 Hello, everyone. Thank you for inviting me to present at your conference this year and to be part of this 3D eco course. And I'll be talking in the next 20 minutes about the standardized approach to trans-caterpillar mitral valve repair. And in particular, I'll try to focus on the important 3D applications. I don't have specific disclosures on this topic, but I received speakers on O'Rearion from ABOT to talk specifically about Mitra, Clip, and Eco. And we are a Phillips reference center. Therefore, all of the pictures, all of the videos that you see, they're all coming from the same platform. We'll be talking about the critical step of this procedure starting from a baseline mitral valve assessment, transeptal puncture, clip guidance, grasping and release of the clip, and assessment of the results. When it comes to mitral valve assessment, we need to go back to the basics. And what's important to assess, to start with, is the etiology of the mitral regurgitation. And we use the Carpentier classification to divide the type of mitral valve regurgitation into three types. The third type is then divided into A and B. And on 3D, Eco, with an unfast view of the mitral valve, we can have a right-of-way picture of what these different types looks like. And what we typically treat with clips are type 2, with excessive leaflet motion, and type 3B, which is restricted mitral valve or functional secondary material regurgitation. In the assessment of the mitral valve leaflet morphology, we can use single 2D images. And this was, to me, one of the biggest challenges when I started studying and learning eco-cardiography, and I was a fellow in Toronto. And you know, there's been many different classifications to identify which leaflet is which. Now, modern technology has made the identification of the leaflet way easier. And what we do on a daily base, but most commonly for mitral valve percutaneous approach, is we start from a mitral commissural view. And in the mitral commissural view, we see we have the left-to-lap-endure to the right, which is the lateral portion of the valve. And opposite to it is the medial portion of the valve. Now, the secondary plane, which is the long-axis view, we know exactly where it's cutting through. It's cutting through the center of the valve. So we see here now the two leaflet, the two scallops, so A2 and P2. Now, if we take our plane and we tilt it more laterally, now we know exactly that in the long-axis view, what we're seeing is the A is the one segment, so A1 and P1. And now, if we take the same line and we move it more medially, now in the long-axis view, we see what we're seeing, which is the P3 segments. So that's the way we usually scan through the valve to assess exactly where the problem is. And that's how we also show it to our interventionists. We explain, we can add color and then see exactly where the jet is coming from and then we can take color away and then see where the abnormality on the valve is. And that's again, also it's important for us for percutaneous approach because we can see where the line is cutting through this regurgitant jet and that's where our clip is supposed to come in and that's where the clip is supposed to sit to actually see the gap that's causing this jet to form. 3D on fast view gives us, again, the option to look at the valve as a whole and we can look at the valve from the ethyl side, we can look at the valve from the ventricular side, but also we can appreciate here that's extremely difficult to appreciate in 2D and make clipping and the resolution of a matter regurgitation with clipping alone, extremely difficult is the presence of indentation and clefts. So the difference between clefts and indentation is whether the leaflet is split all the way to the annulus or only partially split halfway through. So we can suture clefts surgically but we cannot really clip clefts. So if the cleft is the main source of your regurgitation, it's probably not gonna get better with the clip. And if there's a cleft often even when we put a clip then there still is some residual matter regurgitation. 3D allow us to also turn color on and color gives us, in 3D gives us a better appreciation of how big and how wide this jet is and whether it can be assessed or can be addressed with one or multiple clips. The morphology of the valve can also be assessed in 2D on a 3D dataset. So if we use NPR or if we use multi-views or NPR live, now if we put on the green plane, our Mitra commissural view with the lateral portion of the valve with the left-hand lapenda that you can see it here on the right side, now you can see that you have the red plane. Red plane is now your long axis view. You can take this red plane and you can move it laterally and you can move it medially and you can scan in this red panel the whole entire valve. And this is, you see, I've moved my red plane more medially and here I've moved my red plate more laterally. So with the 3D block using NPR, I can scan through the entire valve and looking in this red panel, you'll see exactly where the problem is with these valves. This very well-written review on Jace from a few, a couple of years ago from Charles Neiman from Boston, put together what are the challenging anatomy for clip positioning. So what is difficult to clip is anything that's not in the center of the valve. So if the problem is medially or laterally is more difficult to clip and less likely to be successfully clipped, the presence of calcifications is definitely another challenge. A small valve is a problem. If the posterior leaflet is small, it's a problem because it's difficult to grasp. If the tending is very high, so that leaves a big tension on the leaflet, whether the type of regurgitation