 Our last presentation will focus on rheumatic heart disease and the take home point from the new ASC guidelines published earlier this year. I would like to introduce our next speaker, Dr. Carlos Gallardo, he is the director of the adult cardiac anesthesia national institute of cardiology in Rio de Janeiro, where he completed his magical training and also anesthesia residency. He is a fellow of the American Society of ECHO and from 2015 to 2020 he has served as on the on the international committee of the Society of Cardiovascular Anesthesiologists. Gallardo, thank you very much for being here and I'm going to hand over to you now. My name is Carlos Gallardo, I am a cardiac anesthesiologist currently working at the National Institute of Cardiology in Rio de Janeiro, Brazil, but I'm relocated to Canada very soon to work at the Hamilton Health Science and McMaster University. First of all, I would like to thank the organizers, especially Dr. Vegas and Dr. Papa for the kind invitation for me to participate at the 2023 Toronto Perioperative Ecosyposium. My topic is rheumatic mitral valve disease, what are the take home points from the new ASC guidelines. I have no disclosures, so the objectives are to review anatomic and hemodynamic considerations in the assessment of rheumatic mitral valve disease, discuss technical aspects in echocardiography imaging for rheumatic heart disease, and also apply some recommendations based on the latest ASC guideline in the intraoperative decision making process that was also published in 2020. So this is the guideline that I'm going to talk about, it was published at the beginning of this year, this document provides recommendations for the comprehensive use of echocardiography in the diagnosis, classification, risk assessments, and therapeutic intervention of rheumatic heart disease. So rheumatic heart disease is a major global health concern. There from the World Heart Federation estimates that almost 300,000 patients die as a complication of rheumatic heart disease every year. So there is a high incidence of people living with rheumatic heart disease, and 90% of cases occur in low and middle income countries. So it's also a disease from the young age. Rheumatic heart disease is the most commonly acquired heart disease in people age 25 and younger. In terms of pathophysiology, rheumatic heart disease is the long-term consequence of an immune mediating injury to the heart and cardiac valve following acute rheumatic fever. Early after infection by the group A, better mullitky streptococcus, and manifesting as clinical manifestation as tonsillopharyngeitis, two to four weeks after the infection, which starts presenting some symptoms. Carditis is the most common presentation in the acute phase, and we know that damage to the cardiac valve is a chronic sequela of carditis. So in a more chronic commitment of the disease, with chronic inflammation, response to cardiac tissue, we should start developing vulvular stenosis and regurgitation, and most of the patients usually develop right heart dilatation, pulmonary hypertension, supraventricular arrhythmias, and heart failure. So the most common presentation of acute rheumatic valve light is mitral and aortic valve regurgitation. So mitral stenosis is the most common chronic lesion of rheumatic heart disease. So in the acute phase, there is some aortic and mitral regurgitation, in the more chronic phase, mitral stenosis is the predominant lesion. So rheumatic heart disease is the most common global etiology of mitral stenosis. And if we see we are facing a patient with suspicions or documentation of mitral stenosis, the first diagnosis in mind should be rheumatic heart disease. So in DOA, it's important to use a multi-parameter echo approach used in 2G, 3G, color flow and spectral Doppler. For the assessment of mitral valve, the goal of the exam is to confirm known findings and exclude additional pathology that may alter the surgical plan. So it's important to evaluate interval changes in terms of quantification from the time of the diagnosis made in the patient's indicate for surgery or interventional procedure at the time of the in the OR, because sometimes there is some modification or commitment in the other valves. So it's important also to guide surgical interventions and hemodynamic management and also to assess the results of the surgical procedure at the end. So let's focus to talk about rheumatic mitral stenosis assessment. So rheumatic mitral stenosis should be evaluated in a comprehensive approach, including careful examination of mitral valve morphology, both in 2G and 3G imaging. So to accurately determine the mitral valve area by planimetry and also to assess the severity of calcification, thickness, mobility of the leaflet as well as annulus size. It's also important to quantify the mitral stenosis through Doppler findings. So we usually use color flow Doppler to assess tubular diastolic flow and also PISA, radios and area. So using pulse wave and continuous wave Doppler to measure peak velocity and mean pressure gradients, pressure halftime and deceleration time to estimate mitral valve area. And also it's very important to estimate systolic pulmonary arterial pressure. So in rheumatic mitral stenosis, there are potential different associated findings that we need to look for, not only clinically but also through the echo. So with inflow obstruction for the mitral valve, so there is an increase in right atrial pressure with left, increasing left atrial pressure with left atrial dilatation, supraventricular arrhythmia, a fibis commonis arrhythmia in this group of patients. We can also, we should also