 Yeah, thank you very much, Dr. Bilal, for nice introduction. Actually, I'm enjoying as a cardiologist to be inside the department of anesthesiology. I'm learning anesthesiology. I hopefully I will not forget the cardiology. So I'll just go with this. Okay, so you have the first slide? Yeah, yeah. Yes, okay. So my lecture will be about type two aortic regurgitation for laps of tricuspid aortic valve in a normal aortic route. The case number one is a 66 year old man with diagnosis of severe MR and AR referred to our center for mitral and aortic valve repair. So this is the first view. You can see the patient has flail anterior mitral leaflet and when I put the color here, you see the severe MR and at the same time, you see the severe AR as well. So this patient has a double valve disease. This AR is very eccentric and is hitting the mitral valve. Again, in this long axis view, you can see the severe eccentric posterior directed jet of AR that is hitting the mitral valve. So in this view without color, you can see the prolapse of the right chronic cast and I will talk about the criteria to diagnose the prolapse. And this view again, you can see the prolapse of the right chronic cast down here and you can see the eccentric posterior directed MR, AI. So the direction of the AR jet will help you to diagnose the prolapse which leaflet is. Here for example, you see posterior directed AR, it shows that the prolapse is mainly in right chronic cast. Also, it might have, if you have a two leaflet prolapse, you might have even central AR or multiple jets of AR. This is short axis view of this patient. You see the aortic valve is tightly flipped, right chronic cast is at the bottom and the non chronic cast will decide the interlectoral septum and other one is the left chronic cast. And as you see here, you see the right chronic cast is developing like a double shadow appearance. And here you see the double shadow and that's a hallmark of the prolapse of the aortic valve. We described it many, many years back, like 25 years back ago, we knew it from here, but we didn't publish it and somebody else published it again. So when you see the valve, you see the valve is redundant and has an extra tissue. And again, it's like a mitral valve when we have a prolapse, you have extra tissue here, we have extra tissue as well. In this view, you don't see the AI. I just put this view just to show our people that sometimes when your probe is a little bit high, you might not see the AI at all in short axis. So it doesn't mean that there's no AI. If you go to probe down like a, maybe a half a centimeter, you will see the AI better. So some measurement, when we have a aortic valve and aortic root problem, we do aortic analyst measurement. We measure the science of Valsalva, STJ and tubular aorta. And if you want to go based on the recommendation of the guidelines and including the recent guideline, aortic analyst always should be measured at the mid-systole. Aortic valve should be open like this. And the problem is sometimes you have a sigmoid septum. You might not be able to measure this, especially in transtersic, but in TE you can see it very well. So aortic analyst in this patient was 2.4, so it's normal. 2.2 to 2.8 is in normal range. Science of Valsalva we measured in diastole. So science of Valsalva in this patient is 3.8. Again, it's in normal range. You take up to 3.9 or even 4 centimeter as a normal in a good size person. So this is a normal science of Valsalva. And silent to the junction, again you measure it in diastole. There's one important trick here that is in the guideline, but we don't obey it very well in the war. Where we should measure? Leading edge to leading edge or inner edge to inner edge. Usually inner edge to inner edge is easy for us in the war. We want to do quickly, but if you want to go guideline should be leading edge to leading edge. It means the anterior aortic wall or sinus is included in the measurement. So this leading to leading is applied for all aortic measurement. That's a way that we used to measure in transtersic and we used to measure in TE in the eco lab and that's the recommended one. Because you want to compare this measurement later with post-op of the patient. So leading to leading, but if you do it inner to inner, difference probably will be only two millimeter. It's not a big difference. So in this patient, all the root measurement, they are in normal limit, but this is severe for laps of the right corner cast. Again, this slide was shown a couple of times in today by two previous speakers. And this was described by Dr. El-Houri and I visited him many times in Brussels. So he was here in 95 when I was fellow for six months. Anyway, this is his classification for cause of the AR and mechanism of the AR and how we should repair it. So it's a repair oriented classification. This is a base for many of our lecture today. So type one is a one A, one B, one C that was covered by Anet and Azad and one D. And my part will be type two or cast prolapse. This is very similar to recommendation about or to classification about the mitral valve by Carpentier, that he was the fellow of the Carpentier himself. So he took it from Carpentier classification of the mitral valve and he applied the same way to the aortic valve. And this is a different technique of the repair that we are going to talk about this a little bit later. So our patient fit in this one type two that is the cast prolapse, but normal aortic root. So aortic root is normal, except if the patient has a long standing AI gradually and a loose and so on, so we might dilate a little bit but initial disease is not in the root. Initial disease is a prolapse of the valve. And we are going to talk about that. What is the cause of the prolapse? Is similar to prolapse of the mitral valve? Probably not. So how we make a diagnosis of the aortic valve, aortic leaflet prolapse is not as easy as mitral valve. So for many years ago, for mitral valve, we developed the main diagram that is still is using in many guidelines for mitral valve but for aortic valve, we worked in that time and now we are working as well. So to create some robust criteria to diagnose the aortic valve prolapse. The one that we knew from the past is double line appearance. So anytime it's a double line appearance of the cast that cast has a prolapse. And in this patient, in our patient, you see the right one has a double line appearance. The none has a little bit as well and even left has a little bit. But the main pathology is in the right cast. So