 Okay, so to conclude our session today, we're going to have a panel case discussion on a recent case of a mitral valve edge to edge repair that was done at our institution here at the IDMC. So on this panel, we'll have myself and I'll be joined by Dr. Rose Mammoud. Dr. Mammoud is a professor of anesthesia at the Harvard Medical School. He is the division director of cardiac anesthesia, as well as a network chief of cardiac anesthesia services at Beth Israel. Also joining us on the panel will be Dr. Mario Franz Palin. Mario Franz is an assistant professor of medicine at the Harvard School of Medicine and also serves as the associate director of structural heart disease clinical services here at the IDMC. Our plan is that we will go through this case. We'll have a in-depth discussion about each aspect of the case, and then we will conclude with a panel discussion where all the speakers from today, along with the moderator, Dr. Wendy Sang, will go through audience questions. So with that, we will begin our mitral valve edge to edge case discussion. Thank you. Hello, everyone, and welcome to the case discussion portion of the structural heart disease symposium for this Toronto perioperative echosymposium. My name is Dr. Aiden Sharkey. I'm one of the cardiac anesthesiologists at the BIDMC, and I'm joined here by Dr. Mario Franz Palin. Mario Franz is a assistant professor of medicine at the Harvard Medical School. She's an attending structural heart disease interventionist and also the associate director for structural heart disease services here at BIDMC. And I'm also joined on my left here by Dr. Feroz Mahmoud. Feroz is a professor of anesthesia at the Harvard Medical School, the director of perioperative services at BIDMC, and the network chief for cardiac anesthesia services at Bethesda Lehi. And so today we're going to go through a mitral valve edge to edge repair case. And this is a bit more of a complicated case than our typical case, and it has a couple of kind of good learning points that we're hoping to get across to our audience. So with that, I'm going to go ahead and we will give a little introduction to the case. So here we have a elderly gentleman who had a significant cardiac history, including a previous trinotomy for a bypass. He has COPD, chronic kidney disease, and also age of fibrillation. And he had severe symptomatic mitral regurgitation despite maximum guideline directed medical therapy. And on a preoperative echo, he had a complex Barlow valve disease with a P1 flail, which resulted in severe mitral regurgitation. Other things to note on his echo was he had normal biventricular function. He had moderate tricuspid regurgitation and also had moderate pulmonary hypertension. And of note, he had multiple recent hospitalizations for heart failure symptoms. And so with that, he was referred to, first of all, the surgical team who deemed him to be a high risk candidate and subsequently was referred to the structural heart disease team here at our center at BIDMC. So I'm going to start off the first question to Marie-France and just to briefly tell the audience, Marie-France, what is the structural heart disease team? Who does this entail? Yeah. So usually patients, regardless of where they're coming from, they get to be seen by both an interventional cardiologist and a cardiac surgeon. We review all of their pertinent history and imaging together. We talk with the patient and tell them which therapies would be best, whether it's percutaneous or surgical. And in that case, this patient is a patient who would qualify quite well for a tier like we're going to talk about. Very good. Very good. And so with that, after his referral to the structural heart disease team, a mitral valve edge-to-edge repair was deemed to be a good therapeutic option for this patient. And Marie-France, in terms of offering a tier to these patients, where in the guidelines does this fall in terms of this patient with a complex degenerative disease? Yeah. So this patient has primary MR and he's a high risk surgical candidate. So actually he has a two-way indication for tier. He's highly symptomatic, high risk like we talked about, and he was deemed, and he was seen by our team and agreed that his anatomy was amenable for tier. So in that case, this is like we're going to see it's not the typical anatomy that for patients that are, that were studied in the Everest trial. It's a little bit more complex, but it's somebody who has a two-way indication for an intervention, for a percutaneous intervention. Okay. Very good. And so we moved ahead with the procedure, and this is our first images that we got here. And we can see here we have our midisophageal four-chamber view. And we're seeing a bit of the aortic valve here. So we're more than likely close to the anterior lateral commissure. And we can see an obvious posterior leaflet flail with a resulting very eccentric jet of mitral regurgitation. And just looking at a few other images, we see a commissural view here. And again, we see that much of the regurgitation is originating mainly at the anterior lateral commissure. And then, you