 And kind of as day follows night, it's inevitable that our interventional colleagues will be looking for ways to compliment the traditional surgical interventions for the tricuspid valve. Dr. Wendy Sang is a staff cardiologist and clinician investigator at Toronto General Hospital. She's an associate professor in the Department of Medicine at the University of Toronto. And as we prepared for this talk, my co-host Dr. Moreno described her as a mentor and a valuable colleague for his career. Dr. Sang is the head of the complex valve clinic at Toronto General Hospital. She's been a member of several ASEE, EA, CVI guideline writing groups. And she also serves on the editorial board of the Journal of the American Society of Ecocardiography and is a member of the Royal College Area of Focused Competence Subcommittee for Adult Ecocardiography. She currently holds the Heart and Stroke Foundation of Canada National New Investigator Award. And her research focus is on congenital and valvular heart disease, 3D echocardiography and artificial intelligence. The title of Dr. Sang's presentation is Percutaneous TV Interventions. Wendy. Thank you, that was a nice introduction. It's a real pleasure to be here and be a part of this program. So I'm gonna talk about Percutaneous Tricuspid Valve Interventions. Here are my disclosures. So the objectives of my talk are to update the evolving Percutaneous options to my HDR. And then I'm gonna use a case to review patient selection with a focus on the imaging side of it and pre-assessment for Percutaneous Tricuspid Valve Interventions. And then to explain the role of TE during Percutaneous Tricuspid Valve Interventions. So as previous speakers have alluded to, tricuspid gravitation is a very common problem. This is data from Olmsted County showing that tricuspid gravitation moderate or greater tricuspid gravitation in the green line increases with age. And when you compare the prevalence of tricuspid gravitation against all left-sided disease, it's about a quarter of that in terms of the prevalence. And it's equal to significant aortic stenosis. You've seen data from a net showing that most tricuspid gravitation is secondary in nature. And when you look at the mortality data, this is a different study looking at almost 9,000 patients. And you can see that compared to the general US population, the adjusted mortality for both primary and secondary TR is significantly higher. And when you actually adjust for comorbidities, it doesn't matter whether you have primary or secondary TR, mortality is much higher. And then you just had heard this beautiful talk about the outcomes with surgery and the mortality rates run between eight to 10%. And this is data from the inpatient service administrative databases showing that even though over the years tricuspid gravitation surgeries were both repair and placement have increased, there's still the stubborn elevation in mortality in the hospital setting. So we need something else more than just surgery to intervene on these patients. And so why haven't we had other techniques before that? Well, there've been challenges. Part of this is due to tricuspid valve anatomy. The tricuspid valve is the largest valve in the body, well, cardiac valve in the body. It's a large size, it's shape, it's annulus is irregular and it's got a 3D shape. Most tricuspid gravitation has a lack of calcium. It's very hard to tether something without something solid there. And the annulus of the tissue itself is actually quite fragile. The location of the tricuspid valve also makes it a little bit difficult to deliver devices. There's some agulation in relation to superior and inferior vena cava. And there's structures there we have to be careful about, the AV node, the his bundle, and also the RCA. There's a risk when we put in devices that we could occlude the coronary sinus, the vena cava or the rvo flow chart. And finally, the RV anatomy is highly variable due to the triculations. And this also makes it more challenging when you have to put a catheter in to lead your device in placement. And you have to be very careful, the RV free will, unlike the LV, is quite thin and we could cause good damage. And finally, many of the patients we see with tricuspid gravitation have pacemaker leads and ICD leads, which we then have to actually deal with as well. So when we look at percutaneous tricuspid valve procedures, we actually break them down into kind of three protests. One is sort of devices that simulate a valve repair. And then we actually have valve replacement devices. And then we have heterotropic, essentially valve devices that sit outside of the tricuspid valve. Let's go through each of them. So the most common ones you're gonna hear about are the valve repair devices. And most popular right now are used right now are the tri-leaflet co-optation devices or trans-catheter edge-to-edge repair devices for the tricuspid valve. So essentially what you wanna do is you're gonna bring the two leaflets together and sort of increase that co-optation surface. The other side of this is the tri-cuspid annular application devices to try and reduce the annular size. And that's what these devices are doing. They either cinch it to sort of bicuspidize the valve or they just generally bring in the annulus to try and reduce, improve that co-optation line. Now, one thing I do wanna note is that there's no FDA approval for any of these devices for tricuspid registration, although some of them do have C mark as I've marked. Now, there are many studies on tricuspid edge-to-edge repair devices, but this is probably the most important one to date. This is the tri-luminate