 professional and helping out in this pandemic. It's been really difficult I know you guys have come from far off places a lot of times the fellows want to you know see the country travel which has all been restricted because of this we used to have a lot of social events as well which unfortunately we are unable to I'm just waiting for this to get over and then we can have some fun thank you guys and today you know I've been doing this topic for the last few years T for aortic surgery and AP aortic imaging. As you know briefly I'll talk about the outline one is I'll talk about normal anatomy I'll talk about aortic aneurysms briefly the root aneurysm and asening aorta I'll talk about aortic dissection intramural hematoma and penetrating atherosclerotic ulcers. I'll talk briefly about turcoabdominal aneurysm and T-VAR and use of TE in these situations and briefly about AP aortic scanning. TE is an important non-invasive tool in aortic surgeries and we know that the CT scan is the first investigation in the in the case of aortic pathologies for diagnosis and aortic dissection is one of the most common emergent situation requiring rapid and accurate diagnosis to reduce morbidity and mortality. TE can be used to identify the atherosclerosis of the ascending aorta which is very important in preventing postoperative strokes and AP aortic scanning is ideal for high-risk patients to identify sites of severe atherosclerosis on the distal ascending aorta and proximal aortic aorta. Coming to the anatomy of the aorta from the TE perspective the aorta can be divided into six zones one zone one zone two zone three zone four zone five and zone six. The total aorta you know basically you can classify it as having an aortic root an ascending aorta arch and descending thoracic aorta. From the ascending aortic aorta onwards we have six zones for the TE purposes and for the classification purposes. For example if you take zone two zone two is the typical site of proximal anastomosis in in CABGs and the aortic cross clamp occurs between zone two and zone three and we also know that zone three four and five are not very well amazed by the TE because of the interposition of the trachea and the left main bronchus and the also from the distal to the left subclavian becomes the descending thoracic aorta. Also the if you look at the traumatic aortic injury the most common site of blunt trauma or rapid deceleration during an operation is the aortic isthmus. It is the segment between the distal arch and the descending thoracic aorta right here. The aortic isthmus where it can it can be when the patient is involved in an accident because of rapid deceleration it can give way. As per the ACAC guidelines the following are the clips or the images where we use to image the thoracic aorta. Usually the midisophageal short and long axis view and the upper isophageal long and short axis views are commonly used to image the aortic structures. Coming to the normal parameters of aorta if you look at the annulus between 22 to 24 maximum sinus is 32 to between 32 plus or minus 4 millimeters STJ 27 plus or minus 4 millimeters ascending aorta 33 plus or minus 4 and descending aorta is 24 plus or minus 4 these are the normal aortic parameters based on the body surface area of 2 meter per square. I will start off briefly with aortic annulism of the root. This is one of the common operations which is performed in this site. The first one is the valve sparing root repair of the David operation. Second one is the composite valve graft of the bental procedure and aortic annulism is defined as the dilatation of aortic amortem and 50 percent of the normal aortic diameter. Annulisms are primarily diseases of aging as a result of either degeneration and atherosclerosis. Aging leads to intimal thickening, lipid deposition and calcification leading to dilatation and weakening of aortic valve. Connective tissue disorders such as morphine syndrome, helus dandelion syndrome and hypertension are some other causes of annulism. The thoracic aortic annulisms are divided into three groups. One in the aortic arch, in the ascending aorta, root and in the descending thoracic are the thoracobdominal annulism. First coming to the aortic root annulism. So as I said, AV sparing operation is a common procedure performed because it gives longevity to the operation and prevention of aortic insurgency later on. So the two operations commonly performed are re-implantation technique or David procedure or remodeling technique or a poop procedure. What happens in David procedure is in the native valve is resuspended within the background graft and the coronaries are implanted later. Basically that is the operation tubular tachyron graft where the native aortic valve is resuspended. In a poop procedure, what they do is they refashion or they sculpt the tachyron graft to the sinuses of the aortic valve and then they suture it. As you might know, looking at the technique of the operation, the site where the sinuses are sculpted here are the sites where it