 Hello everyone. My name is Massimiliano Maineri, the co-chair of the Leipzig Health Centre in Leipzig, Germany. And I worked at Toronto General Hospital as a fellow and as a staff for many years. And I'm always extremely pleased to be invited to this conference that's been grown through the years and has actually made it through very difficult time that we could have never foreseen when this whole adventure started many years ago with the hard work of Annette Vegas. What I was asked to talk about was today the use of echocardiography for intraoperative assessment of mitral valve repair, specifically for minimally invasive surgery. I have a few disclosures. I've received honorarium from ABBA to talk about mitra clip, which is not a topic in my talk today. In Leipzig, we are a Philips reference centre. So all of the images we have, they come from Philips machines. Unfortunately, we don't get any money for it, but we get equipment and software from the company. And I'm also part of the writing committee of the National Board of Echocardiography for the TXM. I wanted to guide you through a systematic approach for the evaluation of mitral valve regurgitation for surgery, and I'll be using the guidelines that were actually published two years ago. And we'll talk about some of the measurements that are important or that our surgeon thinks they are important, and we use for communication with our surgeon, and then we'll talk about assessment of the results. These are the guidelines I mentioned. This is a very interesting paper that came out two years ago. It's hard work of a big group of people from North America, including Annette, who was involved in these guidelines. And what these guidelines are, they're basically a roadmap for intraoperative echocardiographers to tell them what it's expected from them to do for specific procedures. And this is what it's written about mitral valve repair. And the guidelines propose a systematic approach that starts from evaluation of mitral valve anatomy. When we talk about anatomy, it's always nice to go back to the actual anatomy of the heart. And we're now talking about the mitral valve, which is this valve that I've highlighted in this animation between the atrial left atrium and left ventricle. It's called mitral because it resembles this head that's still wore by bishops in many churches. And if we turn it around, it looks like the leaflet of the mitral valve. The mitral valve is composed by two leaflets. And what helps us orient ourselves is that usually between 11 and 12 o'clock is the aortic valve, which is anterior, and the left atrial appendage, which is at about 11 o'clock. And as I said, next to the aortic valve is the anterior leaflet and away from the aortic valve, so opposite to it is the posterior leaflet. The mitral valve is not just a valve, but in order to have a functioning, a well functioning valve, all components of this mitral valve complex need to work in synchronous. And these components are the atrium, the annulus, the leaflet, the corded tendine, the papillary muscle, and the left ventricular biocardium. If any of these elements is pathologic or changes itself, then that affects the functioning of the mitral valve and the valve may become incompetent. What it's important to understand is the mechanisms of mitral regurgitation. How many reasons can there be for the mitral valve to leak? And Carpentier many years ago, this is from 1983, described these possible mechanisms into three types. And they are divided into primary and secondary mitral valve regurgitation. And they talk about and they're focused on the motion of the leaflet. So we can have normal leaflet motion, where we have a dilatation of the ring or a leaflet perforation or a cleft or an indentation. We may have excessive leaflet motion, which is what we commonly see or most commonly see that presents with leaflet prolapse or flail. And then we have restrictive leaflet motion. Restrictive leaflet motion can occur in systole and diastole. And that's a degenerative mitral valve or a rheumatic mitral valve. Or the restricted motion is only in systole due to tethering of the leaflet, which means that there's forces that pull down on the cords and prevents the leaflet to close. But the leaflets themselves, they're actually normal. And this is type three A for systole and diastolic restriction and type three B for only systolic restriction. It is always, it's very important that we understand where the problem is in the mitral valve. And as you can see here, we all know we use this carpantienome enclature, where we have divided the posterior mitral valve leaflet into three portions. They are usually identifiable due to a small indentation between them. And more laterally, we have P1. In the middle, we have P2. And medially, we have P3. Opposite to it, opposite to them, we have also divided and we divide the anterior mitral valve leaflet into one, more lateral, two in the middle, and then three medial. This was, for me, one of the biggest challenges as I started learning transasophageal echocardiography in Toronto. And I just couldn't understand how my staff would tell the surgeon it's a P2 problem. It's a A1 problem. It's a P3 problem. And actually, for each of these, so in order to see and to visualize all six of these scallops, we need four or five views. And these are the views that we normally have, and we need to visualize all of them. There's a four-chamber view, mitral commissure view, two-chamber view, and long-axis view. Now the challenge is always to remember which one is which. What's also not always so clear is that