know, finally we're looking at our, you know, long axis view. We can again clearly see a flail and the severe mitral regurgitation. So for those, when you're doing, you know, these exams on these patients, you know, what is your initial imaging approach to deal with these patients? So, first of all, thank you very much for the invitation. And secondly, getting to the question that this is a, you know, complex case. And most of these patients who are getting coming in for H2H repair have been extensively worked as far as the severity of mitral regurgitation is concerned. The intraoperative or the periprocedural transphysiological examination is more so to localize the site of regurgitation and to devise a cliff strategy. So in these patients, like you alluded to, we are very, you know, fond of this monoplane examination of the mitral valve, which consists of moving the TEPRO from the upper esophagus going over the entrolateral portion of the mitral valve, then to the middle portion, then finally going to the post-traumetial component. And as you can see in this view, which was confirmed by the transcommissural view, that this is a flail or abnormality that is involving the more lateral and the entrolateral component of the mitral valve. And the clip, first clip is to be deployed based on this regurgitation jet, either entirely on the lateral side or more lateral to the central that is A2P2 component of the mitral valve. Very good. And so, you know, next we moved on to do a three-dimensional image. And for those, you know, looking at this image, you know, what are you thinking about this valve? First of all, this is an anphos, which appears to be a single-beat acquisition of the mitral valve, which is a rather low frame rate, but still you can appreciate the position of the aortic valve, the left-hand appendage at 9 o'clock position, the aortic valve at 12 o'clock position, the smiley face or the surgical anphos view of the mitral valve. And what appears to be a flail posterior leaflet, somewhat lateral to A2P2 and comprising the A1P1 portion of the mitral valve. That's what I can confirm over here with a flail, with a co-optation defect between the two leaflets. Very good. And then, you know, we did our due diligence. We did a, you know, a 3D on-fast image of the mitral valve with color, and we can see, you know, severe mitral regurgitation here. And therefore, as you alluded there, that the previous image and this image was a single-beat image. And as we saw in our case history for this patient, he has a history of atrial fibrillation. So we're unable to do a multigate acquisition of this patient. So in patients like this with atrial fibrillation, you know, what is your strategy for really interrogating the valve from an echo point of view with 3D? So likely the first point is that whereas we acquired this image with color flow Doppler, you know, information, this is more so for the aspect of completion and comprehensiveness of the exam. And it doesn't really add much to my pre-existing knowledge of where the regurgitation is coming from. And it is a pathetically low, you know, frame rate. And so therefore, not much value at this time or, you know, strategy in these patients in whom we cannot use, you know, a single-beat full volume acquisition with low frame rate is to use a narrow sector live image, which on the left, as you can see, the elevation width has been reduced significantly to increase the frame rate to around 69 hertz, which you cannot even get with multi-gated R-VIP, R-VIP-gated acquisition. So that's a high frame rate examination. You can even see some torn cords on the P1 scallop of the mitral valve. And then you can gradually increase the elevation width, which on the right shows a rather wider sector, where you can see not only the entrolateral portion of the mitral valve in question, but also exclude other abnormalities by gradually increasing the, you know, elevation width, albeit with significant reduction, but still an acceptable frame rate of about 32 hertz. So that's our strategy to use a narrow sector of examination of the mitral valve, which is life. Yeah. Moving back towards our patients, you know, so we've identified that, you know, this patient has severe mitral regurgitation. We've identified the location of the regurgitation. And, you know, we've shown on both 2D and 3D that there is a flail segment, and we know exactly where the regurgitation is coming from. So next, we did our due diligence by performing a complete examination. So we have a transmittal mean gradient of three millimeters of mercury. We have a flow reversal in the right upper pulmonary vein. We did a 3D planimetry baseline and we got, you know, quite a large mitral valve area. And then we also did our due diligence and looked at the, you know, the flail gap, the flail width. And we also got our posterior mitral valve leaflet length. Marie-France, I have a question for you. You know, we, as ecocardiographers, you know, we routinely get all these images. And how do you, as a interventionalist, you know, utilize or, you know, what do these numbers mean to