 Hello again. Thank you once again for having me here and giving me the opportunity to talk about mitrovabric repair and I'd like to sort of put in practice some of the stuff that we discussed in the previous talk with with the clinical case and the disclosure are the same as I had before and the case is a young lady who came from the road as a private patient to our clinic about a month ago. She was 34 years old, tall girl with three children. She was also a physician. She had exertional dyspnea, Asimoto tyroiditis, and paroxysmal atrial fibrillation. On preoperative echo, she knew she had a mitral regurgitation since she was a child, and she was followed by sort of follow-up echoes for many, many years. And the last echo showed that severe mitral regurgitation with an ejection fraction of 60%, she was actually scheduled for a mitrovabric pair with minimally invasive approach. How did we do the echo? And how do we do the echo for mitrovabric pair with minimally invasive approach? We do it just like we do it for all other procedures. Here in Leipzig, we have this protocol with a sequence of views that needs to be acquired as a comprehensive examination. And for each view, it's specified what measurements have to be done and what for each view, what modality needs to be used in terms of 2D color, 3D and Doppler. And so we follow the same protocol. And as we start, we start from the transgustric. Now it's short axis. I'm not only going to show you the views that are relevant to our case. This is a short axis view. It's very important to document that there is no wall motion abnormality. In this patient, we go to a four chamber view. You can appreciate there's a prolapsing mitral valve with bi-different prolapse both anterior and posterior are prolapsing. There's a normal preserved ejection fraction, although there's a high grade mitral regurgitation. And you can see that we can already see a regurgitan jet there. That's sort of a complex jet in the X-plane view. We look at the right ventricle. The right ventricle is normal size, normal annulus, no tricuspid valve regurgitation whatsoever. So absolutely no indication to do anything to the tricuspid valve. And now we go to mitral commissural view, which is sort of the golden view for assessment of mitral regurgitation, mitral commissural view to the left, perpendicular plane, cutting through the middle of the valve on the right. Then we have A2 and P2. And now what we do is what I was showing you before, you start from the image in the middle, and then we take our secondary plane and we tilt it right and left to scan through the entire valve. And we can appreciate where the jet are coming from. So in the middle, we see a jet, but we don't really see the origin of the jet. To the right, which is the more lateral aspect of the valve, there is a small jet that comes that you can start to appreciate with sort of a funny-looking posterior mitral valve leaflet here. And as we move medially, then there's a bigger jet. There's a bigger jet with a small posterior mitral valve leaflet, which is sort of restricted with no real anterior valve prolapse. Now we go to 3D, you can see this is a valve that where everything, but not really everything is prolapsing. We definitely have anterior leaflet prolapse that's more pronounced in the A2 area. There's P2 prolapse, A1 is also prolapsing. But you see here to the right side so medially in the valve, there's a P3 is not prolapsing, it's actually restrictive. And if you look at the 3D color, the jet comes exactly from this sort of posterior-media commissure of the valve. I did the offline analysis of this valve here and you can see at the bottom starting with NPR, starting from more medially, you can appreciate the features of this valve with a sort of restrictive short P3 prolapsing P2 and a prolapsing P1. I also did then offline a mitral valve model just to confirm my findings. As I said in my other talk, we don't use this on a clinical base in the operating room, if there's time I do it, I show it to the surgeon at school, but we don't use this measurement for decision making. So looking at the mechanism, what is the case here? The case is the excessive leaflet motion that is affecting the valve in an asymmetric way. We look at the circumflex to tell the surgeon how far away is from the annulus. I did it with NPR here and I always got five millimeters, so it's more or less five millimeters from the annulus. Does it make a big difference? I mean, certainly when the surgeons hear that it's more than five millimeters, they feel sort of more relaxed in putting the stitches. But when it's like less, they may be more cautious, but I'm not sure if they really change their practice, but it's sort of a measurement that we always give them. Assessing the risk of SAM in this case, the only significant value is the angle between the mitral valve and the aortic valve that in this case is one or seven. And as you see from this sketch from the previous talk is less than 120. So we went on and look for the circumflex. You can see here I started from a long axis. I turn to the left and I follow the left main and you can see the bifurcation