access, look for spontaneous echo contrast in left atrial thrombus, usually at the left atrial appendix in the left atrial wall. So with chronic condition, it's usually to see an increase in PA pressure as well and an increase in pulmonary capillary pressure and as a consequence right ventricular volume and pressure overload, right ventricular dilatation and right ventricular dysfunction. It's also common to find functional TR as a consequence of tricuspid anulus dilatation and also we should look for right atrial dilatation, right atrial pressure overload and also some alteration in the hepatic vein flow. So rheumatic mitral stenosis has some characteristic morphological features, including leaflet thickening with or without calcification, usually the thickening starts at the leaflet tips. Rheumatic refusion is very common findings for mitral stenosis, usually both commissures can be fused. So thickening and shortening of the subvalval apparatus, as we can see in the figures on the right, is all another findings in rheumatic mitral stenosis. So we also should look for the mobility of the leaflet so we can find the restricted leaflet motion resulting in doming or hockey stick appearance of the anterior mitral valve leaflet during diastole. It's also pathogromonic to see doming and hot stick lesion appearance. So just to illustrate the figure from the guidelines, it was obtained through trans-Torasky ECHO, figure A it demonstrates by commissure of fusion as you can see, figure B chordal thickening and calcification, it's in pressure to evaluate the subvalval apparatus as we can see here in the paristhenol long axis view, fusion of the chordus and also calcification and also we can notice left atrial dilatation. Figure C we can see very well the diastolic doming appearance of the anterior leaflet with a hockey stick appearance, also restriction motion of the posterior leaflet, figure G we see very well the calcification on the tip of both leaf, the anterior and posterior and also a doming of the anterior leaflet. Just to illustrate the image obtained by TE in a patient that was scheduled to undergo mitral valve replacement due to mitral stenosis. So we can see a diastomy on the left, midgazofazule for chamber view that we, I can see that there are thickness of the both leaflets with diastolic doming of the anterior leaflet in the restriction motion of the posterior leaflet and also lack of co-optation at the center of the valve. On the right, midgazofazule long axis view, we can see a hot stick appearance of the anterior leaflet, a doming of the anterior and posterior leaflets and also we can see some calcification at the subvalvular apparatus. So another image from 2DTE that we can see on the left for chamber view with color flow Doppler assessing the, we can see the mitral valve inflow acceleration and also mitral regurgitation. We notice also a pizza formation during the diastole. On the right, we can see that there is a center regurgitation jet through the mitral valve. So the guideline also states the classification of severity of mitral stenosis. They recommend to use a multi-parametric approach using calculate the mitral valve area, the pressure halftime, the mean gradient and systolic pulmonary artery pressure. So when patient presents a mitral valve area below 1.5 centimeter square pressure halftime below a greater than 150 milliseconds mean gradients greater than 10 millimeters of mercury and systolic pulmonary artery pressure greater than 50 millimeter of mercury. We can classify this patient as having severe mitral stenosis. On the other hand, patients with more than 2.5 centimeter square of mitral valve area pressure halftime below 100 milliseconds mean grade below 5 millimeter of mercury and systolic pulmonary artery pressure below 30 millimeter of mercury, the patient is great as having mild mitral stenosis. And in between of these numbers, the patient is great as having moderate mitral stenosis. It's important to mention that the mean gradient should be measured with a heart rate between 60 and 80 bits per minute. Planimetry is the preferred method for determining the anatomic mitral valve area. During transesophageal echo in the OR, we should look at the mitral valve area through the transgas gas basal short axis view, especially in the tracing the mitral valve area in the zoom mode at mid diastole. In Thrasurasky echo, we should use the paristhenal short axis view to obtain the planimetry of the valve. It seems there are some key points when we are measured doing planimetry. This is affected by tomographic plane gain and calcification in patients with heavily leaflet calcification or an excessive gain. The patient usually underestimates mitral valve area. On the other hand, when we don't measure at the narrow orifice area of the valve that is demonstrated here at the yellow dot of the line, when we measure above at the funnel shape of the mitral inflow, if we measure above of these, we, for sure, are able to measure or are going to overestimate the mitral valve area. So because of some difficulties that we have by 2D, the 3D is now recommended by the guidelines, using a multi-planar image to guide the planimetry at the mitral valve leaflet tips that we can usually adjusting the tomographic plane on the left to measure the mitral valve area at the narrowest point of the mitral valve. We can also do planimetry through 3D zoom, assessing both the left atrial side or even the left ventricular side, also doing planimetry in both of them, as we can see here, demonstrating the dorsifigured and to estimate both the mitral valve area in all of these assessments. So here, we can see some