can get again annulismal and leading to re-operation. That is one of the fallacies of a poop technique, but it has got a place in the surgical paraphernalia. Next is coming to the TE evaluation of the aortic valve sparing surgery. The single most criterion for patient selection is the morphological appearance of the aortic valve. This is best done by visual inspection by the surgeon, which is added by preoperative TEE. So pre-CPBTE, what do we have to look for in these people? One is the aortic cusp abnormalities. Number two, severity and direction of the aortic insufficiency. Number three, the root dimensions. I'll go in detail for each of these. Coming to the aortic cusp abnormalities. So the more important things are absence of calcification and significant cusp prolapse, because these things can either restrict the motion of the leaflet or the cusp prolapse leads to eccentric regurgitation, which adds to the complexity of the repair. Also thickening and thinning of the cusp, if you see in this image, it's stopped playing. There it is. It's calcified and thickened. It's very difficult for such cusps to be valid to be repaired. A lot of times in such situations, they may have to do a dental procedure. Look at the cusp on this side. It's beautiful. It's thin. It's calcifying nicely. It's minimal AI. This is a sort of a dream aortic root neurism, which can be repaired with Dr. David's procedure. Also curled out edges, like I don't know who was there with me yesterday. There was a patient with the curled out edges, which leads to prolapse and eccentric AI. It's difficult to do. And then also sometimes if it is too much stretched, the cusps are very thin and sometimes there can be minute perforations in those situations as well. They usually do not do the repair. Second, as I said, is assessing the AI. The AI jets in this situation, it is central AI. A lot of times it is due to the dilatation of the sinus and the STJ, leading to alteration in geometry, leading to the central AI, which is not a problematic. However, the eccentric jets, which imply additional cusp pathology, this complicates the valve sparing procedures. Next is the root dimensions. Dilated, if the analysis dilated more than 28, sometimes they require aortic aneloplasty in addition. Number two, a lot of times you might have noticed and we have noticed that we cannot really measure the STJ because it's one straight line from the aortic anelosum to the ascending aorta because it's severely dilated. It's difficult to identify and measure. The other things which can be seen in pre-CPV and can be a predictor or prediction of success would be what is called as the geometric height and the effective height. The effective height is, like example at the end of the case, we do what is called as co-opation height. It is similarly, but it is done pre-operatively. According to, there is one good study on this. They said that the effective height is more than 9mm. The chance of repair is very good. If it is less than 9mm, the chance of failure is quite high. And also, the geometric height is the height of the aortic valve. If it is, I think 13 or 14mm or 15mm, I think is the cutoff. Less than that, I believe the chance of repair is not very good. Coming to the post-CPV assessment of this procedure, once the aortic valve repair surgery is done, what are the things we need to look for? Number one, evaluation of cost morphology and co-optation. Number two, residual AI. Number three, root dimensions. And number four, LV function because they usually re-implant coronaries. Coronary buttons are put into the graft. So, as we talked about the four things we will see. One is the cost co-optation pretty nice. Number two, if you look at the AI, which is minimal, no AI. And then the other thing we need to look at the LV function later on. So, these are the four things we need to look for. And then the important thing here is we look usually for what is called as the co-optation length and the co-optation height, which I will show in the next images. So, co-optation length is the length where the cusps are co-opting right here. Here what have I measured? I have measured about, I think if you see here, about 1mm, 0.9 to 1cm is the length of the co-optation, which is excellent in terms of repair. And co-optation height you have to come from here all the way up to the end of the leaflet. So, as from if you notice from here all the way up to there is the co-optation height and this is the co-optation length. And cost co-optation length in literature cost co-optation length more than five is successful repair and height more than nine is successful repair. And it should be mild or no AI. And in this study from 2009 that is what they measured if the co-optation length is less than 4mm the recurrence rate is 47% and the redo rate is 28%. And if it is more than 4mm the recurrence rate is just 5% and redo rate is 0%. So, that is the co-optation length which has been discussed in the literature. Any questions so far? Okay, I will carry on. Next is