 Good afternoon everyone. And I wanted to start by saying thank you very much to Azad, Marcos and the scientific committee for the invitation. For me, it's a great honor to be one of the speakers of the Toronto Perioperative Echo Symposium this year. And today I will present this study you all see on your screen, published in 2021 in the Journal of the American College of Cardiology, entitled Transes of a Geo-Eco Cardiography in Patients Undergoing Coronary Artery Bypass-Graft Surgery. And this study was performed in the USA with the lead of these five centers. For this presentation, I do not have any conflicts of interest to disclose. And my objectives today are to review the level of evidence of the use of TE insurgers of cabbages, to present the methodology and results of this study, and also to present two clinical cases when TE may have changed the surgical outcome in surgeries of cabbage. So we all know that interoperative TE is an important tool in cardiac surgical care that provides real-time assessment of the heart's structure and function, including global systolic and diastolic function, regional wall motion analysis, and both native and prosthetic valve function. It has the potential to reinforce or improve the palm preoperative diagnosis to guide the conduction of the operation in cardiac pulmonary bypass management and to confirm optimal cardiac function prior to transfer of care to the CVICU. Multiple studies have shown that interoperative TE is safe and has a low complication rate. And the existing guidelines recommending that interoperative TE is used in all open heart and thoracic surgical procedures, and that it should be considered in cabbage surgeries. This is a class 2A recommendation with level B of evidence, and this means that the benefit is greater than the risk, and that there are limitations in the populations or study designs used to support this evidence. However, when we look close into the evidence for the use of interoperative TE, we notice that this evidence is sparse based on prior studies that largely focus on whether TE changed the operative plan, rather than whether TE improved clinical outcomes. Indeed, there are a few studies that assessed outcomes, but they are all small and underpowered. So the authors made the hypothesis that for surgeries of cabbage, the use of TE would be variable across North America and associated with improved clinical outcomes. And they plan to perform a retrospective cohort study of TE using isolated cabbage patients using data from the STS adult cardiac surgery database. The overall study population included more than 1.25 million isolated cabbage performed from 2011 to 2019 across 1218 centers. And to study whether TE was associated with unplanned valve procedure, the population had to be restricted to patients included in newer versions of the STS database. For this reason, the study population for unplanned valve procedures included less patients, close to 830,000 cases performed between 2014 and 2019. The secondary outcome was operative mortality and operative mortality is defined in the STS database as all deaths, regardless of cause, occurring during the hospitalization in which the operation was performed even after 30 days. And all deaths, regardless of cause, occurring after discharge from the hospital but before the end of postoperative date 30. The secondary outcome was the association of TE usage with unplanned valve surgery due to unsuspected patient disease or anatomy. And other secondary outcomes included postoperative renal failure, postoperative prolonged mechanical ventilation, longer than 24 hours, postoperative prolonged ICU stay longer than two days, reoperations and hospital readmissions within the 30 days. The authors decided to include a propensity match score analysis to account for baseline differences and to better investigate the association of TE usage with outcomes. The propensity scores were calculated by logistic regression using the variables to the right side of your screen, all from the cabbage risk model in the STS scoring system. TE and non-TE cases with similar propensity scores were then matched one to one by a matching algorithm. Standardized differences before and after matching are presented in this graph, and after matching balance was acceptable with all standardizes differences lower than 10%. Another important information is that the authors decided to stratify patients in three groups to study patient risk was a modifier of the relationship between TE use and outcome. So they use the STS predicted risk to divide patients into low moderate and high risk of operative mortality. Moving to the results of this study. Let's start with the utilization of TE during cabbage procedures. Of the more than 1.2 million isolated cabbage procedures performed in more than 1200 centers, almost 54% of the patients had interoperative TE. This figure represents the percentage of cabbage patients receiving interoperative at each one of the 1218 centers across North America rank ordered by proportion per center. So we can see that some centers using all patients while others don't use it at all. And this is variable and was found to be not associated with the site's volume of cabbages. As you can appreciate the percentage of isolated cabbage patients receiving TE increased over time from 40% in 2011 to more than 60% in 2019. The authors then present their demographic clinical and site characteristics of both groups in this long table of results that I invited you all to analyze later on. And when comparing both groups, their results show that looking at the group of patients where TE was used. There was a higher risk profile with higher rates of chronic lung disease, diabetes, heart failure, myocardial infarction, shock, arrhythmia and valvular heart disease. Also, TE was used more commonly patients with ACS on presentation in emergent and urgent cases and was associated with a higher rate of interoperative mechanical circulatory support. Another interesting analysis looking at postoperative course of both groups showed that the group of patients with interoperative TE had higher postoperative complications and mortality rates, including higher rates of renal failure, cardiac arrest, hospital readmission and major morbidity. Indeed, cabbage patients who received interoperative TE had a 12.5% rate of major morbidity or mortality compared with 11.6% for those who did not receive interoperative TE. Now let's look at the results comparing groups after the propensity score matching and these results had good evidence with all caveats of a retrospective cohort. They were able to match more than 560,000 patients that had TE done with 560,000 patients that had not. And after analyzing both groups, they found greater odds of longer ICU stay in renal failure and lower risk of operative mortality in the group that had TE used interoperatively. And when looking at groups stratified by the STS risk, TE was associated with lower odds of death in the high and intermediate risk groups, but not in the low risk group as you can see in the figure to the right side of your screen. For the outcome of unplanned valve surgery in the cohort of more than 830,000 patients, 0.32% of the cases required unplanned valve procedure and the mitral valve was devolved with most of the interventions. After the propensity score matching, they were able to match more than 340,000 patients from each group and found nearly five-fold higher odds of unplanned valve procedure in