors. A new category, outside of pure MASLD, termed MetALD (pronunciation: Met A-L-D) was selected to describe those with MASLD who consume greater amounts of alcohol per week (140 g/week and 210 g/week for females and males respectively). Those with no metabolic parameters and no known cause have cryptogenic SLD. Metabolic dysfunction-associated steatohepatitis (MASH) is the replacement term for nonalcoholic steatohepatitis (NASH). MASH is liver inflammation caused by constant fat deposition in the liver cells. The repetitive damage and repair cycle associated with this form of the disease makes it progressive; left untreated it can lead to liver cancer or even liver failure. MASH is not reversible, however, with the proper treatment and monitoring, the long-term effects can be controlled. Notes No. 5 SIEMENS Healthineers Why is quantifying fat in the liver important? SIEMENS . Healthineers ... • Metabolic dysfunction-associated steatotic liver disease (MASLD) affects about 30% of people in the world* Normal/Healthy Liver Fatty Liver • MASLD is the most common chronic adult liver disease worldwide° • MASLD is usually seen in people with high BMI’s • MASLD has little to no symptoms • If diagnosed early, fatty liver can be reversed *Younossi Zobair M. Non-alcoholic fatty liver disease – A global public health perspective. Journal of Hepatology. 2019 vol 70|531-544 °Caussy Cyrielle, Reeder Scott B, Sirlin Claude B, Loomba Rohit. Non-invasive, quantitative assessment of liver fat by MRI-PDFF as an endpoint 6 in MASH trials. Hepatology. 2018 Aug; 68(2): 763-772. Doi:10.1002/hep. 29797 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Why is quantifying fat in the liver so important? About 30% of the world’s population have fatty liver disease – this number has a significant economic burden associated with it. A steatotic liver has little-to-no outward symptoms. This can lead to patients going undiagnosed until they reach a more advanced stage where outward symptoms start to present. Unfortunately, when the disease reaches this more advanced state, it can no long be reversed with simple intervention – sometimes the only treatment left is liver transplant. Early and easy diagnosis of fatty liver disease is key to lessening its impact and easing this global burden. Notes No. 6 SIEMENS Healthineers Who gets fatty liver? SIEMENS. Healthineers ... Contributing factors The exact cause of MASLD is not truly known but is thought to be CAUSE associated with a wide range of diseases and/or conditions such as • Metabolic disorders (individual) such as Insulin resistance CAUSE • • Diabetes • High cholesterol • Hypothyroidism • Prescription medications or steroids Metabolic syndrome* • • A body habitus that has a high BMI EFFECT EFFECT *Metabolic syndrome is a cluster of conditions that occur together that include increased blood pressure, high blood sugar, high cholesterol or triglyceride levels, 7 and excess body fat. This syndrome is increasingly common with up to 1/3 of U.S. adults have it Unrestricted © Siemens Healthineers 2024 Speaker Notes: • The exact cause of MASLD is not truly known, however it is thought to be associated with a wide range of diseases and/or conditions • These include (but are not limited to) metabolic disorders such as insulin resistance, diabetes or high cholesterol • Individuals who have hypothyroidism or high blood pressure are also perceived to be at greater risk for developing fatty liver disease • Medications used to treat a specific disorder can also contribute to this disease process • There is, however, an additional piece to the fatty liver puzzle that provides the greatest challenge to fatty liver management – that being a body habitus that has a high BMI Notes No. 7 SIEMENS Healthineers Who should we be screening for fatty liver? SIEMENS . Healthineers ... Spotlight on large body habitus • The growing large body habitus epidemic is contributing to an increased prevalence of MASLD worldwide – up to 35% • Obese individuals make up a substantial proportion of MASH cases • In a study of more than 8 million people, obesity was present in 51% of patients with MASLD and 82% of patients with MASH • MASH has become one of the leading indications for liver transplants in the western world https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight 8 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Now