 So, today, I shall be predominantly talking on minimally invasive mitral valve repair. It's a surgeon's perspective. Just give you an idea, as I stated about the setup, what kind of surgery repairs we do, and just in short, some of the results which we had from live seeing. I have no disclosures. So, Frederick Moore is one of the pioneers of minimally invasive mitral valve surgery, having performed himself, performed about more than 4,000 minimally invasive mitral valve repairs, and always said that every mitral valve can be operated on minimally invasive. But the goals of surgery have to be very clear. It has to achieve similar or even better clinical and anatomical outcomes to conventional mitral valve surgery. So, in short, it has to have a very high repair rate. And if you're doing a valve replacement, then it has to be efficient and efficacious without parallel leaks, without high gradients, et cetera. You have to maintain the highest patient's safety. Optimal visualization of the valves is extremely important in sternal spreading incisions, because if you don't see the valves properly, it's not possible to repair it. The same goes also for conventional mitral valve surgery. And finally, it should be minimal access. It should not be a 10, 15 centimeter thoracotomy, which defeats the purpose of the operation. It has to be about three to four or maximum five centimeters in length. So, there are definite advantages to minimally invasive surgery, and I think the most important one is it minimizes surgical trauma and therefore reduces blood loss and therefore reduces transfusions. It improves postoperative respiratory function, because basically, you're not playing around too much with the mechanics of the thoracic cage. You're not breaking any bones. You're not breaking any ribs. So respiratory function is usually well maintained. There's, of course, a lower incidence of wound infections. And it therefore leads to early mobilization and potentially shorter hospital stay. But more importantly, what I feel is it improves or speeds up the recovery of the patient once he or she is home. And within about three to four weeks, they are pretty much able to get back to their routine activities. It also does facilitate re-operation at a later date. Re-operation through a sternotomy following a minimally invasive mitral valve surgery is like a primary operation. Provided the first one, the minimally invasive was correctly performed and you've closed the pericardium. Entry into the chest is very safe. You can even saw it with a normal saw. You don't need an oscillating saw for that. And, of course, an added benefit is superior cost masses. Although one must always keep in mind that this is not the primary aim of the operation. It's just an added benefit for the patients. So an advantage of minimally invasive surgery, as you can imagine, is exposure. So when we go through a sternotomy, you can see the root to the mitral valve. It's an acute angle. So you have to have at least three, four, five steps just to expose the mitral valve properly. And that's these first seven steps, which Dr. David always says exposure, exposure, exposure. These have to be performed in a conventional approach. Whereas in a minimally invasive approach, when you approach the mitral valve from the right side, you see that it's a pretty much direct shot at the mitral valve. This is the atrial septum. Once the atrial septum is slightly elevated, the mitral valve is very clearly visible. As you can see here. So this is the visualization that you get. We always use an endoscope or a thoracoscope to perform the surgery. And the advantage is that every structure of the mitral valve can be clearly seen, including the papillary muscles, the cordy tendinates, the valve itself. And not only can the surgeon see it, but even the assistants, the OR nurse, the perfusionist, the anesthetist, the echocardiographer, all of them can have a good look. It's good to even teach your residents and fellows because they can really see what you're doing as opposed to an astronomy approach where you're bending your back in order to visualize the mitral valve from the opposite side. So there are the indications for this surgery are pretty much all patients requiring straightforward mitral valve repair or replacement can be performed through a minimally invasive approach. Even complex mitral valve repairs can be performed. And in addition, concomitant surgeries like tricuspid valve surgery, cryoablation for atrial fibrillation, PF or ASD closures can be performed. There are certain surgeons performing myctomy as well for HOKUM, but I'm not a very keen fan of doing that because the results have not been the best long-term. But it's possible to do it. And of course, myxoma excision is very straightforward operation, which can also be performed through this approach. But there are certain contraindications. So the absolute contraindications, I would say, are a previous right thoracotomy because the lung adhesions are very severe sometimes to go in through the same approach. Again, a heavily calcified mitral annulus or even a very large mitral annular abscess in a patient with endocarditis. It's possible to do it, but it just takes a very, very long time because you do not have too much help from your assistant. So I would still refrain from doing such patients through a minimally invasive approach. Patients having more than grade 