demonstrations that the importance of 3D assessments of the mitral valve, we are able to see very well the bicommissure fusion of the mitral valve, the reduced size of the mitral valve area. We also see on the left side an area of calcification in the close to the posterior-medium commissure at the mitral wendelus. We also are able to see there is some restriction of posterior mitral valve leaflets seen also through the ventricular side. So in terms of hemodynamic considerations, there are many parameters that we should obtain. The mitral valve mean pressure gradient is an easy one, so that during TE, we should look at the midgesophageal four chamber view and midgesophageal long axis view to align our color continuous wave Doppler to get the high velocity through the narrow of the mitral valve. So the Doppler beam is guided by the highest flow velocity zone identified by the color flow Doppler. So it's important to state that it depends on the heart rate and the flow conditions. So every time that we are measuring the mean pressure gradient, we should report the heart rate and blood pressure at that moment. So in case of patient presenting atrial fibrillation, we should average five cycles at least and do them to average the mean pressure gradient. So another parameter to measure is the pressure halftime, the PAT. The PAT represents the time required for the pressure gradient to decrease by half from its peak value at the early mitral inflow. As you can see on the figure on the right side, we see that there are different pressure between the left atrial and the left ventricle. So when the time that it decay from the peak to 50% is how to measure the PAT. So the formula that you use is it's a very simple formula that we divide 220 by the PAT. So the PAT is close to 220 or greater than 220. So the mitral valve value should be at least one centimeter square. So there are some key points to consider, state by the guideline. So we should state that the left vent compliance is normal and there are no other source of left ventricular feeling, such as shunts or auto regurgitation. If we have auto regurgitation or an increased left ventric compliance, the time to obtain the equilibrium between the left atrial pressure and the left ventricular pressure is fast enough and we are going to have a low PAT over estimating the mitral valve area. So PAT is not useful immediately after mitral balloon valve loplasty because of the load conditions that is going to happen after the balloon valve loplasty. So key points to measure PAT. So it's important to optimize continuous wave mitral inflow velocity to coaxial line the best as possible to obtain, to trace the slope of e-wave. The machine software will display for us the PAT and mitral valve area and the same as mean pressure gradients. The pressure halftime in patient with atrial fibrillation, we should also average over five cardiac cycles. There are some patients that present a biphase deceleration slope of the mitral inflow as we can see in the figure obtained from the guidelines. So that we see there is an acute early step deceleration that is represented by the red dotted line and a more gradual deceleration at the mid diastole. If we are in face of this case, the deceleration slope should be traced in the mid diastole rather than early steep deceleration slope. So we should measure at the white dotted line. So continuity equation is another possibility to measure to estimate the mitral valve area. It's also based on the law of the conservation of the mass. So flow volume at the mitral valve should be equal the flow volume at another valve. Usually we use the cross section area or LVOT and the VTI or LVOT to estimate the mitral valve area. If you use this formula, so you also divide by the VTI of the mitral valve to obtain the mitral valve area. So it's important to notice that it's important to have no valve law regurgitation on chance to estimate the continuity equation. And this formula, there are multiple measurements, so there are many sorts of errors so that we should have in mind. So proximal iso-velocity surface area, PISA, it's another way that we should look at the same way that we should measure during the assessment of mitral regurgitation we can use for mitral stenosis. It's also based on the properties of flow dynamic. It applies the continuity principle to color flow Doppler mapping in the area of mitral valve orifice. So as stated and illustrated here, so the principle is that the flow volume at point A, also the maximum acceleration of flow is the same as flow volume at the narrowest point of mitral stenosis. So if we calculate the area of the conduit and the flow velocity, we are able to obtain the mitral valve area. So we use this formula to estimate the mitral valve area. So in this case, we need to obtain the radius of the PISA. If the hemisphere is not 180 presentation, we should angle for correction factors to increase our accuracy of measurements. So we also have to measure the peak velocity to obtain the mitral valve area in this formula. So percutaneous balloon mitral valve loplasty is also stated in the guidelines. It is the treatment of choice from symptomatic rheumatic mitral stenosis. There are several scoring systems proposed to assess the suitability of balloon mitral valve loplasty. One of the most used is the Wilkins score for mitral valve anatomy assessments. They usually take into consideration the mobility of the leaflets, the thickening of the leaflets, the calcification grade, and also the subvalvular thickening of the mitral valve apparatus. So the total score is the sum of the four items in the range between four and 