is carpentier 3A or 3D, so functional or restricted both in systole and diastole, that makes it difficult. And obviously, if there's a big gap between the leaflet or there's a big flail that leaves a big hole between the leaflet, that makes it difficult to grasp. It's all sort of self-intuitive, but this was actually what's derived from a very famous Everest trial on mitra clipping. It is an anatomica specimen from a big heart. And this also gives you an idea. This is the view of the interventricular septum from inside the left ventricle, which we cut through. And what you see in front of you is the anterior leaflet of the mitra valve. And you can see that in the center of the leaflet, that's the A2 segment, there's no cords. You see that there's this margin that comes there and there's absolutely no cords. So if we need to leave or place a clip, there right in the middle, there wouldn't be much of a problem. But as we go towards more medially or more laterally, then you see that we get to deal with the subvalvular apparatus which causes major challenges and it can be a big problem. And the clips can also sometimes stuck in the cords and while trying to retrieve the clip, we've also ripped the cords and make the situation worse than when we started. In terms of measurement, what measurement we take, we usually measure the annulus of the mitra valve in the mitra commissural view and long axis view in diastole. And when we have a small annulus, that's a good, that's an important information that we need to give our intervention on this because smaller annulus means smaller valve. It means that we need to be cautious on how many clips and how big of a clip can we actually place. The length of the leaflet also gives us a good information on how we can grasp this leaflet and normally measure it again in diastole. We need to confirm that there is mitra regurgitation. But as you know, assessing mitra regurgitation under general anesthesia, with the patient who's mechanically ventilated, it's not ideal. And this is a case from last week that I had in the operating room. We look at this mitra valve which is booked through a schedule to be clipped and as we start the investigation with 100 blood pressure, the mitra regurgitation is really, really mild. But then actually as I popped up the blood pressure with norepinephrine, you can see that now the mitra regurgitation becomes really significant. So it's important also in the OR when we're looking at the mitra valve to try to re-establish physiologic condition or to re-establish condition where the condition when this valve was primarily evaluated by the cardiologist on an awake patient. So try to re-establish what was the pre-operative blood pressure. And also we can then look at the endiastolic diameter of the left ventricle and give volume to reach these pre-operative endiastolic diameter to recreate the same or to try to recreate the same condition. They're never gonna be the same, but to try to recreate the same condition. We have a few choice of clips when we're gonna be clipping. Now the newest generation of clip is called G4. G4 means that these clips allow for independent grasping. Each arm can be closed independently when the previous generation they have to be close together at the same time. We have a smaller clip, that's the endi and we have a bigger clip, that's the XT. The endi and the XT clip come in two types. So there's a normal type, so endi and XT and there's a W type, which is endiW, which means wide. So the clip is actually thicker. So normally for a smaller valve and for multiple clips, we usually go for an endi. For a bigger valve and for just one single clip we usually go for an XT clip. The first step of the procedure is the transceptile puncture. We do a transvenous approach through the femoral vein. We come up and then we have to cross the septum. How do we see the septum with echo? So the septum is divided and was recently divided as we started with this procedure in different portion. So what's important to know for us is superior, inferior, anterior and posterior. In the bi-cable view, what we see to the right is superior, what we see to the left is inferior. Here we have a needle that's trying to poke the fossil valleys in the bottom portion. So in the inferior portion of the fossil valleys. In the inflow outflow view, where we see, when we see the aortic valve, the aortic valve is notoriously anterior. So the portion of the septum that's next to the aortic valve is anterior, opposite to it is posterior. For bi-track clip, we usually use an X-plane view where we start from a bi-cable view and now we have a view where we see the aortic valve. What's funny here is that the view on the right, the view on the right, it's been flipped because we started from more than 90 degrees. So then the view on the right, it's flipped. So what we see is it's something that resembles a RV inflow outflow view, but now the aortic valve is not to the right of the septum but it's to the left of the septum. So that's to be remembered because now let's not be confused. Then remember that the aortic valve is anterior. So closer to the aortic valve is anterior, which is here and away from the aortic valve here, it's posterior. So here we have superior, inferior, anterior and posterior. We can flip the secondary plane that we have and we've done it here and we can flip it. And now we put the aortic valve back into sort of the more standard position. We usually just don't do it and we leave it the way it is. We all know that where the aortic valve is anterior in respect to the opposite, that is posterior. Where do we need to poke? We need to poke posterior and superior for mitra clip in order to come as far and as high