1 aortic regurgitation are a contraindication because delivery of cardioplasia becomes an issue and you do not get good myocardial protection if you have more than grade 1 AI. Now, pathology of the descending aorta, I would rather put it in relative contraindications because if you do have a calcified descending aorta or you have a thrombi in the descending aorta, you can do axillary artery cannulation and perform the operation. So I would rather use it as a relative contraindication. Of course, femoral artery calcification, again, the same thing. You can use axillary artery cannulation, obese females with large breasts. It becomes really difficult to do the operation, but it's not impossible. And an ascending aortic diameter greater than 40 again, the risk of aortic dissection or iotrogenic aortic dissection is slightly higher when you're doing aotas of larger diameter through this approach. Now, we all know the functional classification of mitral regurgitation, which was proposed by Allan Kampranti in his famous article, The French Correction, where type 1 was basically involving annular dilatation or cooperation of the leaflet. Type 2, which we most commonly see in the West, is due to either elongation or rupture of the cordy tendinary resulting in prolapse. Type 3, a commonly found in the developing world, usually rheumatic in origin, resulting in restricted leaflet motion. And type 3B is also another aspect that we commonly find nowadays in this part of the world. I mean, not only this part of the world, all over the world, which results in restricted leaflet closure, because it's basically a left ventricular problem. But we see less and less of these patients coming in for surgery nowadays because of advancements in clip procedures. So we'll basically concentrate more on the type 2, which we most commonly see in this part of the world. Now, if you look at the valve pathology and related to the complexity of the cases, now in a type 1, annular dilatation is a very straightforward, simple operation where you just need a ring. There are semi-complex cases where you have a leaflet perforation, which can be patched. And then you have large leaflet defects, which require large patches, but not only the patches should be large, they have to be tailored in such a way that you get good leaflet motion and good leaflet co-optation at this end of surgery. So it becomes a bit more complicated. Similarly, in type 2, if you have just a limited prolapse, it can be just connected by a small triangular resection. Whereas if you have a chordal rupture or elongation, either to one of the leaflets, A2 or P2 or even A3 or P3, but just one segment involved, it becomes a little bit more complex. But the real complex cases are when there's extensive prolapse and flail, particularly a bi-leaflet prolapse, or as you know, the historical barlow, where sometimes all segments prolapse. So these become very complex cases. Again, in a 3A, when the leaflets are reliable, it's still possible to repair even rheumatic valves. And if you have a posterior leaflet shrinkage, then you might have to add a patch to it, which becomes a little more complex. But if it's extensively calcified, I think most surgeons would go ahead with a replacement. But there are a few surgeons, like Tavisac from Bangkok, who would still manage to repair the valve with various techniques. And again, in 3B, if the left ventricular endoscopy damage is usually less than 60, then most likely it's possible to just put in a downsized annular blaster ring and repair the valves, which is again, becomes more difficult if the ventricular size becomes larger and larger because you need to add sub-valvular repair techniques in order to get the valve competent. And I think for greater than the ATI, I think most patients now with various trials that have been published, go ahead with replacement. So there are several repair options, because if you see, you can have a repair level at the level of the annulus, at the level of the leaflets, at the level of the cordy, the papillary muscles and the LB wall. And if you combine all of them by mathematical equations, you can have almost 120 repairs which you can perform. So there are a lot of repairs that you can perform to get the valves competent. So it's important for a mitre valve surgeon to be conversant with most repair techniques. Now the commonest repair techniques that are used are the leaflet resection, either triangular or a quadrangular resection with annular plication. Or if the defect is large, then you need to use a resection sliding annular plasticity. But if you see in all these techniques, there is a reduction in the amount of leaflet tissue. And therefore it inadvertently leads to a reduction in the mitre valve orifice area. And secondly, when you do a lot of work on the posterior leaflet, it usually becomes stiff and it doesn't move at all. So it basically gets converted into a mono leaflet valve. There are other techniques which are propagated by carpentia like cordal shortening and cordal plication, which are not used by surgeons commonly anymore because long-term results are not really satisfactory. Cordal transfer is occasionally still used in a very small area of prolapse. You can do a cord transfer, which works quite well. You can use this flipover technique where you use part of the posterior leaflet to fix the anterior leaflet prolapse. Papillary muscle sliding