 Hello everyone. Thank you very much for having me again at the Toronto Perioperative Team Symposium. It's a honor to be with you. I'd like to be there in person. I hope we can meet each other again soon. And thanks Azad and congratulations for the excellent job that you've been doing and that you've done again with this conference. As you asked me, I'm now talking about structural heart disease and presenting a few cases where ecocardiography plays a significant role in the procedures and in the planning for the best patient care. I have no conflicts of interest in regards to the stock. I do have a few disclosures. I'm a member of the board for the National Board of Ecocardiography Basic Exam preparation. And at Herdcentrum Leipzig, we are a reference center for Philips. Therefore, we don't get any money from Philips. We get eco-machines and software and all of our images are Philips. And I've also received an honorarium from Hubbot to talk about some of the products and eco for some of the devices that are made by this company. So as just said, I'll be presenting two cases. We'll be having a case of Tavi. And here is again something relatively new. We've been moving away from T for Tavi. And now we get a T back in the back in the game and it's starting to play again an interesting role in some of these cases. And then we'll be talking presenting another case of transcatheter mitral valve implantation. Our first patient who presented to us about two months ago was an 84-year-old man who presented for Tavi. He had a previous aortic valve replacement in 2004 with a stentless bioprostesis that failed ten years later, was replaced by with a triflecta aortic valve prosthesis. And in between, he also had bypasses on the left coronary system. And all of the bypasses were patent but open. He had chronic renaly sufficiency. He had a permanent pacemaker peripheral vascular disease heart failure. And the indication for Tavi was severe aortic insufficiency. When we met the day before the procedure with our heart team, our radiologist presented the CT. And as you can see here, it's relatively easy to see how the coronary arteries, the osteo of the coronary arteries are just above the ring of these bioprostesis. And so you can clearly imagine, we draw here, they drew the casts of these prosthesis that as we and if we deploy a valve inside these prosthesis, the leaflet will certainly obstruct these coronary osteo because the coronary osteo are too long. Now, for the left coronary osteo, osteo is not much of a deal, a big deal because we have bypasses that are patent but for the right coronary osteo, obviously if we deploy a valve and we don't do anything that will most likely result into a complete obstruction of the right coronary osteo. Therefore, we talked about or was suggested to do a basilica procedure. What is a basilica procedure? Basilica has nothing to do with the famous basilica in Rome but it has to do with a complex acronym that means bioprostetic aortic valve scallop intentional at laceration to prevent iatrogenic coronary artery obstruction. And this is the first paper where the group from here from Leipzig led by Mohamed Abdelwaham described this technique. Here is going back to the to the CT scan on the left is the left coronary artery, on the right is the right coronary artery and here the radiologist showed how is the coronary artery osteo oriented in respect to the center of the leaflet in this patient. And you can see that in the right on the right coronary artery, the osteo is oriented seven degrees, seven degrees from the center of the of the of the leaflet towards the left side. And so if we want to cut this leaflet in half in order to prevent the leaflet to obstruct the osteo, then we want to cut the osteo right in front. We want to cut the leaflet right in front of the osteo. So this is for example a diagram that I made with like famous Mercedes Benz sign. This is the right coronary cast and we want to cut it right in front of the osteum towards the center of the valve. This is our patient at the baseline the baseline echo. You can see a long axis view with X plane there's an aortic insufficiency, which is in this case actually a good news because normally patient will have aortic insufficiency if we do a basillica and we cause more aortic insufficiency that's usually way better tolerated than patient who have no aortic insufficiency and then suddenly develop significant aortic insufficiency with the basillica procedure. Now we can now look at the left ventricle, right ventricle, there's no wall motion abnormalities and in the deep trans gastric view we can appreciate how this regurgitan jet is actually quite eccentric and flows against the interventricular septum on the right. So here is our short taxis view and from this view by small movement of the probin and out we want to try to identify the cusp of the mitral valve which we want to identify the osteum of the coronary artery which I think it's somewhere around here. And now what I did is I took our CT scan and I flipped it up and down and right and left to orient the cusp, to orient this picture the same way as the echo and here where I put my now my arrow is where probably where we can appreciate the right coronary osteum and that's where we would want to from there we want to start a cut towards the center of the of the leaflet. Echo cardiography plays an important role in the basillica procedure and no one has described it before and we were lucky and honored to be able to write about it and publish this paper last year on jays where