you? Yeah, no, these are actually critical. So this is how we're going to decide which clip we're going to use, which therapy we're going to use, and where we're going to put the clip. So this is all very important. So we know that the valve area is large enough to accommodate. So we're not, because the downside of the precutaneous options is mitral stenosis, right? So that's what we're trying to avoid and have a great result, meaning no significant MR left. So with all of this information, I can tell that this is a large valve with the flail width that is large, but not too large. And the only concern that I have is that it's a little bit commissural, which can make it a little bit more tricky, but we're going to get into that later. So, Fros, you know, given the information we have at the moment, we know this is going to be a edge-to-edge repair that's going to be slightly commissural over in the anterior-lateral commissure. You know, in terms of planning our transeptum puncture, you know, what is your, you know, your plan for this patient in particular? So that's a great question because, as Mary France alluded to, the concern is that this is more or less a closed commissural or close to a commissure flail, which makes it critical to have as little motion of the clip under the valve as you possibly can and do minimal readjustments of the device above and below the valve. So you want to have a straight line, which goes from the point of transeptum puncture on to the edge-to-lateral one. And our plan in retrospect, which also proved to be correct, was to do a rather posterior transeptum puncture so that looking at this, you know, graphic also you can appreciate that a posterior, and when we go on to look at the three-on-phosphory of the mitral valve, you will recognize that this was in actuality a very optimally done transeptum puncture based on our discussion. So we do spend a lot of time deciding where to do the transeptum puncture before we go in there. Yeah. For those of you who talked about the transeptum puncture plan, and now, Mary France, I'm going to come to you and ask about, you know, based on the images we've seen on the echo. You know, what are you thinking from an interventionist point of view on, you know, what might the clip plan be for this patient? Yeah. So this is a wide flail, a large flail with a wide gap, and a little bit commissural. We always try to see if we can get it with one clip. So for this, I would try to plan for a wide and long clip and try to see if we can, exactly. So the XTW and try to see if we can have enough reduction in MR without creating MS with this. And if not, then we'll see what we can do after that. But I just got to say that the fourth generation of the mitral clip is really, really nice. It's allowed us to have a straighter trajectory when we cross the ventricle. There's less movement that's happened. There's more precision in the movements that we make. And with the independent grippers, it's been really a great change to the field. Yeah. Yeah. So yeah. So for this patient, you know, we had decided we would start off the next TW as my friends alluded to, you know, try and make this a one clip case. But knowing that, given that it was quite a large flail gap and flail width, that a second clip may be needed. Okay. And so for those, you know, this is our transeptor puncture that we performed, you know, so we can see in our bicable view, you know, we're quite inferior. We can see in our short axis view, we're quite posterior. And then in our four chamber view, you know, it looks like those adequate, you know, septal height. Depth. And so, you know, was this a satisfactory puncture in your opinion? Yes. And then honestly, as part of our training program, we always do this thing is to put the color flow Doppler on the after the septal puncture has been achieved to demonstrate very exactly this was. So this gives you a little immediate feedback. It gives you immediate, you know, gratification on knowledge that sometimes the 2D isn't like insufficient to tell you exactly the puncture happened. But the, and this positively identified the specific location, what we had planned before, and that was to go relatively inferior and posterior to achieve a straight alignment with the, with the enteral column share of the module. And I think this is highlighted. Sorry, go on first. And as you can see, is if you look at this on-pass view in respect to the aortic valve, we are rather posterior. And if you move this, you know, this point of puncture of the septal puncture, which was very posterior, very inferior, which means away from the aortic valve and close to the, to the, you know, inferior vena cava. Rather straight line of the, of the sheet when it enters and it would fall directly over, over the, you know, the enteral column puncture. As you'll see in the later clips. Yeah, very good. So yeah, so we were happy with our initial, you know, transeptile puncture. And so, you know, with that, we went down to the following stages of the procedure where we, you know, under echo guidance, we, you know, we dilated up the septum. We introduced