plasticity again is not used nowadays. Papillary muscle repositioning, which was propagated by Dreyfus, is an elegant technique to take care of more commonly the posterior medial commissure prolapse, where you stitch the anterior head of the papillary muscle down to the posterior head of the posterior medial papillary muscle, and therefore it corrects the prolapse. But these are not very commonly used. The advantages of cordal repair techniques are there's no foreign material, but the disadvantages are that you're still using the cordate tendinia that are diseased, and therefore you do not know what the long-term outcomes will be if the disease progresses. So artificial cordate came into being in order to address these disadvantages of using the patient's own cordate. This was first used by Frater, who was from South Africa. He used first the pericardial strip as cordate tendinia, but then he also used PTFE cords that we commonly use now in his experiments. And in clinical use of these PTFE sutures were first published by Dr. David, who commonly uses a single suture in order to correct the leaflet prolapse by putting in multiple cordate tendinia to the prolapsing segment, and this is the way he performs it. And at the end it looks like this is a single suture, and the advantage of this is that even if one is short, the other is long. It balances out once the heart starts beating because the PTFE sutures are very slippery. Now this type of a procedure is possible to perform in a combined conventional technique, but it would be a bit difficult to perform through a minimally invasive approach because you need an assistant who can hold the leaflet at a particular height, which is not possible in a minimally invasive operation. So in minimally invasive surgery, many surgeons just use single PTFE sutures. They use two, three, or four single sutures, which are easier to manipulate once they are placed. The left ventricle is filled with saline, and then they tug on the sutures in order to get the leaflet at a particular height and then tie it off. But again, when you tie these sutures, you have to be careful that you don't shorten the cordate while tying. So these are the challenges that you face in minimally invasive surgery. And in order to overcome all these challenges, Professor Moore in Leipzig, he developed the Leipzig loop technique, where we use the so-called loops, and these are loops which are made up of PTFE. These were the ones which are now commercially available, at least in Europe. They're not, unfortunately, not available in North America in this fashion. So this end is placed under the papillary muscle, and the free edge of the loops are then sutured to the free edge of the leaflet with extra PTFE sutures. We will see that. And this is something which we use to measure the length of the sutures that are required. These sutures are loops are available in lengths from 10 to 26 millimeters, which are adequate for anterior and posterior leaflet repair. So that's how we measure the loops from the tip of the papillary muscle, or the point on the papillary muscle where you want to insert them to the free edge of the leaflet. And that's how they are inserted into the papillary muscle. And then with an extra suture, they are sutured to the free edge. And finally, this is what they look like. So the advantages of this loop technique are this precise and it's reproducible. You have better control with a knot pusher, which you have to use in minimally invasive surgery. And thirdly, it also follows nature's laws, because you can have the loops which are slightly longer than required so that the posterior leaflet moves rather than having a stiff posterior leaflet that doesn't move at all. And therefore, you have a valve which is more closer to nature than just a monocusp valve. So the technique now as far as positioning is going to be give a 30 degree left lateral position. And the important thing is that this axillary area has to be completely free and but painted and draped because most of this action takes place in this area as you will see. So here you see that the entire surgery is performed in this small area. The camera is introduced. This glass clamp is introduced in this area near the axilla. And this is the incision. Some surgeons take it more anteriorly. I prefer to go more laterally. And some of the surgeons, of course, use the nipple cut what they call it and do that surgery completely endoscopic. So the first step of the operation is to cannulate the groin. And it is extremely important as far as you or anesthesia is concerned that this groin cannulation is performed under strict echocardiography or TE guidance. So we just open the groin right above the femoral vessels. Then we take purse strings in the femoral vessels as you can see here. And the insertion of the cannula is performed with the Sellinger technique. So the first step is insertion of the wire. And this is the most important step because the wire has to land up in the superior vena cave as you can see here on TE. And this has to be confirmed by the bicable view which you have to show us when this procedure is being performed. So following this the cannula is introduced. It has to go in smoothly. There should be no resistance to the cannulation because once you have resistance, you should just stop because you can have catastrophic complications if you try and push the cannula through