the literature which Maral and Dr. David published recently in 2016, their experience from Toronto General. So, it is I think over 300 or 400 cases they studied I think it is more than that. And then if you look at the they followed up to 15 years. So, if you look at the blue the blue line is the free from re-operation which is almost like 95% at 15 years and the red is free from re-optix in sufficiency it is almost 90% of patients are free from re-optix sufficiency after 15 years of the operation. And this is in figures in the say from the same paper or it is a different paper actually. If you look 5 years 99% 10 years 97% and 15 years 97.8% free from re-operation in David operation. If you look at a Kuba operation if you compare the same remodeling 5 years is 89% and 10 years is 89%. So, this is pretty convincing that which operation is better for EV repair and technique. How does the aortic valve sparing compare with the composite valve craft or the bental position? Bental can be bio bental it could be mechanical bental. As you look here the the green dots are the aortic valve sparing and the hazard ratio for the bio prosthetic bental and mechanical bental if you look it there is no comparison actually. The valve sparing trumps it in all case mortality in major adverse valve related events and in re-operation the the mechanical bental is slightly better but in all others others it is the AV sparing which is a better operation for these patients. So, in summary the re-implantation technique or David's procedure they are better in younger patients with aortic dilatation in the setting of genetic syndromes and those with larger aortic annular diameter more than 28 millimetre. The remodeling technique or a quick technique is better in older patients whose aortic dilatation is not part of genetic syndrome and these aortic analysis is not dilated. So, these are the for the patient selection with good patient selection AV repair has shown excellent durability and low risk of AI recurrence and re-operation over the time. Coming to the first part of my presentation any questions on this? I don't hear any questions so I'll go ahead. Coming to the next part is the acute aortic syndromes these include aortic dissection aortic aneurysm rupture or contained or non-contained rupture intramural hematoma and penetrating aortic ulcers. Coming to this the TE is useful in these situations they can use to define the size location and extent of the aortic dissection as well as presence of a hematoma or a thrombus. It is also very useful to evaluate whether the major aortic branches or arch branches are occluded or patent and to presence and the presence of mark perfusion of an organ. It's an important monitoring tool of cardiac function during aortic aneurysm surgery as you guys are very well aware of. Coming to the aortic dissection it's the most common cause of death involving the aorta. If you look it's a medical it is a medical emergency or the type A dissection is a medical emergency. The initial 14-day mortality is 50 to 75 percent and the risk of rupture increases by 1 to 3 percent per hour in the first 48 hours of presentation. It's extremely important to diagnose it quickly and why does it happen? It is found because of an intimeal tear which is contained by the media leading to the development of a true and a false lumen. The false lumen may extend into the branches of the aorta in the chest or in the abdomen causing mark perfusion ischemia or occlusion with resultant complications. The dissection can progress proximally involving the aortic sinus in fact aortic valve leading to aortic insufficiency and may also the dissection can extend into the coronary arteries leading to this chemical events. So as you know it's classified as type A and type B which is Stanford classification. Type A involves the ascending aorta and type B involves the descending aorta. There is also a debate key classification which means type one is it involves both ascending and descending, type two is only the ascending and type three is only the descending. When we commonly go by the Stanford classification type A which involves the ascending aorta and type B which involves the descending aorta. And in respect to type A 90% of the type A dissection occurs within 10 cm of the aortic valve. Usually the dissection starts within 10 cm of the aortic valve. The imaging modalities and sensitivity and specificity of diagnosing aortic aneurysm we know that the first diagnostic modality people use is the CT scan. CT scan has got the highest sensitivity and specificity of diagnosis. 