our clip delivery system constantly doing this under echo guidance. We had placed a wire in the left up upon Monterey vein and, you know, we're synchronous with, you know, the interventionist menu as they maneuver their clip delivery system across the septum. You know, we are always in synchronous motion with them to, to guide this, this clip delivery system. So that we know exactly where it is the whole time. There's no point in the case where we are doing anything blindly and we're constantly under visual guidance. And so here's a clip where we are, you know, we have our clip delivery system. And we are now guiding the clip. It's come out of the clip delivery system. And here we are just beginning to cross or to maneuver the Coumadin ridge to go over the valve. Okay. And so, Fros, I have a question for you in terms of we talk about trajectory and orientation. What exactly do we mean by these? So the trajectory implies the approach of the clip to the valve, which means the more orthogonal the approaches, the more vertical the clip is in relation to the plane of the mitral valve. Both on the AP view, which is on the right side of the screen, as you can see, and the media lateral direction as well. So that's the trajectory and that is approach of the clip to the plane of the mitral valve. The orientation implies the orthogonal or non orthogonal or relationship of the clip arms in relation to the mitral valve coefficient point. Ideally, we like that to be orthogonal as well, which means when the open the clip arms should be between 12 and six o'clock position. If you are referring to an on-force view in the form of a clock with the aortic valve being at 12 o'clock and the left-hand appendage at 9 o'clock position, the two major anatomical landmarks. Okay. So now we're going to move on. We have our clip. And in terms of orientation here, you know, so Fros, how would you guide the interventionist in terms of orientation? So first, you know, order of business as interventionists are very smart people. They really don't know, don't need to know where they are. We need to tell them where they need to go. So because just telling them the way they are is no information. So first order of business is always tell some positive information and not negative information. Tell them where they need to go and not where they are. And secondly, the two most important landmarks in relation to orientation are the position of the aortic valve, which should always be kept at the 12 o'clock position. And the appendage as this in this case on at 9 o'clock position and avoid the parallax error, which means the image should be as unfossed as it possibly can be. Because if you tilt it on the sides, one way or the other, it is quite possible to place the clip more medially or laterally or more interiorly or posteriorly. If you are not getting a true unfossed, you might allow. So your valve is at 12 and the appendage is at 9 o'clock position. That's the key part in keeping any orientation. Yeah. You know, and my friends at this stage of the procedure from an interventionist point of view, you know, what are you kind of what's going through your mind at this stage of the procedure. Yeah, so I like for all said so the way if we always have the imaging the same way and we talk the same language it's going to be so much easier to communicate and know what we need to do next. So, if you just go back one so we can, we can, we don't know yet if we're above the jet or not but we're going to be exactly so now we're trying to position the clip above where the maximum jet is. We're going to want to make sure that it's perpendicular to where to both leaflets before we cross, and we're also going to have test the grippers so which one is the interior which one is a posterior so that we, if we need to do independent gripping of the leaflets, we'll be able to do that. So we do our final adjustments before we cross the bell. And then especially since we're commissural we're going to want to make sure that we're as perfect as we can as we go in. Yeah. And then another thing, you know, we tend to do is, you know, we tend to, you know, put the patient on apnea. So we take them off to ventilation and to see what the effect of you know that reduction in the inter thoracic pressure has on the position of the clip. And so we can see here that, you know, when we did do that, there was a bit of a medial drift, you know, with the clip. And so knowing this, you know, we readjusted. And so subsequently, we, we crossed the valve and froze in terms of after we cross the valve, you know, this orientation does not look the same as it was before. What would you say? So again, again, going on the clock face, which is shown a graphic on the right side, this clip to me appears to be a little more interiorly than it is. It needs to go more posteriorly. And I think the clip arms are between kind of one and six, 30 to seven o'clock position and not really 12 to six o'clock. So I would ask Marie-France at this stage to move the clip a little bit more posteriorly and rotated counterclockwise about five degrees. Very good. And, you