we described the role of echo and what are the steps and what we need to look for with echo for this basillica procedure. Basillica procedure is made of a few steps so the first step is consists of putting a loop like over a catheter under the valve that we want to cut so that's the snare system positioning and you can see that there's this catheter that goes through the aortic valve here in the LVOT we don't see the loop here because of the orientation we cannot really see it with echo. Now we've positioned the loop now comes the second and most important catheter there's the catheter that's the transversal system so it's a catheter that needs to be positioned exactly where we want to pop the leaflet where do we want to pop the leaflet right against the annulus or the ring here and right where the osteum of the coronary artery is so in this case we have our catheter was positioned exactly there and now if we're once we're lucky when we're happy with the positioning of this catheter through the catheter we get a wire an electrified wire and as we apply cotter into this wire we go through the the the casps off the off these bioprostatic valves and we can see we've gone through that the wire goes through the valve and as we pull through the valve you see that generates a little bit of bubbles and now we want to fish this wire back up with the snare so you can see on fluoroscopy we've now caught this wire with the snare and now the snare like the wire it's on one hand comes out of this catheter here on at the ring at the annulus here at the ring yeah of the bioprostasis the wire goes through the the the the casps comes into the second wire up yeah so the snaring is complete yeah and we can see that there's two catheters one and two one is here at the ring at the annulus and the other one is in the sample and this catheter as we put tension on both they take sort of a V uh like they appear like a V this is also described as the flying V sign doesn't really mean much it's simply that once we apply tension on the catheter the two catheter are oriented and the tips are oriented like a V now we apply to the wire in the catheter electricity again so cottering with like a normal surgical cottery system and we pull the wire and now we've lacerated the leaflet we've lacerated the leaflet the patient tolerated it well we have a little bit more arctic insufficiency in this case we what we also appreciated that happens often is that we may not be able to see exactly where like where this new jet comes from unless there is no the unless there is no insufficiency before but in this case we definitely can see that the initial jet is different so the insufficiency is definitely as like the jet of the the backflow has a different morphology and here actually comes from the anterior or like the right or what was what corresponds to the most anterior casks that corresponds to the native right coronary cask done the procedure we decided don't need to do the right because the left coronary system is has the bypasses that are still open so then we proceed to deploy an evolutar procedure 23 millimeter that's deployed based on fluoroscopy on echo we can see how the valve is released the valve is released and now the valve push the new valve the core valve push the leaflet of this bioprostesis on the against the the arctic root and because one was lacerated that's the right was lacerated the flow in the right coronary ostium is preserved there's no wall motion abnormalities and there was a successful procedure without parabola early and with sort of acceptable gradient with this new prosthesis the second case is a younger patient who presented with severe mitral regurgitation severe tricuspid regurgitation after with so patient who had a mitral valve repair 2008 and multiple comorbidities atrial fibrillation chronic renal insufficiency anemia cerebral infarct hemiparesis tias epilepsy peripheral vascular disease given the the high risk for conventional surgery it was proposed to deal with the art mitral valve regurgitation with the tendine valve the tendine valve is a is a wire so relatively invasive not not minimally invasive because it's done through the apex of the heart but transapical valve system that's delivered through a catheter you can see here the catheter through the mitral valve leaflet this is the tendine valve the valve can be its position it sits on the native mitral valve annulus and can be re grasped and taken out if we're not happy with the positioning or reposition adjusted the position and once we're happy with it how it sits on the annulus then the valve has a string that comes outside of the heart through the apex and the pad holds the string in place and holds the valve so then the valve sits on the native annulus this is our patient giant atria as you can you can see the mitral valve ring there was a son on the previous procedure mitral valve insufficiency in the long axis you can appreciate even so even higher degree of mitral valve insufficiency the problem was here that when we thought about tendine valve now you look at these anterior mitral valve leaflet and you look at at the tendine valve out sits on the mitral valve and you can appreciate that the tendine valve is at least two centimeter high so if we deploy a tendine valve in this patient with this long anterior mitral valve leaflet that you see here then what's left for blood flow in the lbot is limited very limited and it's like extremely small yeah opening below where would the core the tendine valve end and the interventricular septum not only