 Well, good morning everybody and welcome back to the 2023 Toronto Perry operative Echo Symposium and to those who are just joining us today. Greetings. It's Sunday, so I'm sure there'll be a few late comers, but we're going to start and try and stay on time today. Next line my name is Annette Vegas and I'm a staff anesthesiologist at Toronto General Hospital and chair of this year's planning committee. I would like to acknowledge and thank members of this year's planning committee for their efforts in contributing to the development as well as participating in the meeting. You met many of these individuals yesterday and you will meet more today in their role as curators and moderators. A special thanks to Sarah Russell, who is the conference coordinator for tying together all the loose ends. Next slide. As I mentioned earlier this year, we tried something unique by thinking outside the box and creating a virtual meeting representing truly the global expansion of echocardiography. I hope you enjoyed the international faculty that presented yesterday. They were truly multidisciplinary with anesthesiologists, surgeons, cardiologists, internists, critical care physicians, and today we'll meet some emergency medicine physicians. They are experts in their field and they're forefront of research and writing guideline papers. They are leaders and most of all they're passionate speakers. The speaker bios are available on the website, so check it out and learn a bit more about these individuals. Again, many thanks to the speakers for taking time out of their busy schedules to create and speak at this meeting. Next slide please. On day one, next slide. We covered three sessions on the left ventricle, extracardiac, tricuspid valve with groups from Europe, Montreal, and Toronto presenting. These were excellent sessions with great talks and stimulating discussion. I hope you enjoyed these sessions and importantly learned information that you can put into practice. For those of you, myself included, who need more time to digest the talks, remember the recordings will be available about 10 days after the meeting closes for you to review at your leisure. Next slide please. Today is day two. Next slide. And today we'll be covering three additional sessions on the mitral valve, structural heart, and focus. We welcome groups from South America, Boston's and individuals from across Canada and the US during the focus session. Next slide. This meeting is accredited by the Canadian Anesthesia Society for 12 hours of credit. Please remember to fill out your evaluations for your certificate of attendance. We will post a link to yesterday's evaluation as well as today's evaluations in the chat. Please take the time to fill out your evaluations today. The evaluations are important to tell us what you thought of the meeting and importantly to help plan future meetings. The evaluations will be available through a link for one week after the close of the meeting. Next slide please. I'd like to reintroduce the team of Mahmoud, who will be working behind the scenes again today to make this magical meeting occur. Thank you so much, Annette. It's a pleasure to be here supporting the second day of this symposium. My phone number is listed here on this slide, but I'm also available through the chat throughout the day. We have session evaluations for each day. I will be posting the evaluation link for yesterday's day in the chat as well as the evaluation for today. On the screen there is a QR code you can scan, but I will also be posting it in the chat. We would encourage you to have the survey open in another browser and try to complete it throughout the day. At the end of each session we will try to repost the link, but we do recommend to have it open in another tab and get the evaluation done throughout each session. For this event, we are using the Zoom webinar platform, which has three elements of engagement and interactivity available. There will be a couple of polls in one of the sessions where you will be able to vote and see results. And we will not have access, so the participants will not have access to audio and video features. These are disabled to minimize disruptions during this webinar. Please use the chat and Q&A functions to communicate with organizers, presenters, and other participants. I would like to point out an important differentiation between the chat and the Q&A function. We encourage participants to use the chat functions for feedback and dialogue with other attendees. On the other hand, the Q&A button is where you will submit your questions and the moderators will monitor the questions that come in and ask them on your behalf during the designated Q&A sessions. Attendees can also upvote questions submitted in the Q&A tab, so the ones that will be upvoted the most will be answered first and priority. This is especially important when there are a lot of questions, but not enough time during the Q&A session. With this, I'm going to hand it over to the first session's moderators. Thank you. Thank you, Annette. Thank you Fatima for the introduction. Hi everyone. Good morning. My name is Sabyo Papa and I'm a cardiovascular and