the group of patients who had interoperative TE regardless of their STS risk group. Wrapping up, the use of TE for isolated cabbage patients is recommended by guidelines with a moderately strong level of recommendation, but evidence that it improves outcomes is lacking. It is unlikely that a prospective RCT could be effectively conducted, so inference from large observational studies like this is necessary to support guideline recommendations. In their discussion, the authors revealed their most relevant results and used them to support the use of interoperative TE to improve outcomes in patient undergoing isolated cabbage, particularly amongst the highest risk patients. The outcomes may not be affected by TE in cabbage patients who are considered at low risk. To explain how TE could improve outcomes, the author presents possible mechanisms. Firstly, TE could reveal unexpected structural changes leading to changes in the operative plan as seen in their results with more unplanned valve operations at time of isolated cabbage. Secondly, TE after winning from CPB can identify new regional emotional abnormalities, right heart failure, pericardial effusions or aortic injuries. Finally, a high risk TE leads to changes in the course of immediate postoperative therapy in the CV ICU, which may explain the fact that TE was associated with a longer ICU length of stay. Examples of therapies affected by echocardiography would include inotrop titration and management of right heart failure. Interestingly, TE use was associated with increased risk of renal failure, and this may be a result of a confounding that was not measured. But an alternate hypothesis is that TE use is associated with different patterns of vasoactive medication medications or inotrop use or fluid management strategies, which in turn can predispose to kidney injury. The conclusion of this study is that one point of the 1.3 million isolated cabbage procedures across more than 1200 centers. TE was associated with greater frequency of unplanned changes to the proposed surgery and lower operative mortality. And these findings support the use of TE for isolated cabbages to improve outcomes in the high and intermediate risk patients. In the last part of this presentation, I present two cases when I believe TE was useful and may have changed outcomes both performed in the last year. The first case is a high risk patient, 78 years old patient known to have a skimmy dilated cardiomyopathy with a low EF 22 at 25%. Mild AI, moderate MR, moderate TR and pulmonary hypertension, book it for a cabbage times three. After induction, this is the baseline TE exam and we don't need any quantitative method to assess this LB function once it's obvious that it is severely depressed as advertised. So here's the two chambers and then the long axis and the trans gastric in short axis. Knowing that this patient has mild AI previously documented the surgeon asked me to confirm this finding. And the aortic valve long axis with colors showed as small jets compatible with mild AI. So I confirmed the previous finding to the surgeon. Besides, not an impressive just an extension here you can see the vina contract of almost three millimeters again compatible with mild AI. The surgical team at this moment decided to use an integrated perfusion of the coronary arteries to deliver cardioplasia and arrest the heart. So after we go and bypass, I noticed that this heart needed 2.2 liters of cardioplasia to arrest, and that attracted my attention. Although no electrical activity on the ECG I decided to look at the heart using the echo. And this is what I found a dilated heart dilated LV with the smoke and compatible with low flows and backwards flows across the mitral valve as you can appreciate. I also identified flows across the earth valve. And that was the source of the LV dilatation. The flow was flowing back to the LV and then back to the left atron. The trans gastric bill confirmed LV distention and my concern here was myocardial protection during the cardiopulmonary bypass. So convinced that this was suboptimal, I suggest that the surgeons change their protection strategy, which they agreed and switch it from integrate to retrograde their fusion, venting the aortic root and decompressing the left ventricle. Unfortunately, I don't have an image of the empty left ventricle to show now. The mouth bypass was relatively smooth with minimal inotropic support of epinephrine three micrograms per minute. And here are some views, for example, this four chambers mid exophageal. And then a two chambers and the long axis. And finally the trans gastric short axis. So here are the pre and post images compared showing better contractility post pump with the caveat of different loading conditions and inotropic support. But the concern about pre protection did not confirm. So here is the two chambers comparison, long axis view pre and post plan. And finally trans gastric short axis pre and post plan. You never know what would have happened if they kept the integrate perfusion. Maybe the outcome will be the same, but I am convinced that this was a good call that might have changed the result. The second case now is a low risk patients, 69 years old patient with the history of hypertension, dyslipidemia, obesity and smoking, found to have triple vessel coronary disease on a checkup routine by his family physician. This is the only function on the underground elected to have a cabbage times three. So post induction tea exam confirmed normal LV systolic function in the mid exophageal four chambers. Same in the two chambers. And here the three chambers are long axis room and good LV function in the trans gastric short axis room, and also in the trans gastric two chambers. So I'm just curious to go bypass, come time was 95 minutes. Among the three graphs this patient received the lead to lead. And coming off bypass him or him or dynamically the patient was stable, but my initial impression in this media exophageal four chambers view is that the lateral wall is not the same. I don't see much thickening here. And I had the same impression when I saw the interior wall in the two chambers view. And when I saw this long axis view I was convinced that although the hemodynamics was stable, something was wrong with the interior and lateral walls of the LV. And the surgeons agreed. So we went back on bypass a second time, and they found a dissection of the leader, or the IMA. They were able to redo the anastomosis with the led after resecting the dissected region in the native archery. And we came off bypass second time. And this time we see a hyper dynamic hard with the better thickening of the lateral wall. Same thing the anterior wall in this two chamber view. And much better in the anti receptor wall here in this long axis view. So let's compare the three moments now pre bypass in the left post bypass one in the center and post bypass two in the right side of her screen. So here's a four chambers. Clearly normal here hyper dynamic here and something is wrong with the entire lateral wall here. Same thing here in the two chambers view. So normal here, hyper dynamic here but contracting well. And here, something is wrong with the anterior wall. And here the long axis view. So normal here, something is wrong with the eight or an anti receptor wall. And here's much better than the first one run. And that's all. I hope you guys enjoyed and once again, thank you very much for offering me the opportunity to be part of this fantastic meeting.