that we have some idea what is thought to cause fatty liver, it is pertinent to ask the question of who should we be screening for it. Since fatty liver is a silent disease, having a means to screen everyone would be the optimal request, however if we must narrow down fatty liver disease screening to a specific patient population, overweight or obese individuals would certainly top that list. The overweight and obese populations make up a substantial proportion of the resulting MASH cases in those with MASLD worldwide. In the western world, MASH has become one of the leading indications for liver transplants. Note: Statistics from https://www.who.int/news-room/fact-sheets/detail/obesity-and- overweight Notes No. 8 SIEMENS Healthineers Objectives SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 9 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 9 SIEMENS Healthineers Current methods of fatty liver detection SIEMENS . Healthineers ... Liver biopsy the (“imperfect”) gold standard • Pathology grades on severity of fat from 0 - 3 • Sample represents 1/50,000 of the organ • Prone to sampling errors • Risk level to patients • Unrealistic to perform bx’s on all MASLD pts Conventional ultrasound • Observation based • Bright/echogenic • Posterior attenuation • Heterogenous/visibility of vessels • Cannot grade or stage MASLD • Excellent first-line diagnostic test/limitations 10 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Currently, liver biopsy is the reference standard for diagnosing and grading hepatic steatosis. Liver biopsy is, however, inappropriate for routine screening or frequent monitoring as it is invasive, prone to sampling errors, observer variability, and the risk of complications. Conventional ultrasound is the most common imaging modality for assessing hepatic steatosis. In conventional ultrasound, assessment is made based on qualitative features of the B-mode images of the liver, such as brightness or visibility of vessels. The sensitivity and specificity of conventional ultrasound for the detection of moderate-to-severe fatty liver is high, however the sensitivity decreases markedly in incidents of mild steatosis where less than 30% of hepatocytes are affected. Conventional ultrasound assessment techniques also suffer from operator and machine dependency, which leads to variability in the detection and/or severity of hepatic steatosis. Even with these limitations in mind, ultrasound remains an excellent first- line diagnostic tool. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 10 SIEMENS Healthineers Current methods of fatty liver detection SIEMENS . Healthineers ... Hepatorenal Index (HRI) • Developed to aid B-mode HRI = 𝑩𝒓𝒊𝒈𝒉𝒕𝒏𝒆𝒔𝒔 𝒐𝒇 𝒍𝒊𝒗𝒆𝒓 • Semi-quantitative 𝑩𝒓𝒊𝒈𝒉𝒕𝒏𝒆𝒔𝒔 𝒐𝒇 𝒌𝒊𝒅𝒏𝒆𝒚 • Quantifies liver echogenicity relative to kidney • Limitations include inclusivity of all patients (renal disease) and issues with positioning of samples at the same depth Elastography • Quantifies fibrosis, not fat • Different vendors, different numbers FO/F1 F2 F3 F4 11 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Ultrasound has evolved to try and meet the demands of fatty liver disease diagnosis or screening. Hepatorenal index was developed to aid in the B-mode image for diagnosing fatty liver disease. Hepatorenal index, or HRI, is a semi-quantitative approach to classifying the degree of fatty liver disease. HRI relies on comparing the echogenicity of the liver parenchyma to that of the renal cortex of the kidney. The two values are measured using a caliper function and a ratio is then calculated using the two values. While HRI is a nice tool, it is not without limitations. It cannot be used on patients who have renal disease, and it can be challenging to place both sample points at the same depth during the measurement process. Elastography, while a quantitative ultrasound (QUS) approach to liver disease, quantifies the level of liver fibrosis, not liver fat content. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 11 SIEMENS Healthineers Current methods of fatty liver detection SIEMENS. Healthineers ... Controlled Attenuation Parameter (CAP) • Steatosis is measured alongside stiffness using Vibration Controlled Transient Elastography (VCTE) • Measured over a pre-defined/fixed area and probe depth • Reported in decibels per meter (dB/m), with range of 100 – 400 dB/m (median of at least 10 sample) • Higher the fat content the higher the CAP Value MITTIT • Limitations: TUTTI • Non-imaging • Accuracy in high BMI may be decreased 12 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Controlled Attenuation Parameter (CAP) is a noninvasive method used to evaluate hepatic steatosis alongside liver fibrosis. The degree of fat present in the liver is estimated using a non- imaging ultrasound-based device. The piston-like probe is placed between the ribs on the right side of the patient where it can emit an ultrasound wave that travels through the liver. The attenuation of the emitted wave is then measured, and a value calculated in decibels per meter (dB/m). The calculated value taken, over at least 10 valid measurements, is aligned with fat content by way of the higher the fat content, the higher the CAP value will be. While CAP can be performed rapidly and somewhat painlessly, it has several challenges that can prevent use in certain patient populations and/or lend itself to the inability of the operator to avoid certain artifacts. Unlike conventional ultrasound, where the liver and surrounding structures are visualized on the imaging screen, CAP is a non-imaging or “blind” test. The lack of visualization of the liver can result in the inability of the user to avoid fluid-filled vascular structures or unknown ascites in a patient, both of which can affect results. The system has fixed depth parameters, which, in patients with a body mass index (BMI) higher than 30 (obese), the accuracy may be decreased. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 12 SIEMENS Healthineers Current methods of fatty liver detection SIEMENS. Healthineers ... Magnetic Resonance Imaging (MRI) • Sensitive to proton signals in mobile, unbound molecules such as water and triglycerides • Technique involves water-fat separation achieved by the frequency differences in [their] protons • Difference is exploited to calculate the fat fraction in percent (%) • Known as Proton Density Fat Fraction (MRI-PDFF) • Has a 5% threshold in determining if a patient has steatosis MRI-PDFF = 𝐹𝑎𝑡 X 100% 𝐹𝑎𝑡 + 𝑊𝑎𝑡𝑒𝑟 13 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Magnetic resonance imaging (MRI) has had the most success to date in the imaging world with fatty liver disease detection, as it is very sensitive to proton signals in mobile, unbound molecules, which just happens to include fat and water. The technique involves water-fat separation whereby MRI acquires images at two or more echo times after signal excitation. MRI then exploits the difference in resonance frequencies of the protons in water and fat and estimates the tissue fat fraction. This fat fraction is known as Proton Density Fat Fraction, or PDFF, and is displayed as a percent. MRI-PDFF has a threshold for disease presence of 5% - you will recall earlier that a “normal” liver has 5% or less fat contained within it. Thus, livers that have a PDFF value of more than 5% are classified as being fatty. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 13 SIEMENS Healthineers MRI Proton Density Fat Fraction (MRI–PDFF) SIEMENS . Healthineers ... MRI-PDFF closely correlates with the histologic assessment of liver fat content, thus it is currently thought of as a “surrogate” to liver biopsy There are, however, pitfalls: • Expensive • Not everyone can get access • Time consuming • Need for sedation in some cases As a result, there is a need for new noninvasive, easily available/accessible, cost-effective test such as… Ultrasound Derived Fat Fraction (UDFF) 14 Unrestricted © Siemens Healthineers 2024 Speaker Notes: • Several studies in support of MRI-PDFF have shown that it closely correlates with the histologic assessment of liver fat content. With this correlation in mind, it is currently thought of as a noninvasive “surrogate” to liver biopsy • There are, however, pitfalls with this technology that make it challenging to be used as a routine or everyday screening tool or scan. These limitations are based on cost, access, exam time length and exam conditions • As a result of these challenges, there is a need for a new noninvasive, easily available and cost-effective test such as Ultrasound Derived Fat Fraction (UDFF) Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 14 SIEMENS Healthineers Objectives SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 15 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 15 SIEMENS Healthineers Ultrasound Derived Fat Fraction (UDFF) SIEMENS . Healthineers ... What is it and how do we determine it? Ultrasound Derived Fat Fraction (UDFF) quantifies fat in the liver UDFF determines fat content by measuring properties related to fat (attenuation and backscatter) The attenuation coefficient (AC) and backscatter coefficient (BSC) are both measured; a proprietary algorithm linearizes the BSC to MRI-PDFF % UDFF is an index, as is PDFF, and is displayed as a percentage from 0 – 50% 16 Unrestricted © Siemens Healthineers 2024 Speaker Notes: What is Ultrasound Derived Fat Fraction and how do we determine it? • Ultrasound Derived Fat Fraction (UDFF) quantifies fat in the liver by using properties related to fat within the liver – that being attenuation and backscatter • Coefficients for both parameters are derived and using a proprietary algorithm, are linearized to MRI-PDFF. The UDFF index is displayed in percent and has a range of 0 to 50. UDFF shows strong agreement with MRI PDFF in adults • and children. UDFF exhibits bias toward slightly larger values versus MRI-PDFF. Larger differences between UDFF and PDFF occur at higher UDFF and MRI-PDFF values, with some outliers present at these levels. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 16 SIEMENS Healthineers Attenuation SIEMENS . Healthineers ... • Attenuation is dependent on: • Depth Attenuation • Frequency • Tissue type • Not all tissues attenuate sound at the same rate – sound through fatty tissue will be more readily absorbed than in ACUSON xva non-fatty tissue • Numerically, tissue attenuation is determined by estimating the frequency content of a wave at different depths and comparing the values to those from a known reference Depth Tissue 17 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Attenuation is something we deal with in ultrasound everyday. Attenuation is the reduction or loss of energy (intensity) from sound waves, and it greatly affects our ultrasound image. Sound is lost (attenuated) more readily with increasing depth making structures located deep within the body more difficult to visualize. Sound attenuation is also affected by frequency, as higher frequencies tend to have higher sound absorption rates. During an exam, we try to accommodate for both these factors with transducer and scanning frequency selections. There are, however, patient factors beyond our control. In ultrasound, not all tissues attenuate sound at the same rate. Fatty tissue will tend to absorb sound more readily than non-fatty tissue, thus a larger body habitus can also challenge the ultrasound exam. Attenuation can be measured and, in some cases, used to generate other advanced measurements or observations. To determine tissue attenuation, we estimate the frequency content of a wave at different depths then compare those values to values taken from a known reference. This method allows us to isolate for the attenuation of the tissue and estimate its attenuation coefficient. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 17 SIEMENS Healthineers Attenuation coefficient (AC) SIEMENS. Healthineers ... i. No Attenuation • The Attenuation Coefficient (AC) is determined by estimating the slope (orange line) of the sound wave as it propagates (and is attenuated) through the tissue • The attenuation coefficient is measurement in dB/cm/MHz • Attenuation alone is not sufficient for estimating fat content of the liver – microscopic tissue properties also have an affect ii. Moderate Attenuation iii. High Attenuation 18 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Estimated attenuation is measured in decibels per centimeter per megahertz (dB/cm/MHz) and is known as the attenuation coefficient or AC. The attenuation coefficient is determined by estimating the slope of the sound wave as it propagates through tissue. As sound travels and is attenuated, the slope of the sound wave changes. It is this change that allows us to determine the degree of sound attenuation. In the example on the right, the slope of the attenuation is represented by the orange line in three different mediums. The first diagram represents a medium where there is no, or almost no, attenuation. In this type of environment (water is an example) the slope representing