study. And it took 350 patients and they randomized them to either receiving the tricuspid valve edge-to-edge or device or medical management alone. Now, their outcome was a hierarchical composite outcome, which means they looked at death from any cause or tricuspid valve surgery, hospitalization for heart failure, and improvement in quality of life. And this was assessed using a questionnaire. This was a safety and efficacy trial and they showed that it was safe. They had about a 7% leaflet detachment rate, but overall 98% of those who underwent the edge-to-edge repair were free from major adverse events at 30 days. Now, in terms of the efficacy, they met their target for the primary endpoint with the TUR group. Those who received TUR did much better. However, when you looked at the heart outcomes, it wasn't driven by need for surgery or death of any cause or hospitalization for heart failure. It was mainly driven by improvements in the quality of life scale. So for many of us, these lack of heart outcome improvements was actually quite disappointing. And there's a question as to why this might have been the first which was brought up by Dr. Ladder is maybe the comorbidities and not the TRs that actually cause mortality in this population. And fixing the TR doesn't make a difference in what happens to these patients. The other question is whether the patient selection was appropriate for these devices. Compared to prior TUR studies, these patients were less ill. There's a significant portion at NYHA to class two symptoms and they excluded patients with pulmonary hypertension and dialysis who make up about 50% of the TR patients we see in our clinics. The other thing is the mean of the ejection fraction was 59% in this trial. This means that we excluded a major population who had secondary TR. In the TR group, 13% had severe or greater residual TR and whether this played a role is also a question. And similarly, the medical management, the last Lasix was used there and perhaps some of these patients still required Lasix afterwards and that might account for some of their worst outcomes. Finally, whether or not one year outcomes were too early to demonstrate a benefit. And all of this now is done during the COVID period and so whether that played a role as well. So a lot of interest is gonna be on the next coming TUR studies because that will really determine the fate of this intervention. In terms of tricuspid annular placation devices, as you look, the number of published studies are actually quite low. The number of patients enrolled in these studies are also low between 15 to 30 patients. Overall, most of the success rates for implantation and procedure success are quite high. However, we have limited information on fall-up and outcomes, although they're quite positive in the small studies that have been reported so far. There's no procedural death or new for cardiac surgery outcomes or intervention at this point. Now we've talked about the tricuspid valve repair techniques but sometimes if there's too much shattering and annular placation, there are these devices that have been developed that are space devices or what they do is they try and reduce the effect of regression orifice area and improve the co-optation. As you can see here, you put the device in and then you get better co-optation. It decreased the TER. There has been one device that was published on this. However, in the feasibility study, it showed a RV perforation and late anchor dislodgement and so it was pulled from the market for redesign. And so the future is really unclear whether or not it will be coming back out for use. So the other big area that people have focused on is on the valve replacement technologies as shown by Dr. Ladder in his last few slides. These are basically a percutaneous way of developing a valve. There are quite a few that are in clinical trials right now. However, overall, the numbers of patients in these are very small because it's accessed only through clinical trials or through compassionate use. The outcomes that have been reported, once again, we don't have a lot of information but procedural success ranges from 87 to 100%. However, there's still significant rate of conversion open surgery in one study at 6.6%. And 30D immortality is also not insignificant at 10%. Now, these trans-cathered tricuspid valve replacements also have some issues that need to be addressed. We know from the trans-cathered mitral valves that these valves have to be anticoagulated. But in these patients, TR who might have underlying overt or latent hepatic dysfunction, what is their bleeding risk on anticoagulation? And will this actually mitigate some of the improved outcomes that they receive from getting the tricuspid valve? And then the other thing is for these trans-cutaneous valves, what happens if you have a pacemaker elite? So this study is taking registry data from the vivid database and looking at all patients who had trans-cathered tricuspid valves. And they broke down these patients into whether those who had pacing systems, no pacing systems. And then if they had a apocardial system or a transvenous system, and then if the transvenous system was entrapped at the time of the placement. Overall, if you look at the grass on the left, they showed that whether or not you had a pacing system or not, there's no difference in depth, the need for tricuspid valve intervention or tricuspid valve dysfunction. And specifically if you look, there's no difference between whether or not you had a entrapped RV lead or not. But if you look at what happens after, there were about 10% or three patients had problems with