 Hello, everyone. Once again, thank you for having me here and in the second round of talks, we're going to go back to the same topic that we discussed before. There was the use of percutaneous mitrovav clips for mitrovav repair, and we're going to take it, take the concept that we've discussed before and dive into two real cases. I have a few disclosures. I received speakers on Orion from Abbott, and we are a reference center for Philips, and therefore all of our images are from Philips platforms. So as I said, we're going to present two cases, and we start with our first case. There was a 77-year-old gentleman with idiopathic cardiomyopathy, and a decreased left ventricular ejection fraction that was previously measured as 30% chronic atrial fibrillation, chronic renal insufficiency, and severe mitral regurgitation with New York Heart Association 3. As we started the exam, you can appreciate here, you can see a four-chamber view, and you can appreciate there's some pericardial effusion, and that's very important to identify the beginning of a case like this, because we can definitely, with the clip and with our catheter, cause pericardial effusion. So we want to know exactly if the pericardial effusion was already there or not. And you can look at this mitral valve, we have a big heart, big ventricles, both right and left are dilated, and this mitral valve, you can tell right away that it struggles to close because the leaflet are just pulled down, from the dilated left ventricle. And if we go further in our examination, this is a mitral commissure review, you can see that from the center of the commissure there is a pretty bright jet that sort of comes centrally and shoots towards the roof of the left atrium. This is a mitral commissure review and explain or also what we call the view that we most commonly use for grasping of the leaflets, and you can see and you can further appreciate the tethering of both anterior and posterior leaflet, which characterizes this as a mitral agitation type 3B, according to the Carpentier classification. The annulus was also dilated, about 40 millimeters, and the leaflets were normal length, the posterior leaflet was actually 17 millimeters. And these actually are characteristics that we're going to be taken into consideration for to predict how difficult it's going to be to clip this valve. We look at 3D, we love it, unfast view, and we confirm the mechanism of mitral agitation, you can see that there's a big gap in the center of the valve with a centrally directed jet with a pretty bright but a very central jet. And if we go back to what we discussed in the first talk, if we're looking at optimal morphology, challenging or unsuitable morphology, we have all of the characteristics of the optimal morphology. The regurgitation is in the center, there's no classification, the annulus is big enough, the leaflet open without problems. The posterior leaflet is more than 11 millimeter, the tenting height in this case was about once, one centimeter, the leaflet, as we said, they move normally the only element that that poses for challenging morphology is that this Carpentier type 3B. And the flail gap or flail leaflet in this case are not to be taken into consideration because it's a restricted valve. This thing poses for a good valve to clip, and our cardiologist decided to attempt to clip this valve with an NT wide, so a small clip, but wider than sort of the basic model, and that's what we decided to do. We started with puncture, and here we were quite satisfied with the position, the puncture, the indentation you can see here on the left is superior in the fossil valleys, and it's posterior. So that's exactly where we wanted to be. In this case, what happened is what unfortunately happened to me very often with our cardiologists who have no patients, I didn't get a chance to measure the distance from the mitral valve that they were already through the interraterial septum. So once they were through the interraterial septum, the catheter was passed through and you can see the catheter on the right, and here is the delivery catheter. On the left, you see that the delivery catheter, the dilator from the delivery catheter is already in the left atrium, and now the delivery catheter is just making its way through the interraterial septum. So this is one of the most dangerous steps of this procedure because here is where the cardiologists, they are trying to push this delivery catheter into the atrium, they have very little control and we need to focus not on the interraterial septum, but we need to focus on the interraterial septum and on the tip of this dilator because if they push too hard and too fast, what we can do is with the dilator, we can actually injure the left atrial wall. On the right, the catheter is passed through the septum and we're sort of happy with the position and we advance our clip. You can see the clip comes in and now the clip, we need to be able to follow and see the clip all the time. As you can see that the clip is like hitting the wall of the left atrium. Here on the left here, you can see that it is hitting the leaflet, we need to tell the cardiologists, say, guys, be careful, and now they started bending the clip down and now the clip is coming above the mitral valve. So the clip is in position. We want to try to position the clip because this is the central jet right in the middle of P2 and A2. We look with 3D and you can see that here the clip is a little bit too on the left, the clip is a little bit too lateral and the clip is a little bit, so one hour counterclockwise rotated as we wanted it to be. So we reposition the clip, as you can see on the right, we move it more medially and we give it a little clockwise tilt and now the clip is in a pretty good position. We're ready to dive. So we go through the valve and what we normally do at this point is we stop the ventilation. And as I was telling