which may lead to life-threatening bleeding in the abdomen. Following this we put in the aortic cannula and that's again performed through the Sellinger technique. So in this case you have to show us the guide wire in the descending aorta. And once this is confirmed then we dilate and push the cannula in. So that's very important. So the involvement of anesthesia as far as echocardiography is concerned is extremely important in this step of the minimally invasive operation which otherwise you wouldn't pay much attention to in a conventional surgery. So now moving on to the actual technique of surgeries. But this is just a patient with posterior leaflet prolapse. It's a P2 prolapse. You can see the eccentric jet directed anteriorly. So this is how we drape the patient. The incision is taken just lateral to the nipple and we enter the chest to the fourth intercostal space because that's the best, anatomically that's the best space that gives us access to the mitral valve. So I'll just run ahead with the cannulation again. So as you can see again purse strings and once the cannulation is done we put the patient on pump. Because we directly put the patient on pump, at least I personally just use single lumen endotracheal tube. So we do not use double lumen tube for mitral valve surgery. So once the patient is on pump and the pericardium is open, we put in the cardiopage or purse string suture. We put in the root needle inside and the root needle is then brought out through the chest just lateral to the sternal border. Following this we put a stay suture on the right superior pulmonary vein which is again pulled up to the same puncture wound lateral to the sternal border. And once the aorta is clamped and cardiopagia is delivered, the left atrium is open. It's the same incision which we take through a sternotomy, the parasympial incision. And following this the left atrial retractor is inserted again through the puncture wound lateral to the sternal border. And this is how we pull up and see that it can get beautiful exposure of the mitral valves. Then you assess the mitral valve as usual with your nerve hook. Here is the prolapsing P2 segment that we saw on the ECOGA program. And here is the measurement of the cordate and so the loops. So this is the caliper that we use and you have to measure it from the point on the papillary muscle where you're going to put in the these loops to the plane of the mitral valve or about two millimeters below the plane of the mitral valve. So here you're seeing the loops as being attached to the posterior medial papillary muscle. And once the posterior medial is done, this is now the antrolateral papillary muscle loops being attached. And once the loops are attached, then we take separate sutures and fix it, fix the loops to the edge of the leaflet. So the trick here is that if you feel that the prolapsing segment is too long, then you can go deeper on the leaflet. So you go about four to five millimeters away or deep to the edge of the free margin of the leaflet. But if you feel that the posterior prolapsing segment is not too long, then you can go just at the edge of the free margin of the leaflet. So this adjustment obviously depends upon the experience of the surgeon. Unfortunately, everything cannot be just done according to mathematics. Some amount of judgment still remains. But the advantage here is that once you've got your loops fixed, when you tie it off with a knot pusher, there is no way of shortening the length of the loops, which is possible when you're using freestyle cordy tending with PTFE. So then we perform that water test. It's just a rough test to see if the prolapse has disappeared or is corrected. And once you feel that the prolapse has been corrected, you then start putting your annular plastic sutures in. One thing when you're using the water test is many times you will see that the anterior leaflet is prolapsing. And so this is many times a pseudo prolapse. So it's extremely important for you all as echocardiographers to let us know beforehand on the echocardiography whether the anterior leaflet was prolapsing. If the anterior leaflet does not prolapse on echocardiography, then when you test the valve, it is usually a pseudo prolapse and you do not need to correct it because if you correct it, you might over correct the valve and you might have a restricted anterior leaflet. So it's extremely important as far as the anterior leaflet is concerned that the echocardiographer is able to tell you for sure whether it has a prolapse preoperatively or not. So once all the annual plastic sutures are put in, it's passed through the ring and you can either tie the sutures with a knot pusher or now a more elegant way of doing it is using the core knots. It speedens up the process and once you've done the, put the ring in, then you again test the valve and see if there's good co-optation. The line of co-optation should always be posterior and should be parallel to the posterior mitral annulus. So once you're satisfied with the repair, then of course you go ahead with closure of the left atrium, just run ahead. Once the left atrial closure is performed, then you come off pump first and check the valve. So once you're satisfied that the co-optation and the valve is competent, then you have to go back on pump again to finish the procedure that is to decanulate, to put in your pacing wires and to take out the cardioplegia