 So, what I'm going to cover is we're going to go through two cases. And as we know, mitral insufficiency can be graded as primary or secondary MR. And I'm going to go through two cases of functional or secondary MR that can be compared and contrasted and actually go quite well together. I have no competing interests. So this is the arpenger classification, which, you know, classifies the MR according to leaflet motion. So type one is normal leaflet motion. Type two is excessive where you can get prolapse and flail, and type three is restricted leaflet motion, which can occur with ischemia, LV dilatation, and like, you know, rheumatic balls. In terms of type two and type three are mainly primary MR, and type one is secondary MR where the actual leaflets themselves are not that abnormal and their motion is generally normal. The problem is either top or bottom of the valve is either the LV or the LA that's causing an issue. So case one, we have a 77-year-old male, history of atrial fibrillation, congestive heart failure, has had previous bypass to obtuse marginal, and a previous mitral valve repair with a small band three or four years ago. So now he's come back and he's presenting with left main osteom stenosis and severe MR. He has no known allergies, and he's on some heart failure medication, beta blocker, anti-hypertensive, and a statin. So this is their four chamber view, and the board doesn't know that the RV function looks normal. It's starting on the right side. The LV doesn't look quite normal, but it's mildly reduced. So the valve leaflets themselves don't look taken or calcified, and they seem to be meeting in the middle. They've got a bit of color on the mitral valve. You can see that there's a clear failure of co-optation, and there's a large central jet that's hitting the base of the atrium. There's a bit of color on the tricuspid, and there's a bit of trivial TR there. Here we've measured the annulus. So the annulus is ideally measured in the midisophageal long-axis view. So the upper lip and her normal is 3.6 centimeters. Here it's 4.7 centimeters almost, so it's quite dilated. And again, scanning through the valve, you're at the commissure level where it's quite normal to see the appearance of two jets, but the scan is cutting through it twice. We're at the two-chamber view. Now you can see the mitral valve, again, small leaflets, the ventricle, less than normal. But there is an abnormality just north of the valve leaflets on the left side, by point to my arrow. That's probably the old band, which seems to be misplaced and not doing what it was supposed to do. I'm going to color on the jet again, and then moving to the three-chamber view, midisophageal long-axis. And this is the ideal view to measure the vena-contractor. The 3D on fast view gives you a nice view vision of the co-optation plane. And you can do this with TT and TE. And if you look carefully, you can see the band at the level of the posterior leaflet, it's not extending from fibrous trigon to fibrous trigon, as you would expect. There's some color, and you can see that the jet looks quite severe. But again, my colleague will talk about the limitations, pros and cons of jet area in the next talk. So we've measured the vena-contractor here. It's at 0.505 centimeters, which is in the moderate range, according to this. But with the grading mitral regurgitation, it's important to not just have one measure, but you have to look at jet area, flow convergence, and the vena-contractor. So it's multiple parameters, where you can decide whether it's mild, moderate, or severe. Just a couple of points on vena-contractor, just to refresh your memories. It's the narrowest portion of the regurgitant flow that occurs at or immediately downstream of the regurgitant orifice. It's characterized by high velocity laminar flow, and it is slightly smaller than the anatomic regurgitant orifice. The cross-section area of the vena-contractor represents the measure of the effective regurgitant orifice area, which is the measure of lesion severity. And it is independent of flow rate and driving pressure for a fixed orifice. And compared to things like jet area, the vena-contractor by color is much less dependent on technical factors. So it's a good semi-quantitative measure. So like I said, it's a 2D measurement, and if the 2D measures less than 0.3 millimeters, it's considered mild, and greater than 0.7, it's considered severe. There's a table by Sogby for the 2012-2017 guidelines. But again, look at a number of parameters, including LV size, the MB morphology, the color flow jet area, the flow convergence, and then some Doppler sets. We'll look at some of these in turn. What they have included there is something called tenting height. So this is the maximum distance from the leaflet tips to the annular plane. If it's greater than 1.1 centimeters, it means you should replace the valve. It's the only time you say that mitral valve replacement is better than repair. And the repair was failed because of the ventricular remodeling. It's also a measure of the degree of tethering of the leaflets because of the abnormal size of the ventricle. Here we have a pulmonary venous flow on the left upper pulmonary vein, which shows systolic blunting of the S wave, which would imply at least moderate MR. And again, good practice is to try and evaluate more than one pulmonary vein to get a better, more accurate measure of the mitral regurgitation. You may not see it in one vein, but you may see it in two more. So what they've done here is they've tried to