because this anterior mitral valve leaflet it's long but also because the angle between the interventricular septum and the ascending aorta is relatively acute yeah it's it's a it's a it's a short it's not it's it's there's there's quite an angle between the septum and the aorta the ascending aorta sentence yeah so what we decided to do is or what we consider to do is to do so-called lampoon procedure lampoon procedure is is basically the the use of the same technique that you see for the so for the aortic valve but applied to the mitral valve so we pork the anterior mitral valve leaflet with an electrified wire that's caught by a snare here is in this animation done through the aortic valve so from the aortic arch now we electrify this wire we pull and then we cut the anterior mitral valve leaflet and this is the difference between having deployed a valve inside the mitral valve with lampoon or without lampoon and with lampoon the valve the anterior leaflet is split in half and that's a core sapience valve as you can see that sits in the mitral valve position this is our patient we look at the ring here we look at on the right with color massive mitral regurgitation what's interesting though is that when we're looking at the unfast view here I would have expected to find the aortic valve right here at 12 o'clock in respect to my annulus but in this patient the aortic valve is actually not sitting at 12 o'clock in respect to the mitral valve ring here it's actually sitting at like 10 11 o'clock here so at the level of the lateral commissure of the mitral valve so what was interesting is okay so normally with the lampoon procedure we cut the anterior leaflet of the mitral valve in half where this arrow is here but in this case that's not exactly where the lbot is the lbot is more a little bit more lateral and at a slightly different angle so that's where we decided just based on 3d yeah where we would be poking the anterior mitral valve leaflets and where we're going to proceed with the lampoon procedure the first step though was the trans trans apical approach so before we started anything we wanted to be ready to then deploy the tendine valve so we first identify the apex of the heart which is a critical step you see with the finger of the surgeon is poking on the apex of the valve here and we're trying to yeah identify the apex yeah where the apex is we do a per string around the apex and then we start with the lampoon procedure in our case we did it through the inter atrial septum that's the trans the the transseptal puncture catheter that came down this is an indentation we poke right in the center of the fossil valleys and superior uh in um so sorry and posterior so center and posterior and here is the catheter through the inter atrial septum through the catheter we park a wire as for clips in the left upper pulmonary vein and then we advance the second catheter through the inter atrial septum because for for this procedure we'll need two catheters at the same time which we can appreciate them on 3d on the right which is something that normally we don't see when we do other procedure through the septum because we only have one catheter and one wire so now we proceed with the with the lampoon the lampoon starts with the um positioning of snare system similarly to what we saw for the basilica procedure this snare system is positioned under the mitral valve and you can see here that there's one catheter that's going through the mitral valve and it's like sitting in the left ventricle and now the second the second step is the positioning of the transverse system so the transverse system uh is this catheter that needs to be positioned where we want to poke the leaflet then you can see that now the position in 3d here it's exactly where we saw before where we want to poke we're not we don't want to poke right in the middle here we want to poke more towards the um towards the lateral commissure and here you can see that also the catheter in the this mitral commissure of you is a little bit not right in the center but a bit more lateral and here you can appreciate the angle of incidence of this catheter in respect to the leaflet and we want to poke and position this catheter as close as possible to the annulus of the mitral valve once we are happy once we were happy with the positioning then we electrify the wire inside the catheter we push the wire through and now the wire is through the anterior mitral valve leaflet as we poke through the through the leaflet we got a little bit of bubbles and now the wire has to be catch caught by the loop that's underneath and here we were lucky that playing around with the with the probe we managed to get a also short axis view with the loop with the wire inside and now the loop is pulled back and the the wire is near and then now we have uh something similar to what we saw before for the aortic valve with like sort of like a v or like a flying v where we have like one catheter goes in the second catheter that goes out the wire is in the middle we're sort of ready to electrify and pull back and um we electrify we pull back and now we've lacerated the anterior mitral valve leaflet on 3d this is how it looked with our mitral insufficiency that was there and now it's there's also obviously even more mitral insufficiency given the degree of mitral insufficiency to begin with in this case this laceration didn't make a big difference um to the amodynamics of the patient so patient was stable and now we can proceed with our tendine deployment we have a wire a needle that's