physiologist at San Michael's Hospital in Toronto and also curator of this session. First of all, I'd like to thank you for being here so early on a Sunday morning. Today is the second day of our Toronto Periopty Symposium. Yesterday, we had really great talks and this morning we'll be dedicated to the mitral valve and also structural heart procedures. Our first session starts with a minimally invasive mitral valve surgery, what the surgeon needs to know, and the key importance to guide the procedure, followed by functional mark, the key assessment and the surgical implications, finishing up with mitrist analysis. If you have any questions for discussion, please use the Q&A at the bottom of the screen so you can discuss them at the end of the session. Without further ado, I would like to introduce to Dr. Zamper who will moderate the first presentation. Dr. Zamper is a good colleague and friend. He is the Cardiac Anesthesia Program Director and Cardiac Anesthesia Fellowship Coordinator at the Western University in Northern Ontario. He obtained his M.G. from the University of Sao Paulo, Brazil, and also completed his anesthesiology residency at the General Hospital of the University of Sao Paulo. Subsequently, he completed his Cardiovascular Anesthesia and Periopty and also an ultrasound fellowship at the London Health Science Centre at the University of London, Ontario, where he currently works as a staff anesthesiologist and also is the director of the Cardiac Anesthesia Fellowship Program. Rafael, thank you so much for being here. I'm going to hand over to you now. Thank you, Fabio. I hope you all can hear me and see me okay. Yeah, I know it's a great pleasure for me to be here today. I'd like to first thank the organizing committee and Annette for the invitation. It's always a pleasure to be part of such an outstanding symposium. So, when we thought about this session, on minimally invasive surgery of the mitral valve, we decided to invite two speakers, one surgeon, to present their point of view and what they expect from our exam. And also one anesthesiologist with significant experience in tea for minimally invasive mitral valve areas to present their approach on the TE exam in a program that strongly relies on echo as a decision making to in all phases of the surgery. So without further ado, we'll start the session with Dr. Michael Chu's presentation. Michael is a cardiac surgeon at London Health Science Center in Western University, where he specializes in valve reconstructive surgery, aortic surgery and transcatheter valve interventions. He very much balances echo partners and feels that they are a critical member of the team, making better as a reconstructive surgeon as echo provides constructive feedback to evaluate outcomes and continuously improve. Thank you, Michael, for being here with us today. And let's start with this presentation. Hi, everyone. It's a pleasure to be here with you today. I'm pleased to be able to present to you with Rafa and Hilda, and I would share with you a little bit about how echo has an impact on mitral repair and minimally invasive approaches. These are my disclosures. So we've been fortunate in London to have a wonderful place to work and, most importantly, a great team. We've been fortunate to work with so many wonderful cardiac anesthesiologists, residents and fellows. And what we've been able to accomplish is that, you know, we have a very broad and wide offering for minimally invasive, including minimally invasive valveular disease, hybrid operations, general operations and endoscopic cordial heart disease, which we've been doing since 2000. And we've been able to do over 2400 cases and been able to achieve a really excellent oak on December. We're very proud of that. So with patients who come with mitral gregetation, we have the whole array to be able to offer them the open sternotomy repair, minimally invasive endoscopic repair, transcatheter edge repair, or some other transcatheter options. And what I'm going to focus specifically on are two areas, echocardiographically guided valve repair and the critical role of echocardiography and ensuring safe and effective minimally invasive access. So this is my area of expertise, endoscopic mitral repair, where we use a five millimeter, a zero degree or a 30 degree endoscope and use that to be able to repair the mitral valve with some long chapter instruments. And what I'd like to share with you is, you know, how we do this and, you know, in many cases for us insurgents, we oftentimes, particularly with our trainees, wonder, you know, how do you get from A to B. And sometimes things seem unnecessarily complex. And sometimes it's a related to surgical team experience, but you know, the reality is that when we go to meetings, there's a magic element that's created and there's unnecessarily complicating terminology and techniques. And the reality is that most mitral repairs are really quite simple. And most of them involve posterior lethal disease, single segment disease, and, you know, there are reproducible techniques that we can use to do these repairs. And in our center, we like to use Neoport A loop reconstruction and around 85 to 