 Our next speaker joining us by a video was Dr. Masino-Lena Mineri. It will be presenting on focus TE to detect wall motion abnormalities. Max is one of my mentors and teachers. He is currently the co-chair of the Department of Anesthesia at the Hearth Center in Leipzig. And he's also a professor of anesthesiology at the University of Toronto. Dr. Mineri completed fellowship training in cardiac anesthesia at Toronto General Hospital, where he went on to become the director of peroperative echo and a founding director of the Lynn and Arnold Urban Advanced Peroperative Imaging Lab. His academic focus is on peroperative echo and 3D echo. He is a major contributor to the peroperative interactive echo education website, the PI simulator, is another tool that many of you are familiar with. And he's organized and led many courses around the world, including this one for many years. So I'll hand it over to Dr. Mineri. Hello, everyone. Thank you for inviting me again to the Toronto Perioperative TE Symposium. And congratulations to Anet and Azad, who managed to put together and this great meeting again with phenomenal speakers and that you carried on the torch to where it is now. And it's always for me a bit emotional to be able to talk at this meeting because this was the first meeting I ever gave a talk and Anet was the first one who gave me this opportunity and I will always thank her for that. And working here now on the other side of the ocean in Leipzig, I've been asked to talk about focused TE to detect wall motion abnormalities, which is basically sharing our experience in doing TE for cardiac revascularization for cabbage patients. I am going to talk about, I have a few disclosures. I received honorarium from ABO to talk about mitra clips and echo, and now we are a Philips reference center. I don't get any money from Philips, but we get equipment and we get customers who come to our centers to see the machines. And I'm part of the basic exam writing committee at the National Board of Echo in the US. I'm talking a little bit about the guidelines and evidence for the use of TE in cardiac revascularization. We'll talk about our approach to interoperative assessment, our protocol and a little bit about the data that I sort of put together from our last year's experience. Should we do TE in cardiac in cabbages? Of course, we should do TE in cabbage, and this came also quite strong from this editorial that was published two years a year ago in the red journal JCTVA, where the authors stated that doing transesophageal echocardiography is a major step towards improving outcomes in cardiac surgery. So there's no more excuses not to do TE, and why did they do that? And I'm just going through what it's written in this editorial is like based on two big studies. This is a first study from Metcos and co-authors published a year before in the Journal of American College of Cardiology. They looked at from a database review from the STS database, all the patients who underwent from the big database cabbage surgery who did have a TE or did not have a TE, looking at how striking the numbers are. So we're talking about half a million patient in one arm and more than half a million patient on the other arm. And what comes out from this survey, from this analysis, is that first TE is being used in cabbage surgery more and more often. You can see it in the center of the screen through the years to get to a peak of 60%. So also in the U.S. we're not or the STS database sort of partner centers. It's we're not still 100% or not even close to 100%, but definitely as there has been a significant increase by 20% from 2011 to 2019. The use of TE, it also depends on the center. So in some center, they use it all the time. In some center, they don't use it at all. And the patients who did get a TE, they seem to have a better overall outcome. So they have a decreased mortality, which is, as you can see here in this plot, it's not strikingly lower, but it's definitely significant in comparison to those who didn't get a TE. And actually, depending on how sick these patients are, the sicker they are, the more benefit from having a TE. The sicker they are, the higher is the reduction in mortality if they get a TE. Similar database study with the large cohort of patients here is like we're looking at slightly lower numbers, but extremely well-designed center, a well-designed study that was actually and actually looks and tries to overcome the bias of the previous study. And maybe these patients, they got a TE because they're in a better center and that's why they do better. That's nothing to do with the or having a TE. And actually here, when they look at the outcome of cabbage, when you do a TE or you don't, there is overall slight decrease mortality. They do get a TE and a decreased composite of stroke and mortality together if you do a TE comparison, if you don't do it. So those who get a TE, they do better. They have less complication, they die less. And actually, now these statement is not only true in general, in the general population, but also when they corrected for centers and they corrected for surgery. So there seems to be that actually TE has an impact on the outcome of cabbage patients. Now, do all get a TE and why and how do patients for cabbage surgery get a TE. This is another database analysis that involved again, like