16. If the patient presents with a score below nine, it's suitable for percutaneous balloon mitral valve loplasty. So the successful procedure is done when the mitral valve area at the end of the procedure is greater than 1.5 centimeters square with no more than mild mitral regurgitation. So let's focus now on the assessment of rheumatic mitral regurgitation. So the guideline also states that the mitral regurgitation is the most common valvular abnormalities at the early rheumatic heart disease stage. The rheumatic mitral regurgitation is caused by incomplete leaflet coaptation due to thickening and scaring of the leaflets as well as cordal shortening that restrict the motion of the leaflets in systole and diastole. If you remember the rheumatic mitral disease is classified as type 3A in the carpenters functional classification of mitral regurgitation. So rheumatic mitral regurgitation assessment should be done in the same way that was previously recommended by the ASC guideline on native valve regurgitation published in 2017 with an update in 2020. The integration of multi-parameter should be done. It is required in more accurate evaluation for rheumatic regurgitation severity. There are multi-parameter that we should look for. The most difficult to grade the severity is when we have a patient in between moderates to severe mitral regurgitation, but there are many important parameters to classify patients as having severe mitral regurgitation such as the vina contractile width greater than 0.7 cm, the PISA radial greater than 1 cm, at a nyquist limit between 30 and 40 cm per second, central large jet area greater than 50% of the left ato area, systolic flow reversal at the pulmonary vein. So the effect of regurgitation or if it's area greater than 0.4 cm2, regurgitation volume greater than 60 ml, regurgitation fraction greater than 50%, we all of these parameters grade mitral regurgitation as grade 4 or severe mitral regurgitation. The guideline also recommends that quantification of mitral regurgitation severed by vina contractile and PISA methods should be included whenever feasible. So we also, every time that we access mitral regurgitation, we should assess the three phases of the jets, the proximal flow convergence zone, the vina contractile and the regurgitation jet area. Based on this parameter, we are able to calculate the regurgitation flow, the effective regurgitation orifice area and the regurgitation volume. So 3G became very important in the assessment also to degrade rheumatic mitral regurgitation. It provides an accurate and reliable measurement. And combined with COLO Doppler has the ability also to determine the origin, the extents and the trajectory of regurgitation jets. We also have to measure the vina contracta and estimate the radios and the PISA area by doing the multiplanar reconstruction with COLO flow. So in summary, rheumatic heart disease is a major global health concern, echocardiography plays a major role in the assessment of rheumatic heart disease. Rheumatic mitral stenosis and mitral regurgitation should be evaluated with a comprehensive approach using different echo parameters. The typical anatomic findings in rheumatic mitral stenosis are commissure of fusion, thickening the leaflets, restricted the leaflets motion and chordal thickening and classification. Rheumatic is the preferred method for mitral valve assessments done by 2D and 3D. The 3D echo provides an accurate and reliable measurement of mitral valve area as well as mitral regurgitation quantification. We should use whenever applicable and possible the vina contracta and PISA obtained from 3D. An integration of multiple parameters is essential for the assessment of both mitral stenosis and regurgitation. Severe rheumatic mitral stenosis is classified when the patient presents mitral valve area below 1.5 centimeter square, a PAT greater than 150 milliseconds, mean gradients greater than 10 millimeter of mercury and pulmonary systolic arterial pressure greater than 50 millimeter of mercury. Severe rheumatic mitral regurgitation is classified when the patient presents with vina contracta with greater than 0.7 centimeter vina contracta area greater than 0.4 centimeter square, effective regurgitant orifice area greater than 0.4 centimeter square, regurgitant volume greater than 60 millimeter, and regurgitant fraction greater than 50 percent. So thank you very much for your attention. I'm glad to participate and look forward to the Q&A section. Thank you Carlos. It was a great review of the new guidelines. So I would like to invite all speakers to our Q&A session. So I can see Rafa is here, Yanis. Thank you all for being here. Like such a great presentations. We have many questions. We have like probably 20, 25 minutes to discuss most of the questions. So Rafa, why we like how we try to like you do the questions related to your presentation and I can do the questions for Yanis, Caroline, and also Carlos, what do you think? I think it's okay, Fabio. I just have a technical issue here because I cannot, I don't have access to the questions in my end. Okay. I'm trying to find then. The Q&A? The Q&A, it's completely blank for me. Okay. No, that's fine. I'm sure they're going to fix that. I have all the questions here with me. First question goes to Dr. Schultz. Dr. Schultz, thank you very much for being here to such a great presentation. So Dr. Schultz, the first question is how much time do you spend pre-bypass reviewing ECHO, the ECHO with the cardiac anesthesiologist? Do you stand at the head of the bed and look on the cart monitor or there is another screen in the back of the room to review? This can be