90% of the cases where we find that, you know, you can apply it to posterior lethal disease, anterior lethal disease, commissural disease, violation of disease, you know, any and all of these combinations and get very good results. The reason that is because, you know, the Neoport A maximized quantization surface, they create a lower gradients and really get a nice durable repair. ECHO is really the hallmark to how we do the operations. And I'm going to show you here, what's really most important is that you go through and do a very careful and thorough segmental analysis, both on 2D and 3D and correlate the regression jets to the segmental findings. And it's this careful analysis that really can allow us as a surgical team to know the plan, the details to the repair so that we're not blind going into the operation. We should have a very comprehensive idea of exactly what we're going to do to each and every segment before we even get into the operating room or before the patients, before we start the operation. And here you can see this, this, this case, you know, yes, we can look at an examine the valve with our eyes, but I would argue time and time and time again that ECHO is far more accurate than what we can actually visualize with our eyes. And here you can see that based on the TE, I knew exactly that I need to force that the neoprene loops to the anterior to the posterior and following the midline of both between anterior and posterior and then the midline from the upper lateral and the mouth. And here you can see this sort of post repair result on the saline test, you can see a nice prominent valve. And most importantly, again, checking on the post-op repair ECHO and you can see that there's nice laminar flow and there's known as a double rotation with low gradients. So the most important principle that I'll talk about today is really trusting the ECHO and not your eye. And this really, you know, is, it tells us, you know, how important ECHO and you as the authority are to us because, you know, it's much more accurate, much more detailed. It's a functional assessment rather than trusting what we can identify on the arresting cart, you know, just by pulling on a leaflet with an instrument. And so this is where it's important that, again, I take what I learned on the ECHO and then I check after with my eyes, not the other way around. And what I can't stand or I don't like is the idea of heading into an operation without any idea based on what the ECHO beforehand. I think that's just going to blind, adding unnecessary risk and likely belonging to a cross plant at some time unnecessarily. So in terms of neocortin implantation, it's fairly simple as very important. You know, you choose the most adjacent top area muscle. It's the posterior-middle muscle attaching the neocortate into it and then using four broken suture to attach them to the prolapse in a flail segment, which you can see here with separate sutures. And it's really a nice, simple technique. And in this case, you know, I attached some leaps posteriorly and anteriorly because of the violet and prolapse. Which I think you can see here. And I'm able to achieve a nice sort of result in the salient test. But again, similarly to what I said before, the salient test is nice. But again, what's most important is trust the ECHO after, not the neocortin implantation. And the ECHO will tell you exactly to see, you know, is there any result of regurgitation? What's the co-optation height and what are the gradients and the most important things. So some simple rules don't cross the midline. Keep anterior to anterior, posterior to posterior. Don't disrupt the immune response. You're telling me in the ECHO that the length of the neocortes is, you know, there are lots of different ways to do this. But the majority of them will rely upon eyeballing and, you know, it's trial and error. And I make the argument that these measurements are made out of static, arrested heart. And that's why, you know, I think that oftentimes when you do that, you can result in neocortes that are too long or too short. Either way, results in visual recurrence, much regurgitation, heart failure in some cases, molestice. And so that's why I think that, you know, using an echo-based method to be able to identify the length is far more accurate. So we use minisoftial views between zero and 120 degrees. You need to be able to visualize obviously the flail segment, the adjacent papillar head, and then the opposing leaflet. And in most cases, the anterior leaflet. And it's really to develop a reproducible systematic way to predict the neocortae length to simplify its use of neocortes. So for posterior leaflet, perhaps it's simple. You basically need to rotate that posterior leaflet down and subtract the additional redundant length. And so basically, you measure x from the papillary muscle, the adjacent papillary muscle up to where you want the flail segment to collapse with the anterior leaflet. And you subtract that residual portion of the posterior leaflet. So x minus y equals the posterior leaflet neocortae length. So just to show you that again, here you can see your posterior leaflet flail. And