dislodged RV lead after the entrapment or failure in the followup period. And then we also haven't dealt with the fact is what happens if these pacers systems get infected. What happens to those patients at that time? And that would have to weigh into the scales of how we manage these patients. Now to move on beyond the actual interventions on the tricuspid valve itself, there are heterotropic devices. They're typically valve devices. They can either sit in both the SVC and IVC at the same time or they sit in the IVC. Some are unique devices and others are devices taken from the Tavi world and then repurposed. The aim of these devices are actually just to mitigate the effect of tricuspid regurgitation on the surrounding organs. And what it does is essentially it sacrifices the right atrium and so these devices are really directed to end stage tricuspid valve disease in patients with significant tricuspid angular enlargement and tethering of the valves that preclude the use of other devices. Now how are we deciding how to use this? Now this is an actually simplified algorithm. There are more complicated algorithms but I like this because it kind of gives you an idea of where we're heading for in terms of what to do depending on the patient in front of us. So if it's a patient who has primary TR, if it's a restricted pathology or perforation, you are looking at a transcaptor valve replacement. If it's got prolapse or flail, then you're trying to think about maybe heading towards an edge-to-edge repair technique. If you have an implantable device, I think it depends on whether or not you have the ability to remove the device and then what the anatomy looks like underneath there because it may be a candidate for edge-to-edge repair or you may be looking at a valve replacement. Now patients with secondary TR are a little bit more complicated. If it's simply an isolated annual list with no or minimal tethering of the valve, then you're gonna be thinking about those annual plastic devices. If it's not annual dilatation with a little bit of tethering, then you can think about using an edge-to-edge repair. However, if you've got significant annual dilatation, tethering, then you're looking at the valve replacements or cable devices or a spacer device. Now, how do we image for these tests? How do we assess patients for them? So on the imaging side, I've made this table here and as you can see, I've broken it down to what the pre-procedural, inter-procedural and false-procedural imaging is, our requirements are and essentially breaks down to two main imaging modalities for pre-procedural assessment, CT and transcaptor levicocardiogram and inter-procedurally, we're mainly using TE and in some places they are using a lot of ice and we'll talk a little bit about why towards the end of this talk. And then follow-up is mainly transterrastic with some use of CT if needed. Now, what does CT provide? Well, CT allows us to actually size for valve devices so we can get an angular, try to get an angular size or IVC or SPC size. It also gives us an idea of where the regulations are located as well as the RCA and better idea of the venous anatomy. So now I'm gonna move on to the sort of second half of my talk and focused on how we actually assess for the patient. So first step as Dr. Ladder I guess discussed in his talk, we really have to assess these patients when they're chemically-optimized. If you take them when they're wet, you're gonna see a lot of TR but you may also see bigger gaps than you that they would be then would be there if they're dry. And so we really want to optimize them. In some R case, sometimes we have to admit them, get a right R gap and then diaries them before we do our assessment. Once they're optimized and they still have severe TR present, then we will assess for whether or not they've got severe RV dysfunction, RV dysfunction, forcing of inflammatory hypertension. Now, depending on your program, some of these may be softer things that you will use rather than exclusionary criteria but it's important to note if your program is a whole pathway, heart failure management program, then some of these are not gonna be quite the strict criteria or exclusion as you know. And then you go to the tricuspid, sorry, assessment by transit software do like a cardiogram. Now, when I break, I like to break things down into steps. So sometimes we kind of do it all in a gestalt manner when we're assessing these patients but I'm gonna go through the case next and we'll go through each of these steps but I think the main thing first is that you have to have good windows and we'll see why when we actually get to the device implantation stage. And then you wanna look at where the jet location and the mechanism is because that'll be important into determining how you're gonna intervene on these patients. And then you'll look for specific things to determine what devices you're gonna be using co-optation gap, length of leaf and length of leaflet length and adverse features. So this is a case of an 83 year old woman who actually had history of bypass surgery who had significant tricuspid regurgitation with increased RV size and really didn't wanna have surgery again and was referred for her assessment. So the first step is always the good as TE windows. And this is because if you don't have good windows before your procedure, once you start putting in all of your devices or the catheters and so forth, put in the devices, there will be a lot more shadowing and your windows will deteriorate without a doubt good windows become worse during the procedure. So it's important to make sure that you're trans-gastric, your