before, we use this Emil concept. So if we want to be more lateral, we give less peep. If we want to be more medial, we give more peep. So the clip is under the valve and you can see that the leaflet are just in the right position to engage with the arms of the valve of the clip. And you can see that we have the short axis of the clip, so the short profile of the clip on the left and the long profile of the clip on the right. And we can clearly see the clip with all the arms and all the, and the graspers on the clip very well on the right side of the screen. Now that we're under the valve, we want to control again our clocking. And you can see that on the left side, so we decrease the gain to see through the valve. We see the clip. And we weren't so happy because now the valve, the clip is a little bit rotated clock clockwise at like one and seven o'clock. I wanted more of 12 and six o'clock. And that's why we reoriented the clip here. We reoriented the clip at, as you can see here on the right at 12 and six o'clock. Now we are through the clip, we grasp the leaflet and we close the grippers and you can see that you start to see tension on this leaflet. And now as we make, as we make, and we close the valve, the clip completely on the right, you can see that the leaflet have even more tension. So they move even less. That's exactly what we're looking for. So we're looking for a good tension on the leaflet. That means that the leaflets are well grasped from the clip and they are pulled together from this little device. Now we control, we check for, we check for residual regurgitation and I usually go back to 2D without X-plane, turn on the color because with 2D and color I have a way higher temporal resolution as I have with the X-plane and color because X-plane is already at a lower temporal resolution or frame rate as 2D. And now if I add color, I drop my temporal resolution further. I also need to measure a gradient. Here the mean gradient was 1 and so we look again with 3D and also with 3D we confirm that there's not residual regurgitation. We've grasped this leaflet right in the middle. The clip is exactly where we want it to be. It's stable, we can release it and then the clip is here released. What's important to do is, no, we don't have enough, we need to always check after we've released the clip because the final position of the clip, we have it only when the clip is released because always when the clip is still attached to the leaf, to the delivery catheter, the clip is pulled and then it can still move with a different angle and sometimes we'll be very surprised to find a jet that wasn't there before just after the clip is released. So that was sort of an example of a good result with a typical patient who comes with secondary schemic matter regurgitation and we get the good job done with one clip. Our second case is a little bit more complex, although this patient was not as sick as the first patient. We have now a 76 years old female with New York Heart Association 2. She has dyspnea at the exertion and a normal ejection fraction and minimal comorbidities and severe matter regurgitation. So the patient comes for a clip and we look at this heart and the only thing that's comparable to the previous heart that also this patient has a little bit of pericardial effusion that you can see here. But what you see is a completely different mitral valve. So now there is a big jet that we can see also in the four chamber view, but both leaflets are actually prolapsing. So this is a completely different mechanism of matter regurgitation. And as we go to our matricommissural view, we can confirm that there's a bi-leaflet prolapse and there's a bright regurgitan jet in the matricommissural view and a central regurgitan jet in the long axis view. These are the measurements of the annulus which wasn't particularly big. And when we look at 3D though, there's a Barlow's looking valve with prolapse not only of the P2 and A2 segment but also the A1 is prolapsing with the anterior commissure and the posterior-medial commissure is also sort of involved by this pathology, although the main jet comes from the center of the valve. We did 3D reconstruction. We look at the cross-sectional area, the 3D cross-sectional, vina contract the cross-sectional area that was 0.47 centimeters square. And now if we look at this table, we have a bit more characteristics that make it more challenging than the previous case. And that's the reason for given the degree of prolapse and given the amount of leaflet and the how big this leaflet were and how bright the gap was. So our cardiologist decided to start with an XT clip wide. So a big clip that was actually, so a big clip that was, that was sort of in the sticker version. So septal puncture here again where we're sort of relatively happy with the long axis view, sorry, the my cable view. And now we measure in the four chamber view and the height from the mitra valve leaflets to where the indentation is, it's just over five centimeters. We said between four and five is what we're looking for. So we went ahead, we position our delivery catheter, and now we can see in 3D where the delivery catheter is and where the posterior commissure of this valve is. So the delivery catheter falls right on top of the posterior medial commissure, which is what we are actually looking for. So we advance one clip, we look at this clip, see where the clip goes, and now the clip is above the valve. And we decided to go through the valve and as we go through the valve, we have a clip that's now sitting almost in the middle of P2 and A2. I would have asked our cardiologist at this point to maybe rotate the clip a little bit counterclockwise. What we decided to do is yeah we rotated the clip and now we try to get the leaflet in. We have a very good positioning of the leaflet. We've advanced the problem a little bit in in order to have a better picture of the