about 250,000 patients in the US looking for different procedures, single valves and bypass surgery. And actually what it looks like that plays and so to our specialty, a big favor is that if you get to the OR in the US and you get a single valve surgery, you almost certainly going to get a TE. The chance of getting a TE, it's a little bit higher if the person who does the TE is an anesthesiologist. On the other hand, if you come to the OR for cabbage surgery, then if you get an anesthesiologist to do a TE, you have a much higher chance of getting it in comparison to a staff model or the cardiologists are involved. And this most speaks about the dynamic nature of TE for cabbage surgery and how it's not just a spot like it's not just a single picture coming in taking pictures going out but it's staying there and integrating it into a clinical management of the patients. What do the guidelines say, and I'm here talking about a paper that Annette wrote that Annette invited me to give this talk so it's a it's a it's I'm very glad to be caught in this paper. And what do the guidelines that have been published recently in supported by the American Society of Ecocardiography say is that what kind of TE should we do for cabbage surgery. They suggest that has to be a comprehensive TE examination and must be focused on assessment of the ventricles and then also assessment of the valves for the pre procedural assessment. And after the bypass, we are supposed to do another comprehensive TE again focused on myocardial function and then detection of complications of cardiopulmonary of bypass surgery that could be, for example, I'm thinking of the graft or dissection of the aorta or worsening valve function. In this paper, we can actually appreciate this very nice table where we have now the suggestions where we're not only supposed to assess ventricular function for the right for the left ventricle, but we also are supposed to assess diastolic function, as well as the atheroma of the aorta. If you look now, the suggestion is not only to do to the but to do multi plane and to also use 3D imaging for assessment of the LV anatomy. And actually, I completed a few months ago a survey through the actor I see the European Association of Characteristic Anesthesia and intensive care that we're in the process of publishing. And, and I thank you if any of you has actually are actually active members and responded to this survey. And from the survey, what we noticed and it's the third, the fourth group of columns from the left is that from those who responded to the survey. There is 3D it's only used for cabbage surgery in a in just over 40% of the case in all the cases, all the time, and 25% of the of the survey responders, they use 3D for cabbage surgery, never. So and everybody else is in between. If you came and visit us in Leipzig or if you've listened to my talks in the past, you probably know that here at our centers we have a standardized scanning protocol where we have a set sequence of images that we acquire in the or and we start from a deep trans gastric view and then we finish with the orta and we develop that together with my chief professor and they're like trying to minimize the movement of the probe and manipulation and make these exam as smooth and as quick and as efficient as possible. And you can also see on the side of this off the off the off the images here that for each view what you're supposed to do and measure. Actually, unfortunately, again, so it's suggested by Niko Ara et al. And also, and it was involved in this phenomenal guideline paper. We don't do a complete exam as you can see here for cabbage surgery. This is what we've sort of come up with for cabbage surgery and for surgeries that don't involve any anatomical changes. What we see here is we basically using X planes or their multi plane technology so two views perpendicular views at the same time. We simplified our protocol to 10 views and really we can do this exam in about in less than than 10 minutes and that's what we do for all our bypass cases at our center here in Leipzig. Using this protocol. I looked at the last 12 months. We've done echoes on 6 or 690 cabbage patients. And these are, I would, I would say that these are pretty much under percent of the cases we've done because everybody gets an echo here. And in 30 of these cases, which is close to 5%, we did change the surgical planning, either because we found a valvular abnormality that needed to be addressed or because of calcification in the aorta, we decided to do off pump or add an operation. And in 53% of the cases, in 53 cases, which is about 10, just a little bit less than 10% of the cases, which is now one in 10. And you may say, yeah, well, your surgeons are not so good. But yeah, actually, our surgeons are quite good. I must say we changed the surgical plan after the bypass surgery, which means that in the majority of cases, what we detected were war motion abnormalities. I'm extremely lucky that we educated our surgeon in a way that when we detect new war motion abnormalities or changes in war motion abnormalities, we go straight to the cut lab. So we have a very low threshold to cut our patients if there's a doubt. If the surgeons liked it or not, most of them obviously are not happy, but when we detect and prove that there is an abnormality, then we take the patient to