you're going to rotate that down to meet with the anterior leaflet. So again, x, which is the distance from the papillary head up to the anterior leaflet, subtract the redundant portion of the posterior leaflet being y. And in many cases, you'll find that x will be on average between 28 to 30 millimeters, y will be approximately 10 millimeters, and again neocortae length is 18. For anterior leaflet prolapses, rarely as redundant, so it's simply just measuring from the papillary head to the posterior leaflet. And bi-leaflet prolapses is simply a combination of the two techniques. And you can see that in our experience, this measurement technique is accurate 90% of the time. And in the five other patients, we had to convert it through a resection technique, and they were able to repair it successfully. And let me show you an example. So here's an anterior leaflet, a flail patient. I measured a 23 millimeter neocortae. But you can see here there's a reversal of that jet. And so I was concerned enough that I thought this wouldn't be a durable repair. So I went back and measured by hand and made a 27 millimeters length and you can see that resolved through MR. And so my error in this case was that I accepted suboptimal windows where I thought that I saw the papillary muscle and I made the measurement. And it actually wasn't the papillary muscle. I just couldn't visualize it well enough. So it's really important to try and optimize those views to be able to see the papillary head, the flail segment and the anterior leaflet. You can see that the average anterior leaflet neocortae length is around 26 to 30 millimeters, whereas the posterior is about 10 millimeters shorter and around 16 to 20 millimeters. And the most important thing is the results. So you can see that out to almost nine years, there's about 90% that are still alive. But what's most important is that the freedom from mitral augmentation greater than two plus is 98% in nine years. So really quite good. Most of the patients in the MYJ class one or two and very few read-offs or valve-related complications. You can see here just of interest when I compared minimally invasive versus strontotomy, there was no difference in terms of quality of repair from recurrent MR, nor was there between survival. The second point is about how echocardiography enables safe and effective minimally-based access. And I can't stress this point enough. If you're going to do a minimally-based operation, you need to have superior echocardiography to help guide. So just in terms of the setup, we use a 20 degree lateral to keep this position. And what's most important is the team. And here you can see one of our anesthesia fellows and this is Jill, my right-hand woman and one surgical fellow here. And it's about teaching the team to each take responsibility for each portion and to be able to have a seamless transition and save significant time and energy. And so for cannulation, this becomes really important. So ECHO really can help to guide both arterial and venous cannulation and you need to frequently recheck. So this is where it's really important that ECHO is rechecked throughout the entire pump run. You know, every 30 minutes. So you check the order every 30 minutes, make sure there's no dissection. You check the right atrium to make sure the cannulas haven't moved. They're in a good place and that the right heart isn't filling up and that there's good venous greenage. So for the neckline, we use a 16 French percutaneous arterial cannula inside the internal injector vein. And we have a protocol to do this. And what's most important is that we check on ultrasound, surface ultrasound. We see both on short and long axis, the wires in the right place. And then by TE that the wires are inside the heart and the cannula in the right place. And then after that, you check that the venous drainage is actually working properly from the neckline. And you'll see it here. You have to check it before you go on pump because otherwise you won't see it drain properly like them. Okay. And so there's a checklist and we go through this because, you know, it's a safety mechanism. We do this on every single patient. And we put in a neckline in every patient because of randomized trial that Dan Bainbridge and I had done several years ago where we looked at randomized patients to a neckline plant or unclamp. And what we found was that there's significantly improved certain view. There's significantly improved venous drainage and a much lower CBP. And from this, we feel that a neckline is needed to support cerebral venous drainage and subsequent brain confusion in each other patient. Additionally, we also cannulate most patients with a side graph on the arterial side rather than cannula to try and reduce the risk of dissection and to main distal leg confusion. Now, last thing is an important issue that I want to highlight is about avoiding a myocardial connection injury. And this is where echo is really important. So when you give cardioplegia, you need to be there looking at the looking on echo to make sure that you can see the root fill. That there's not that much AI and that the heart's not understanding because