and you can see the flow in the circumflex as it starts. And I didn't see any more flow as the circumflex goes along the annulus. Canulation is a key component of this procedure. We look for the wire in the arterial line. We look for the wire in the superior vena cava, and then we advance the cannula, follow it in the superior vena cava. What I see very often is that we see the wire in the superior vena cava and then the surgeons dilate. And once they've dilated with the here that we use three dilator of progressive size, so bigger size. So after the second or the third dilator, often the wire comes out of the superior vena cava. So this is, it's very important to detect that because now the wire railroads, the cannula, if we advance the cannula and the wire is in the left atrap and the joint or in the left ventricle, then we can really perforate the left atrap and the joint of the left ventricle. Before the surgeon advance the cannula, make sure the wire is in the superior vena cava. And this is everywhere in the world. The surgeons have no patience. They need to wait. They cannot advance the venous cannula from the groin until we've seen the wire in the superior vena cava. So the surgery went well. Our surgeon in this case was Michael Barger. He found the A2P2 prolapse with a restriction of P3. He decided to put neocords on the lateral portion of P2 and then he did secondary cordal transfer to pull down the A2 segment. And then he put a physioflex ring that was 36 millimeter and the anterior mitral valve leaflet, we actually measured it was 34, I think, and we did cryoblation for atrial fibrillation. So now we just release the cross clamp and you can see here on the left with color flow, I can follow the circumflex and I can see flow in the circumflex. All the way and under the new, so the new ring that was put in. So I've demonstrated yet right away that there's flow in the circumflex. And then the heart just started to beat and the valve, the heart is empty. It's not pumping. I can check the aortic valve for regurgitation and there's no regurgitation. Now we came off pump, we did what we call a trial. So we just cross clamp, we haven't reperfused yet. We still need time to warm up the patient but we come off pumping quickly look at the valve. So in four chamber, two chamber, we look at flow, color and morphology. The valve is, since there's no more prolapse that can be detected and there's no flow. We look closely in the long axis view and we can identify a very small regurgiton jet. We get a better look at the valve now with full load of the left ventricle with X plane. I do the same trick. So I start from the center of the valve in this Mitra commissure of you and then I go right and left. And I can actually identify a small jet medially and a small jet laterally. Now with 3D we look on fast. You can see the ring to the left and on the right, you can see these two small jet one is a little bit bigger on the right side that's more media. That's where this P3 segment was tethered down into the ventricle. Now we look at the short axis view to confirm there's no one motion abnormality, despite we've already seen that there's flow in the circumflex we need to confirm it with a normal short axis view. And remember that for these procedures, we have to guide the weaning from cutting pulmonary bypass. The surgeons don't see the right ventricle because the chest is closed and they don't see it at all. So what we need with echo then to look at both ventricles and have a look at the right ventricle as we come off. So this was sort of accepted as a good result because the patient was young. She had a very complex pathology and a small regurgitan jet that was left on the medial aspect of the valve was thought to be acceptable. She, the matricle agitation also in physiological awake condition before discharge was still trace. And the patient was discharged home seven days post op, given our policies. The patient stayed longer than she would have stayed in the hospital probably in Toronto but this is sort of a very normal post operative course, and the patient send me an email two weeks ago. From home to tell me that she was very appreciative of our care and she's very happy and she's doing great recovery from her surgery. Thank you very much and I hope and I think there's going to be a nice discussion and I'll be waiting for your questions and I hope we'll be able to answer them all. If not, then please email me and anytime. Once again, I invite you to come and visit us in life. Thank you very much. Thank you very much to our speakers for a fun, fantastic session. There's lots of questions that came through in the chat so I'm going to start off here the first one is. Yeah, I think it's directed at previous do you prefer lung isolation, or only pushing the lung away with abdominal back. And what is the impact on per surgical ventilation. This one that goes with this is why do you prefer not prefer one lung ventilation in to repair one single human tubes. Well, that's a good question. Somehow we had, we had a few cases in Leipzig where using double lumen tube finally resulted in, I don't know whether it