the attenuation is flat since there is little to no attenuation. The attenuation coefficient in this medium would be zero or very close to it. The middle and the bottom diagrams represent mediums where there is moderate to high attenuation. You can see as the attenuation of the sound wave increases; the slope of the orange line changes to reflect the greater loss of the sound wave. The attenuation coefficient in either of these situations would be much higher than the first illustration in the diagram. With this in mind, we can say that the greater the degree of slope, the greater the attenuation coefficient will be. Attenuation alone, however, is not sufficient for estimating the fat content of the liver. Microscopic tissue properties also have an impact on the sound wave. Leaving this important fact out could decrease the accuracy of the liver fat content estimate. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 18 SIEMENS Healthineers Backscatter SIEMENS . Healthineers ... • Physical characteristics/cell size of tissue determines reflection of sound A B • When fat accumulation occurs, cell size increases NOSnow • The larger the [fat] cell the greater the reflection of sound • The higher the percentage of large fat cells, the Wave hits small particle resulting in a weak amount of backscatter greater the amount of sound (on average) reflected back to the transducer A B Nosnow Wave hits larger particles results in a greater amount of backscatter 19 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Underlying tissue properties, such as cell size, have a direct influence on the amount of backscatter or reflection of the echo signal. As more fat is deposited within the existing fat cells and the normally non-fatty hepatocytes of the liver, the cells begin to grow in size. As the cells enlarge, they begin to reflect sound differently than normal sized liver or normal sized fat cells. Smaller or normal sized fat cells, as seen in the top two diagrams, have little interference with the sound wave and produce a small amount of backscatter. The larger, more obstructive fat cells, as depicted in the bottom two illustrations, interfere with the sound wave more intensely. This increased interference results in a higher amount of sound backscatter. When fat cells increase in both size and number, a higher the amount of sound will get reflected back to the transducer. In B-mode ultrasound we see this high degree of backscatter as a bright or fatty liver image. It is this increased intensity that we measure to determine the backscatter coefficient, or BSC. Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 19 SIEMENS Healthineers Backscatter coefficient (BSC) SIEMENS . Healthineers ... • The backscatter coefficient (BSC) represents the tissue microstructure information when calculating the UDFF index • The greater the fat content, the higher the backscatter coefficient Backscatter • The backscatter coefficient is reported in units of [cm-sr] -1 BACK2C9ff6L 20 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Now that we understand the information that backscatter presents us with, we can say that the backscatter coefficient represents the tissue microstructure information when calculating the UDFF index. Note: Sr = solid angle Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 20 SIEMENS Healthineers Calculating UDFF SIEMENS . Healthineers ... Both the attenuation coefficient and the backscatter coefficient increase with increasing fat content and contribute to the calculation of the UDFF index value The UDFF index is obtained by linearizing the BSC to MRI-PDFF using a proprietary algorithm (P) ( 𝑃 𝐵𝑆𝐶 3𝑀𝐻𝑧 ՜ 𝑈𝐷𝐹𝐹 The UDFF index demonstrates similar clinical utility to MRI-PDFF, and unlike the AC or the BSC values, exhibits a linear relationship with the fat content i.e., the UDFF index value increases as the fat content increases 21 Unrestricted © Siemens Healthineers 2024 Speaker Notes: • Both the attenuation coefficient and the backscatter coefficient increase with increasing fat content within the liver. Ultimately, both the attenuation coefficient and the backscatter coefficient contribute to the calculation of the UDFF Index value • The attenuation coefficient is first calculated and then used in the calculation of the BSC. The BSC is then linearized to MRI-PDFF using a proprietary algorithm • The UDFF index demonstrates similar clinical utility to MRI-PDFF, and unlike the AC or the BSC values, exhibits a direct linear relationship with the fat content (i.e., the UDFF index value increases as the fat content increases) Note: for complete list of citations or more information, please refer to the Ultrasound Derived Fat Fraction technical white paper from Siemens Healthineers. Notes No. 21 SIEMENS Healthineers Objectives SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 22 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 22 SIEMENS Healthineers Ultrasound Derived Fat Fraction (UDFF) SIEMENS . Healthineers ... Access software VT 23 Unrestricted © Siemens Healthineers 2024 Speaker Notes: The UDFF technology is accessed using the Virtual Touch (VT) rotary key on the control panel. Notes No. 23 SIEMENS Healthineers Ultrasound Derived Fat Fraction (UDFF) SIEMENS. Healthineers ... Touch Screen layout • UDFF key is located within the Virtual Touch Abdomen 1816 2 1514 9C2 Workflow tab > pSWE/UDFF Patient 2D Virtual Touch • Software option is available on the 9C2, 5C1, Imaging and DAX PSWE / UDFF SWE Review PSWE UDFF sc2 Report SCI DAX End Exam Site Site 1 Liver Segment Mass No Label No Label ACUSON NOSOY × NOSnow Compounding • Preset - Abdomen Frequency H Mid • Approved for use in Adults • DAX is not an option on ACUSON Sequoia Select 24 Unrestricted © Siemens Healthineers 2024 Speaker Notes: The UDFF key is located within the point shear wave (pSWE) Ultrasound Derived Fat Fraction (UDFF) tab in the mid left area of the Touch Screen menu. For this software release, the option is available on the 9C2, 5C1,and the deep abdominal (DAX) transducers in the abdomen exam preset. UDFF is approved for use in Adults. Please note, the DAX is not available on the ACUSON Sequoia Select ultrasound system. Notes No. 24 SIEMENS Healthineers Ultrasound Derived Fat Fraction (UDFF) SIEMENS. Healthineers ... Imaging screen • When the UDFF key is selected, the pSWE ROI will change in size to a larger UDFF ROI UDFF UDFF DAX • UDFF measurement will be displayed as a percent in the MDA after the acquisition is complete • Cooling time is minimal and will not interrupt multiple acquisitions 25 Unrestricted © Siemens Healthineers 2024 Speaker Notes: When the UDFF key is selected, the point shear wave (pSWE) region of interest (ROI) will change in size. The ROI will change to a 3 x 3 cm UDFF ROI for the DAX transducer and 2 x 2.5 cm UDFF ROI for the 9C2 and 5C1. The UDFF index measurement will be displayed as a percent in the measurement display area (MDA) after the acquisition is complete. The cooling time is minimal and will not interrupt the flow of multiple acquisitions. Notes No. 25 SIEMENS Healthineers Image layout – UDFF SIEMENS .... Healthineers ... Sequoia DAX MDA displays Liver Site 1 Abdomen UDFF=8 % TIB:0.85 percentage of fat Depth=5.5 cm TIC:2.44 TIS:0.85 and depth MI:1.38 20fps 95% 2D H Low UDFF region of -3dB/DR60 interest 3 x 3 cm c=1540 PSWE Liver capsule marker 16cm Cooling 10 26 Unrestricted © Siemens Healthineers 2024 Speaker Notes: The image layout looks the same as the pre-acquisition Auto pSWE image layout, as both technologies use the same ROI size. (3 x 3 cm ROI for the DAX transducer and 2 x 2.5 cm ROI for the 9C2 and 5C1). When the UDFF acquisition is complete, the MDA displays the labeled measurement with the liver fat percentage along with depth at which the measurement was taken. Like Auto pSWE, the max depth that will be displayed for the acquisition is eight cm – this value is determined by the center of the large ROI. Note in this image, the sample marker is correctly aligned with the liver capsule indicating proper sample technique. Notes No. 26 SIEMENS Healthineers UDFF Report SIEMENS ... Healthineers ... • Results will be displayed for each acquisition Liver Ultrasound Derived Fat Fraction Measurements (UDFF) Liver Site 1 • Measurements can be deleted UDFF Depth % cm 5.9 6 5.9 5.9 6 5.9 5.9 LAWN - Mean 6.0 Std Dev 0.7 Median 6.0 IQR 1.0 IQR/Median 0.17 Overall Statistics Mean 6.0 % Std Dev 0.7 % Median 6.0 % IQR 1.0 % IQR/Median 0.17 27 Unrestricted © Siemens Healthineers 2024 Speaker Notes: The UDFF report will display the results for each acquisition along with the depth at which the measurement was taken. Note that measurements can be deleted in Edit Report, but not edited