 Each of our speakers will have about 20 minutes for their presentations. I'm going to encourage you to submit your questions for the panelists to the Q&A that's at the bottom of your screen as we go along. If you wish to communicate among the audience, you can use the chat function also at the bottom of your screen. We'll answer as many of your questions as we can during the Q&A session after all of the speakers have presented. And so let's get right to it. Dr. Ahmad Omran is a cardiologist working with the perioperative echogroup at TGH. It's not an exaggeration to say that he is beloved by our fellows, our anesthesia echocardiographers and our surgeons for his knowledge and his ability to share that knowledge with all of us. Ahmad's a staff cardiologist at the Toronto General Hospital. He has fellowship in echocardiography and at the Toronto General Hospital in 1996 and subsequently collaborated with Dr. Tyrone David in developing intraoperative imaging techniques that support the development of novel techniques for aortic and mitral valve repair. He's the author of landmark papers on TE assessment, the mitral valve anatomy and the suitability for mitral valve repair. He's published more than 35 papers on the role of TE and valve repair and contributed five chapters. He's published chapters in five echocardiography textbooks, including the role of 3D TE in the cardiac operating room. And he's currently working as a staff cardiologist supporting the perioperative echogroup at Toronto General. He's highly regarded as a teacher in echocardiography and runs the quality assurance program for us at TGH. The title of Dr. Omron's presentation is echocardiographic TE assessment using 2D, 3D TE and practical assessment of TR. Ahmed. Okay. My name is Dr. Ahmad Omron. I am a staff cardiologist in the department of anesthesia and pain management in Toronto General Hospital. And I'm working with intraoperative TE team in the cardiac OR to help the team to do the TE during the cardiac surgery. First of all, I want to thank Professor Vegas and Professor Moreno for inviting me for this symposium and giving me this chance to talk about the tricuspid valve. I have no disclosure. The objectives of this talk is identify important views for imaging the tricuspid valve, recognize the additive value of 3D TE in assessing the TV and review the assessment of TR. The tricuspid valve used to be called forgotten valve and pulmonic valve at the same time used to be called unnecessary valve. That was reason that, you know, all time during the collection of technology follow, they were doing valve autonomy for pulmonic valve and they didn't care about the PI. Now we know that PI is a big problem. At same for tricuspid valve, we didn't know the importance of tricuspid degurgitation in the survival of the patient. Even in this survey of EuroHeart survey that was published in 2012, again, they talked about AS, AR, MR and MS. And nothing about tricuspid valve. About 60% of young adults have mild physiologic TR and moderate to severe tricuspid degurgitation affects between 5 to 8 in every 1,000 people in the US, about 1.6 million people in US. This is a very nice paper from Rebekah Han from the University of Columbia about anatomial physiology of tricuspid valve and a very nice editorial by Judy Hang from Mass General that the forgotten valve finally gets some respect. This is a comparison between anatomy of mitral valve and anatomy of tricuspid valve. As you can see, the mitral valve is thicker. The corridor number mitral is less than tricuspid valve is a continuity between aortic valve and the mitral valve, but there's no continuity between pulmonic valve and tricuspid valve. And of course, tricuspid valve most of the time has a 3 leaflet, mitral is 2 leaflet. And in the mitral, all part of the 2 leaflet goes to both papillary muscle. But in tricuspid valve, each leaflet is attached to its own papillary muscle. And as I said, the thickness of the mitral valve is 3 to 4 mm and thickness of the tricuspid valve is 1.5 to 2 mm. That paper-sine leaflet in the tricuspid valve makes the imaging much, much more difficult. That is the surgical view of the right atrium and the tricuspid valve. As you see, the anterior tricuspid leaflet is adjacent to the right coronary cusp of aorta, aortic valve. The septal is adjacent to the non-coronary cusp of aortic valve and to the septum and cornesinos. And posterior leaflet is adjacent to the IVC. Cornesinos drains somewhere beside the commissure between septal and the posterior leaflet. And this is the triangle of the coche. In terms of etiology of TR, 90% of TR are secondary to the left side valve. And 10% are primary. I'm not going to talk about the secondary TR because there's a second talk after me. And it is talking about