really resulted but we saw that we had unilateral pulmonary edema. And to the tune that some of the patients had to go on ECMO. The reason I was told that they completely abandoned double lumen ventilation for mitrowab surgery. So, by when I joined they were already doing single, using a single lumen endotracheal tube and basically we go on pump right away. So, you generally do not need, you do not miss the single double lumen endotracheal tube because once you're on pump the lungs are down. And when we come off we close the pericardium even before we come off. So, pretty much everything is done on pump. And then we come off. You hear me. Yes. Yeah, so hi. Thank you for having me that's awesome to see you all I'd like to be there in person but it's still sort of a challenge. So, so please do organize this symposium next year and invite me I'll come. So the, so to, to, to Piroce's point, we did a study, I think so obviously if you use a single lumen tube you commit to a slightly longer by past time, but in comparison to double lumen tube but you obviously don't have the relative challenges of a double lumen tube. Well we actually what's been reported by most of the other centers will use the double lumen tube after micro valve repair with minimal invasive approach. There's a significant eye incidence of reperfusion pulmonary edema. So unilateral pulmonary edema, and we actually did a study and we quantify with the radiology the pulmonary edema in our patients and there was a sort of doctor by the master thesis for one of my colleagues and the incidence of unilateral pulmonary edema after my micro valve repair or mixed cabbage or meat caps in our patients population using a double lumen tube was way way lower than what's been reported in the literature elsewhere. So for us the choice of of a double lumen tube is for simplicity so whatever so we try to keep things simple and and whatever makes it faster we we go for it and also to decrease the incidence of post operative unilateral pulmonary edema. So just to add to that max that we've used double lumen tubes for many areas, but somehow we have never touched up until now I've never experienced this problem. When we do a minimally invasive area. Yeah, but I mean, I don't know what we. Yeah. So something which probably we need to study that more in detail probably. I mean to get the answer you should do a randomized trial but I think for us is because for us is sort of using a single lumen tube is is sort of become the standard of care. So then that's, that's basically what we go for. On the other hand, I don't know when you were here in life, maybe you were doing more of this minimally invasive. So we write anterior lateral to the economy. But like right now we don't do that many so because there's only really one surgeon who does them. And on the other hand, we do, we do a lot of mid caps and mitral valves with the top economy. Yeah. Yeah, I mean we do. I mean there's also here it's the, it's the smallest number that we do have a very good as it is a very difficult to come by nowadays with tabby. Exactly. But the cases which are on the borderline between tabby and surgery then they agree to undergo surgery if you're offering minimally invasive so right anterior to me we are so. Okay, thank you very much that was a very interesting discussion I have another question here. Can you elaborate a bit on any differences or specific challenges in P3 disease in terms of surgical technique and other factors that influence durability of a repair. Is it simply that P3 problems are corrected, correlated with basal aneurysms and medial papillary dysfunction or informed. So the P3 I'm not usually it is ischemic it is only isolated P3 and as Max has shown the, you know, the different factors that go against repairing the valve. You have to be observed and it's particularly the tending height is greater than one centimeter and your angle is more than like almost 40, then you would avoid doing a repair. If you want to do a repair in such situations then there are different techniques which you have to apply at the level of the papillary muscle. And so you can either approximate the lateral and the medial papillary muscles with a tube graph, which is placed within the ventricle, or another technique is to pass a pleasure to suture through the papillary muscle, the posterior papillary muscle and bring this suture through the annulus of the posterior at the level of the P2 P3. And then once you put in the ring, you inflate the ventricle, you know, with your water test, and then gradually tug on the suture. And you will see as you dug on the suture, the P3 and that part of the mitral valve, the medial part will start coming up, you actually see it coming up. And then you decide at what point you think that you have adequate co-optation and you have adequate height of the co-optation of the mitral valve and at that point then you tie that suture off. So that's something which you can use. So these are different or then of course you have to can put in a patch and extend the P3 and the P2 P3 area to compensate for the tethering. So these are all different techniques which you