it's not even so, we're not even 100% sure that what we see is what we think we're seeing. So when we have a four-chamber view, the four-chamber view cutting right in the middle of the valve, which is a perfect four-chamber view, then we see the two portions. But actually, if we take this probe and we pull it up and we start to see the aortic valve, then we are no longer seeing the A2 portion of the valve, but the two portions of the valve, but we're moving laterally. And then actually, if we push the probe in, we start to see the coronary sinus, and now we're going to see the more medial aspect of the valve. So with a four-chamber view, we can use this view to scan through the valve in and out. Something similar we can do with the long-axis view, where now instead of pushing the probe in and out, we can turn the probe right and left. And if we turn left, we're scanning through the more lateral aspect of the valve in the one segment. And if we rotate to the right, we scan into the more medial aspect of the valve, that's the three segments. Now, we don't have to think too much about it anymore, because we have multiple planes that can be displayed at the same time. And this is what we normally do. We display the mitra valve in the mitra commissural view, where you can see here in the middle that's highlighted in yellow. And that's you see the yellow line on this model where it's cutting through. It's cutting through P1, which is actually to the right side, where the left lateral appendage is P2 in the middle, sorry, A2 in the middle, and P3 to the left side, which is the most medial aspect of the valve. Now, if we place the secondary plane right in the middle, what we see on the right side in the long axis, now we know for sure these are the two segments. What we can do is now stay in there, just move our secondary plane more medial or more lateral. And now if we move more medial, we're going to see the three, which is what we see to the right. Or if we move more lateral, then we're going to see the ones, that's what we see to the left. Obviously, now we have 3D imaging, and you know, I'm a big 3D fan. And the 3D imaging really allowed us to fully appreciate the complex anatomy of the mitra valve. We can obtain a block of the mitra valve. We look at it from the left atrium down into the ventricle. We can see the valve just like the surgeon sees it. We can actually flip it and look at the valve from the bottom. So from the ventricle to the atrium. And just looking at the 3D, the unfast view, which is the surgical view, which is the orientation of the valve, the same way the surgeon would see it with the anterior leaflet at the top, the aortic valve at 12 degrees, 12 o'clock, and the posterior leaflet at the bottom. Just looking at these blocks, you can probably tell right away what type of problem we have here, and how it correlates to what type of disease or what type of, what is the cause of that agitation. With 3D now and newer technology, we can make this block looking more realistic using with the philip system, so-called true view or glass view. And what really, I think 3D big difference for the mitral valve is to be able to identify clefts and indentation. And I never understood how can we see a cleft in 2D. It's extremely difficult. Now after many years of experience, I could probably make a diagnosis, but we don't need to do it anymore because if you look at the valve on the left, you can clearly see that there's a cleft between P1 and P2. And if you look at the right, there's an indentation, which is sort of an incomplete cleft that goes through the leaflet. Then this is very important to tell the surgeon, so the surgeon can appreciate little details that sometimes when they look at the valve, the heart is empty in diastole, and the valve is not loaded, and these details may, they may not be able to appreciate it. Once we have a 3D block, we can still cut this block into perpendicular planes. And we can use this multiplier reconstruction that we did it live here that's using so-called multi-view with the philip system. And we orient the blue plane to cut through the mitral valve manual. So now at the bottom left in the blue panel, we have the mitral valve in the long axis, in the short axis, and we have at the bottom the aortic valve. And now we can position our red plane right in the middle. And as we position it right in the middle, when we look at the red panel, now we're looking at the P2 segments and the A2 segments. We take this red plane, we move it now more medially, and this is what we did on the left. And now we're seeing the three segments. You take this red panel and you move it to the left. Now we see the one panel. You can do it as we did it live, or we can do it offline with multiplier reconstruction. This is an example from another data set where we see in the bottom left, the A1 segments in the middle of the two segments and on the right is the three segments. And we still have our eye can still much better appreciate a leaflet pathology and leaflet morphology in 2D, better than in 3D. But 3D gives us like an over look at the whole valve in just one blink, one shot. We can take these 3D models with 3D block and then build a 3D model of the mitral valve. We do it and we've done it many times for research purposes. We in Leipzig don't do it on a regular base, although these models we did studies when I was still in Toronto with Tyron David and we demonstrated that they're reliable and they correlate with direct measurements of the valve. And you get a whole set of automatic measurements. But this is a matter of