low esophageal and the inflow outflow view as well as your true for and reverse four chamber views are allow good visibility. And in this case, this woman does have these nice windows here. All right, now one of the things I'm gonna talk about is these lower deep esophageal views. Many of us are used for the mitral valve to use a mid esophageal view where we have a nice view of the left atrium and then we can see the valves clearly. But we found that because the tricuspid valve is a very anterior structure, you wanna slide your probe down so just above the JG function. So that way you can actually move a little bit more posterior and you can sometimes bring out visualization of the leaflets much earlier. And you'll see in my images that we do images both at mid esophageal as well as the deepest esophageal depending on the windows of the patient. And it also slides for patients with mechanical mitral valves or aortic valve sometimes by doing some of these moving up and down a little bit, you can bring out that tricuspid valve for better visualization. So we have good windows for now looking at where the jet. You wanna look at both where the jet is located as well as what the mechanism is. So here we're in the transgaster view looking up at the valve and you can see that we have a nice central jet here. Ideally for many of the edge-to-edge repair devices you wanna see if there's a jet between the septal and anterior leaflets. And if there's a pacemaker lead, you wanna see that there is a jet that is coming on an area separate from where the pacemaker lead is we try not to jail it if we can. Now we tend to do cut planes through all of our views in order to look at the mechanism of the leaflets. And we try and cut between the anterior posterior leaflet as well as the septal and posterior leaflet and through the main body of the jet. And when you're looking at these it's not very prescriptive. What you wanna do is you wanna actually put the color on and then put your biplane through because you wanna see what the mechanism or what the underlying anatomy is at the site of the jet. Not just looking at the leaflets for the leaflet's sake itself. And here we can see that it's mainly tethering and there's a co-optation defect over here. Now after we do our transgaster reviews first in our lab and then we tend to pull up to do our midisophageal views and that's because the patients tend to be more comfortable at the beginning. Now for the midisophageal views the most important ones are these reverse four and this inflow outflow view. And the reason for that is because this is how we know whether or not we're anterior poster and this is where we can see the leaflets in order to know that the clip devices or other devices are in the right place. And when you look at this you can actually see how this works. So here's your aortic valve and there's your mitral valve and there is the anterior leaflet and posterior leaflet and septal leaflet in the background and you can see how this plays out with the biplane imaging. And so here we are we've pulled up to the midisophagus and we are now going to sweep across the valve from the lateral side to the medial side. So we both see the anatomy as well as what's happening. And once again, we kind of I have it from left to right but usually we put the color on first, see where the jet is and then we want to look at the anatomy underlying it to see what the mechanism is and where the location is. Once we've done that then we actually want to look for certain things. We want to look at the gap size here. This is a low esophageal view. You can see the coronary sign is coming in here and this is the esophageal view. We're looking for gap sizes in this woman. It was less than seven millimeters. And then we also want to look at the septal leaflet length. We want to make sure it's more than a centimeter and it's not curled or tethered. And you can see that it comes up nicely in this patient here. And then we do a reverse for it to look for similar things once again just to make sure that we have a good view. Finally, we're also looking for adverse features and adverse features are as some patients may have three or four leaflets. They can have deep canyons that can make it difficult and our clips will slide through if we try to clip over here. And if you see here we have significant cords going to the wall here. And if we actually try and clip there we actually may have trouble getting into the space located over there. So things to be aware of when we're planning where we're going to put our clips. So now I'm just showing you this because Amran showed a beautiful slide showing what the ASC guidelines recommend with the septal leaflet at the bottom. And this is the RV perspective and I actually prefer this because I can see the tips much more clearly and the RA perspective with the septum at the bottom. But as you notice, I have been for many of our clip procedures. We do use this position where we have the semilunar valves or the AV valve at about one o'clock compared to the tricuspid valve. So it can help us identify where the anterior septal leaflet or the posterior septal leaflet. And you'll see both of these views on the next few slides, but that's why we've done that. So we decided that this patient was actually very good for an edge touch repair. And so we went forward with that. And here you can see what's happened with her images. She's now on her back in the cath lab. And you can see once we're starting to put this device in and you can see the shadowing here and our beam is going to be going here. And you can see there's ring down effect and shadowing. And