the AI is actually shunting the blood away from the coronaries. And this is really, really, really important. And every time you give cardioplegia, you need to make sure that you try and look by echo and that the surgeon looks with direct vision. And so that initial induction goes and the view on echo is really important to look for. And traditionally, most places do not look for this at all. Additionally, you know, one of the things that that could be helpful is, you know, there's all sorts of DRA tricks. And here you can see where I've ever paired the valve and fill that ventricle with as much fluid as possible, close up the left atrium and then vent all that air out through the audit route, which you'll see here. And you look by echo, you know, to be able to see how much air is left in the ventricle and keep venting it and move the bed around so that air, you know, kind of floats up before we're moving across. And this is a small work to really help. So in summary, echo is really key to planning and executing a perfect micro repair with careful segment by segment to the analysis. The surgical team should have a comprehensive plan for the upper repair, along with backup plans before starting the operation. Echo guidance is key for safe milling of use of access. And as, you know, echo priority for you guys with the eyes and ears inside the patient that needs to be monitored frequently and often to ensure safe operation. So I'll pass it off now to Hilda and Rafa. Thanks so much. Thank you, Michael for the great talk. And to follow, I'll invite our next speaker, Dr. Hilda Faro, associate professor of anesthesia at Western University, who will present the routine at the point and the point of view of the interoperative echo cardiographer in this case the cardiac anesthesiologist. Hilda is a cardiac anesthesiologist at LHSE Western and she was trained in anesthesiology at CES University of Columbia and cardiothoracic anesthesia at UBP University of Columbia. She also has a master's in professional education at Western University. Thank you, Hilda, for joining us. It's a great pleasure to have you here today. Hello, everyone. I would like to thank the organizers for inviting me to participate in this symposium and to Rafael and Michael to share this lecture with me. So today we're going to talk about what is what does the surgeon needs for the minimal invasive microbiome repair and how does it affect the approach. Already Michael touched in some of the objectives for this presentation. I want to try to cover the rest of them. I have no nothing to disclosure for this presentation. And basically I want to establish the difference from the tea perspective with the with the open mitral valve valve approach. So I want to salvage the three important important things. The number one is this the tea has is going to have a limited time due to the participation of the anesthesiologist in some of the surgical procedures, especially cannulations. And number two, the fact that we need to use one lung ventilation during the procedure and this is going to limit the quality of our images. And finally, that in order to answer all the questions from the surgical surgical team, we need to have focus exam to be able to be time efficient. So through the years we find out that the base approach to be able to accomplish these goals is through a step by step approach. We divided the echo and three different and sorry, four different steps. The step number one is before the neckline is place. The second step is the placement of the neckline. The third step will be the assessment, the preoperative assessment and the IBC cannulation. And lastly, the assessment of the match of our repair. So for the first step, we need to keep in mind two things. The first one in our institution, we count with the support of tea person that is dedicated just to do the teas during the day so that person is the one in charge of the tea images. The anesthesiologist in the room is the one performing the procedure. But we use the same machine for the whole case. So during this step of the tea, both lungs are going to be ventilated. So is the quality of the images is going to be the best. That's the reason why we dedicate this time to the more critical information, which is to confirm the matriculation mechanism to measure the new cordae, which is the basic technique that our surgeons use in the institution, as is our tick valve and the tricuspid valve to adjust the surgical plan. So for this first step we use a lot of 3D images. We have a very good cardiology lab that provide us with excellent echo images for the surgeons to plant in advance the surgical repair. And because the time is limited, we found that 3D provide us with a significant amount of information to try to adjust and modify the surgical plan, according to the findings. Unfortunately, with our patient come after long periods after the preoperative tea have done on some of the patients, this has progressed. So we find these images help us to complete the surgical plan. It's unusual that the surgeon has to change completely their approach based on the interoperative images, but it helps the surgeon to refine