and as posterior as possible to the mitral valve. We start with the catheter in the superior vena cava and then we come down and we come down on the septum and then we start to push on the septum and you see an indentation. Once we see the indentation, we usually go to the fourth chamber view and we measure how high it is in respect to the mitral valve and we take anything that's between four and five centimeters. Once we're happy with the position and the height, then we push through and we get with the needle and then we get a catheter through. Through the catheter comes a wire that's parked in the left upper pulmonary vein. And now what we can do also, if we go to our fourth chamber view, we can then select as an area of interest with 3D, our interraterial septum, and then display the way you see it on the right. And here what you see is you see where the wire is coming from and then you see the mitral valve and the posterior-medial commissure. So where you wanna see this wire coming is just above the posterior-medial commissure here. That means the right position of the wire because when the catheter delivery system comes, it just has to bend down and will be diving into the mitral valve. So here we're trying to push the catheter through. This was an interesting case where it wasn't easy to put it through and it was coming parallel to the interraterial septum. We want to ideally go as perpendicular as possible to the interraterial septum and what's important is to always follow the catheter and see where it is in order to follow the tip and see that the tip is not poking and it's not going through against the wall of the left atrium and then with the risk of perforation. Once the guide and the dilator are out, we have the catheter which is through the interraterial septum and now we're ready for the clip. The second step is the advancement of the clip. The clips come up, it's bent down, as you can see here, and now we try to position the clip where we think that the defect is and where we think where the jet is coming from. So we can move the clip anterior, posterior, lateral and medial, the clip is open and now the clip is positioned perpendicular to the opening and then what we do is we can also turn the clip and we sort of do the clocking so we can rotate it so then it comes right perpendicular to the connoisseur. We typically use for guidance this mitra commissural view and explain because the mitra commissural view allows us to guide the clip lateral and medial and then the perpendicular plane that I've explained is gonna be guiding the clip anterior and posterior. Here the clip comes, you see to the left is like going against the Kumadi ridge and then it's plunging down into the mitra valve. Once we have the clip on the mitra valve usually when we're ready to go through the valve we stop the ventilation. We discover through the years this Emil principle so expiratory hold medial, inspiratory hold lateral. So when we want the clip to be more medial we stop the ventilation and we decrease the peak. If we want the clip to move more lateral we stop the ventilation and we increase the peak so that the clips moves more lateral. The clip is open and now we do what we call clocking. So we look in 3D at the clip above the valve and we rotate the clip to make sure that the clip falls right where we wanted to fall and that the clip is right perpendicular to the opening of the valve. For the positioning what's also important is to turn on the collar and then see where the jet is and see where the clip is in respect to the jet. And like if it's a small jet or if we plan to use only one clip we position it in the center of the jet. If we wanna go for a two clip strategy then we can start either medially or laterally. So on the medial edge or on the lateral edge of our regurgitan jet and that's where we're gonna position the clip. Once the clip is through the valve and we turn 3D on before we start grasping we can still look at the clip. How do we look at the clip through the leaflets? We just decrease the gain as low as possible and we see that the leaflet would disappear but because the clip is a foreign material it's a metallic clip. It's still very ecogenic and we're still gonna be able to see it. Grasping means to get the leaflet engaged in the clasps and then we can now grasp the clip or re-grasp the clip and then we will close the clip and then when we're happy with the results we may choose to release the clip. Until this point we can always open and let the leaflet go and re-grasp again. So for grasping it's important that in the Mitra commissural view we see the thinner portion of this clip and so that means that then at 90 degrees we're gonna get the long axis of the clip. Sometimes as we see here we get the shadow from the delivery catheter to shade to cast shadow on the anterior leaflet we don't see it very well. How we can get rid of the shadow is by advancing with our probe and just try to go under the clip a little bit. It's gonna be a little bit off axis in the Mitra commissural view but we end up having a better view in the long axis view. The grasping sometimes when we've tried with X plane and it doesn't work we can also try and do it with the long axis view alone. Something that can happen, you can see here there was a case where the leaflet got stuck on the grasping arm before the grasping arm was actually closed. So that's obviously something that we want to avoid because if you now close the grasping arm the leaflet stays outside of the grasping arms. How do we know that we've got enough leaflet inside the clip? We need one thing that we can do is we can actually measure the length of the leaflet before at the beginning of the procedure and then