allowed and distracting time, hard to concentrate. Yeah, thanks to the organizers and thanks, Rafa, for organizing this great session. This is a wonderful opportunity to talk about some really important things and we're very lucky in London that we have such amazing acrocardiographers. So just to answer your first question, I think it's really important as a surgeon and as a surgical team to understand the ECHO images preoperatively and to have a complete plan with what you're going to do. So in fact, it really depends on how much time I spend beforehand looking at the preoperative imaging. So every patient that comes to the operating room will have a trans thoracic echo, a trans esophageal echo and I'll review those images in detail often when I see the patient that oftentimes before I even enter the operating room and depending on how well I understand those images and how happy I am with my primary repair plan, my backup repair plan, then that will determine how long I'm going to spend with the acrocardiographer looking at those images because as you're totally right, it's a very busy time beforehand. There's a lot of things going on. So usually I'll take that time to confirm, nothing's changed, there's been no progression in disease, there's nothing new there, that's a big surprise and then we'll move on. And that's where you saw it with the presentation from Hilda, the main highlights of the things to hit up at that very early stage and then to move on because everything follows a very tight cadence and you don't want to try and delay your sort of operative steps because of that. So it really varies from case to case but in most cases it's a matter of confirming what we suspected on the preoperative imaging and our cardiac anesthesia group spends a lot of time reviewing the preoperative imaging as well. And so oftentimes what will happen is Rafa will send me a message and we'll talk the day before and say listen, this looked okay, this was a little suspect, maybe we can just confirm this, talk about it in the morning up and then move forward with the plan and I think that's equally important. Okay, I totally agree with you. We have a... Fabio, just to add one thing, yes, we have the TE images on screen in front of the TV that he uses for his video cameras, just besides there's a full screen with the TE that he can follow in real time during the procedure. Okay, thank you. Another question for you, Dr. Shu, regarding the safe distance from the circumflex artery and the inner margin of the mitral animal zone TE, do you have any institutional guidelines regarding the distance? How do you approach that? Yeah, that's a really good question. So there is... We don't have a specific guideline based on the distance based on TE. I guess there's a few caveats to remember and to think about. So one is that based on the pre-op of coronary imaging, whether BCT or an angiogram, that's the first thing that we should be looking at. So as a surgeon, we look to see is it left dominant or is it not? Is there a big, you know, a big circle branch in the AV groove, which can be at risk? That's the first thing. Second thing is about is it going to be a mitral repair or replacement? So we did an anatomic study a few years ago where we looked at the differences and the risk is much higher with repair than replacement. And it's simply related to the angle that we place the anioplasty sutures. When you do a replacement, the sutures are perpendicular to the circumflex. And so it's much more common to... You can hit the circumflex, but it's very uncommon to completely ligate it. Whereas with a repair suture, because you're kind of going parallel and the angle that it dives off at, you can be at higher risk for injury in the circumflex. Now, the distance on echo really only shows you that portion where you can see it in the AV groove. And that's where it's difficult, because you can't see it all the way around all the time. And so even in that portion, just because you can see whether the floor there or not doesn't necessarily mean you didn't injure it more distally. And so what I would say is the most important thing is that after when you're done your repair and you're looking on T is to really look very carefully and evaluate the segmental wall motion and to look for that lateral and the inferior lateral wall. And it's hard because as a surgeon, you want to obviously think that you never make mistakes. And it's at that point when you're reperfusing, you just want to give a little bit more time. Is it error and all these sorts of things? But this is where it's really important that you have that relationship with your anesthesiologist and a cardiographer that you trust each other and you evaluate it. We're very lucky in London that we have a hybrid group. So in fact, we have a protocol where if we're concerned enough, then we will actually go ahead and do an on-table angiogram at the same time to be able to evaluate and assess just to rule it out. And obviously, you're going to look for the main things. So obviously, T is going to be the first thing that's going to identify it. Second is going to be ST elevation, recalcitrant VF. These are the sorts of things that will be common. And it will happen whether you do it only basically or sternotomy. And it's just it's important to be vigilant for that sort of thing. So I think that it's in our patient's best interest to have a indexed suspicion for that when you see wall motion abnormalities on the echo after the fact. Amazing. Now, I totally agree with you. Rafa, anything to add on? No, no, I totally agree. OK, thank you very much. Dr. Alfaro, thank you very much for