the plan at this point. And as we can see in this patient as a prolapse OP2 with the consequent findings in the color. And we try to use the most the best quality of images to help the surgeon. This multi-view is really helpful as with just one image you can manipulate the angles and the planes in order to cut through the different segments with the use of minimal time to the acquisition of the image. And as I mentioned before, the most common thing that happens to us is we have new findings adding to what was already identified in the preoperative settings. This patient came for a repair of the P2 and then we find that other segments were compromised and not just prolapse but also cleft some of the same and some of the segments were fine in the interoperative echo. So the modified modifications for the surgical plan were made at this time. We confirm the size of the annulus as all our surgeons use in top of the new neocardial also annular plastic ring. So we confirm the findings through using 2D and 3D for better alignment of the annulus. And we proceed to answer the next question which is the measure of the neocardial. Michael already touched in detail in how they do the measurements. I want to emphasize in the structures that we need to have interview in order to have an accurate measurement of the cordae. So we need to have the prolapse segment interview, the annulus, the opposite leaflet in the co-optation sound and the most difficult thing to find in the SMU is the head of the papillary muscle. So according to the pathology anterior posterior wide leaflet, we modify the measurements that we do but we need all the structures for the measurement of any of those pathologies. Usually we made between four to five measurements and we get the mean length for the surgeon to the cordae. So as Michael mentioned before, when the pathology is in the posterior leaflet, we measure the distance between the head of the papillary muscle to a co-optation sound in the opposite leaflet, the anterior leaflet. And we subtract for that distance the length of the prolapse segment. When we are measuring the pathology of the anterior leaflet, we measure from the head of the papillary muscle to the co-optation sound of the posterior leaflet. And when ISA by leaflet prolapse, we proceed to do a combination of both measurements and provide the numbers to the surgeon for them to create the neocardial. The next step is to establish the severity of the ortic insufficiency if it's any. Ideally for this procedure, we want no more than mild ortic insufficiency and we found quite often that the patient has progression of the disease. So when the patient has more than mild AI, due to the difficulties for to provide adequate cardiac protection, the decision is made to convert the procedure to open. And it's important to do, assess the ortic valve early in our TE exam. The last thing that we do during this step is to assess the tricuspid valve. The decision to repair the tricuspid valve for our surgeons is based on the size of the annulus, the severity of the tricuspid regurgitation and the symptoms. We learn the findings of the preoperative echo and we try to do that before we isolate the lung. As I mentioned before, not just decrease the quality of the image, especially in the right side of the heart, but also the one lung ventilation can change the haemodynamics of the haemodynamics in general and can't make it possible to interpret the degree of tricuspid regurgitation. So we try to do this early into our TE exam. The second step is the neck, neck like placement itself. So it's the cannulation of the SVC. So for that one of our anesthetics scrub and is in the surgical field. Before that we try to pre-scrub scanner to establish an anatomy of the patient. Ideally we want to place the line in the right side. So we place two wires, one for the surgical cannula and one for our central line. For that we use a short and long axis view and we support the findings with TE. Before we provide heparin to double the ACT or get the ACT over 250. So the image in the top left we see we do a scan before we place any lines. Ideally we want to place both lines in the same side in the right side, which is make easier the drainage for the surgeons. But if the anatomy is not favorable, we place our central line in the opposite side or place also the surgical cannula on the other side. Once the wires are inside of the internal jugular vein, we visualize them in short axis and long axis view. Sometimes as you can see it's challenging because of the presence of valves. So very early into our program, we decided to confirm the presence of the two wires using TE by cable or modified by cable view, which facilitates the visualization of the two wires. After the two wires are seen in the superior vena cava, heparin is going to be applied to the patient. Some potential complications that we see during this cannulation. The most common one is the puncture of the posterior wall of the internal jugular vein creating hematomas that can expand after full heparinization is given. Less common, this is an image from my initial training where a patient, after we provide heparin to the