 Thank you, Rafael. Thank you, Dr. Shu. Thank you, Dr. Alfaro. For some reason I cannot turn on my camera. But that, oh, yeah, now I can. Okay. Thank you, Rafael, Dr. Shu, Dr. Alfaro. That was a great session. I'm really looking forward to our discussion at the end of this, of the whole session. Moving on to our next presentation, we will be discussing the echocardiographic assessment and the surgical implications of functional mitral regurgitation. I would like to introduce our next speaker, Dr. Yanes Amador. Dr. Amador is an assistant professor and cardiovascular anesthesiologist in the department of anesthesiology and perioperative medicine at Kingston Health at Queen University in Kingston, Ontario. Dr. Amador completed his residence training in anesthesiology and emergency medicine in Costa Rica. Subsequently, he completed a research fellowship at the best Beth Israel Deaconess Medical Center in Boston, followed by a clinical fellowship, a cardiovascular anesthesia fellowship at Toronto General Hospital. Yanes, thank you very much for being here. Looking forward to your presentation. Greetings. My name is Yanes Amador. I'm a cardiac anesthesiologist at the Kingston Health Science Center. I will be presenting the echocardiographic assessment for the functional mitral regurgitation. In a later session, we're going to review the surgical management. It's a pleasure to be here for you. For the following talk, I have no comfort of interest, no financial disclosures. But it is important to mention that in our center, the OR has only Phillips machines. So it might seem biased, but the truth is that every one of the measurements and techniques that are going to be describing is achievable across the different vendors. By the end of this talk, we will be able to trace not only the ideology for the functional mitral regurgitation, but also a stepwise approach for the assessment of the functional MR. The following is the content for the present talk. Let's begin. Whenever we discuss the functional mitral regurgitation, we need to remember that the functional mitral regurgitation has a normal leaflet anatomy. And the disease is basically the ventricular dysfunction, the main source of the MR. The leaflets are fine, but the ventricle is the sick one. Now, we have three different ideologies for that. And those are the atrial functional MR, the ventricular function MR, and the ischemic functional MR, which is a specific group out of it. Important is to remember, why is it that we are talking about this topic? Well, whenever it comes to functional mitral regurgitation, it is important to remember that there is a high mortality associated with it. If we compare both panels A and B, which are functional mitral atrial regurgitation, and the ventricular functional MR, compared to the right side of the screen, which is organic or primary mitral regurgitation, we see the mortality of the functional MR is not trivial, is substantially higher than the primary MR. So this is quite impressive. And it is more relevant whenever it comes to the association of MR and a myocardic infection. As you can see on the screen, the survival is not good. Let's begin with the first one. And that is the atrial functional MR. What is the natural history of the functional MR? Whenever we step into one of these cases, we need to remember that one way or the other, they start with the atrial fibrillation. And this atrial fibrillation is going to have some sort of mechanisms that are going to be affecting the LA initially as a temporary conditions, and then settling down into a permanent condition, such as LA stretch, fibrosis, and electrical remodeling. And this is going to be permanent sometimes. This is going to be affecting the mitral anodal dilatation, which is going to be on that axis A2B2. Let us remember that the anterior leaflet is anchored to the trigons. And this is a fixed tissue, fibrotic tissue, that is not prone to any dilatation. Whereas the posterior leaflet rim, it is a muscular tissue that it is prone to any type of dilatation. And this is in this angle that the mitral valve is going to be settling less. So the mechanism is not only the mitral dilatation, but also that insufficient leaflet growth. And this is sufficiently for growth has been not only identified as a potential deficiency, but also for the atrial, but also for the ventricular one. So the mechanism is noted on the slide, but the fact is that this insufficient leaflet growth and the combination of the mitral valve anodal dilatation are going to be producing the mitral regurgitation. How do we see this? Well, it's quite easy to understand the difference between the atrial functional and ventricular function whenever we compare them both side by side. In here, the atrial functional MR is primarily driven by the LA, which is substantially enlarged more than the LV. In here, we have the typical findings, a central jet and a co-optation point that it is moved up into the planar angle of the mitral valve. And if we compare this with the functional ventricular MR, we can see that the driven chamber of the ventricular functional MR is the ventricle and not the atrium, like in the example on the right-hand side. And this image shows us the difference between the both of them. How do we see this in the echo images? Well, it's quite the same. If we see on the right side of the screen, we will see that the atrial functional MR is more towards the atrium, is driven by the atrium. And whenever we see on the left side of the screen, we will see that the ventricle is the driven force of the MR. On TTE, what we see is that on the left side of the screen, what we can see is the central jet of the MR that results from leaflet mild co-optation due to atrial and an anal dilatation, which is going to be insufficient. And this will lead us to the classic jet. As time goes by, as you can see