know, just because we are, we are beyond the valve at this stage, we, you know, we will reduce the 3D gain so that we can really see the orientation as the clip is beyond in the left ventricle beyond the valve leaflets. And so at this point, we're really constantly transitioning between, you know, commercial long axis 3D on fast views. And we can see here in this, you know, commercial view that we are, you know, kind of where we wanted to be in terms of being, you know, slightly more medial to the A1P1 or lateral to A2P2. So this looks like we're in a pretty good, you know, position with this clip. And so, you know, with this clip, Rose, I might get you to talk us through. We are trying to grasp the leaflets here. So we are essentially below the valve and you're trying to secure the leaflets between the grippers and the clip arms. And as you can see in this long clip, you're rather getting very easily the interior leaflet and the grippers are moving. But we're having trouble and with all this beautiful maneuvering, we were able to put this, you know, secure the posterior leaflet at the same time. And you can now confirm by a motion of the grippers, we're going to go through the same thing over again. And as you can see that this is, you know, both the leaflets have been grasped between the grippers and the clip arms, and we have closed the clip to about 60 degrees. So that's our protocol to see whether we have, you know, achieved where we are. And we again, flip between the AP as well as the Transcommissioned View to confirm that it is exactly at the location that we want it to be. That's where we're going to spend a lot of time, right? Because that's going to be the critical part to ensure that we not only have leaflet, but have enough leaflets. So we're not going to have a leaflet, single leaflet detachment after. Exactly. And this is a good example about what my friends alluded to earlier about individually grasping each leaflet. You know, that was a good example of that there. And so, you know, we, we tend to close on the color. And so my friends, given all the images we've seen before, and you know, are you happy to close at this location? So before we finally close, we want to make, you know, we want to check a few things. We want to make sure that we're where we want it to be. So the clip is exactly where it's supposed to be. We have enough leaflet like we talked about so that there's not going to be any detachment and that there's the gradient looks, well, we'll check the gradient once we're closed. But we want to make sure that we have, we're in the right place. And so far, what I'm seeing looks good. It looks like we're where the MR is. Very good. So we went ahead and we closed, you know, the clip at that location. And, you know, this is what we are left with. And so, you know, we can see here that there's still, you know, residual regurgitation. It is reduced. However, there is still a residual regurgitation. So at this stage, you know, it's our job as ecocardiographers to, you know, do a couple of things. So we want to first, you know, where is this coming from? You know, and is there room to optimize the location of this clip? Or is there room to do a second clip? And so, as my friends alluded to, you know, first of all, in terms of locating where this MR is coming from. As you can see here, we did a monoplane examination and we saw that this was coming, you know, lateral to the first clip. So that's what we figured out where the regurgitation was coming from. We next did a transmittal gradient. So we saw the transmittal gradient was two, you know, so there was potential space for another clip. We then went on to do a 3D image. And really on this 3D image, we can just see with color that there's still regurgitation coming very lateral to this clip. And then on 2D imaging, we can see that there is a residual flail segment. And again, this was lateral to where we initially placed the clip. And then, Rosa, I might get you to talk us through this. You know, we did another 3D examination and we can see a good tissue bridge. However, what else are we seeing here? This clip is only for Marie-France because she likes it. But you can see in this one that there's the clip in the middle and there's a rather flail, residual flail segment of the posterior leaflet, which is very well highlighted by this circle. So our plan was to carefully approach this specific segment because we wanted to take care of this regurgitation jet. And we had a decent enough gradient to go for another clip in this station. Okay. So Marie-France, in terms of a, from a procedure point of view, you know, what are your concerns and in terms of second clip? What's the plan in terms of, you know, what clip might we use? And what are your concerns from your point of view? Yeah, so now that we have a, excuse me. So this clip actually looked pretty good. So keeping it was the right thing to do. So now that we want to go put a second clip, we're going to be more commissural even. So it's going to be important to avoid touching the first clip to avoid any movement of that clip. And the good news