that. And in terms of the primary TR, I might show you some of the cases during my talk. How to image the tricuspid valve by 2D and 3D TE? We have to always keep in mind this diagram. This is a specimen picture showing the mitral valve, tricuspid valve, and aortic valve that is wedged between these two valves. And so this is at the base of the heart, showing from posterior to the anterior. As you see, this is septal leaflet beside the internal septum and non-coronary cusp. This is the anterior leaflet beside the right-coronary cusp of the aorta. And the posterior leaflet is beside the IVC. This is how the tricuspid valve will dilate. The dilation of the tricuspid valve in secondary TR is from the commissure between antroceptal to the commissure antropostero. This direction. But this is not the direction that we measure the tricuspid annulus in TE4 chamber view. This measurement was done first by Dr. Arifous, a cardiac surgeon from UK and Monte Carlo. If you want to measure the same way that the surgeon measured, we should measure in about 60 degrees the tricuspid annulus. But the one that we are measuring at a zero degree is actually the diameter of anterior and septal. There are some limitations in the imaging of 2D and 3D TE4 tricuspid valve. Imaging of TE4 by 2D TE4 can be challenging as well because of the thin structure and positioning of the TE4 in far field and oblique in relation to the TE4 probe. And low, special and temporal resolution of 3D TE4 are the additional limitations for imaging of the TE4 by 3D TE4. This is two guidelines. One guideline that Americans try to go in 2013 and Society of Cardiac Anesthesia. How we do the TE4? And this is the recent guidelines. It's a joint guideline again between American Society of Cardiac Anesthesia and STS. And this is a guideline mainly decision making in the war. So there are some views that is TE views from the TE guideline. And I want to show you how it looks like in the specimen. So in this view that's a five chamber view, we don't see the tricuspid valve very well because we are cutting at this blue line, dashed line. So we see the aorta, we see the mitral. You might see a little bit of the tricuspid. Okay, tricuspid is a little lower compared to the mitral valve. But if you do a four chamber view, we see the septal leaflet and we see the anterior leaflet of the tricuspid valve. So that is this blue line. When we do view number 11 and view number 12, that is the midisophageal RV in through out through view and midisophageal modified by cable TV. You can see the TV this way. So the septal leaflet and anterior leaflet are together here inside the aorta. But the other leaflet will be the posterior leaflet. That is this blue line that is cutting during this view. So this is view number 11 and in view number 12. Again, you're showing the anterior leaflet and the posterior leaflet in view number 19 of TE guideline. Trans-gastic RV basal view and number 20 trans-gastic RV inflow outflow view. Again, we see the tricuspid valve here. In the number 19, we see the septal leaflet, posterior leaflet and anterior leaflet. And in number 20, we can see the anterior and posterior. And in number 23 view, again trans-gastic RV inflow view, anterior leaflet is below the picture and posterior leaflet is at the top. This is a very good view again to see the degree of the TR and even align it by Doppler and measure the RV SP. What about 3D has any role? It will add anything to the 2D TE assessment of the tricuspid valve. This is a guideline of 3D. It was published in 2012 and all big names in 3D are there. Roberto Lang, Luigi Badano and from our center, Wendy is there. In this guideline, they recommended imaging the TV mainly by trans-gastic echo because it's easier to get the tricuspid valve. And the view that they showed, we always show the valve in a way that the septum, intertial septum is below the picture. So 3D TE, at least in our center, when I was before here, I was in Saudi Arabia. This is the first view that I could get in 2010, 3 valve or 4 valve together. I was very excited to get this 4 valve together and I always show it because it's very similar to the anatomy specimen. So this valve, mitral is a romantic tricuspid valve is second as well. So that's the reason that it can be shown better. Again, posterior fluid, anterior fluid and the septal fluid and the aortic valve is wedged between tricuspid valve and the mitral valve. So how I get this 3D of a tricuspid valve by TE? Also in the guidelines says it's better to do it at 0 to 30 degree. But the way that I get it, I believe that every valve should be taken in a perpendicular to the valve. And we are in the war always. We know that the view that is perpendicular to the TV is 120 or 130 degree. So this is the tricuspid valve. My