cannula because you cannot do this with the heart beating and the lung expansion. So the important, this is the most important step again I feel for preparing for a redo. You have to close the pericardium completely because if you leave the pericardium open at this point, the lung sticks to the right atrium and it becomes a nightmare to do a redo operation for the next surgeon or even for yourself if you're doing the redo operation. So it is very important to completely close the pericardium for that reason. If you don't close the pericardium, it does not affect the entry as far as sternotomy is concerned because you still have the pericardium covering at that point below the sternum. But this is important to make your life easy so that you do not have to dissect the lung of the right atrium. Both the structures are very delicate and you have multiple injuries to both the lung and the right atrium if you try and dissect them. So that's very important to close. So just to ensure a few results, this was a paper we published way back in 2013. This was the experience in the LIBSIC from 1999 to 2010. Almost 3,500 patients, close to 3,000 were Mitrava repairs and about 609 Mitrava replacements. Now if you look at the Mitrava repairs, we used a ring in 100% of the patients and most commonly we used a complete ring and very few patients we used the partial ring that is the cost growth band. And about 10% of the patients, 30% of the patients received cryoablation, about 10% received tricuspid valve repair and a similar proportion of patients also received closure of the patient for aminovil or atrial septal defect. The only disadvantage I think of a minimally invasive approach, it takes longer. So if you see the mean clamp times, aortic clamp times about 75 minutes can extend up to almost 120 minutes if you're doing a complex mitrava repair. Whereas in a conventional sternotomy you would be able to get through a simple repair in about 45 minutes and a complex repair would take about one hour or one hour 15 minutes. So that's the one disadvantage and similarly the cardiopulmonary bypass times and the total length of surgery also is higher or longer than a conventional technique. Conversion to sternotomy if you see was only 1.4% and the failed mitrava repair for degenerative mitrava disease patients was about 1.6%. Now if you consider these results are actually great because it involves the learning curves of multiple surgeons who have trained at Leibzig Heart Center. At least I would say 20 to 30 surgeons must have trained to do mitrava minimally invasive surgery there and despite these learning curves the conversion rates and the failed repair rates are extremely low. The 30-day mortality is about 2%. Stroke rate is about 2%. And if you see the long-term outcome which was recently published about two years ago, if you look at 10 years the survival is about 85% and freedom from cardiac death is about close to 90% and freedom from re-operation at 10 years is close to 97%. So it really gives good very good long-term outcomes as well. Now this is just to show that the repair rate is extremely high and this is a single surgeon experience. Patrick Perrier was one of the famous minimally invasive mitrava surgeons. Just to tell you that once the surgeon achieves expertise in this type of surgery the repair rate is almost close to 100% and with very low mortality rates. So once it's just the experience of the surgeon which is very important and of the team particularly of the team as well which is very important to get excellent results. All pathologies and repair techniques can be performed. You can perform anterior leaflet repairs, you can perform bi-leaflet repairs and you can also perform complex repairs as in the case of Barlow's. So this was a paper published again from Leipzig of 145 patients with Barlow's and as you can see a majority of them receive the loop technique and a few receive also the leaflet resection technique because sometimes there's just too much tissue in Barlow's disease and you do need to resect. So again you can see the freedom from more than grade two or more than grade two MR were at 10 years was almost close to 90% and again freedom from re-operation at 10 years was 94% in Barlow's patients. So here's just a this is a case we did in Toronto which is again you can see it's a bi-leaflet collapse it's almost a Barlow's patient and here you can see the anterior leaflet prolapse as well. So when you see it look at the 3D it's a P2 prolapse with a sort of A3 prolapse. So this patient we again use the loop technique. So these are the loops which have already been placed to that from the anterior enterolateral papillary muscle and as we go ahead you can see we are putting in now the sutures in the papillary muscle for through the posterior medial papillary muscle for the medial part of the P2. So here you will see that we do not have those loops that were available in Leipzig and these are slightly different but the concept is pretty much the same. So there's the needle going two needles pass through the papillary muscle and then the Pledgeut is being pulled down onto the papillary muscle and that's the other Pledgeut for the other side going down and then you tie off the loops onto the papillary muscle. So one more important aspect here to remember is that while tying down you have to be careful that your knots do not include either the neocodyl or the