communicating with the surgeon and making a decision together how we can use these measures to guide their repairs. Now that we've looked at the anatomy of the valve, we need to evaluate the severity and confirm the severity. And how we do this, we do it with color Doppler. So with color Doppler, color Doppler will help us to further confirm the cause of mitral regurgitation because the color normally goes away from the prolapse and towards the restriction. So whenever we see something in 2D, we put color on, then it needs to make sense. Yeah, if it doesn't make sense, then we've done something wrong. Most likely with our 2D assessment or 3D assessment without color because the color is always displayed where it is. Therefore, we need to find the reason for a jet that's going in a certain direction. With multiple planes or X-plane or D-plane or multiple planes, at the same time, we can use the mitral commissural view just like I showed you for the 2D image. And we're going to also use this technique with the case that we present in later. And we can then use the position, the secondary plane on the primary plane on the first plane, so on this mitral commissural view, and then scan through the valve and go look for the jet and see exactly where the jet is coming from. We can use 3D color. 3D color gives us a nice depiction of where the colors come from. Now with the newer probes, we can have a good enough temporal resolution so that in one beat we can display the color. And what is never to forget is that we are now evaluating a patient who's intubated, with mechanically ventilated, and who's asleep. And this patient was evaluated before in the echo lab, but he was awake, and he may have had a TEE, and the TEE was extremely uncomfortable, and the blood pressure was very high. So it's important that we try to recreate in the operating room the same physiologic condition as we had in the echo lab when they did the preoperative assessment. Or what we think, or what we know that the preoperative condition for these patients are, and before the patient was put to sleep and before the patient was breathing spontaneously. This is an example of a case of an ischemic mitral regurgitation, where you can see the same patient on the left with 100 over 60 blood pressure and on the right with 170 over 90 blood pressure. So what looked like a minimal mitral regurgitation was actually severe mitral regurgitation, and this patient was actually treated for that. What we also have learned from a 3D color Doppler is that this jet that we thought that the jet is actually around comes from around orifice. When we actually cut through it, we realized that this orifice for ischemic mitral regurgitation specifically is actually not round, but it's oval. So that sort of speaks, so adds more information in one direction. This would be for ischemic mitral regurgitation and also it highlights the limitation of measuring the vena contracta in 2D and in one play alone. So we've seen now the reason for the mitral regurgitation we've looked at the jet. Now we need to see whether there are elements that are speaking against the repair of this valve or things that may make this valve difficult to repair. What do we provide our surgeons so then they can sort of make a decision? We usually provide them the annular diameter, which is the anterior posterior diameter, the length of the leaflet, C-sub distance diameter and length of the ventricle, tenting height and tenting area for ischemic regurgitation, and then we look at the distance of the circumflex from the mitral valve annulus. If you want to actually have a roadmap that's sort of very helpful in decision making in the OR, this is what our colleagues in Boston proposed and in this paper there's one of the ex fellows from Toronto General Hospital that's Aidan Sharkey that's become extremely productive in Boston as they move there. And you can see that what they suggest is that when we see mitral regurgitation then we need to establish the pathophysiology of this function and then understand whether this is ischemic or non-ischemic and then exclude predictors of repair failures. What are the predictors of repair failures that were identified by this group in this paper? These are the tenting height and tenting area, so more than one and more than 2.5, the angle of the P3 segment of the posterior leaflet, a very dilated ventricle in diastole and in systole. And these are actually all the parameters that have been proposed and described in the literature to speak against a repair in case of ischemic mitral regurgitation. These are basically proportional to the extent of tethering of the leaflet and to the dilation of the ventricle. When the leaflet are extremely pulled down, when the ventricle is extremely dilated, then the chances of successful repair are much less. What happened though with ischemic mitral regurgitation is that ischemic mitral regurgitation presents itself with two very different phenotypes. One phenotype, which you see at the top, you have all portion of the leaflets anterior and posterior are pulled down into the ventricle and you have a central mitral regurgitation jet. So you see the jet is central, comes from the middle of the valve. Or when you have involvement of the posterior papillary muscle and the inferior wall of the left ventricle, then you have tethering of the P3 segment, then you have an eccentric mitral regurgitation jet. This is the case where the repair of this valve is not going to work. It's going to eventually very, very soon fail. Here is another paper that showed that the most significant