on the right side of the screen, a posterior MR jet results from the posterior annular herniation over the left ventricle free wall. And this is called a hamstream. The graphic is going to show us a little bit clearer. But the point is that initially, and in the majority of cases, what we're going to see is a central jet. Eventually, we will see that in a third of the patients, it'll be a posteriorly directed jet. On the TTE, what do we see? Well, these are typical findings of hamstreaming. And this was done last week with atrial fibrillation patient for an ablation. So this is the typical classical findings and the typical classical patients. In summary, the atrial functional MR will have normal leaflets. They could be a little bit of a thickening, a little bit of a calcification, but it is not the leaflet itself, the problem. It's the ventricular disease. The LA is going to be substantially enlarged, way more than the LB. And the enlargement of the mitral valve analysis is going to be substantial. And we measure this in the midisophageal long axis, more than 35 millimeters. The co-optation point, as we mentioned before, is going to be pulled up into the planar angle of the mitral valve. And this will have a result as a central jet. Moving forward for the ventricular functional MR, what we see is that we have two reasons for this. And it is a ventricular reason or a ischemic ideology. What is the natural history of it? Well, in a pure classic representation of a carpenter tribe type 3B, what we see is that the LB dilatation is going to be global. And this global dilatation is going to show us as a tetrene forces pulling down the mitral valve leaflets into the apex, pulling down. Sometimes whenever we step into the ischemic lesion of the cases, what we're going to see is a popular muscle displacement that is going to be pulling down more towards one side than the other. If we analyze the geometric differences, this is pretty easy to understand. On the top of the screen, what we see is that atrial functional MR is the driven force for it. And you can see that the atrial functional MR has a really big atrium and a fairly normal ventricle. The annular dimension, the AP diameter is extended, as you can see on the red side, on the red line. At the bottom, we see that the atrium is normal, but the ventricle is enlarged. And it's important to notice that the AP diameter is normal. Another difference that we can see is that the co-optation point in the case of the atrial functional MR at the top, it is moved up towards the planar angle of the mitral valve, whereas the ventricular MR is going to be pulling down the tip, which means that the co-optation point is going to be moving downwards. And whenever we step into an ischemic collision, what we're going to see is that the ventricles are going to be pulling apart and tending downwards the leaflets of the mitral valve. And on the atrial functional MR, the popular muscles, the distancing between them, and the distribution of the ventricle is going to be normal. So in the case of symmetric and asymmetric functional MR, what we see is that the popular muscles could be symmetrically pulling down or asymmetrically pulling down. If we see a symmetric motion or symmetric tethering, what we see, and the most easy example to remember, is that it might be associated with a global cardiomyopathy, dilatated cardiomyopathy, non-ischemic, most likely, a central tethering, a central jet, and a because of asymmetric tethering. On the other hand, the asymmetric tethering, most likely, is going to be associated with a ischemic lesion, and this will produce an eccentric jet. If we compare the three of them, this is what we're going to find. On the far left is a normal condition. On the middle, we have a non-ischemic, and on the far right, what we see is an ischemic MR excentric jet, because of the popular muscle dysfunction and the pulling down specifically towards that side. The MR severity quantification remains a cornerstone for the evaluation of the patients with the MR, with the mitral valve disease, and the echo is the primary tool for that. We remember that Dr. Zombie's MR classification paper from 2017 still holds through, but the thing is that we need to keep an eye on the far, the far right will be severe, and the far left will be mild. But the moderate to severe is a quite tricky group to define, especially because we don't have one option. We have several options, and that was reinforced in the 2020 focus update from the 2017 paper of Dr. Zombie's. In here, these type of quantifications can increase of complexity, and we might be biased to understand that the higher the complexity, the more accurate they are, but they have, as well, every one of them, limitations, and we need to remember that this is not a fixed or a constant disease. This is dynamic, and these dynamic conditions are throughout the case. For example, the patient on the left, he arrived to the UR, he was induced, and later on, we noticed that the patient was 100 on number 60 and no MR, and on the patient on the right, we noticed that the patient shows a beautiful MR after the blood pressure was increased. Another example, right after induction, the blood pressure dropped significantly. We increased the blood pressure to 103 over 60, and we noticed that there could be potentially something further to analyze, and we found that there was significant regional wall motion abnormalities associated with not only the blood pressure, but the MR. So whenever we consider the MR quantification, we need to remember that this is not a fixed issue. This is dynamic, and it is also dynamic whenever we consider that the venicontractor is not fixed, and the shape of the MR is not a circle, it's a crescent moon, and this crescent moon is difficult to analyze, especially whenever we put color and venicontractor assessment. If