being here. So there is a question for you regarding the new cordyce length. And like the question is asking you, how can you like how do you select the endpoints of the especially the Y prolapsing segment? Does it depend on the leaflet hinge point or crossing of annular plane? How do you measure the especially the Y segment, prolapsing segment? Thank you so much for the question. Very interesting. The main problem with the prolapsing segment is it's difficult to have it in the same in the same image with the head of the popular muscle. So basically, we just take it from the portion that you can see in the same co-optation plane that you can see the opposite leaflet. And that's for the posterior leaflet, the anterior leaflet, we just measure from the head of the popular muscle to the opposite leaflet and the co-optation, but in the posterior, just the segment. So we don't go from the hinge point because that will add a lot to the prolapsing segment, just the portion of the segment that is above the co-optation plane. OK, thank you. And how often, like in terms of like percentage, sometimes it's hard to find the popular muscle. How often is your success in acquiring this image to help guide in the distance? To be honest, at the beginning, when we start training our fellows, it's a little bit more challenging. But as Dr. Chu mentioned before, most of our surgeons, they just corroborate the distance. So we do the exercise to find the head of the popular muscle. So we use most of the time four or five chambers of view. Sometimes we use long axis view and in other circumstances, we have to go to mid commissure of view because of the problem that you are addressing right here. It's difficult to align, but I would say it's close to all the times that we are able to make the measurement, especially when we have a designated person in TE that can spend a little bit of extra time to acquire the image that better reflect and allow us to better resolution for the measurement. But I would say most of the time close to 100 percent of the time. OK, thank you very much. Rafael, anything to add for this session? We have more questions, but I think we should move to the... No, I think, you know, Mike was here and he always comes to the OR with a plan in his head. And we use the measurement of the cordae just to confirm his plan. How often do you have difficulties, Mike, when you're seeing the pre-op TE? Because they are performed under different conditions. The patients sedated, you know, sometimes the images are suboptimal. How often do you come to the OR and the interop TE pre-bypass changes your plan in terms of length of cordae or any other resection and so on and so forth? Yeah, thanks, Rafa. I think it really depends on the quality of the pre-op TE. You know, if the pre-op TE is not well done, then, you know, we rely heavily on the interop TE and that's where it takes a little more time to interrogate it further, you know, and sometimes specifically for neocordae measurement, if we can't find any views to be able to see the paplar head in the same view as the flail, then, you know, quite often we'll go with a resection based technique instead where we don't have to worry about it because in those cases, you know, the neocordae-length estimate will probably be more erroneous. So, you know, I think it really depends if there's a really good high-quality TE done beforehand and I think that, you know, the plan changes very infrequently. If the TE beforehand is not well done, then I would say, you know, the plan changes often based on, you know, the interoperative TE and it really, it's a testament to, you know, the importance of high-quality imaging, you know, because it makes all the difference. And as we've discussed many times before, you know, having high-quality imaging really improves the quality of the surgical repair that we can do and its assessment after. You know, it's taking the guessing out of it. You know, I think that the days of the, well, you know, as the surgeon, we're just going to come in and I'll see what I'm going to do when I look at the valve. You know, I think that's historical. I think Echo is far more accurate than what we could see with our own eyes. And it's far more functional. So, you know, having that high-quality echo assessment before, in the OR, and after is really, it's absolutely key to the quality of our repairs and reconstruction. Rafael, can I add something? Sure. I will add to that. Of course, we have, my call is one of our main surgeons to my travel repair. We have a couple of other surgeons to do minimal invasive repair. And as from the co-cardiography perspective, I will say that the echo, interoperative echo add to the already previous preoperative. It doesn't change completely. It's unusual that change completely apart from the surgeon. Maybe even we have an excellent cut, sorry, a co-cardiography lab. I will say in the OR we use a little bit more of 3D that helps to kind of see that commissure prolapse, see more, if it's more medial, more lateral. So the surgeons just adjust the repair to the interoperative findings. I don't feel, in my experience, it's not very common that completely change what they were planning. It just helped to add that piece of extra information. And we use a lot of 3D, I will say, to help with the views. Thank you. Yeah, no, I agree. I agree totally. And I think we, one thing, I don't know how if they do this in the echo lab, but we use more, we spend more time with the multi-view, as you mentioned in your presentation, aligning plans and being more accurate to make sure that we are in the exact point that we want to be. And I think that