measure against predictive of failure for mitral valve repair was a P3 tethering angle of more than 30, which basically means that the P3 segment was pulled down way more than the other segments of the valve. And this is an example of how this with multi-primary construction can be measured. We are talking about the mitral valve. In a good portion of patients with mitral valve disease, we have concomitant tracaspid valve disease. Why is it important to look at the tracaspid valve? Because if we operate the tracaspid valve at the same time as the mitral valve, there is no increase in risk of death and in morbidity for this patient. So it's basically the same. And it's not that difficult for our surgeon. What's important for us when we do minimally invasive mitral valve surgery is that if we need to repair the tracaspid valve, then we need to put a neckline. And we in livestock do it in the induction room. Before we go to the OR, it happens sometimes that we identify tracaspid regurgitation when we were already in the OR and we had to put it in the OR. That wasn't really very, was an idea because the surgeon had to wait and we have to work with much more stress. But when should the tracaspid valve be addressed at the same time as mitral valve repair? The guidelines from 2007 are very clear. All the time when the tracaspid valve regurgitation is severe, it's class one indication. When the tracaspid valve regurgitation is mild or moderate, then if the annulus is dilated, which means tracaspid valve annulus measured in the four chamber view in diastole more than four centimeters, or when there is no tracaspid annular dilatation, but there is evidence of pulmonary hypertension. Now, tracaspid valve repair includes the use of a ring in the great majority of cases. So we pretty much always use a ring, whether there's so many different types of ring, complete rings, partial rings. How do we choose the ring? So at our center, what we do is we basically want to choose a ring that's pretty much as big as the anterior mitral valve leaflet. And that's why the surgeons want to know the length of the anterior mitral valve leaflet to have an idea of how big of a ring they're going to put in. Other measures that's been used is the inter-trigonal distance, which is basically the distance between the two commissures of the valve. We in Leipzig don't really use it. How important is it to pick the right ring? It's very important, but the surgeons will still use a sizer. So our measurements, they're not going to be the final decision on what type of ring we're going to use. It's more to give them an idea of how big of a ring and how much they can play with the ring in this specific patient. SEM is a phenomenon that can occur after mitral valve repair, and there have been many studies describing the risk factors for SEM. These are what's been described from Andy Maslow and many years ago, and that's actually included in the guidelines that I mentioned before from 2020. And these are the measurements we're also using in Leipzig. It's the ratio between anterior and posterior leaflet less than 1.3, angle between mitral and aortic valve less than 120 degrees, septum more than 1.5 centimeters, and a c-sep less than 25. Zirconflex artery runs just next to the mitral valve annulus, and there's a high chance or there's always a risk that when we put stitches on the annulus, we take the Zirconflex within. And in Leipzig, we've described, my colleague described in my boss a few years ago in this paper, and the video is from the paper, a technique to actually look and follow the left main into the Zirconflex and to see how the Zirconflex runs within, so next to the mitral valve annulus. We can do it with 2D, we can do it with color, and I'm going to show you in the case later how we actually do this. With 3D, with a 3D block and multi-primary construction, we can actually identify the Zirconflex and measure the distance between the Zirconflex and the annulus at different points, and here you can see we've done these measurements and we not only know the distance, but we actually know what is the distance at which and which specific points. There is an information that our surgeon actually like to have in order to sort of know how much relaxed they can be or more nervous need to be when they put the stitches in the annulus. This technique has been compared to CT and actually demonstrated great correlation with CT in this paper. That's the work from one of my colleagues, Carmen and Bevilacqua and many of my current colleagues that work together to put together this very nice study. With minimally invasive approach, as you all know, and Elmeri has certainly already talked about it, we need to place lines in the groin, so a venous line and an arterial line. When it comes to the venous line, the first step is to identify the wire in the superior vena cava, and then we advance the catheter, the cannula in the superior vena cava. What is very important is that you need to see the wire in the superior vena cava, and I'm not going to say it, I'm never going to say it enough. What's happening very often is that especially after the wire has been placed in the right position, the surgeons dilate, and after the second or the third we use three different dilators, then the wire comes off of the superior vena cava, now they want to advance the catheter. That's extremely dangerous because if the wire is not in the superior vena cava, it can be in the right ventricle, it can be in the right atrapendage, and if we now advance the cannula with the dilator of the cannula, then there is