we use the biplane, the X-plane, or the orthogonal plane analysis with color, we will see that in the pure functional MR quantification, these are not going to be the same, and the reason for that is because it's a broad jet, a different structure, and this is part of the dynamic conditions that we have whenever we are quantifying the MR. This paper by Dr. Standard Group showed that the functional MR is different throughout systole, greater at the beginning and at the end, and this was compared to the primary MR, in which case is bigger at the end of systole. So the higher the frame rate, the higher the clips, the higher the accuracy that we can have, because we're going to be able to select different frames from different analysis, so that is a key element whenever we are assessing a 3D images. Another measurement that we should assess is the tenting height, which is the measure between the anoreal plane, the horizontal line, and the vertical line, which is the intersection between the anoreal plane and the co-optation point of the leaflets. Another measurement that we should do is the tenting area. The tenting area is exactly the same, but it is the area under the curve, under the straight line of the anoreal plane on the microvalve. And finally, the other important reference point that we need to have is the tenting angle over the pre-3 segment, and this is significantly important because of several reasons that we're going to describe in a moment. But this is not only the only issue that we need to remember. Let us remember that the microvalve is a 3D structure, and we need to take advantage of the 3DD actual systems because more accurate measurements we're going to have. For example, in here, we have a nice data set with a fairly amount of frame rate, which is 19, and we're measuring the A2P2 region, the tenting height over that specific spot. As you can see the measurement, it is 102 centimeters, and on the bottom left, you can see exactly where we are. But if we move a little bit meter or ladder, you can see the resultant distance, the tenting height is quite different, and this is something that we need to take into consideration whenever we're measuring the MR. So what we need to do is take a nice clip. Hopefully we're going to have a nice sector size reduced so we can have a higher frame rate, more accurate measurements, because we're going to have more clips from where to measure. We align the different planes, the green, the red, and the blue, and this is in the different angles. And then we can go to the nearest portion of the MRJet, and we can calculate the effective recorrected orifice area. And in here, we can trace it. And on the top right, as you can see, is 0.58. And that is above the cutoff value that was described of 0.4. So if we apply different techniques, we need to remember the limitations. For example, if we apply PISA to this MRJet, we're going to be way off the measurement. So even though PISA still hold through for mostly of the primary MR assessments, it's not the same case for the functional MR in which the MRJet is going to be in a different conformation. Another option that we can do after acquiring beautiful 3D images with a high frame rate and no motion is that we can do NPR analysis. And the multi-planar reconstruction analysis are quite easy and important. It's not only that we can follow here the software and have beautiful cool images like in here, but the most important value of it is the measurements that we can have. And these measurements are the ones that we can provide to our surgeons in order to take in consideration for the benefit of our patients. It's not only the technique, but also the pathway. And remember that the pathways and the algorithms are a great tool that we need to consider. And this is, as I said before, not an easy task, especially when we consider that these algorithms are different depending where you read it. Now, once the information is acquired, we need to tell the surgeons specific things to decide whether or not that repair is suitable and if that repair is going to fail over time or not. And this is not only a great summary from Dr. Mahmood, but also this was reinforced a couple of years ago by the 2016 New England Journal of Medicine papers in which they reinforced and mentioned a couple of the measurements that Dr. Mahmood summarized for us. In his paper, he mentioned that whenever the tending height is more than one centimeter, whenever the tending area is above 2.5 centimeters square, and whenever the tending p3 angle is more or greater than 29 degrees, and the surrogates of the diameter of the ventricle whenever it is blown away, where the most likely this repair is going to fail in within the couple of years. So these are relevant information that the surgeon needs to take in consideration in order for the benefit of the procedure. Final words. In summary, the functional MR is not benign. It's far from being benign. And we need to consider that the baseline blood pressure and the baseline loading conditions of the patients are really important for the appropriate quantification. Not only we have one, but three different subset of methods for the acquisition and the quantification of the MR, it is important to choose wisely which one we're going to use. And remember that we have not only linear measurements, but 3D measurements that will increase the accuracy of our procedures. It's been a pleasure to be here with you. I'm looking forward for the Q&A session. My name is Yanis Amador. Here are my contacts. Feel free to reach out. Thank you very much. Thank you, Yanis. Really great presentation. Now to follow up with the surgeon's perspective on the surgical management of functional MR. I'd like to introduce our next speaker, Dr. Caroline Tang. She is a cardiovascular surgeon and also assistant professor at Kingston Health Science