the cut lab. This is, I decided to take you through a sort of standard exam that I've done like a few weeks ago by myself. And we start from trans-gastric fuel short-axis and you look at this view and you think, yeah, it's pretty good trans-gastric short-axis. We may criticize it. You can say that, yeah, maybe it could be better resolution. And I mean, what's important is to optimize the view. What do we do to optimize this view is I go to explain, I can use this view to sort of address or assess with anatomical and mode. It's war motion abnormalities. You can see that if I use my inch point in the center of the ventricle, I can actually, which is what you see in the center. Then if I move my scanning plane through the antero, to the inferolateral and anteroceptal wall and to the right, or the anterolateral and inferoceptal wall to the left, then I have a M-mode representation of the movement of my walls. Do I need it as an experienced echocardiographer? I probably don't, but this is something that, you know, it's a good start if you are a trainee. What we've learned in Toronto and what I still teach my students is I can take a piece of paper and I cover half of or a quarter. I cover half of the heart in this short-axis view and I look at the movement of the other walls. Going back to my short-axis view, how do I know that my short-axis view is a good short-axis view? Look at the left. This is on the left, exactly what I had before. And if you look now with X-plane, you look to the right and you see that the left ventricle doesn't lie horizontal as it's supposed to be. So what did I do here? I was a bit too deep, so I came back and I got the image at the right. I also adjusted antiflexion and retroflexion. And what I want to do is I want to make sure that I'm really truly cutting through the popular muscles when my ventricle is horizontal and my plane is cutting right in the middle of it. And what I did here, I also decreased the frequency of the probe from general to penetration to gain a little bit more resolution and get a better picture. So I could also do it from a two-chamber view transgustric. This is a two-chamber view at the left and then I activated my secondary plane from a two-chamber view. You see it at the right. But what I find is that I find it way more difficult to actually get a proper short-taxis view, starting from a long-taxis view. What I normally do is the other way around, I start from, and everybody does it here, from short-taxis, I activate my secondary plane and then I make sure that my longitudinal view of the left ventricle to the right is nice and well positioned. Then, once I've been in the transgustric view, I can come back into the mid-esophagus and you know how difficult it may be to get a good four-chamber view. But really, for detection of one motion algorithm is extremely important to get a good four-chamber view. Here, for example, I actually have more of a five-chamber view in comparison to the four-chamber because the aortic valve comes in the middle. I can retroflex the probe or I can sometimes, if I've tried everything and I'm sure I'm cutting through the true apex of the left ventricle, I can also increase by a few degrees my angle to get an optimized four-chamber view. Once I've optimized my four-chamber view and only then, then I activate my two planes. Now, to the right of this image, you have a four-chamber and a two-chamber simultaneously on the screen where you can see now 13 segments of the 17 segments of the heart. And from these two perpendicular views, you can use sort of speckled tracking software and then get an ejection fraction. If you want to, now some of the machine do it fairly quickly and automatically. And I can only need one more picture to actually get all the 17 segments of the heart. And that was my long axis view. So you have now four-chamber, two-chamber, long axis. So with transgastric as an alternative confirmation of all motion abnormalities, four-chamber, two-chamber, long axis, you got it all. You have really good, also good, known for shortening images of these three views. Then you can analyze them and use, for example, other technology to look at the motion of, or automated analysis of the motion of the walls. All of us who've done it for a long time, we can just look at the screen and do it. But if we have good images and we have the technology, you can have here, you can use strain to actually look at all the segments. And you can also add sort of a single strain values for each of these segments. And then, again, if you look down at the bottom to the left, you would actually look at achinesia, dyskinesia, and hypokinesia, depending on the color that's been displayed. And this is something that we don't, unfortunately, do on all cases because we only have two out of 11 machines that we have that can do this. But if we have one of the good machine, I would, I always try to do it if I have good enough quality images. The guidelines suggest 3D, what can we benefit from 3D? Once we get a 3D image, it has to be acquired. This is with an older probe over four heartbeats to get a good enough temporal resolution. Then I can analyze it and get something like this. And here you can see that each segment or each wedge that underlines the specific segment of the hearts. The changing volume of each wedge is now depicted in this graphic