measure the length of the leaflet from the edge of the clip here to the annulus. That gives us an idea of how much leaflet is inside. And we wanna have like usually like the same length so almost the one centimeter of leaflet like inside. So like inside the arm of the clip. The other thing that's important to look at is here you can see that here the leaflet are quite mobile. As soon as we close the clip, the leaflet, there's tension on the leaflet, the leaflet are held very tight inside the clip and that's a sign of good grasping of the leaflet. We can see that in 2D, we can also turn color on and see if there's a residual material agitation. And here is on X plane, we went to see exactly where this jet was and then we released the clip. And as we release the clip, then sometimes we need to wait and see until we've released the clip because sometimes the micro agitation will still change after we've released the clip. And this was a case when we decided that we couldn't just leave it alone and we went for a second device. The more lateral or the more medial we wanna leave or position our clip, the more challenging it is. And you can see this is an example where we wanted to clip A1, B1. And you see that in the short, in the Metricommissional view, we cannot really align our plane and in long axis view, we can't see the clip very well. This is where when we use X plane, we actually, sorry, we use 3D, then with live NPRs, we can then position our planes as we can see here, right perpendicular or right perpendicular through the clip and then better assess the position of the leaflet. With NPR or this multi-view, so live NPR, we can position our planes independent of where the, or dependent of an inch point because with an X plane, we always have an inch point. And here we can position the planes right perpendicular to the clip. And you can see here that both leaflets are actually inserting very well inside this clip. And in terms of grasping, we probably cannot do anything better than this. And this is now another example of a clip that's been already released. And now we position our plane perpendicular to the clip and we can see and we're happy with the thing. Assessment of the results obviously start with assessment of the residual mitre regurgitation. And we don't, we try or we don't want to accept more than trace other mild mitre regurgitation. We definitely want to have an improvement of at least two grades from baseline. We assess the residual mitre regurgitation with color in X plane with color in 3D. And also we usually look at the pulmonary venous flow and the change in pulmonary venous flow before and after the clip. Our cardiologists would also measure the left atrial pressure through the catheter. This is on one hand, we want to minimize mitre regurgitation. On the other hand, we don't want to cause mitre stenosis. And this is after we've grasped the leaflet, we access the mitre lymph flow. And this was a very good result because the peak gradient was four and the mean gradient was two. We don't want to accept anything that's more than five millimeters of mercury. For assessment of the residual opening of the valve, we can also do it in 3D. Once we've got a 3D block, we can use NPR to do planimetry of the two orifice and sum them together. And ideally, we want to have at the end of the procedure a opening area that's more than two centimeters square. Finally, we've been going through the interatrial septum. And as you can see here, there's usually a residual interatrial septal defect. As long as the shunt is left to right, we usually don't do anything about it. So I've been working here for now two years. I've done more than a hundred clips and I haven't still closed an ASD. Until now, there has been cases where the patient also had concomitant severe tracuspid regurgitation and the patient ended up having left to right shunt. And in that case, that was the only case when it's been decided, I've been told, to close the interatrial septal defect. In summary, we need to know the technical aspects of this procedure. There's a lot to learn and there's very important steps that we need to know. We also need to follow what the cardiologists are doing using fluoroscopy. We are lucky that we have a screen that's above our echo machine where we can see the fluoroscopy and we can see at every moment what the cardiologists are doing and where the probe is in respect to the clip. And that helps me sometimes to actually get rid of some artifacts and optimize my imaging. Planning is very important, communication is key. Explain is the fundamental image modality for this type of procedure. 3D, on fast view, provide us always a picture of where we are and what we're doing. Multi-view and live MPR modes is becoming more and more useful and more and more used for this procedure, although the spatial resolution is not as good as 2D and is not as good as explained. I'd like to thank our colleague interventionalists, Particular Philip Lourdes and Christian Bessler, who are in charge, who you see them in this picture, who are in charge of doing all of these clips from whom I've learned a lot. And also my chief, Professor Renderer, who's taught me pretty much everything I know on clips and he's mentored me and supported me through these years to get to where I am at the moment. Thank you very much. This is my email and I'd like to invite you to join us in life sickness here. If you are interested in to see this procedure live at the perioperative TE masterclass on June 20th to 22nd, the event will be broadcasted also online, for those of you who cannot make it here. Thanks again for having me and I'll be available to answer any question in the question and answer time period.