can use. We do not know really the long term outcomes of all these techniques. But with the trial comparing P3, you know, I mean the ischemic functional MR versus repair versus replacement for functional MR, it was quite humbling to see the number of recurrent mitral regurgitation 30% at two years, which is a hell of a lot. And I think surgeons have changed them more towards replacement than repair for such cases. Perfect. Max, did you want to comment? Yeah, so I mean the only thing that I mean this is what Piroz described is unfortunately techniques, there's very few surgeon who can do it, but there's not many people around the world who can do it. So my point was and the older I get, the more I try to keep things simple. So what we have here, so what we do are practicing like it is if we have so unique when you have a secondary matter of regurgitation in the OR and you're doing surgery. When you're clipping it's a different story, but if you're doing surgery, then what we do is we look at the tethering height. If the tethering height is more than one centimeter, we don't repair the valve. If the tethering height is less than one centimeter, then we may repair that you have a central jet and the whole valve is equally pulled down into the ventricles. Then you put a ring is going to be fine. What you need to know though is that if you look at the valve and you have an eccentric jet, then you need to think about this second situation where just putting a ring is not going to be enough. And even if you may get away in the OR, it's not going to last as a repair. So that's to me was sort of the point of presenting these two phenotypes that I think it's important that we identify and we tell the surgeon, okay, yeah, you'd be fine or this is going to be something complicated. And you're measuring the tethering height specifically at each scallop. Not just one tenting height in the middle. You're doing sort of, no, we just, no, no, no, we, we measure just the tenting height in four chamber view. And that's it. I've got another question here regarding circumflex distance assessment. Do you measure in lastly or in systolic. And sometimes it's difficult to differentiate between the circumflex and the sinus usually it's feasible in 3d but do you have any useful tips. The useful tips is is if you don't want to do MPRs. So there's two cases, either you don't want to do MPR just because you hate it or you don't like it or you don't have time for it, or because you don't have a good enough 3d data set because that's also happens that you just don't have a good enough quality data set you have a block of the micro valve you import it into MPR and you just cannot recognize the circumflex and then if you cannot recognize this you cannot recognize you can make it up but if you don't see it you don't see it. In that case, what what my suggestion is and that's what we do when when we saw if you if you don't have time, you look at the mitra commissural view in the mitra commissural view on the right side of the valve. You, you start to see the left at the end of just right under it, you always almost always see and record can recognize the circumflex and then there you can measure the distance from the annuals, you just have one point but you're very close to where the highest chance of actually catching the circum, circumflex, circumflexes, and I mean and I'm very glad I, I hope I had this discussion when it was still in Leipzig but I mean I think people can probably comment, because the surgeon are always asking me no, it's very important tell me how far away is the circumflex, I mean, is it like does it really change your technique heroes or or is just knowing that the circumflex is not so close just makes you feel better. I think the latter is true. But no, so it's very important that when you take your annual plastic sutures in the area of the circumflex that's probably from the commissure, the lateral commissure going across to the P1 P2 area that your needle angle is extremely important. So if you take the stitch this way, you tend to use your stitch tends to go into the left atrium more than the annuals, and everyone should know at least a surgeon should know that the circumflex does not run in the ventricle it runs in the atrium. And that's how you need it. So the important thing is when you take the stitch it has to be this way so you take a forehand which goes towards the ventricle muscle and towards the ventricular lumen. So if you do that, I think 99.9 times out of 100 you won't nail the circumflex. And that's particularly important in minimally invasive, because in minimally invasive if you if the natural angle of taking the shot in that area can easily nail the circumflex you don't have the luxury sometimes of holding the plane of the annulus in a way that you can actually take it that way. So you have to be very careful and see that your needle is always perpendicular to the plane of the mitral annulus and goes towards the lumen more than going away from the lumen. And I think you can pretty much avoid it every time. However close it is. So the other thing that I wanted to tell about the circumflex is I must