first view zoom mode and this will be the 3D zoom that I can get by that view. So IVC is here. Aorta is here. I will rotate this picture. And when we rotate it, you will have this picture. Also, as you see this tricuspid valve here is second. So that's the reason that we have a better picture. So there are a couple of landmarks. Aorta is here below the picture and mitral valve is here. So this is the posterior leaflet. This is septal leaflet. And this is the anterior leaflet beside the RA appendage. This is a surgical view of the tricuspid valve. Again, we have to be careful about the landmark. As I said, anterior leaflet, the landmark is RA appendage. And part of the Aorta may be septal leaflet. The landmark is intertial septum and posterior leaflet. The landmark is IVC. So again, this is the surgical view. Septal leaflet, posterior leaflet and anterior leaflet. Surgeon is standing here. So posterior leaflet is beside the right hand of the surgeon. This is one of the patients that had TR because of the dilatation of the tricuspid valve. So it's a secondary TR. And again, you can see by 3D, we show that there's a large gap at the middle. And that's a cause for TR. That's a gap. And when we did the repair by a ring, you see the gap is taken out. And there will be no TR. This is another case that had a trauma about six months ago. You can see a mobile mass here. This is a papillary muscle that is ruptured. And this is severe TR. This is 3D. Again, surgical view shows the anterior papillary muscle. So the anterior leaflet became flail. And here you can see by this movement. What about TR assessment by echo? Again, 2D and 3D. This is one of the regurgitant jet. Doesn't matter if this is a mitral, but tricuspid is the same. In every regurgitant jet, you should see the three components of the regurgitant jet. That's a flow convergence, venocontractor and jet area. So if you don't have or we don't see the flow convergence very well, it might overestimate the size of the venocontractor. So that's a very important trick that we should be aware of that. So that's how we measure the flow convergence. You have to be careful that because the TR velocity is lower than mitral velocity, you have to bring the Nyquist limit down lower than the mitral one. So the mitral one, we bring the Nyquist limit down to 40 cm per second. But here we have to bring it like 20 cm per second. So this is the venocontractor, however measured. This is trans thoracic view. And in 3D we can measure the venocontractor by 3D as well. Like mitral valve, we can use the pizza in tricuspid valve to quantitate the degree of the TR. But again, we have to bring the Nyquist limit down to about 20 cm per second. This is one of the examples of the patient with a rheumatic mitral valve. This is trans thoracic and rheumatic tricuspid valve. You see the large gap between the leaflets. That's a severe TR, but you don't see the flow convergence. So we might overestimate the size of the venocontractor if you don't see that fellow convergence. That's a Doppler. You see the Doppler has an early peaking. It's a triangular shape. And the velocity is not very high. Because the pressure difference between RV and RA is not very high. It's not very big when we have a severe TR. This is the hepatic vein and IVC. You see IVC is dilated and there's a flow reversal in hepatic vein. And this is a T. You see the transverse, it was much, much better to show the tricuspid valve in this patient. So T, we don't see the leaflet very well. And this is severe TR. This is the TR jet. This is another case of Epstein. You can see the sale like anterior leaflet. And you can see the severe TR. So this is a cone repair. It was done in our center by Dr. Honjo. And you see the valve. He made it like a cone. This is the opening of the cone to the RV. So this is a TV inflow. And this is CDD exactly. It's like a cone. I put the flow flow from RA comes to the inside the cone and goes out from the mouth of the cone. So in summary, echocardiography plays a major role in assessment of tricuspid valve and differentiating between primary and secondary TR. Interoperative T evaluation of TV should focus on anatomy and function as well as physiologic effects on surrounding structures. CDDT has an additive value in defining morphology of the valve and mechanism of TR. However, imaging by CDDT can be challenging as well because of paper scene structure of the leaflets and positioning of the TV in the far field of the probe. So thank you very much for listening and hopefully we can answer to some questions. That's really wonderful. Thank you so much. And, and certainly I'll encourage people if they have some questions to go ahead and put them into the Q&A. And we'll get to them at the end of the of our all of our presentations.