with the wave that goes down. If the wave goes up is a dyskinetic segment or if the way is flat, then there's no movement of that segment. This is actually a nice way of further confirming presence or absence of one machine abnormalities. We do it for the whole ventricle and we can really display it nicely. It can be well documented. We need a good dataset. We need good echo images and we need to make sure that the software tracks the endocardium properly. In our protocol, we also have a look at the valves and in this case, you see that there is some mitral valve insufficiency that I wanted to better assess. If we do find something that's abnormal, then we do a further focused assessment on that specific pathology. We documented in this protocol. This is a pre-reversalization protocol to the left and a post-reversalization protocol to the right where we actually documented our findings. What's important to document is the wall motion abnormalities for each segment. We have zero, one, two, three and four. One is normal, two is hypokinesia, three is echinese and four is dyskinesia. It's important to document it also on paper because then call to do a post-exam again or when my colleagues tell the post-exam again, I can look right away on the pre-exam and see if and where the wall motion abnormality was. After revascularization, I do have further focused exam where I only look at the ventricles. What I looked here is obviously trans-gastric with the X-plane and 4-chamber with the X-plane. I added color and actually in the post-exam, there was a little bit more mitral insufficiency that in this case came to a vina contracta of 4.5 millimeters. So that was sort of a one to two without any valvular abnormalities and we sort of decided to leave it alone and see if the remodeling would take care of it. This is our setup in our operating room. We have for each in each room a screen with a computer where we have our storing system. We use TomTech here in Leipzig and where you can display the pre-images that you've uploaded during revascularization or during cardiopulmonary bypass on the screen that you see that's sort of glare. Unfortunately, it's shining back and you can show the actual pictures on your echo machine. This is what we have and what we do to actually convince our surgeons to do something about the wall motion abnormalities. And this is a way where you can see right away what it was before and what it is now. Very important is not to forget after revascularization that you do a post-exam and you also need to repeat your exam and look at the ventricles after chest closure. Because after chest closure bypass can kink and something as in wall motion abnormality can happen. So in summary, for bypass surgery, there are clear guidelines that is there's quite strong evidence that doing a TE it's correlated with a better outcome. The question is, should we do a focus that a complete exam, someone may say why do you need to do a focus exam on the guidelines say you need to do a complete exam. It's not against it. Every institution has their own sort of main manpower and organizational challenges. Therefore, it's actually not so, it's not doable everywhere to do always a complete exam. We need to get good quality pictures in order to talk to our surgeon and convince them that there's a problem. There are new artificial intelligence technology or automated technology that allow for quick strain and assessment of ventricular function without us having to do much. And there are new probes, the newer probes, they definitely allow for much better quality images. What's important is, and my take-home message would be that whatever you do, if you cannot do a complete exam, but do focus on getting good images. And you do need good images at baseline and you do need those to then demonstrate after that there is a problem. With that, I thank you very much. I invite you to visit us in Leipzig anytime you want. And next year in June, we'll have again our third edition of our TE masterclass that's going to be live and virtual. They're very welcome to come or join us online. Unfortunately, on Saturday, when the conference, so now I'm not available to answer your question because I'm traveling, but this is my email address and I'll be very, very glad and happy to chat with you on any topic and any topic related to my talk. Thanks again for inviting me and thank you for listening to me and thank you for keeping a constant collaboration between our center through the years. Thank you very much. Bye. Thank you very much, Max for that great talk. Unfortunately, I can't join us for the Q&A period, but I'll invite the other panelists to join us. And Dr. Vegas will be helping moderate the Q&A period. We have a few questions that have already been posted. If you have any more questions, please enter them in the Q&A. We have 20 minutes for discussion. Just give one more minute. Is everyone connected? Yes, I've requested their audio and video. They should be connecting shortly. We have Yakov here and ready. Okay. I'm Dr. Huska. And is Dr. Morakova available as well? Yes. Okay, perfect. So the first question was practically speaking in your daily work, how often are you quantifying LV by other measures besides EF and which measures do you use and which cases do you make a special effort to get additional quantification in? So I measure