so if you don't have a good image before you start, once these devices go in, we get much worse. And so here we're in the right atrium looking down at the tricuspid valve. The anterior leaflet is here, septal leaflet, posterior leaflet. And we are going to go first into this area and we can move the tricuspid device into that anterior septal position. Here we are now diving underneath the valve leaflet. This tells us where we're at the anterior poster and this is gonna be how we know that the device has grabbed the arms properly. We go from the midisophageal back down into the stomach. We're gonna look at the orientation of the clip to make sure that we're perpendicular to co-optation line. And then here we've rotated a little bit and we've dropped out the leaflets a little bit just to make sure we can see that clip. And then here we are coming up and you can see the clip closing onto the leaflets there. And this is where once again, it's very challenging with all the shadowing to make sure that you have leaflet in the device and that it's adequate to hold there. Now this is us after we've put that first device in, we do still have some tricuspid regurgitation left and this is a 3D view but it's from our V-View showing that clip and the residual orifice here with the regurgitation. So we decide to go put a second device in and now we deal with shadowing from the first device as well as putting the second device in. And here we are, we're in the right atrium again going down the first device is over here, if you can see it. Here we are into diving into the ventricle and then here we are trying to close the device in the ventricle and there we have the two devices next to each other. The co-optation gap is a little bit smaller. And so then we made a decision, do we wanna put a third jet in? We go back into the stomach and you can still see that we have a significant jet here. And so we thought we would try a third device. And so here we are going down but as you can see our visualization in this plane is actually very tough. We were not certain that we could confirm the device placement. And so we actually aborted the procedure at this point given that we had a reduction in the empty arm. Now post-processing, what do you, post-procedure what do you want to assess? So you wanna look for residual TR. You wanna look at the position of the device and the leaflet attachment. You wanna assess for remodeling of the dark has been valve apparatus, if you can and changes in RV size and function and looks for signs of reverse remodeling. So that may be more long-term. And you wanna assess with complications pericardial fusion RV strain, new pacemaker lead positioning and changes in RV stroke volume. Now you saw in that case, we went up and down into the misophageal views and then down into trans-gastric multiple times. This does cause trauma. So this is a study looking at an EHR database of over 12,000 TEEs. And the complication rate of using ICD codes of bleeding esophageal archerous pericardial injury within 72 hours of the procedure was 3.6% in trans-catheter procedures versus 2.9% in the OR. And when you actually look at the different procedures, there is a huge range in what the rate of complications are. And while there are very low numbers here, I would expect that because if there's a lot of manipulation that would be higher for some of these devices. And this is a nice study in 50 patients where they actually did endoscopy before and after the TEE for the procedure. And almost 86% of the patients had new injury, whether it be minor or complex and about half of them actually had complex lesions. And the risk factors for complex lesions were longer procedure time and poor suboptimal image qualities because you're struggling a lot more and causing a lot more manipulation of that probe. Now, that means that there has been some contradictory data from the Mayo Clinic, Mayo being different from everyone. And one of the things though is when they did have complications though, they did tend to be in patients who were higher risk, which is something that is what we also see in our experience here. And so this is where there's been a push for intracardiac echo, not in isolation, but complementary to trans-tranosophageal echocardiogram. This is actually Mayo Clinic data showing their use of TEE-4, sorry, ICE and TEE-4 tricuspid valve interventions and showing that they have an improvement slightly, even though it's statistically not different in reducing the TR grade for these patients. So in summary, there are many devices that have been developed and the most common one of the edge-to-edge repair devices, though tricuspid valve replication devices are also being used. Trans-castor valve replacements are also but they bring their, also being used, but they bring their own complications in terms of what you do with pacemaker leads as well as the anticoagulation needs after that and these bigger trials are needed. The bicable and IBC valve implantations devices are sort of an end-stage treatment, try and improve morbidities at this point. And when you're assessing it, you wanna make sure your patient is hemodynamic stable with significant TR, your assessment is going to be a combination of trans-tranosophageal echocardiogram as well as CET if you think you're going towards that device. And if you don't have good trans-tranosophageal images, you need to think about using ICE and once again, you're looking at the location and mechanism as well as size of the gap and leaflets, lengths in order to decide what devices you're going to use. Thank you for listening. Well, and thank you for presenting, Heidi. That