admit that so this is a it's a it's a life. It's a little bit of a life thing because like I never looked the circumflex in Toronto then I come to life again, like, and I had to learn how to look at it. So, and I can say my experience is you need to, I think it makes sense to look for it before the surgery you don't always see it. So if you see it, you see it. If you don't see it, it doesn't really mean that it's not there. And the same time is when you unclamp when you unclamp my experience now in Leipzig and we do a lot of these procedures and we look at it almost all the time so definitely for my travel but I also look for other procedures. When you see flowing the circumflex in about 70% of the cases when you see flow, it means that there is flow. If you don't see flow, there's two possibility either there is an occlusion, or that you just don't see it because of the anatomy of this patient so the fact that you don't see flow doesn't always necessarily mean that there is an occlusion. One thing. Second, especially for my for trackers after mitral valve repair. If you have a circumflex occlusion, you will also have one motion abnormalities. So it's important to get a good short axis you before you won't pump to document that there isn't any one motion abnormality when you come off pump. You look at the, you look at the, on the other hand, look at the ECG. So the ECG, if you have an occlusion of the circumflex is not going to be normal. And then, finally, so it's three things flowing the circumflex almost an abnormality ECG. And if, if you have any doubt, then you have you cannot take the patient to the intensive care unit or the recovery room. It has to go directly to the cut lab. We have many times, and when we have a very even a smaller, the smaller suspicion, we call the cut lab we activate so what is a sort of the equivalent of a semi cold semi they make a room available for us, we go from you are straight to the cut lab and do a cast and before you take the patient to the to the ICU you cannot take a chance of a patient who has no coronary disease to actually have occluded circumflex. I think it does help in at least identifying patients who might be a problem. I mean, they may not be a problem. I agree with you. But at least you won't miss the ones who have the problem. And you will be able to address or at least investigate further and prevent a long sort of drawn ischemia or in fact right. Absolutely. If you guys have another question if you can, when do you decide to use a complete ring versus a band. Most of the time I use a complete ring. But sometimes there is a discrepancy between the size of the ring you want to use and the intra trigonal distance. Now if you feel that you need a larger ring for an anterior posterior diameter. But when you use that size and you see that the anterior posterior is fine but it's overshooting the trigons. Then you cannot use that ring because you cannot overshoot the trigons because that's going to deform the valve in that situation and I go to a band because I'm not restricted because the band will take the shape of the of the annulus itself and so that will prevent deformation of the annulus. The second thing is also when you have calcification in the posterior annulus like a short segment of calcification where which you don't really need to excise sometimes in that situation again I would take a band because stitching a band to that calcified area is okay but if you're going to suture rigid to rigid, there's a chance of dehesions whereas a band will not dehes. And finally of course again if you're doing a annular reduction so if you want to downsize the annular plasticity and you feel that you're downsizing too much just because the leaflets are very small but the annulus is big. In that situation again it would preferable, it would be preferable to use a band, otherwise you will get a dehesance. If you crunch a rigid structure, use a rigid structure to crunch the annulus too much, you are bound to get a dehesance. So these are the situations but the most common one is the first one where there's a discrepancy between the anterior posterior diameter and the intra trigonal distance that I would use a band. And one more point when I feel that there is a high risk of sand. In that situation again I would use the band more often than a rigid ring. So that the anterior annulus is free and it does reduce the risk of sand later on. That's a great answer, thank you very much. So then I've got a question here, regarding seeing the guide wire in the SVC, what do you do regarding central venous axes to avoid misidentification of your CVC and the guide wire? I think explain helps a lot with my feeling. So what we do, I must say that what we do in Leipzig we use endovascular ECG when we place a central line for all of our cases. So you basically connect the ECG lead to your wire for the central line and we position it so we leave it at the depth where the P wave is two thirds of the R wave. And I never see my CVP line in the superior vena cava where the wire is. So I never have the problem. The problem you have sometimes when you, if the patient has a pacemaker