numerically (i.e., you cannot change a value from 7% to 5%, etc.). Notes No. 27 SIEMENS Healthineers Patient preparation and positioning SIEMENS. Healthineers ... Patient prep and positioning is the same as with elastography • Have patient fast for at least four hours Position patient supine or slight (30º • ) left lateral decubitus – support with wedge if necessary • Position right arm about the head to maximize intercostal spacing and avoid ribs 28 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Patient preparation, positioning and scanning protocol for UDFF is the same as with elastography. • The patient should fast for at least four hours prior to the exam • Position the patient supine or in a slight decubitus position – some patients will require a support wedge in order to remain still and hold the position during the length of the exam • Place the patient’s right arm above their head to maximize the intercostal spacing and avoid the ribs Notes No. 28 SIEMENS Healthineers Scanning protocol SIEMENS .... Healthineers ... ROI depth and sample marker alignment Optimal sample location and positioning of the ROI DAX is important Liver Site 5 Abdomen UDFF=10 % TIB:0.85 Depth=5.5 cm TIC:2.44 Measurement obtained in right lobe using TIS:0.85 • MI:1.38 an intercostal approach 20fps 95% 2D Sample at least 1.5 – 2 cm below the liver H Low • -4dB/DR60 capsule c=1540 PSWE • Align sample marker (“+”) parallel to the liver capsule – will ensure proper sample depth and ROI position 16cm 29 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Sample depth and proper placement of the region of interest is important in order to obtain a valid UDFF index measurement. The UDFF measurement is obtained within the right lobe of the liver using an intercostal approach at a depth of at least 1.5 to 2 cm below the liver capsule. Measurements are taken at this depth or below to avoid reverberation or other potential artifacts. Aligning the sample marker parallel to the liver capsule will ensure both proper sample depth and correct ROI positioning. Notes No. 29 SIEMENS Healthineers Scanning protocol SIEMENS . Healthineers ... ROI positioning and sample marker alignment DAX 30 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Improper or non-parallel alignment of the UDFF region of interest can result in falsely elevated values. Avoid improper alignment by tilting or rocking the transducer until the marker is parallel to the liver capsule. Alignment is also important when this technology is paired with Auto Point Shear Wave (Auto pSWE). Notes No. 30 SIEMENS Healthineers Scanning protocol SIEMENS .... Healthineers ... ROI placement - areas to avoid Avoid placing the ROI in regions with: ✘ ✘ ✘ Liver Site 1 UDFF=6 % Depth=4,9 cm TIS 0.09 UDEFAX Liver Site Tis 0 08 UDFF-NA Depth=4.9 cm 53fps 2D H Low 2D -1dB/DR63 H Low C#1540 -1dB/DR63 PSWE c#1540 PSWE Vessels Shadows of any kind including those from anatomical edges/interfaces or ribs 31 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Best practice techniques also involve avoiding certain areas or image conditions. While during processing, the software will remove any strong artifacts, clutter or backscatter characteristics that do not meet the thresholds for the accepted signal to noise ratio, it is still best to avoid them as much as possible. Areas to avoid include: • Tissue containing vessels or ducts • Shadows of any kind, including those from anatomical edges/interfaces and those caused by ribs Notes No. 31 SIEMENS Healthineers Scanning protocol SIEMENS ... Healthineers ... ROI placement - areas to avoid Avoid placing the ROI in regions with: o ✘ O ✘ 5C1 ✘ Liver Site 1 UDFF=7 % Liver Site 1 Abdomen UDFF=6 % TIB.0.16 Liver Site 1 UDFF-NA Depth=4,7 cm Depth=4,6 cm TIC:0 86 TIS 0.16 Depth=4.9 cm ME1:36 20105 JB/DRES GB/DRES Echogenic boundaries such as the Loss of contact Blurry images (movement, gallbladder wall breathing, etc.) 32 Unrestricted © Siemens Healthineers 2024 Speaker Notes: (Areas to avoid continued) • Echogenic boundaries such as the gallbladder wall • Areas where there is a loss of contact or any images that are blurry from breathing or other patient or user movement Notes No. 32 SIEMENS Healthineers Scanning protocol SIEMENS .... Healthineers ... Acquisition and number of samples When obtaining the measurement: DAX • Have patient suspend their breath