adds a lot to the patient care. Thank you very much. Thank you. Thank you all. Moving now to the second presentation, Dr. Tang, thank you for being here. So we have actually two questions for you. The first question, I think I can ask both questions at the same time. So in case of moderate functional micro-regurgitation discovered at the time of the cabbage, do you use the butamine stress test, stress echo pre-CPB to tell whether or not the MR might improve after cabbage and also the same case in patients with secondary moderate micro-regurgitation, but unfavorable predictors of repair success. Would you replace the valve or would you leave it alone, hoping that after the cabbage there is a more favorable remodeling would decrease on the MR severity? Thanks for those questions. I would say that, yes, it's always very important to understand whether there is some dynamic change that happens to that micro-regurgitation when you increase the blood pressure and get that heart rate up. That is really key because obviously, as stated previously, the difference in sedated patients the loading conditions are different and therefore the micro-regurgitation may be underrepresented. So if you do see that dynamic change and you're able to increase it to the point where it is severe, it makes you think that this is something that might need to have something to be done. If we have these circumstances under which, depending on what the difference is, if it is cabbage that we're doing, there's an area specifically affected the papillary muscle and then you have that tethering response and depending on the crinicity of that coronary disease and whether you think that there's a lot of viable myocardium in that area as you revascularize it, you're going to assume or help like it'll kind of sway you to think that once they're revascularized that MR is going to improve and probably you don't need to do anything for the MR. That's the reason that we would kind of leave that moderate micro-regurgitation alone. It is helpful to know obviously how favorable the anatomy is for any type of percutaneous approaches we'll have later to that mitral valve. It's a comforting thing to know that if we are wrong about this and that MR does get worse with time that we're able then to clip that mitral valve at some later date rather than have to go back in and open them up again and do a redo. Just those considerations along with other considerations obviously this is always a time that wades the risks and benefits of what we're doing. Obviously we err on the side of trying to get the most benefit for the least amount of risk at any one procedure. With moderate we really do want to be very certain that we need to add on another procedure because obviously there is increase in cardiopulmonary bypass time. Especially if we're going to think that we're having to replace the valve there are disadvantages to any type of project valve that we put in and so we have to also consider in the lifespan of this patient what some of those risks could be. I totally agree. Thank you very much. Yannis, we have a question for you. In terms of when you are assessing the mitral valve in terms of mitral valve linear measurements do you do the measurements and we know we have limited time in the OR so do you usually use the 2G measurements or do you spend more time doing the 3G assessment? We take of course a little bit more time. What's your practical approach for mitral valve measurements? Thank you very much for the question and thank you for the invitation once again. The classic way of measuring things in the OR is by 2D and this is the same all across the different vendors and there's no difference between them. It's quite easy and it's quite quick which is something that the surgeons are going to share for sure but there's a caveat. However, if you do those things you need to remember that the 3D valve is a 3D structure so whenever you think about that you need to consider that there's a Y, X and Z vectors so if you align the measurements you can actually increase the accuracy of your measurements. Whatever you're doing in a 3D structure if you consider a 3D imaging technique that's a more reliable measurement. Now, it not necessarily means that you're going to take a lot of time but the newer machines, the newer processors are quite easy to give you a lot of details with a really good frame rate if you remember the basic principles essentially you need to remember that the great 3D starts with a great 2D and after that if you reduce the sector size if you reduce the color size as well you're going to have a really good frame rate from which you're going to be able to measure more accurately and that applies for the LBOT, the Mitraval, anything. It's the same thing. Just to give you a heads up on that possibility as well. Oh yeah, I agree with you. I think as we should always try to do both measurements 2G and also 3G doesn't take that long anymore so we have pretty good softwares nowadays that allow us to make almost in real time and offers much more information. I totally agree. Thank you. I don't want to sound biased but we're talking about views of the live playing, multi-plane, NPR, live NPR nowadays they actually have phenomenal, phenomenal frame rate. If you play with the sector size you're not going to be behind any... your surgeon is not going to be on top of you as I remember when I was starting Dr. Vegas was showing us how to how to assess the Mitraval after the repair and I remember pretty clear when she said well just ask the surgeon what was he doing over the weekend, what was he spending the money on or things like that and they're