is that, you know, we still have a low gradient and plenty of room. So putting a smaller clip would be the way to go. So a smaller clip lateral to it, we're going to be very careful as we advance it. And that should take care of every single one. Okay. So that was the plan. We were going to go lateral to the first clip and look at using one of the NT clips. So here we can see, you know, our decision was to place a second clip. And then we went ahead and, you know, place this clip, you know, very carefully knowing that it was very commissural. And we placed this clip lateral to the first clip. And we went through all the, you know, stages that we've already talked to about. We, you know, you know, we went below the valve and we individually grasped each leaflet. We confirmed the grasping and then we closed under color. And so here we see this is where we deploy the second clip. And we can see a much, you know, better reduction in the degree of mitral regurgitation. So for those, you know, we've now two clips placed. We have a pretty decent reduction in the regurgitation. And do you think this is an acceptable result? Or do we need to further optimize or even place a third clip? I, first of all, to think check is that you have not created any stenosis before we detach. And secondly, once we have, I personally think, I mean, eventually it would be very Francis decision, but I personally think that we have more than two great reduction in mitral regurgitation. And if you have a decent gradient, we'd accept this result and declare victory. Yeah. Yeah. And so my friends, in terms of, you know, you're looking at these images and you're also probably looking at the, you know, the V waves hemodynamics. And I think we saw good reduction in the V waves at the time. You know, what are you thinking from an interventionist point of view? I think you're muted, Mary France. Apologies. So yeah, so I'll ask you to show me a little bit more in terms of gradient and imaging, but so far I'm very happy with what I'm seeing. At that time, in that case, we noticed a decrease in the view waves and increase in the systolic pressure, which is always a great sign that we had a great reduction in MR. And you'll show us, but the gradient, the MR was actually quite reduced and the gradient was acceptable. Yeah. And so we went on, we did a, you know, a final 3D image. We can see, you know, we have a good tissue bridge. We have our, you know, classic double RFS. We're not seeing any more flail segments. And, you know, as both speakers alluded to, we looked at a transmittal gradient. We were getting a gradient of two, which was, you know, very acceptable. And, you know, we also went ahead to measure each individual RFS. And we were getting, you know, quite a decent mitral valve area, you know, a combined area of, you know, 3.8 centimeters squared. So, you know, very acceptable mitral valve area. We looked at the right upper pulmonary vein, which pre was had reversal and post, you know, we see a good, good flow in the, the right upper pulmonary vein. We looked at our iatrogenic ASD and we had a unidirectional, you know, left to right shunting. And, you know, just overall looking at the pre and post, this is our images. And so, Marie-France, from your point of view, a successful case. I, well, it's always, we always let the echocardiographer decide. So you guys tell us, but from my standpoint, it looks pretty good. Yeah, yeah, as a froze from your standpoint. First of all, I'm very flattered for making this decision over here. But again, I said it's we have more than two great reduction in mitral regurgitation severity. There's acceptable gradient and we have objective evidence of, you know, for reduction from severe to just about trace to mild MR. I think it was one of the better clips we did. Yeah. Yeah. So that brings it to the end of this case. You know, I think this case was at a couple of complexities. It was a first of all, it was a patient with Barlow's disease, which is not typical for our tier interventions. Second of all, it was a patient who had a commissural pathology, which again, you know, is not our routine. And lastly, this is a patient who, you know, had to undergo two clips placed, which is again, you know, is not your standard. So I think this case encompassed a lot of good points. And, you know, I hope people got a bit out of this. And I hope to answer any questions that there might be in the panel discussion after this case. I would like to thank my both panelists, both Dr. Maya Franz-Perlan, Dr. Feroz Mahmoud for their insightful thoughts. And we look forward to hearing your thoughts in the panel discussion. Thank you very much. Thank you. That was a great case there. And there's actually a couple of audience questions first. I'd like to get addressed first before we move on to, before we move on to lunch to try and get those in. And sort of seeing that first, that case that you just presented, the lesion was very much in the medial lateral sort of middle to the lateral side of the valve. And kind of, there's this question from the audience saying, do you have a formula