passed through the apex where the bursting was made the needle is directed to the um mitral valve now a wire is inserted over the wire the delivery catheter is inserted and now through the delivery catheter we need to position our valve now let's go back one step and let's look at this tendine valve so the tendine valve the top of the valve is not flat is um has a saddle shape just like the native mitral valve venues and just to remember that the tendine valve is higher anteriorly and lower posteriorly so you can see here that this portion of the valve is is higher than than the portion at the back so then as we orient these valves how do we orient it so how do we orient the highest portion do we orient it in respect to the aortic valve here or do we orient it in respect to the mitral valve venues and what we decided to do is to orient it in respect to the mitral valve venues because that's exactly that's where this valve is going to sit so regardless of the fact that the aortic valve is here at 11 o'clock then we still orient our valve so then the highest portion is like oriented towards the anterior portion of this mitral valve ring we start to deploy the valve yeah and as we release the valve you see that this is the highest portion that comes here anteriorly this is the aortic valve is still here at like sort of 11 o'clock and there's a point where the valve is the top of the valve is deployed but the bottom of the valve is not completely released and there's basically no flow through the valve and no flow through the mitral valve and you can appreciate it by the smoke that you have here in the in the left atrium and now the valve is fully deployed we have normal flow through the valve and now if we look in the long axis unfortunately the valve is stable it's now the string is pulled to the pad at the apex of the ventricle there is no a here and anterior paravalval or leak the gradient across this new valve was four millimeters of mercury and there's no LVOT acceleration so the lampoon procedure was successful there's also no turbulent flow although it's not easy to assess the turbulent flow given the shadow from the valve itself here is in 3d the valve is fully deployed sits nicely opens nicely and you can see and you can appreciate the location of this paravalval or leak which is comes exactly from where we started cutting this anterior mitral valve we tried to adjust the tension on the valve by increasing the tension on the string to see if this paravalval leak would get better but unfortunately despite our attempts the paravalval leak stayed there so we sort of accepted it as sort of not perfect but still acceptable result for this patient so basillica procedure for tavi is now becoming more and more common we do here roughly more or less one one every two weeks obviously echo then as we come back into the tavi room as well as general anesthesia because whenever we do echo we also do general anesthesia for basillica our cardiologist and we believe that echo makes a big difference it decreases the amount of radiation increases the the precision in which we we do the procedure and it also allows us to promptly detect complications and manage them then consecutively in a more prompt way we need to know the steps of these procedures and we need to follow what the cardiologists are doing on fluoroscopy we're lucky that here we have a screen just over I have a screen just over my echo machine so I can I just by moving my eyes I can see the fluoroscopy on this on the second screen so which obviously increased our communication and so and also sometimes I asked the cardiologist to to just turn on the fluoroscopy to see where my probe is in respect to the structures and respect to the devices that we're using sometimes it helps to optimize the quality of my images Lampoon is now become an option for mitral valve valve valve and more than ever is important to appreciate and understand the three-dimensional anatomy of the mitral valve and the lbot and three the echocardiography plays and makes a huge difference here in guiding our colleagues to complete a successful procedure I need to thank the interventionalists with with with whom I've been working in the past two years and who would do all of this procedure in our hybrid oar and particularly Philip Lurz and Christian Bessler and Mohammed Abdel Wahab who have been very patient especially at the beginning when I couldn't speak to German to to work with me and from whom I've really learned a lot together with Professor Ender who's my chief who's mentored me and helped me learn and be integrated in this team and to whom I owe all I know in in this new and exciting field of interoperative echocardiography here is my email you're welcome to email me anytime you're welcome to visit us anytime it's it's if you come to europe is you pass by here we're not far from berlin we are in sort of former east germany not far from the polish border we're easy to reach and next year in june i'd like to take this opportunity to personally invite you to join our team masterclass which is going to be a three-days event with online transmission of real cases from our operating room not only cardiac room but also hybrid rooms there's lots of good names that are going to come as as the speakers to our conference the conference would be both in presence so you can come to Leipzig and see our center as well as online so you can also follow us from canada once again thank you for the invitation thank you for having me and i hope we will have the opportunity to meet in person so bye