patient, after the placement of the SVC cannula, the patient became very unstable. We decided to look what was happening, hypovolemia was found in the lead ventricle and we found a volume in the right pleura. And this patient has a dissected hematoma of the medial synom in a conversion of open technique was required to correct this. The third step is the images before we go to CPV. In this time, we complete the TE exam like in any other match of our repair. It's the same images that we do in the open repair, so we try to find the function of the lead ventricle, the presence of PFO, they need to be closed during the procedure. And have images to be able to diagnose potential complications after we come out, come out full bypass. I'm going to dedicate the time to talk about a particular case that is specific of minimally invasive is the placement of the IVC cannula. So the placement of IVC cannula is by the surgeons from the femoral vein. So the first step is to place a wire at the entrance of the SVC. So it's a dynamic procedure. So we try to use 2D and 3D to help with the placement of the line. Once the wire is in the adequate position, then the cannula is advanced around 1.5 centimeters into the SVC to get optimal drainage, venous drainage for the patient. And again, we use 2D and 3D to confirm the placement of the cannula. The most common complication is the misplacement of the cannula. We have one case of a placement of the cannula inside of the left etching, so completely rupture of the intracereal septum. It's an unusual complication. The most common complication is the impossibility to pass the cannula all the way to the SVC. So the cannula have to sit in the right etching, which can make the drainage of the venous line difficult. So we need to be aware of that and have extra monitors during the interoperative settings to be able to diagnose this problem. And the last step is the postoperative echo. In this one, we're going to use the same criteria for much of our repair in the open approach. The first step is we're going to help with the de-airing of the lead ventricle before the vent is removed. So this can take a little bit of extra time, so the T is used to guide the process. And then we are going to assess the repair itself. We use color to see the degree of residual mature degradation. Ideally, we are looking for mild level of degree. And we use the 3D to try to establish the location of the residual MR. And then decide with the surgeon if it's necessary due to the degree to go back on pump and which specific segment is compromised. So the adjustments can be done at that point. Also, we mentioned the coordination length. For that, we use again 3D and 3D to align in the segment that was corrected. And we're looking for a measurement of one, which the papers has shown that is the one that is proven to have more durability of the repair. So a co-optation length of one, we look at different views. And again, we use 3D to better alignment of the specific segment. And of course, we measure the gradients to the new repair. The complications that we can find at this stage of the TE or the operation are no particular of minimally invasive. The most common ones that we find at the beginning of our program were hematomas in the aorta for the cardioplegia cannulation site, or in more severe cases dissections that need to be repaired and converted to an open approach. This particular case was a patient with preoperative images of a prominent circumflex. When the repair was completed, we have difficulties coming out by pass and we find multiple regional wall motion anomalies in the circumflex territory. We perform an angiogram that shows partial occlusion of the circumflex. So the patient was put again into cardiopulmonary bypass and the surgeon released some stitches of the anuloplasty. After that, the angiogram showed complete flow into the circumflex and the TE confirmed regain of normal contraction of the lead ventricle. And also we find some complications typical of mitral bar repair in dependent of the approach, like for example the presence on some for the patient's hemodynamics or the quality of the repair itself. So it's important to have enough preoperative images that allow us to compare the presence of these new findings. So in summary, I can say that the TE is important tool for the performance of minimally invasive mitral bar repair. We need to keep in mind that it has a limited time to be performed. A step by step approach will help you to optimize your time and get the best quality possible of the image that help us with the information needed by the surgeon and by you to perform a success for repair. So it's important to use all the features of the machine and trying to do it in an efficient manner. I want to thank you all for attending this lecture and I hope to see you all during the question session later on. Thank you very much for the excellent content of your presentation. It is a pleasure to work with you and Michael on a databases in the OR and we'll have a chance soon to discuss more during the Q&A session. So now I'll hand over to Fabio who will introduce our next speaker. Thank you very much.