ejection fraction. Fraction are shortening regarding the global longitudinal strength. We don't use it every day in our practice. One of the reasons is that not all of our machines are having the software. If it is a normal left ventricle function, I'm using M-mode and fraction shortening is sufficient to give you some answer for the left ventricle function as well. 3D ejection fraction again at certain patients and when we have a time, very operatively in theta. Thank you. Dr. Moska or Labis? Yeah. I'm always an idea that the more you practice, the better you become. So I always have a trainee with me in the operating room. And if patient stability allows and surgical time allows, before going on by pass, we try to accommodate every modality to check left ventricle function. It's not only because we need the number, but it's because practice get us better. So we go through a sequence of measurements from M-mode to D into 3D and try to get a comprehensive assessment of the left ventricle. In global and the regional motions. And do you have strain available in all of your rooms? Unfortunately. For all your machines? Unfortunately not. We have 3D available but not strain yet. Thank you. So that's the same in our department. We're trying to do 3D assessment of the left ventricle and we have the software on our machines. And not all our machines have strain software on in the UR. But in two machines, it's available. And at the moment we are trying to explore automatic analysis from our vendor of the software for the application of introoperative assessment. But this is now an exploration. As a question, Dr. Moravkova, can you comment on measuring diastolic function with TE intraoperatively versus preoperatively with transcerastic, what some of the concerns are and whether it's something you do routinely? So I do routinely examination of the diastolic function. I think it is important to know the limitations such as this dependent on the loading conditions on age. Where you place the sample volume, if the patient has any regular problems like heartache or mitral disease. I personally used the simplified grading to start with where I examined the lateral tissue Doppler lateral annulus of mitral valve and depending on the velocities continue with the examination of inflow of the mitral valve. So these these two I do routinely. Thank you for her lab is a deus strain for diastolic evaluation at all. We're starting with this. At the moment, I think there's only few data for this introoperatively, I think what described three years ago from a group from Chicago. They did it, I think the first time and publish this. So at the moment, we performed about 50 60 patients in the period operative course, and it works well with our software. There's no problem doing it introoperatively. It's at the moment, quite a lot of work. And perhaps it will change in the near future. And I can say it works. And we're presenting the data of this investigation and at our European annual Congress in two weeks so I can show you the data at the moment. But we started to to perform it. Unfortunately, we cannot put in a swan guns catheter in patients with preserved left and right ventral function or not severely depressed function in Germany. In our first patients, there's no correlation to invasive measured hemodynamics. But for as first step, I can tell it works. And which measures are using or look most promising for a diastolic function. The strain rate of the eyes of volumetric relaxation and the strain rate of the early feeling. So, I think, aside the operative setting, this was the two most the two parameters with promising results. And perhaps having more patients, I can tell you more about this. Thank you. Thank you. Do you think a 3D strain or three principle strain sort of combining all the different dimensions into one, one parameter. Do you think that has much potential? Yeah, you probably probably the itself is depends how much the AI and automatic algorithm can help us on on performing this. You know, is is always a little bit challenging in the operating setting for all the reason myself and my colleagues as press as an easy this. I need to look after the patient as well and keeping stable communicated the surgeon and all the stuff. So, if requires long time, you may not be practical in the in the clinical them scenarios. As a workflow dependent. And I had a question from Dr. Dano was asking, what are the applications for time to peak strain. And do you use it in your practice or look at it as for any of the speakers. It's often displayed next to the strain value. But yeah, I, I do not use this. Perhaps it's even more time depending. It's, it's much to do without automatic assessment so we do not assess this but it's a very interesting topic. And actually, when you look on a twisting and untwisting for diastolic function. So, perhaps that's an interesting parameter but clinical I don't use this at the moment. Thank you. And that any some questions. I'd like to congratulate and thank all the speakers that was just a brilliant session, you know, a lot of very complex information presented very clear and concisely. And I hope our audience enjoyed all three sessions, all four sessions actually sorry max. Dr. Labis I do have a question, I mean I've used strain in the operating room I've seen the evolution of many iterations of