was terrific, just the tour de force of what's going on out there in the world of devices. And I really wanna say thank you to all of our speakers today. Just a great series of talks that kind of bring us forward around this valve that as Dr. Amran told us 10 years ago, barely showed up in a survey and now has enough interest, both in surgery and interventional cardiology. And I think for echocardiographers in particular, trying to understand how we can contribute to decision-making in those areas. And surprisingly, it's a young group area of information. Jehobel, I'm thinking we'll go back to your cases just because it'll be interesting. And then really importantly, I think we'll get on to our questions. We have some now. If anybody has any further questions, please put them into the Q&A so we can get to them when we need to. All right, Jehobel. Perfect, thank you, Mike. And thank you to all the speakers. Like that was a good session. I really appreciate your help to the symposium. And we are going to go very quickly because I don't want to keep the people here waiting. We have already abused them in these Saturdays, but we'll try to actually close it in a fast way. So cheers to go back to, let me see. We can find it over here. So cheers to go back to the first two cases that we were presenting. After actually visualizing the lectures that we have, so the big question for the audience is in the first case, and we are going to actually ask you to please participate on the pool now. We have a case of micro-recognition that was going for repair. Then we find that there was a moderate annulus dilation at 3.8, and then with moderate tricuspid recogitation. So the question for the audience, if you can please answer, we give you like 20 or 30 seconds to do. So what should we do? Should we leave it as it is? Should we try to attempt and repair it in the same surgery? Should we repair it in the third surgery? Should we actually go and try to do like percutaneous intervention in the same surgery or afterwards? So you guys can please actually ask the question. We will get the pool from the audience. At the moment that we got the results, we will ask our panelists about their opinion. We've launched the poll and we'll give it another 15 seconds and then we'll close and share the results, okay? Perfect, thank you. Thank you, Fatima. No worries. Okay, so 81% of the people has actually said that we should repair it and in the same surgery. What do the experts think about that? Well, maybe I'll go over first, Jacob. Well, we're in the operating room. We've just finished operating on the mitral valve. The MR is there. If I understood the presentation correct, it looked like there was some prolapse of the posture leaflet as opposed to tethering. And that's pretty easy to fix. You can do an alfieri-type stitch which is similar to what the tri-clip was doing where you're attaching a prolapsing leaflet to an adjacent leaflet that's not prolapsing. Or we could even do a bi-cospitization where we sort of exclude the annulus that the posture leaflet sits in and just end up with a two-leaflet tricuspid valve with an appropriately sized annular plastic. I think that'd be highly durable and highly successful and offers really minimal incremental risk to the patient. It certainly adds a bit of surgical time, but none of the data I've seen in adding tricuspid valve interventions during mitral valve surgery results in any sort of excessive or increased operative mortality risk. So I support the audience's decision on that. But it is reasonable as Dr. Tang's talk was fantastic. And this option number E is becoming more and more of a reality. And it's almost similar to what we're experiencing in aortic valve surgery when we do bypass surgery with moderate aortic stenosis. We say, well, we'll leave it and we'll do a tabby in five years or 10 years. So it is changing the landscape. I'm interested to see how that all plays out. Wendy, what do you think? I think so, but I mean, in this era, I mean, I agree with you, I would probably fix at the time of surgery because I think it's a simple fix. And the other thing is that as good as we are at reducing it, we don't get as good of a surgical result as you would because you would not leave moderate. We have the scale of torrential massive to down to severe and somewhat to make us feel better on the imaging side. But in all seriousness, you would not leave moderate in the OR, you would get rid of that. And that has to play a role in long-term outcomes on these patients. And in some of these younger patients, I don't know if it's appropriate to just leave that and wait till they have problems down there. And now I think a lifelong approach to the valve interventions is something that we're probably heading towards. And it depends on what technology it is because the edge-to-edge repair techniques may actually not be the ones to go forward. Yeah, I just read an article talking about how in the interventional world, we're going from repair to replacement whereas in the surgical world, we went from replacement to repair. So it's like coming full circle almost, but we're still in the development phase and another five or 10 years from now could be drastically different than what the technologies we have today. Great. So I'm sorry, my video is not on. Yeah, but anyway, I want to say, I want to support these two ideas, Dr. Latter and Wendy. This is probably even more than moderate because you had the floor reversal in the hepatic vein and you had the effective orifice area of 0.4 centimeters squared. So in some criteria, it was more than moderate. So we are very happy if it's more