100% sensitive and 98% specific. TE comes pretty close second 98% sensitive and 95% specific. So there are multiple correct answers which are there. Anybody? Systolic expansion. Okay that's correct. Anything else? There is one answer which is opposite of systolic expansion which is diastolic collapse which happens in the crew domain. So the correct answers are the diastolic collapse and systolic expansion. As I said there are two correct options. Sometimes in your exams they it's not just a single answer question, sometimes it's like multiple answers like there are two correct answers, sometimes three correct answers, sometimes all four are raw, five are correct answers. So make sure you read the question properly in the exam several times. We lose a question by not reading the question properly. So it's very important. Those are the two reasons why I put up this question. Make sure you read the question properly while answering the it's very simple thing which we sometimes overlook and we may lose a few marks in the exams. Coming to the true lumen as I said it expands during systolic and there's a diastolic collapse. There's a forward systolic flow you can put a Doppler through that and then you see the systolic waveform pretty good systolic waveform and number four there's absence of secondary traumas. The false lumen there are it's often larger that the diastolic diameter increases may have a thrombus in it and you can have a reverse or delayed or absent flow if you put flow through that the Doppler flow. This was the case which I did on maybe last week. I think who was with me? Philippe was the fellow I think Juan was also doing the echo with Marcus that was the case here. If you look here can you tell me which is the true lumen and which is the false lumen. We had a little bit difficulty in diagnosing but eventually we got it right but can you say which is the true and which is the false lumen and why do you say that. Anybody? The right one? The right one is what? The right here what is this one? This is the false. Right and this is the true. Yeah if you the ECG in the in the OR we could freeze frame by frame and we could see you know this happened during systolic the flow and as you said there is it's flapping around too much because there's a lot of flow in between that and that but you're right this is the false lumen there's less flow here and this is the flow during systolic that's one and other thing I will mention it later this is one of the things they ask us when we are helping out for t-vars I'll come again if you look at this structure here which is bright spot there that is the guide where they wanted to know whether the guide where is in the true lumen or the false lumen and you know we debated and then eventually they also shot an A they also shot a fluoro means the DSA and they knew from there but also they were asking us oh can you see it's in the true lumen or the false lumen that is a question they frequently ask us where the guide wire is before they put the stent or deploy the stent see the pigtail and they put they put the guide wire they put the pigtail and then they inject the diet to make sure they're in the right spot they keep asking the question there you can see the bright spot there no see that bright spot that is the that is the wire all right and go to the next yeah true lumen and false see it's a nice laminar if you put the flow like pw or cw we'll get a forward flow in this it's all over the place there's some thrombus in between as well we could see pretty well last week you know the thrombus in the false lumen and the true lumen was beautiful coming to the complications of dissection complications associated with dissections are aortic insufficiency which occurs about 50 to 70 percent of the cases sometimes you can get coronary dissections as well 10 to 20 percent you'll get pleural or pericardial effusion and global lv dysfunction if the dissection flap involves the coronary arteries so here coming to the aortic insufficiency here as you see there's an eccentric jet happening and you can see the dissection flap as well and some there are other there are reasons for AI in a type A dissection include a malcoaptation because the dilatation of the ascending aorta because of the dissection leads to malcoaptation leading to aortic insufficiency that's one of the cause second cause is cusp prolapse the dissection the cusp prolapsing into the lbot because of pushing by the dissection flap number three dissection flap per se going through the aortic valve into the left ventricular outflow tract leading to aortic insufficiency combination of these can lead to aortic dissection in these patients aortic insufficiency in these cases this is in the dissection if you look here this is the aneurysm extending all the way down and if you look here there is a left sided pleural effusion which they can empty at the end of the case any questions on aortic dissection anything to add some of you might have seen something different found something different anything have a left out or anything no okay we'll go to the next one the intramural hematoma you know this is quite common actually we we do see you know in sometimes post decannulation of the aortic canola you see sometimes hematoma developing in the in the aortic valve usually you know it's small and then it's insignificant and we just leave it alone that's why we always ask people to to look at the aorta at the end of the case there