measure the radius of the pizza. And again, pizza is not something I regularly use in my practice because we could do a whole 45 minutes on the pros and cons of pizza. But here they've measured the radius of the pizza, 0.65. Guidelines say that if the blood pressure is 100 to 120, any radius greater than 1 centimeter implies severe MR. And it's indispensable to have the flow convergence, the venocontract and the jet area in as linear as possible when you're making your measurements. So this is a trans-gastric short axis view of the left ventricle, which shows that again that it's not quite normal and it's got some left ventricular hypertrophy associated with it. Again, and this is the same ventricle at 90 degrees. So looking at all those images, it's easy to characterize that this is a mitral regurgitation secondary to annular dilatation. So what did the surgeons find? Surgeons found that the posterior leaflet was restricted when they went in. The old band had not gone from the fibrous trigon to fibrous trigon. In fact, the band was seven millimeters away from the annulus actually in the left atrium. So the plan they made was to remove the old band, put in a 29-size Hancock valve and do an LED bypass. So these are the post-bypassed images and you can see that the valve is in place. There's a little bit of air that you can see just coming off pump. It seems to be opening well, but some color across it. There's no residual MR, just scrolling through the valves that you can see that everything looks fair. And the LV function doesn't look as good, but that's normal coming off pump initially after one of these operations. Putting some Doppler across, you can see that the mean gradient across the valve is three millimeters, which is encouraging. And here, now that you've got another 3D on-flats view of the Hancock valve, it's functioning quite well. I don't have a color one, but going back to the Wiener contractor, just some tips and trips for our fellows, again, like I said, keep the flow convergence and jet area as linear as possible. Have a zoomed view to minimize measurement inaccuracies. You should position your size and position of the box should be adjusted to focus on the region of leaflet co-optation, not necessarily the entire regurgitation jet within the LA. You also want to keep your color flow sector as narrow as possible to maximize lateral and temporal resolution. And have your scale setting to about 40 to 60 centimeters per second. Like I said, the midisophageal long access view for the Wiener contractor avoids cutting the co-optation line obliquely and potentially overestimating the width of the jet. Classical MR is generally hollow systolic, but you can get an overestimation when it's not. And you would have that in situations like mitral valve prolapse, where you get a late systolic. And so it's important to time your Wiener contractor measurements with your jet. Other things that affect the Wiener contractor width is the geometry of the orifice. So primary MR is associated with a nice circular flow of convergence. But in secondary MR, it's more semi-lunar or elliptical. And that can lead to underestimation of your Wiener contractor. And this is a 3D cartoon, which shows from the 2017 guidelines, which show two cases evaluating and quantifying the Wiener contractor area with 3D echo and multi-planar reconstruction. Primary MR is the upper panel, and it's got a circular VCA and a hemispheric PISA. And the secondary MR is at the bottom panel, which shows an elliptical VCA and non-hemispheric PISA. And it's thanks to 3D echo that we have discovered that the regurgent orifice is often crescent shaped in secondary MR. And in such cases, the assumption of circular orifice geometry inherent to Wiener contractor width may result in underestimation of the secondary MR. And in a recent study, 3D Wiener contractor area greater than 0.4 centimeter squared denoted severe MR. However, studies relating to 3D VCA to outcomes really haven't been performed yet. So I'm not an expert in 3D echo, but some points that it's useful for VCA area, it's more accurate for the EROA than 2D Wiener contractor width. It's useful for multiple jets of differing directions, which is a limitation of 2D VCA. But it has to be measured offline by re-orging your images and cropping your planes. And to find the smallest flow area can be difficult and tedious, because small errors in measurement can lead to large percentage errors. And again, from the 2017 guidelines, this is a nice table that summarizes the technique, the examples, the pros and the limitations of 3D echo, and I would highly recommend this paper. Moving on to case two. So this is a 66-year-old male with long-standing atrial fibrillation, congestive heart failure, non-obstructive coronary artery disease, so it's mild, no allergies, and again, he's on some Ramaprol spartanolactone, fruzomide metoprolopicsinone and isomaprosone. So this series of images that I'm going to present are from the pre-op echo. So this is a patient who's having concious sedation as opposed to a general anesthetic. And I'll illustrate why later. So you can see that there's the four-chamber view, and again, the one thing you might notice is that the left atrium looks absolutely huge just on that view alone. You have at least a moderate regurgitation jet, again, normal-looking valve leaflets. And again, this is zooming in on the valve itself to check the co-optation, rotating again through the commissural views and the two-chamber view. And it's hard to appreciate the significance of that