leaflet and the grasping and the grasping system and the graspers as well as the arms of the clip. And you can see that this is what usually happens when the leaflet are well inside the graspers. Is that as the, insistently, the leaflet, especially when we have this big Barlow's valve with long leaflets, is that insistently the leaflet would push the graspers up. Yeah, you can see as it happens here. So we close the clip. And now we look at the results. And in 2D, you can see here with color that we have a relatively big jet that's more medial to the clip and there's still a small jet that it's lateral to the clip. So here we started to think, well maybe this is not the right strategy, we're not going to get away here with just one clip. So what we decided to do then is move the clip a bit more medially. And now we grasp the leaflet again, we close the clip, we look again and we definitely have a bigger regurgitan jet lateral, but we still have a medial regurgitan jet. So then we decided to then open the clip again and then re-grasp and go way more medial. So once we've done that, we grasp the leaflet, we close the clip, we look at the color and you see that the medial jet is pretty much completely gone. So we are at the very edge of P2. And so we decided that this was actually a pretty good results for the first clip. So we measure the gradient, the gradient is two millimeters of mercury and so we decided to then go ahead and position a second clip. So we now advance the second clip and the second clip now is to sit on the lateral to the first clip, the clip goes through, we stop the ventilation. And we open the clip and now we grasp the leaflet, you see on the left the leaflet are going inside the graspers, we make the graph, we close the graspers, and you can see here how the leaflets are moving the graspers up and down. What you may appreciate here is that it's always, it's sometimes challenging with the second clip to have a good visualization of the clip and also with our scanning plane, with a secondary plane, when as we move, like sometimes we think we're looking at the second clip, we're actually looking at the first clip. So but here we were actually satisfied. So then we sort of close the clip, we look at with color and there's barely any material agitation. We look at, we measure the gradient, the gradient, it was two before now it's four, so four between four and five, that's the maximum that we are accepting. So it's sort of on the border of what we normally accept, but it's still an acceptable gradient for this valve. Another option to assess the stability and the insertion of the leaflets, especially when you have more than one clip or when you have a difficult angle with which to align your planes is you can use multi-view. So in this case we use multi-view and with multi-view we align the yellow, sorry, the red and the green plane along the clip. And so you can see that now the clip on the, we can see the clip on the right here and we can very well see the insertion of these two leaflets. We've released the clip and now this is the second clip here and we're now looking again at the insertion of the second clip on the leaflet on the second clip. And this is sort of a very good result that that's what we were looking for. When we look at in 2D, we can appreciate now both your clips, they are moving together with these big bulky leaflets. There is still trace to mild regurgitation that you can appreciate there and we sort of accepted it as a good final results. What it's always important to look at and never forget about it is to look at the residual ASD. So in this case we pull the catheter out, we look at the interaternal septum and as you can see there is a regurgit, there is a flow through the interaternal septum. And the catheter went also sort of transversal sort of a bit of a sideways through the interaternal septum. And here you have sort of a jet that's going left to right. Normally when we have a left to right shunt we leave it as it is, we don't do anything about it. And we only consider closing an interaternal septum effect when we have elevated right sided pressures and now we have this saturation because of right to left shunt. So as tips for successful micro clip insertion implantation, you need to optimize our views. The better the views are, the quicker our cardiologists are going to be and the more precise and successful they're going to be. Optimize the imaging means also sometimes look at the position of our probe in respect to the clip on fluoroscopy and sometimes and try to go under the clip in order to avoid the shadow from the delivery catheter. When we use 3d we can play with the game and playing with the game allow us to see through the valve so when the clip is underneath the valve, if we drop the game completely. Now we don't see the leaflet but we do see we still see the clip. And then finally, for those of us who have this option multi view is also another modality to assess the insertion of the leaflets on the clip. That from we take a 3d block of the metro valve, and then we play with an angle with our panel with our planes, and we align it to the clip and we can see very well the insertion of the of the leaflets in the clip. One hour cardiologists don't like it very much because as you can appreciate, as you use multi view the resolution of your to the images of multi view is not as good as the resolution of your to the images using to the or or explain. Thank you very much for for listening. This is my email you can email you always email me come visit us anytime and connect with us for our upcoming very operative team masterclass that's coming next June, there's going to be lots of you can see your broadcasted live from our and you'll have the opportunity to interact with with us and the guest speakers they're coming from all over the world. Thanks again, and I hope to see you next year in person. Bye bye.