are intramural hematoma is there a dissection after the cannulation and these are the last images we always do at the end of our case right this is a you know this is a very big intramural hematoma so now what is it it is a variant of aortic dissection there's thickening of the aortic valve more than five this is pretty thick here 0.5 centimeter it accounts for 10 to 25 percent of the acute aortic syndrome the causes and rupture of the vasovasorum in the medial layer the blood supply of the aortic valve is by the vasovasorum they can get damaged either during cannulation or any other ethrosclerosis and whatnot leading to the intramural hematoma and they are characterized by thick aortic valves without an intimal flap it can involve both the ascending or descending thoracic aorta leading to swelling the hematoma is involving the ascending aorta is is a surgical emergency it's like a type A if it is big they have to go and they have to repair it a lot of times you know it just accumulates in the small blood layer accumulates in the media and usually it's not significant and we just leave it alone just observe it but the problem is it can progress to intimal fracture and leading to frank aortic dissection or aortic rupture so that's the that's the problem intramural hematoma so there we usually you know for the NBE exams in the PTA they usually have a question on intramural hematoma they'll put a picture like this and they'll ask what is this if this intramural hematoma is a penetrating ureting ulcer or they'll give a thrombus or something else so you have to it's more discernible than this one what images they give there is usually a question on this i've taken the exam twice both the years i remember having these questions the next one which is another aortic pathology is called as a penetrating urethral ulcer we do see such cases time to time usually in the abdominal urethra and tom linsee or tom forth they put a evar and they and they and it's done so we do see you know patients comes with pain and sometimes it extends the problem is it can cause the aortic rupture that's why they put a stent and cover it off before it causes any more damage so it's the least common of the problem it's due mostly due to ulceration of the atherosclerotic lesion and it penetrates through the aortic media most often in the mid and distal uh descending thoracic aorta is commonly commonly occurs in elderly patients with hypertension hyperlipidemia and the atherosclerosis and it often as I said occurs in the descending thoracic aorta any any other question and go to my next uh so this can progress to true aneurysms pseudo aneurysm or it can rupture so these are the complications of penetrating aortic ulcers coming to type b dissection so type b dissection is a dissection of urethra distal to the left of cleavine artery lot of times it is medically managed the surgical surgery is indicated only there is an ischemic complication or if there's an impending rupture so these are the two common reasons yesterday there was I think they did a t-bar for a type b dissection probably due to impending rupture the one we did last week uh type b dissection was due to ischemia of the spinal cord so uh there should be some ischemic consult to either bubble or due to spinal cord or to the limbs then they get the operation or if there is a impending rupture if it's expanding then they'll get most of the time it's a if it's a good anatomy they do a t-bar if not they'll get a thoracic aorta and aneurysm uh repair so this is an example of descending rupture or thoracic aneurysm here you know I could not figure out which is the true lumen or the false lumen can you one of you figure out it's happening simultaneously you know the blood flow this one I I don't know where I got this clip from but what do you think guys ECG also you know it's tough in this clip but if we play in single maybe we'll be able to figure out it's tough right no I can't say all right so coming to TE for a t-bar in type b dissection as I said uh one is to confirm the correct guide word placement in the true lumen number two we can rule out uh plaques at the proximal neck to prevent uh endo leak you can say oh there's a big plaque there the aortic cathiroma so they can avoid that that part of the aorta and number three is uh uh for uh assessing the retrograde type A dissection during the procedure this was the ask in the last case we we did this was the primary reason why they asked for TE they want us to know you know when they deploy the stand because they were going really high almost they covered the lefts of clevee and artery in this situation uh they were they wanted to know if they create any retrograde type A dissection while deploying the stand that was the common reason uh for that was the reason they asked uh for us to do a TE last week so I have a question type one endo leak after T bar is A inadequate seal at the proximal or distal landing zone B retrograde flow from the aortic branch into the aneurysm C structural failure of the strength