going to they're going to get distracted. So just to give you a hint. I agree. I think now the softwares and the capabilities of the softwares are much better now so we have enough time to do this. I totally agree. Thank you. Carlos, we have actually also a couple of questions for you. So for you, what is it? Question to Dr. Gallardo. Our surgeons rarely try to repair the rheumatic mitraval. What's your percentage of repairing the rheumatic mitraval instead of replacement and do you have any specific key findings to suggest the surgeon of repair? For the question. So our rate of repair mitraval for rheumatic mitraval is very rare. So the majority is to replace the valve unless there is a primary heart valve replacement and we see also some moderate mitravegratation that we have to assess especially when we have a fused comsure that the surgeon can do comsurotomy. So that's in the case that we repair the mitraval in rheumatic patients. So usually we have to send some information for him to repair. Also the grade of calcification should not be very high. So the fusion of subvalval apparatus also is difficult to repair in this case. So if you have a playable leaflets move with good mobility and restrict the calcification that's a good point for him to for the surgeon to repair. But it's very rare. Even in here in Brazil the majority of rheumatic heart stenosis is replaced. Thank you. We also have another question here. It's well known that patients with mitra stenosis they have a significant reduction in the global oxygen to no strain. So it's not clear if this decrease is entirely due to LV dysfunction or is also caused by reduced preload to the left ventricle. So my question is a very practical question. Do you use strain for your evaluation in patients with mitra stenosis? What do you think of this technique for this patient? I think it's a timely question. I think we have seen some even more application of strain in the OR. But I don't use in my routinely assessment of mitra stenosis. The clinical relevance I think is still remains uncertain. We have field data. Although we have some data in rheumatic mitra stenosis that the preoperative when we assess the global strain for the left ventricle and left atrial function we have some perspective in terms of how the prognosis of heart failure in this patient as the disease progress we see decline in global strain. So it should be an important factor to measure. But I think also the car diet is also involved the myocardium. So sometimes it's not related to the mitra vulva error itself but the patient can start presenting some heart failure due to left ventricular dysfunction and I think global strain should be a nice application for to assess this patient. But routinely I don't use strain to assess mitra stenosis. Okay, no, thank you. Rafael, we have another like two minutes. Do you have any other questions that we'd like to answer or discuss? No, I think I'm all done. Okay, so I have one more question. I think we have time for that one. So this question is more is very practical and is related to the central line insertion for the minimum invasive mitra valve cases. So we show those that use like a like like two guide wires for the on the same thing not only to put the central line but also put the drainage canola. How does it work in terms of practical terms in the operating room? Do you like since you have to use different size of dilators to be able to thread the canola? Do you do it yourself? Someone from the surgical team also joins you to do this procedure. And also how do you keep the sterile conditions with your central line since they're all going to be on the same surgical field? Yeah, thank you, Dr. Papa, for the question. Yes, we do the placement of the central line in the surgical canola with the surgical team. So we scrap with them. We have a dedicated assistant to help us with that. A fellow or one of the surgical assistant or the surgeon himself. And in other than that, we have a profusion that is in charge of the infusion after the line is placed and is the one who is in charge of flashing the lines and all that. And usually we have two people in that cardiac OR in the forms of a fellow and a consultant or two consultants. So one is completely scrubbing. The other one is kind of taking care of patients and doing the echo. So we do have two different sets of dilators. So we use two dilators for the surgical cannulation because it's a big canola. Usually it's in French. So we keep the serility of the field in the way they place the surgical drapes. So they place the surgical drapes in a way that we can't remove them after the central, the surgical cannula is placed. And we have like a big piece of plastic going all the way up. But it's a sterile as well. And it's going to be placed between the surgical cannula in our central line. So we usually try to have a separation of at least one inch between, I mean, when patients anatomy allow. So we have enough room for them to do the compressions and the removal of the cannula at the end of the procedure. They have enough room for that. And also to put a sterile barrier between them and us. So we can just put the dressing in our central line and continue the procedure. Okay. Yeah, make more sense. I was curious. Well, we don't have more time. I'd like to thank you all for being here. It was such a great session. I truly appreciate all the information that you guys brought to us. I'm going to finish the session now. Don't forget to answer the evaluation forms. And we can regroup again in 15 minutes for the next session. Thank you so much. Thanks. Thanks everyone. Great session. Thank you.