wire, so then sometimes you have a pacemaker wire then you don't know which wire it is. So and explain helps. And the other, and this is also we see it for for for clips and for transceptile puncture. It's you basically need to, to maybe you ask the surgeon to wait or we drew them withdraw the wire, and then have a good view of the superior vena cava before the wire comes in so then you know which one it is, which one is which which one is your wire and which one is your, your, your pacemaker wire. I must say that, yeah, as I said with the with the central with the central ECG, sorry with the endo luminar or endovascular ECG on the wire for the central line insertion. We are usually have the central line that's high enough. Actually not to see it in the by cable view. Yeah, the other option would be that then when you place your central line, you, you put a tea probe before you put the central line you can confirm the presence of the wire as it comes from the internal jugular vein. And then second you can actually position your, your, your catheter. So then it's in the vein and you don't see that it's not far enough. It's not too deep into them up to the junction of the superior vena cava to the right. I think the other issue is also if you have a PA lining then it becomes also then you also have another thing that's, that's in, in that area I also find it useful if you ask the surgeon to go back to the IVC. And if they turn the guide wire and you actually follow them, if you go very slowly. I think it's, I mean, because it's very, very well educated but in general, it's, it's a matter of like educating the surgeon and now, I must say, unfortunately, I need to admit we had a few complications of for Venus. For a line for, for category by past. And also the surgeons who were a bit more aggressive and less patients have realized that the others, there's, there's, that's not really that's not worth it. So because if you if you have a complication for from Venus cannulation then it's a really bad one. Yeah. I have another question here. It's for you. What's the philosophy of thinking between leaflet resection and cordyceuture for MR. How do you select the technique. Well, I usually use the respect technique that I avoid. So let's put it this way I use the resection technique only in maybe Barlow's or severe mix of matters disease where you have like extremely large amounts of leaflet. And if the prolapsing segment is like three centimeters in height. In that situation I would use a resection plus. So I won't use a formal resection which they used used to used before like most surgeons used but I just use a limited resection. And then I again put cordy to that because the idea is to have the largest or if it's possible. And secondly also as I mentioned before in my talk that I prefer to have the posterior leaflet a bit mobile, rather than just using it as a platform for the anterior leaflet to smack into. So for all these reasons, you have to use a respect technique because the moment you start respecting too much, it's going to become stiff. There is no way your leaflet is going to be mobile. And it does give a longer line of co-optation which has been proven we have papers from Leipzig which have proven that with the loop technique we have a larger orifice area, a longer line of co-optation, which would both go in favor of a better long term outcome. I think I'm going to do one last question here and Max this one is for you. Do you think that there are any advantages to choosing between 2D, 3D or BSA indexed martel valve tinting area measurements. So differences, I mean there are studies that like, so with 3D you can measure the tinting volume, but the majority of the guidelines and the majority of the studies are actually based on 2D measurements. And to measure the tinting volume you need to use a 3D reconstruction of the mitral valve using whatever 3D, for the MV from Tomtec or the MVN from Philips or the old sort of MVN because now Philips has taken over Tomtec or with the cement system you use the other 3D measurements software. But clinically, honestly I don't see an advantage and at least in our center we rely on what's suggested in the guidelines which is the tinting height from what I would add is that a lot of these 3D measurements are not standardized. So depending on which software package you're using, you may get very different measurements from the same 3D data sets. Especially when you're doing volume measurements where they have to measure the volume from the some kind of angular plane and how they're developing that angular plane will make a big difference in terms of what you get for the volume value. Very good point. Thank you so much to Piroz and Masi for joining us and I really hope next year we can have you in person. Thank you for having us. It was amazing. I was so happy. It was really good. It was so nice to see a surgical, you know, to see the surgical perspective with the echo. I think that was perfect. Thank you very, very much for your time. Thank you very much. Thank you very much. Great session. Thank you. Nice to see you, Max. Bye bye. Nice to see you to Piroz. Bye bye.