uh perforations of fractures D strength graft porosity what is the right answer for type one endo leak anybody that is correct so endo leaks uh if you look in these answers uh A is type one B is type two it is retrograde flow so they put a strength and then there is a retrograde plan say an SMA or an aberrant SMA or aberrant something bleeding the blood back into the aneurysm leading to dilatation that's what it is the structural failure it's obvious that is type three endo leak it's obvious like fracture or perforation and sometimes uh you know the strength graft porosity leads to leak of blood into the aneurysm with sac again and there is a type five as well called the aneurysm expansion without obvious endo leak it's also called endo distension did who was there with dr minkowitz today in the operation any of your fellows or there was a resident because today's case leo was discussing with me this morning you know he was telling me I think the the type because they didn't find any of these problems in that strength they thought it was due to aneurysm expansion without any obvious cause so we I was thinking it's a type five and they put a second I think they put two stents with for sensitations I don't know the surgery is done yet all right coming to the next topic the Turco abdominal aneurysms and T for it as you know the classification one two three four extent one extent two extent three extent four extent one is from the left subclavian artery up until the renal arteries extent two is the the largest one extent from the left subclavian all the way to the iliacs this has got the highest risk of all sorts of morbidity and mortality extent three extent from the level of about six three and to the iliacs and extent four is infrared diaphragmatic abdominal mainly abdominal aortic aneurysm so the correct answer here correct statements there may be two two correct answers so a type two is associated with highest complications b ascending greater than four is an indication for surgical repair the threshold for surgical repair for aortic aneurysm is less than 0.5 centimeter in patients with Marfan syndrome than normal and both TTE and TE are good modalities to evaluate the aneurysm involving the descending distal ascending uretham distal ascending uretham so choose the correct statements a is correct then here i think uh are you sure or c c yeah c is correct any of correct correct correct in any of the in any of the uh connective tissue disorders it's 0.5 centimeter less than you know normally the threshold for surgical repair i've got it in my next slide i'll show you so these are the correct answers absolutely right i told you type two has the highest complications because of the extent of the aneurysm and all the results involved kidney problems spinal cord lb dysfunction etc etc so indications for uh as i said surgical repair of thoracic aortic aneurysms for ascending uretham 5.5 centimeter descending it's 6.5 marfan's or whatever then it becomes less the threshold is half a centimeter less than the regular cases okay why do we need TTE for uh uh during the throat abdominal repair number one very important check for other words because i myself was embarrassed i had a case years ago about you know when we missed everybody missed in the preoperative evaluation the patient had multiple valvular abnormalities in fact it was due to endocarditis and we opened the we opened the chest means the whole incision was done and then the echo team was a little bit late to come to our room and they found a lot of problems in the valves eventually we we continued with operation we did the operation but the the outcome was not very good so it's better to to fix other things before we come take on this massive exercise that was an extent too and it was not a good outcome unfortunately it was a fault of all the whole system we we we missed it that's why you know whenever i put a T probe uh in these patients the first thing before the full echo team comes i do a quick look i look at other things so make sure we don't make a big incision uh only to detect some other problems uh that that's the lesson i learned uh it's a very important for for us as doing the management of the case to know the lv and rv function uh volume status during the left half bypass you can guide through the te and also guide the cannulation for cpb that's important you know sometimes we have we have been extremely useful resource in this situation i'll show you like especially this case this is one of my cases if you look here they were putting the inferior uh cannula from the femoral vein and they were pushing and it was it was even more you know when they pushed it was uh impinging on the intrate inter atrial septum it was almost tempting like that you know if that pushed more we might have uh we might have we might have had a rupture of the inter atrial septum fortunately you know we recognize we said hey guys be careful pull it out and they gently maneuvered back into the mid part of the right atrium so that is