native cordy because if the native cordy or the loop the neocodyl gets stuck into your knot then you will have a problem because the cord will be extremely short. So you have to be very careful when you're even tying these knots that you do not include any extra tissue. So here the loops are being now tied onto the leaflet. You can see here how deep I have taken sutures onto the free edge of the loop. So the free edge is here and it's almost 7 to 8 millimeters deep. So this is because the posterior leaf prolapsing segment of the leaflet was extremely long. Now here you see the water test. The posterior leaflet prolapse has disappeared but here you can still see the A2, A3 area prolapsing. So we use again measure the loops that you're going to need and once the measurement is done we can put in this malleable retractor which really improves the visualization of the papillary muscle. You can see here and you can very well then put your loops into the papillary muscle. So this is a very clear vision that you get which I don't think besides a few surgeons in the world really get this type of vision through a sternotomy approach. So again here we've placed the loops the one pleasure going down that's the loop end of the pleasure at the loop end and that's the pleasure at the other end and then you tie it off. So here you see that we try and place these loops in the fibrous portion of the papillary muscle but you could also put them in the belly of the muscle. It usually does not rip off because we use the gadgets and secondly, Kapanti always said that the perimissium of the papillary muscles is extremely strong and usually does not tear off. So perimissium forms above the first the superficial 2 to 3 millimeter layer of all papillary muscles or in fact all muscles and it's very strong. So here we again put the connect the loops to the free edge of the anterior leaflet. So in the anterior leaflet you see you really go close to the edge of the leaflet not too deep into the leaflet because the anterior leaflet prolapse has to be corrected perfectly. There is no play room for the anterior leaflet just as you have in a posterior leaflet. So once that is corrected you put the ring in you check your again a rough test. You can see now that the A to A3 area is slightly inverted inside and now once the ring has been placed you again do the water test and you see that it's now completely corrected. This area which was bulging now has completely been corrected and the line of co-optation is parallel to the posterior annulus. So this was the postoperative echo. You can see a very good line of co-optation. You can also see a slight movement of the posterior leaflet rather than making it flat here it moves a little bit. I would have liked it to move a little more but it's still a bit mobile and I think that reduces the tension on the anterior leaflet and would probably provide a much better long-term result looking at 2030 or 40 years. So finally this is a meta-analysis which is not new. It is about 10 years old which compared conventional versus minimally invasive surgery. Unfortunately there are no randomized clinical trials on that comparing minimally invasive to conventional surgery. So this meta-analysis showed no difference in mortality between the two techniques but the factors that favored minimally invasive surgery was lower incidence of atrial fibrillation, less amount of chest tube drainage, lower rates of wound infection, the ventilation time, length of ICU and hospital stay was lower and patients returned to normal activity much quicker and of course patients' satisfaction was much greater with the minimally invasive approach. The relative drawbacks of minimally invasive surgery are that there is still a stroke rate of about 2% as opposed to 1.2% with normal conventional surgery. Aortic dissection is still a possibility. It's very rare but it's not zero unfortunately. You do get groin infections every now and then but the way of avoiding them is to stay exactly on the artery not to raise flaps in the groin which is very often lead to lymph fistulas. Frenic nerve palsy also occurs with this type of surgery but what we have learned in Leibzig is that once you open the pericardium anteriorly and do not tuck the pericardium too much, frenic nerve palsy pretty much is zero. Of course as I already mentioned it has longer clamp and pump times. As far as long-term outcomes were concerned again they did not find any difference in mortality at one year, three years and nine years. There was no difference in recurrent MR, infective endocarditis or valve related re-operations or in fact the NYHA class of the patients. So with that I'd like to conclude that a variety of cord repair techniques are available to repair degenerative mitral valve mitral regurgitation and a combination of techniques is used to repair complex mitral pathology especially in patients with anterior leaflet or bi-leaflet prolapse and in patients with Barlow's disease. A specialist mitral valve repair surgeon must have the ability of performing as many repair techniques as possible to improve the rate and the quality of repair particularly when you're performing minimally invasive mitral valve surgery and you can almost always achieve a near 100 percent mitral valve repair rate for degenerative mitral valve disease. And with that I'd like to thank you for your attention and would be happy to take any questions.