regarding the optimal site for the transseptile puncture, according to the site of where the clip you want to place the clip. And I'm going to direct this to Dr. Sharkey if you could answer that. Yeah. Thank you very much, Wendy. And so, you know, we don't have a specific formula that we follow rigidly. You know, we look at every patient individually. But for, for lesions, you know, for the majority of lesions, we find that going mid-fazza, you know, you know, kind of, you know, slightly more inferior, slightly more posterior will be able to tackle most lesions. And the issue arises with the more commissure lesions, especially the more media lesions where you really need to concentrate on getting adequate septal height. And so that's where you need to need to spend a bit of time to ensure that you get adequate septal height for those real commissure lesions. But for the vast majority of cases, routine cases, I think mid-fazza is where you're going to, you know, have good maneuverability with your transseptile puncture. Okay. That was great. Now I'm going to direct a question to Dr. Nyman here. So, you did a lot of like, and I see both in the case here as well as in your presentation, you used MPR to get, get those mitral valve areas after the procedure and in the middle of the clip case and I know that the interventions are usually chomping at the bit to go, should we let go, should we let go. So, what kind of pointers would you give to someone who wants to start integrating MPR both in guiding the procedure as well as in doing the assessment after the clips are placed? That's an excellent question. And I think it really comes down to the fact that in the heat of the moment where one needs to make this decision is not the time to learn. And historically, when one had to go off-platform into sort of septic software launch, you really couldn't do this real-time in the moment. But now all the vendors offer the ability to do real-time imaging and plane manipulation and you can do measurements consistent with your routine practice. And so in that context, I actually encourage my fellows to practice making multiple measurements, rapid plane adjustment on the pump run. So that when you're having to do it real-time with time pressure on you, you've now been practicing in a location or a setting where there isn't this production pressure. And if one becomes facile with it, you can generate these numbers as quickly as you can do a 2D measurement. And there are some tips and tricks depending on the vendor to auto set up how you'd like to orientate your planes to facilitate the speed with which you can achieve this. That's great. Those are very helpful hints here. Now, this is probably directed to Dr. Boulin as well as to Dr. Segal. Dr. Segal's presentation mainly focused on edge-to-edge repair techniques with the clips and as well as the trans catheter valve. I remember a few years ago there was this whole discussion that perhaps we could actually do a complete repair with annual plastic or cords and so forth. Do you guys both think the field is going with that? Are we actually looking at just an either or for TUR versus trans catheter valve? Or are we going to be going back to including some of these other techniques and putting $100,000 worth of material into people? I can give you my two cents. I think, I don't know if we really do know yet. There was a time where we thought that TUR was the way to go and then it kind of moves towards trans catheter valve. I still think it's going to be, it's going to depend on the anatomy and many other things for patients. I don't think we quite know yet which patients are going to benefit most from one or the other. But I don't know if we have some, some of the new valves actually look pretty promising, but they're still fairly new. So I think the time will tell, but some of the new valves that are coming are going to be pretty good for our patients. And some of the clips that we have, especially the four generation, are pretty good. So I think it's going to be a mix of both, but I'd be happy to hear your thoughts as well. I personally think that there's been a huge amount of money invested in the space with a variety of technologies. And so I think it's going to be very patient stratified or patient specific. Some of the annular technologies look promising. The actual valve replacement have some challenges with regards to LVOT obstruction. And then the edge to edge repair addresses only one component of the entire valve apparatus. And so I think that this is not going to be as simple as the aortic space. But I do think that with the amount of money that's been invested and the selection of technologies we're going to have available to us, we should be able to choose a device that's tailored to the best outcome for that specific patient. It will definitely not be a one size fits all. Dr. Scal. Oh, I think you're muted still. I'm not sure he can hear me. So there is one other question from the audience here. And it goes back to the case that was just presented. So perhaps Dr. Sharkey or Dr. Nyman could even time in on this. When the degree