what they did uh this time that's it's very important to guide the cannulation even for ECMOs and whatnot they keep asking us it's very important to make sure you know it does not impinge sometimes if there's a little hole or pfo it can keep impinging on that and it can go through the septum you have to be careful there so the next uh topic is the apiotic scanning before that i just want to mention that uh cerebrovascular accident of stroke after cardiac surgery is a significant uh event which we all of us who work in ICU we know how significant this problem is the incidence in the surgical population is about 1.9 percent in off pump surgeries on pump cabbage 3.8 percent and the aortic valve surgery almost 5 percent it's quite a quite a big risk and one of the major risk factor for perioperative stroke is proximal aortic atherosclerosis or a calcified urethra uh we always look for this uh in the descending urethra the Montgomery classification but what i mean to say more of more is the use of apiotic ultrasound and the apiotic scanning involves direct intraoperative ultrasound imaging of the urethra car and the root the it's an intraoperative tool for accurate assessment of ascending aortic pathologies and atheromas identification of significant disease by by this uh all can cause alterations in the surgical procedure right such as we can adopt a femoral arterial cannulation we can alter the site of the aortic cross clamp we can change the type of cannulas used for extracurricular circulation we can say okay this patient needs off pump primary surgery or they can alter the site of the graft anastomosis in the urethra based on where the atheroma is so it hence it's very it's very important to know where the atheroma is uh the apiotic scanning is a very important tool for us because as i already mentioned uh in the earlier part we have a uh window where we cannot see the urethra you know that's in zone two zone three and zone four sometimes zone two and zone three are where they put the uh urethra cross clamp so it's very important to make to tell them that there is a calcification usually the surgeons feel the urethra to see there is no calcium but it's not foolproof that's where the apiotic ultrasound comes into picture these are very high frequency probes they can be linear array sequential transducers or rectangular shaped which gives a rectangular shaped image or a phased array transducer this gives a fan shaped image right now we we also have a matrix array transducers which gives 3d and explain as well in the apiotic ultrasound so it is important we need to have a standoff either some saline uh um or gel inside the the the sheet we use so that there is a standoff between the urethra and the probe so you get a good image of the of the ascending urethra and we all know how useful it has been in our recognition of the atiroma and avoiding the cannula at that site so this is a use very very useful image imaging technique all right thank you for listening to this talk and if you have any questions or comments you might have something you might have seen uh please let me know hi tree this is milka i have a question do we measure the geometrical height no right oh i'll go back to that yes so it's the valve the height of the valve this length of the valve i i usually don't measure them for uh for the um so this is the size of the you know the valve from the geometrical height see here the arrows pointing here got it yes yes but we don't usually tell me again we don't usually do that measurement right we don't we don't in this play i i don't i don't know if any of my colleagues do i really don't i don't even do this one uh but uh normally we do the uh for the biker speed valve we do the angles you know right uh if the angle is is bigger the angle the better if it is 120 degrees and something it's bad 160 170 is a good angle uh i didn't i don't have a slide on this but i'll show you in the operating room when we measure the angle so they usually ask for it in biker speed valves and if it's a shorter valve the angle is shorter if it's a longer elongated valve you get a longer angle it's better for they believe there's a paper from europe i think belgium i think which shows a better uh outcomes if you have a bigger angle in biker speed erotic valves so this paper i will send you guys yeah i i have uh i have one paper from 2010 i think that's where i got this image from i'll just look somewhere in my desktop i'll find it and i'll send it to you but i don't do this measurement does any of our colleagues do it i haven't seen anyone doing that no no yeah i mean either uh this is one of them not even dr omron yeah we can check with amat whether he does it but i uh yeah i've done several cases with amat that's never mentioned it to me but this is in a paper so you guys can we can probably we can start doing and see right i'll send this paper and see if we can we can try to do them and see what happens the outcome etc all right thank you thank you guys thank you tomorrow bye bye thank you