jet, but then when you actually compare it to the intra-op echo, which is coming up, you'll see a big difference. So here's a 3D view that's not oriented very well, but just shows that there's no abnormality in the leaflets themselves. And color flow Doppler, color of 3D, shows that there's a micro-regurgitation jet coming through there centrally. This is the pre-op TTE, which shows, again, highlights the size of the left atrial chamber. You can see that the left atrial end systolic index, end systolic volume index, and the two-chamber view is 57.5 mils per meter squared. The normal range is 34 mils, and anything over 43 is severe. So now in this slide, you're seeing the pre-op TTE versus the intra-op TTE, and this basically highlights the effect of loading conditions. So the grading of MR severity can be significantly impacted by hemodynamic changes, particularly blood pressure. Hemodynamic variation can be seen with conscious sedation during TTE, but it's very challenging in the operating room brought about by anesthesia and vasoactive agents. So you commonly encounter intra-op decrease in loading conditions or contractility, and it, as highlighted here, leads to an underestimation of your MR. So this guy had no echo pre-op and was just coming in. We, you know, it's very likely that we may not comment too much on the mitral regerge. So this is why in functional MR, we judge on pre-op TTE, and if we're looking for pathology, we look at the TTE. For primary MR, there's not that big a difference. So this is the, you know, the intra-op TTE 3D on fast view. And again, if you compare it to the previous, the regerge, even on 3D, doesn't look as impressive. This view highlights the annular dilatation again, healthy four centimeters. So what's the difference between case two and case one? Again, both are annular dilatation. Normal leaflet motion. But the first case was secondary to ventricular enlargement. This case was secondary to atrial enlargement. And this happens in long-standing atrial fibrillation. Surgical findings, they found a moderately dilated left atrium. Minimum mix of changes in the mitral valve. Small leaflets. When they say small leaflets, they're saying small leaflets relative to the actual annular size and gross annular dilatation. So the decision was to repair with a simplicity band, 56 millimeters long to the posterior mitral annulus and do a maze procedure, cryo-relation to the posterior wall and the dome of the LA to actually treat the aphid. So post-op, you can see that the mitral valve has been repaired. The posterior leaflet is fairly mobile and the anterior leaflet is coming up to meet it. And there's no further mitral regurgitation. Again, there's very little gradient across the valve. And this is a nice 3D on fast view of the band, which if you compare it to the first case, you can see that the fibrous trigon to fibrous trigon connection by the band is pretty intact. So this is atrial mitral regurgitation. It's due to atrial myopathy, which is solely due to long-standing atrial fibrillation and left atrial enlargement. Ventricular dimensions are generally normal. And this occurs in 5% to 6% of cases of functional MR. Proposed mechanisms include posterior mitral annulus displacement, tethering of the leaflets, and some have suggested that inadequate mitral leaflet remodeling can also contribute. And most of the time these cases do not come to the OR because they're treated with, they're treated by treating the rhythm and the rate. So non-surgical therapies and catheter ablation therapies. This is a paper by Silbiger in 2014, which highlights the pathophysiology. So you can see the normal disposition of the mitral valve apparatus on the left. The leaflets rest just at the level of the annular plane, which is shown by the purple dashed line during systole. And in AFib, which is Caption B, you can see the left atrial mitral annulus dilatation displace the posterior mitral annulus above the crest of the left ventricle inlet, pressing the posterior mitral leaflet against and leaving little surface of the leaflet for co-optation. And then this distance between the papillary muscle and the posterior annulus increases leading to the posterior leaflet tethering and the MRJET. So my two MCQs is, which of the following is a functional cause of mitral agaritation? Is it mitral valve endocarditis, dilated cardiomyopathy, mitral valve prolapse, or rheumatic mitral valve disease? And the answers should have become clear throughout this presentation, but, you know, through this session, you'll have figured it out. And then the following are indications of severe MR. So systolic flow reversal in the pulmonary veins, regurgitation fraction of over 60%. Sorry, the question is the following are indications of severe MR except. So systolic flow reversal, regurgitation fraction of greater than 60%, EROA of greater than 0.4 centimeter squared, or being contracted diameter of greater than 0.3 millimeters. Thank you. There are my two cases. Thank you, for an excellent talk. Does anybody have any questions for Dr. Insari? I'm sorry. I'm sorry. I don't see any questions on the panel. A quick question for you, if you do a 3D venecontractor, if you have like two venecontractors, do you add them up or do you just take the largest one? If you did a 3D. I think this is one of the limitations that to do, first of all, you have to do it offline. And again, that's laborious and you need to do it for individually for each MR jet. But I, as far as I know, you don't add them up and you treat them individually.