extremely high chance that we're going to perforate the right ventricle or the right atrium. The surgeon must wait, if you don't see the wire in the superior vena cava, please scream, you are allowed to scream, you need to scream and tell him to stop, wait until I don't see the wire, you don't advance the cannula. We've seen already, unfortunately, in my short time in life enough complications because the surgeons just didn't want to listen and didn't want to wait. For the arterial cannula, we identify the wire in the descending thoracic aorta, we don't see the cannula, and as we go on pump, unfortunately, this is what can happen, this is a case of very unfortunate case of pelvic dissection after cannulation of the femoral artery. After repair, what do we need to look for? The guidelines are suggesting that we look for residual MR, we need to exclude mitral stenosis, exclude SAM, and look at left ventricular systolic function, and then also have a look at the other valves. What we do in Leipzig is, as soon as the clamp comes off, and you can see here, now with color flow, we follow and look at the circumflex and we look at flowing the circumflex. When you're still on pump, this is the time where you have the best chance and the best look at the flow in the circumflex, and what you can see here, we usually drop down the max limit to 15 or 20 in order to sort of be able to appreciate lower velocity flows in the coronary arteries. We look at co-optation lens. In Leipzig, we never reject, we respect the leaflets, so we put new cords and it's always nice to see that there's a co-optation that's more than five millimeters. We look for residual MR and anything really that's more than trace or mile, we don't accept it. So we go back on pump, we try to repair and if it doesn't work, then we go and replace the valve. Mitral stenosis has to be taken into consideration, doesn't happen very often. Ideal way is to have a gradient no more than four millimeters of mercury. If you have elevated gradients across the valve, you need to look at the hemodynamic conditions and you also have to look at, you can also use 3D to planimetry the valve and actually see what the effective orifices of the valve after repair. I warned you about coronary circumflex occlusion, it does happen. When it does happen, it presents itself with lack of flaw in the coronary artery, but also a very obvious whole motion abnormality in the lateral wall. As you can see here, this was a patient that from Johara went directly to the cut lab and this is an old echo, which I've taken from an older presentation, but this is not something that hasn't happened in the last couple of years. Still once twice a year in a high volume center is something that still happens. SEM is a problem. You can see here just a case of SEM after mitral valve repair. What is the solution volume? Yeah, we can give volume, volume and beta blocker and just ignore it. That's probably not the right solution. There shouldn't be any SEM. We've had a case where after we had a significant SEM, then the surgeon was and was Michael Barger, went back on pump and he took the ring down and put a bigger ring. The valve was still competent and the SEM was gone. This is something to keep in mind if you use the smaller ring and you have SEM, then you need to think of if the valve would be able to tolerate a bigger ring. After mitral valve repair, we also need to look at the other valves. This is a case where you can see that the aortic valve and the aortic valve is basically in continuity with the mitral valve annulus. Here is a case of a patient who as soon as we came off pump and we checked the mitral valve, then present itself with this aortic valve regurgitation that wasn't there and you see it before. You can see that the jet is not actually coming from the center of the valve from where we normally see a jet, but it's coming from the leaflet itself that actually was perforated by the surgeon as he put the stitches of the mitral valve ring. This case, it's actually one of these cases from the experience of our surgeons in Leipzig is that the mitral, iatrogenic mitral insufficiency, aortic valve insufficiency as a result of damaged leaflet is not going to get better over time. It's not something that you can say, oh, it's mild, we just leave it alone. Putting it all together, you can follow what we do in Leipzig, but there's guidelines and guidelines now are pretty clear. The mitral valve regurgitation has been extensively studied and our work as a co-cardiographer in DOR has been always a key component of treatment of the patients. It is important to understand the anatomy and the mechanism of mitral regurgitation. You need to assess the severity in physiologic condition. You need to talk to the surgeon and create this bonding with the surgeon and this is also the advantage of working often with the same surgeon and actually have a strong team and you need to be familiar with possible complications and I don't have to tell you, I think it's quite self-explanatory that the advent of 3D made a big difference, especially in the assessment of mitral regurgitation and planning for surgery. I'd like to thank you very much for inviting me and for your attention and this is my email if anyone wants to ask me questions that you didn't dare asking or we didn't have time to answer and you're welcome to visit us in Leipzig for our master class next year in June or anytime whenever you want to come and see our center and have a trip to Europe and Germany. Thank you very much and we'll have a chance to interact a bit more in the Q&A session.