of residual MR is questionable because there is shadowing from the device from the from the cathars in the in the atrium. Do you decide on a further clip or not based on the degree of improvement and actual Ford stroke volume do want to comment on that? Dr. Sharkey, you're still a mute. Sorry. You know, I think there's no one parameter that you look at. I think you have to look at it in totality. You know, and so, you know, I think, you know, if you're having a improved hemodynamics, you know, the V waves that you can measure hemodynamically are much improved, which are still seen as some degree of, you know, you know, moderate, moderate regurgitation. You know, I don't think you go chasing that, especially if you already have a gradient that might be marginal. You know, so I think, you know, you need to take things in totality. You know, how many clips have gone on? What are the hemodynamics? You know, how much fluid has the patient gotten? Are they truly optimized in terms of their medical therapy, diuretics, and all that? Perfect. I think that the ones where you've had an obvious reduction in MR, those are the ones that are fairly easy. Let's let this go and move on. It's the ones where you've got questionable amount of residual MR and your gradients are borderline. And as I mentioned in my lecture, I think in that situation, it's becomes hard to quantify how much of that gradient is because of the increased stroke volume because of the regurgitation. And so when you encounter that, one really has to go down to the point of measuring at the leaflet tips. I suppose theoretically you could measure the 3D volume of the LB and work out a true regurgitant volume, and sort of try and figure out what your true quantified MR volume is. But the reality is that's cumbersome and takes time, so we tend not to do that. So the quickest thing is to actually measure the venous contractor and take that in context with the measured leaflet tip at the leaflet tips valve area of each orifice. And like I said, you don't want to go below a valve area of 1.9. And the gradients, there's a lot of gray area in the studies. Certainly, one has to also take the patient into context. If this is an attempt to keep the patient out of a heart failure admission and otherwise they sedentary living in a wheelchair, you could, in theory, tolerate a slightly higher mitral valve gradient. But if this person's fit and active and independent, that patient's not going to tolerate mitral stenosis in the setting of someone that actively increases their cardiac output. So remain the physician, talk with your proceduralists, and you then make the decision about the second clip. And another, you know, that Charles alluded to is that our doctor measurements are velocity based measurements as opposed to to volume measurements. So, and at the end of the day, it's forward flow that really is going to make improvements to these patients. So doing something like a volumetric analysis as opposed to a velocity analysis that we use on color flow Doppler, you know, is, is, you know, quite important for these patients. I think one of the things that we do in our lab is we always make sure that the blood pressure is at the patients, our regular blood pressure, not optimized under anesthetic. Before we actually make a decision how much regurgitation is left because if their blood pressure sitting around 90, and we're going to make that assessment when they come off pumping their back at their 130. We're going to be very unhappy with the results there. So I think that's one of the other things that that people have to keep in mind about these lesions. So can you want to add Dr. Segal before now that you've rejoined us before we finish here. Yeah, I mean we've done some cases where you know despite significant reduction in MR and, you know, we've improved the floor reverse on the pulmonary veins we still see that the V waves. That the proceduralists are measuring directly in the left atrium are still high. So it's also important to rule out that there's any, you know, ventricular dysfunction in terms of diastolic dysfunction and how much fluids we've given to the patients during the case that may actually be contributing and confounding some of the results that we see in these cases. So, you know, you start doubting yourself, you know, we are at the cusp of, you know, hitting four or five mean gradient. We have reduced them are significantly so why, you know, the hemodynamics are not favoring the results of the echocardiographic results and those discrepancies should be should be carefully sorted out. Excellent. So it's, it's past one o'clock so I'm going to let everyone go for lunch. I'd like to thank Dr. Sharkey for creating this excellent session as those four doctors, Segal, Naiman and Pullin and Mamoud for being part of this. It's been a wonderful session. Great ideas and talks here. Thanks. Thank you very much, Wendy. Thank you very much, Wendy. And thanks to, you know, Charles, Sonka, and my friends for doing all those recordings. I think they came out very well. Yeah, thanks team. Nicely done. Thank you so much.