Center in Kingston, Ontario. Dr. Tang completed her magical degree at the University of Toronto and residency in cardiac surgery at McGee University in Montreal. She then went on to a fellowship in North Carolina focusing on minimally invasive and robotic cardiac surgery with emphasis in mitral valve repair. She spent more than 12 years at Southlake Regional Health Center leading the minimally invasive and transcended her mitral valve program until recently being recruited to Kingston General Hospital. Dr. Tang, thank you very much for being here today. I'm going to hand over to you now. Hi, my name is Caroline Tang. I'm one of the cardiac surgeons at Kingston Health Science Center and assistant professor at Queens University. Yanis has asked me to discuss the surgical implications of functional mitral regurgitation. I have no disclosures. So Yanis has already gone over the technical aspects of functional mitral regurgitation and I thought I would just focus on some of the surgical implications. At one time all MR was seen as the same. So basically we treated it the same. We replaced the mitral valve and as surgical techniques evolved and we began to repair more valves then it was thought that all valves should be repaired. For primary mitral regurgitation this involved techniques like quadrangular resections with or without sliding plasties, triangular resections, cordial transfers, and neocords. For secondary mitral regurgitation downsizing annual plasti rings were the predominant repair. But though the downsizing annual plasti ring did rid the patient of MR at the time of surgery the durability was in question. So recurrence of moderate to severe mitral regurgitation at one year was 33% and at two years it was 58%. So the distinction between primary and secondary mitral regurgitation became relevant because the surgical planning and the outcomes of surgery for primary versus secondary mitral regurgitation were very different. Since secondary MR repair was thought not to be durable, surgery for secondary MR then became cordial sparing mitral valve replacements. However not all secondary MR is the same as Yanis has alluded to. It seems that some patients repair failed early while others were more durable. Factors that predicted durability for secondary MR included tending height, tending area, and the tending P3 angle. As well things like LVN diastolic and end systolic diameter seem to make a difference. These factors along with LV function help us to distinguish atrial versus ventricular FMR. Now in the FMR group the subset of those functional patients with durable repairs seem to be the atrial FMR patients and as you can see with atrial FMR the leaflets are pulled outwards rather than downwards into the ventricle like ventricular FMR. That downward pulling of the leaflets into the ventricle with ventricular FMR causes that longer tending height and that larger tending area and in the cases of ischemic MR which often retracts and restricts the P3 segment there is that increase in tending P3 angle. I thought I'd also discuss one particular intraoperative decision-making challenge and that is what to do about moderate mitral regurgitation. So in most cases this will come up with a patient who is undergoing cabbage and during the intraoperative TE moderate MR is noted. Obviously it's preferable to know the MR status of a patient with a preop trans thoracic echo as the loading conditions of a patient under general anesthetic is somewhat artificial but sometimes the MR intraoperatively comes as a surprise and there may be no preoperative echo to compare. In those cases as Yanis has shown on his previous intraoperative echo images driving the blood pressure can help us determine if the MR is dynamic and will it increase in severity when the patient is awake and active. If the MR is moderately severe to severe valve intervention should be considered while keeping in mind the relative risk for that particular patient for instance the age the frailty EF and comorbidities. In some patients with ischemic MR in a large territory of reversible ischemia affecting a papillary muscle revascularization alone may improve moderate MR though severe MR is less likely to be completely resolved. If the MR remains moderate with increased pressures or if the risk of adding a mitral valve intervention is high it's good to know whether the valve would be anatomically suitable for a trans catheter intervention at a later date. So you know we'd like to know what the mitral valve area is what the leaflet lengths are is there any calcium or thickening of those leaflets what the transeptal height is. This might help guide our surgical decision-making. So what do surgeons want to know? Well you obviously want to know whether it's primary versus secondary mitral regurgitation sometimes it can be a little bit tricky to tell in cases where you have a posteriorly directed jet obviously you want to know whether that's because of a prolapse prolapsing anterior leaflet versus a restricted posterior leaflet and pseudo prolapse of the anterior leaflet. We want to know is if it is functional mitral regurgitation is it atrial or is it ventricular fmr what chambers are enlarged is there impairment or preservation of the lv function we want to know the tenting height the tenting area and the tenting p3 angle and that will help us determine whether or not a repair will be durable versus us needing to replace the mitral valve. And finally in moderate mitral regurgitation we wanted to know the mechanism of the mr we want to know whether it's dynamic and also we would like to know the anatomical considerations for future transcatheter repair. Thank you so much for your attention it's been a great honor to speak to you today. Yes thank you Eunice thank you Dr Tang for the brilliant presentations I'm sure you have a lot to discuss at the end of this session.