software that have come through. And this recent iteration is a somewhat automated software, which I actually decried because it doesn't really give us an ejection fraction the previous software that you presented, allowed us to calculate strain, as well as gave us an ejection that's not true with the software. But my question was strain really is the ability to sub clinically assess the left ventricle because in theory we're supposed to be assessing contractility to a certain degree. One of the valuable aspects would be the ability to predict someone who has say much regurgitation, who you don't really know what their left ventricular function is going to be like, after their mitral regurgitation is fixed. In AI, we already know the ventricles kind of poached a little bit right, but what about MR and why don't you think strain, because a lot of the papers you presented wasn't valuable in assessing patients who come from mitral regurgitation. And so I was not presenting mitral valve surgery because of time I saw just a choose cabbage and auto valve replacement, but there is data, there is pre operative trans thoracic data, and strain values with the cutoffs for unfavorable outcome are much higher or lower, if you regard the negative values. But I think there is data but interoperatively, I think there is very few data I cannot remember at the moment if there's any data interoperatively, perhaps, because of the image quality before and after replacement, I don't know. Perhaps it's more difficult and a promising technology for this, which is only available for one manufacturer is software combining strain, longitudinal strain and pressure values. So perhaps this is a technology for this patient population with mitral regurgitation, where there's a change of a big change of loading conditions, but we have not explored this yet. Thank you, Dr. Mosca. So Max also presented this concept of using 3D for assessing LV regional wall motion abnormalities. Do you use that in your practice? And number one, are you really assessing regional wall motion abnormalities? Yeah, I mean, it's always a little bit tricky and challenging the interoperative images. I found useful to a lot explain for that. Again, quite quick information to communicate to the surgeon in the postoperative period, post bypass period. And in a rare situation, we could fix the problem of regional wall abnormality by lifting the heart and look at kinking vessel. It happened. And some other times, we also use Catlab as a rescue strategy for these regional wall abnormality, which demonstrate at least once a dissected vessel. So it helps utilize regional wall abnormality analysis in the postoperative setting compared to the preoperative and communicate to the surgeon there is actually a problem. So yeah, in the summary, I'll assess the segments in the postoperative phase. But you're using really 2D to do this, right? You're not using 3D. Is that correct? I'm using X-Plane if you can call it 3D. Yes. Yeah. Well, I mean, you know, 3D, I think most people would reflect 3D as being the 3D segmental model. Yeah. That you're developing. I think it's important not to leave the audience with the assumption that the graph that you developed from your segmental model is not a model of wall motion. It's a model of how much each segment contributes to the cardiac output or the ejection fraction, actually. So you can say, oh, it's flat, maybe it's a kinetic, but it is important to know this is not a wall motion assessment. Dr. Markova, what do you use in the operating room if you had a choice and you wanted to quantify LV function and you have all the money in the world? And you had a choice between 2D, 3D, or strain. What number would you hang your patients hat on? I think it's a tricky question. Yes, yes, it is. I think regarding experience and how often we do 2D. So I rely on 2D assessment of the left ventricle function. As Roberto presented, 3D is more accurate. So if we can have the ability and experience is a great way to assess the LV function and regarding the strain. I think needs a bit of more work and more data to be used in a daily practice in theater. Any other comments from anybody else as we close the session? There were a few questions that people have posted. There was 2 related to original wall motion abnormalities. One was whether there was any comparison data comparing 3D volumetric assessment to strain for detecting original abnormalities. So what's the question? For detecting original wall motion abnormalities, is there any data comparing 3D assessment versus strain if one is more sensitive or specific? I would certainly say that 3D is not the most sensitive for regional volumetric. And do you use either strain or 3D imaging to, aside from prognostication, to actually guide interpretive management? So we try, but 3D strain, I think there's not enough data for prognostication either before the operation or intraoperatively. But using 2D strain, I think there's few data, but by combining with other methods as 3D volumetry, it gives a good picture of LV function. Thank you. Thank you very much to all the panelists for excellent sessions and excellent Q&A session. With the answer to the remaining questions, we'll post on the Q&A box. We'll have a 15 minute break now and we'll resume the second session on extra cardiac ultrasound at 1115. Thank you.