than moderate. I already go ahead and say, we should do it even we don't need to measure the tricuspid annular dimension. So that should be done in the same session in the war. And as Dr. Latter was saying, adding tricuspid valve repair in the war really does not add anything to the mortality of the patient in that surgery. Perfect, Matt. We will try to fix your video. We will contact Fatima and see if we can actually get this video for Dr. Ombran please fix. And then exactly that's actually what we did in that case. And then before we go to the... What was the repair? Was it just a simple annual past year or is there some leaflet work? Annular plastic. Yeah, but the surgeon probably sort of placated out the area of the prolapsing PL so that it's sort of almost no longer contributes to the conflict. Correct, because the co-optation gap was from the posterior leaflet. That's the one that was sent. Yeah, similar to what I sort of showed in that stuntman where that area between the septum and the posterior leaflet can really be quite large. And there's just no way the leaflets can co-opt theirs, but you placate them out with the annual past so you can take care of that. Yeah. So before we go to the rest of the Q&A, like we have a second question for the audience and it's regarding that's a little bit more difficult. Like that will be regarding the second case that we did. So as I remember as a summary, it was like a liver transplant patient where we find like pre-operatively have like just no significant TR and then when we went in through out, we did find actually severe TR, but under those conditions. Now, when you go for a liver transplant, you have a volume overload, you have some cirrhosis cardiomyopathy. So the difficult question that we find that day and I was called there to actually give my opinion on the TE and the cardiac surgeon what's actually called in the room to actually give the opinion, it's what should we do? Should we leave it as it is? Should we try to repair it? Should we do it in the same surgery of the liver transplant or should we actually try later on or in the same surgery to do a percutaneous procedure? So we'll leave some seconds for the people to answer and when we go with the answer, we will go at it. I'll give it another 10 seconds and then I'll show the results, Yukogo. Perfect, thank you very much. No problem. This is interesting because I remember the time that we're doing the liver transplantation, we have probably like six different people coming from the cardiac department actually what was going to be the final decision. So this is one of those days. Okay, so 45% of the people just leave it as it is like 32, like probably a triclip. Why do the experts think? When did you want to go first? Because I'm no expert. I am. I mean, I think this is complicated. I personally probably would have left it and seen what happens after the surgery because there's a lot of fluid shift, they're not hemodynamically optimized. And you've got to kind of believe what you saw on a baseline trans thoracic that there wasn't there. So what else could there be in the hemodynamics? Liver surgery is a big surgery and there's a lot of fluid shifts there. So I would be patient and see if it actually gets better and let them recover from the liver surgery and then make a decision. Now I may regret that once they develop their AFib and they're calling me at the morning to manage it but I think it's sort of what I would kind of tend to do. I would be conservative in this stage and get them through the transplant. Yeah, Ahmed, do you have a comment? No, I totally agree with Wendy because that guideline for TR, the degree of the TR is based on the trans thoracic guideline, trans thoracic study. It means we look at the study of the patient before war outside where our decision is mainly in the secondary TR based on the trans thoracic echo that was done before the war. So before war this patient had only mild TR. Now, as was said, we have a massive fluid shift. So this severe TR is mainly because of the fluid and we should do nothing in this session. Yeah, we follow that. I agree. To add a cardiac procedure on to a person who's just undergone a liver transplant, I think that would be really risky. And I'm sure Annette who would be sort of one of these people. Well, I mean, I would make a couple of comments. One, you know, we have a very large liver transplant program here. The evaluations for our patients can be up to a year before they present for liver transplants. So it may well be that you can have changes in the amount of cardiac performance before they have their liver transplant. We get by this by actually not echoing our patients. So unless there's a hemodynamic event interoperatively, we do not routinely in eocobal nosis, routinely echo our liver transplants here. So I think those two things would mean that we probably would be flying blind and just approach the patient as a normal liver transplant. Yeah, I agree completely. And I'm hopeful that, you know, it just shows you how fluid balance can really influence the severity of TR. So hopefully this would get better post op with appropriate therapy. And if it didn't, I think, you know, these future transcutaneous options are becoming a reality and could well be affected. And, you know, if you needed primary, if you needed cardiac surgery a year later or six months later, that would be unfortunate. But that's not impossible too, but to add it at the time of a liver transplant, I think is excessively risky. So I would have left it alone. So that was actually the common decision between everyone. We decided to leave the tricuspid as