for Liver Site 5 Abdomen UDFF=10 % TIB:0.85 acquisition Depth=5.5 cm TIC:2.44 TIS:0.85 MI:1.38 • Obtain five measurements at the same site 20fps 95% 2D There are no data-related metrics H Low • 4dB/DR60 (IQR/Median ratio, etc.) for the UDFF exam c=1540 PSWE 16cm Cooling 6 33 Unrestricted © Siemens Healthineers 2024 Speaker Notes: When obtaining a UDFF measurement: • Have the patient suspend their breath for the acquisition • Obtain five measurements at the same site – five measurement is the total number of samples required to complete the UDFF exam Additionally, there are no data quality related metrics for the UDFF exam. Notes No. 33 SIEMENS Healthineers UDFF and Auto pSWE SIEMENS. Healthineers ... • UDFF can be used alone or in SC1 18L6 Abdomen 9C2 Workflow conjunction with Auto pSWE on the 9C2 and DAX Patient 2D Virtual Touch Imaging Measurement display area (MDA) PSWE / UDFF SWE • Review results will display values for both Report PSWE UDFF Auto PSWE • Simultaneous usage of UDFF and Auto nd Exam Site Liver Segment Mass pSWE is a workflow benefit Site 1 No Label No Label • Using Auto pSWE at the same time will increase the cooling time X Compounding Frequency 34 Unrestricted © Siemens Healthineers 2024 Speaker Notes: UDFF can be used as a standalone feature or, to aid in workflow, and can be used in conjunction with Auto pSWE during a single acquisition on the 9C2 and DAX. When used together, the MDA will display both results on the imaging screen. To use UDFF and Auto pSWE together, select each key from the Touch Screen to activate both technologies. Once activated, UDFF and Auto pSWE share the same best practice techniques and sample protocols. Note that when Auto pSWE is used in conjunction with UDFF, the cooling time between acquisitions will be increased. Notes No. 34 SIEMENS Healthineers UDFF and Auto pSWE - DAX SIEMENS ... Healthineers ... DAX Abdomen Measurement Liver Site 3 Vs Median=1.20 m/s TIB:0.90 display area shows E Median=4.4 kPa TIC:2.47 UDFF=8 % TIS:0.90 Depth=5.6 cm MI:1.38 both values 19fps 95% 2D H Low 0dB/DR60 c=1540 PSWE Auto pSWE and UDFF measurements calculated within the same area 17cm Cooling 12 35 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Here is what the image will look like when Auto pSWE and UDFF are used together on DAX. Since both technologies use the same overall ROI, the only visual change is the display of the sub-ROIs and associated dots for Auto pSWE sample once the acquisition is complete. The MDA on the image will list the percent value for UDFF results along with the median values for velocity and elasticity for Auto pSWE. The left panel will also display the individual values for each Auto pSWE sub-ROI along with the sample depth and overall statistics for those measurements. Note that the UDFF percent will not be displayed in the left panel. The UDFF value will only be displayed on the image in the MDA and in the patient report. Notes No. 35 SIEMENS Healthineers UDFF and Auto pSWE – 9C2 SIEMENS .... Healthineers .. 9C2 Liver Site 1 Abdomen Measurement Vs Median=1.53 m/s TIB:1.05 E Median=7.0 kPa TIC:2.04 TIS:1.05 display area shows UDFF=9 % Depth=4.1 cm MI:1.29 both values 95% 2D H Mid 5dB/DR65 c=1540 LD 1 JA 2 MapD/T5 P2 PSWE Auto pSWE and UDFF measurements calculated within the same area 8cm 36 Unrestricted © Siemens Healthineers 2024 Speaker Notes: Here is what the image will look like when Auto pSWE and UDFF are used together on the 9C2 transducer. Notes No. 36 SIEMENS Healthineers Summary SIEMENS . Healthineers ... • Outline a brief introduction to UDFF • Discuss what fatty liver is, why is it important to know if someone has it, and who should be screened for it • Describe current detection methods for fatty liver • Explain Ultrasound Derived Fat Fraction • Describe the Touch Screen layout, image layout, and how to perform a UDFF measurement 37 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 37 SIEMENS Healthineers Trademarks and disclaimers SIEMENS . Healthineers ... ACUSON Sequoia and Virtual Touch are registered trademarks of Siemens Medical Solutions USA, Inc. 38 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Image: HOOD05162003330011 Notes No. 38 SIEMENS Healthineers Thank you for your enthusiasm! SIEMENS . Healthineers ... Questions? 39 Unrestricted © Siemens Healthineers 2024 Speaker Notes: No speaker notes. Notes No. 39