it was. And then after the transplant and when the patient recovered, he came in for a follow-up echo and it was only diagnosed with mild PR. And then we leave it alone. So just to finish, I'm going to actually stop to sharing the screen. And then, Mike, if you want, we are open for the questions from the audience, please. You hope I'm cognizant of the fact that it's now four o'clock. I'm going to ask one question and then, and then I think we're going to have to wrap it up. All right? Yep, go ahead. So for no other reason than he was the first from Dr. Shim, this is a question for Dr. Ladder. Would you perform tricuspid angioplasty in patients with a TV angular diameter greater than four centimeters, but only a mild degree of TR upon left-sided valve surgery? Well, it's a good question. And in fact, that's basically what was done in the Mount Sinai paper from David Adams. They did, everyone who had a lead, who had moderate TR or worse were operated on and or if they had an annulus greater than four centimeters, they were operated on. And so that's how they got to a rate of 65% of mitral valve patients were having a tricuspid valve procedure. And they showed less TR, less right-sided heart failure, you know, three, four, five years down the road, but the same survival. The group out of the original paper from England that talked about the seven centimeters was a similar concept. The seven centimeters in the linear diameter is roughly four centimeters in a circular diameter. And they operate on those patients as well and had good outcomes. So I think, yes, I mean, an annulus that's dilated, it has a significant risk of getting more dilated and developing significant TR, even if it's only mild at the current time. So yeah, I think I've modified, and I may modify my approach a little bit more after this talk, but I'm gonna be a bit more aggressive on dilated annuluses. And four centimeters is bigger than normal for sure by a significant amount. I really like the concept that Wendy introduced as well as the lifetime evaluation of that valve. Just the sense of where the patient is in terms of what's gonna happen. I think that's an important part of the decision-making in there as well. Great. So what's a normal annulus dimension in a, it's like 30 millimeters, 28? So 40 is like, it's enormous, really. When you're talking yourself into operating. Well, I think a little bit depends on where you're measuring things, obviously, but I would like to ask Dr. Ladder, if you have moderate TR and you have unfavorable repair options. So in other words, you have leaflet tethering, your leaflet tethering area is high. What would you do in that situation? Well, that's a great question. Because we've been down that road with mitral valve. And we know when you have significant tethering in mitral valve and we put an annular plastering on, it looks better in UR and often looks better by the time they go home. But within a year or so, it starts to come back because it's not just the annulus, it's also the tethering. So that's why Robert Dionne has suggested that you ought to be doing a leaflet extension with a bit of a pericardial patch. I haven't done a lot of that to be honest with you, but I think it's probably a good idea because that's the only way we can address tethering by giving a longer leaflet. So we have more ability to co-opt. So I think if you're going to intervene with significant tethering, you've got to put the ring on and try and do something to give you more surface area of anterior leaflet. So I think just to emphasize the point here, it's not just all of the annular measurements. I think as echocardiographers, we really do have to look closely at where that co-optation point is and help our surgeons by telling them information that potentially they may not want to hear because I think they're all set on just putting that annular plastic ring in, but obviously I think it uses to just at least provide that information and they can determine what they want to do with that information. But thank you everybody, great panel. I think that's an excellent comment. And we really do allow you to give us eyes on the functioning tricuspid valve because when we see it, it's just a floppy thing. And we don't really know the geometric sizes of a working right ventricle. You know, I wish we had more time. I got to be honest with you, because I've got a whole list of questions here. Anyway, once again, I want to thank all of our speakers for their generosity and sharing their knowledge with us this afternoon, especially on a Saturday afternoon in September. In particular, I want to highlight the work done by Dr. Mario in curating this session, both in conceiving the topic and then arranging the speakers. I hope I'll leave the last words for you. All right, I just really wanted to thank the speakers, like their generosity to actually join the symposium. And I think they were really helpful. At least if I wanted to actually do a good review in tricuspid recogitation and cardiac surgery, definitely I would put it that way, no. First analyzing how we analyze the TR, then going for functional TR and clarifying the differences, go to the surgical decision and then the cardiologist point of view with the percutaneous intervention. I think it was great. Thank you very much. Pleasure. Thanks. Okay, and I think that will wrap us up for today. We're gonna be starting back tomorrow at 8.45, is that right? And then, and so we'll look forward to seeing you all there tomorrow. Again, thanks to all of you who've stuck with us right through to the end. It's really been very enjoyable. Thank you. Thank you, Ryan. Thank you all.