by our experience and many published data, right cast is the most common one that will prolapse. And after right cast is the non-cast and left cast rarely will prolapse, rarely. And we don't know the pathology. When I asked David a couple of days ago, he said, I don't know why the right has more prolapse and the two other cast are not prolapsing. Because if we say, because the flow in the LV to the aorta is more from the right side is not correct. The flow from the LV to the aorta is more from the area of the non-coronavirus. But for some reason, the right coronavirus will prolapse more than other one. When we open the valve, you can see the valve is redundant. You see there's lots of extra tissue. And again, during the closing, you can see the double line. So double line right coronavirus, double line non and a little bit left as well. So it's a three leaflet prolapse that is not common and is very difficult to repair. So what we learned from surgeons. Actually, I myself as a person that I'm in the OR now for almost 35 years, I learned almost everything about the echo of the valves from the OR, not from the echo lab. Because that's the best place to learn. You make a diagnosis and the surgeon will open and I will tell you is right or not. So what we learned about the diagnosis of the aortic valve or aortic leaflet prolapse from the surgeons. This is Dr. Schaefer from Hamburg and he is the main person that developed lots of things about the aortic root dimension and measurement. And especially cardiologist from Paris Montessori Hospital and that is my friend, Dr. Alan Berreby. He developed this diagram and this diagram now is in the recent wide line. Anyway, for measurement of the prolapse, Dr. Schaefer suggested that we can measure the effective height of the leaflet, effective height. And he developed this caliper. So this caliper is a way that he put this part of the caliper to the leaflet and measure from here the tip of the leaflet to the base of the leaflet. If we draw a line here, this will be like our virtual aortic analyst. So from virtual aortic analyst to the tip of the leaflet, that's the effective height. This effective height as Azad was saying should be more than nine millimeter in normal people. Anytime this effective height that's easy for us to measure in the eco lab as well in the during the TEE came below the line that leaflet has a prolapse. Maybe it's not severe but has a prolapse. But when the this tip came below this ambulance that we got negative effective height. That is severe prolapse like the case that I showed you. So all the root measurement, all the root measurement they are in diastole except analyst that should be insistent. So analysts measure insistently the rest is on diastole and these are the number. The co-optation height or co-optation length normally should be above four millimeter. That's a co-optation height or lengths but effective height from analyst to the tip should be about a nine millimeter or eight to 10 millimeter. There is another important thing again we learned from the surgeon is the geometric leaflet height. So the geometric leaflet height is actual height of the entire leaflet that normally is about 16 to 22 millimeter geometric effective height geometric height of the leaflet is for example in this diagram is from here to here. This one is very easy by surgeon to measure by a ruler in the OR for us by echo is not always easy because this is a curved measurement. Some echo machine they don't have a curved measurement they have a straight measurement. So but like a pick machine Phillips has the curve measurement. So if you measure from the tip to the base of the leaflet that is geometric height. If you ask me what's the role of this? It is very important because if the patient leaflet decrease the geometric height that leaflet by definition is retracted. So it's a retraction. At the retraction is the most important criteria against the valve to be referable because when you don't have enough tissue in the leaflet less than 16 millimeter in tri-leaflet valve and less than 19 millimeter or 20 millimeter in biker's bed valve. When you don't have enough tissue you cannot repair that valve. There's no enough material. So geometric height of the leaflet is very important. If I'm gonna give you an example one will decrease is the robotic disease. So in robotic disease your leaflet is retracted is a short is shrunk and you cannot use it for repair. So again, I use that surgical criteria here. So this is easy one because if I stop here and measure the effective height you see effective height become negative because the tip of the right to the casp is below this line. This is our virtual aortic analyst. So this is negative. So this is a severe pull out. But if I go to this casp that's a non-query casp the tip is about two, three millimeters. So this one has a pull out as well. So in this patient the right corner casp has severe pull out is below the line and the non-query casp has a pull out is two to three millimeter above the line. If you ask me what about left corner casps? First of all, I will answer you. Thanks to God, the left corner casp does not pull out too much. But if you wanna measure it is difficult by 2DT is difficult because here this casp can be none can be left but we cannot have both of them at the same time. But we can do by 3D NPR and we can see each lifted one by one and measure this height. So that one need a little post processing maybe in the OR is not easy to do it always. But as I said, these two are collapsing more and we can easily measure it by this height in the OR. Direction of the OR as I said is helping us as well. If the direction is towards the posterior it means the pull out is more in anterior or more in right corner casp. So all diagnosis was severe pull out of the right corner casp, moderate pull out of the non-query casp and maybe left corner casp pull out because of that double shadow and all of this finding was confirmed by Dr. David in the OR. And he repaired the right corner casp by Gore-Tex reinforcement of the free margin of the leaflet. He repaired the non-query casp as well the same way but when he was trying to repair the left corner casp he saw some fenestration there and beside because of the age of the patient that was like a 68, 69, he said, okay, if I repair this valve the chance of the recurrence will be high. And if I put just the bioprosy valve it works very well as he believed that any Hancock valve that you put after the age of the 60 that patient will not come back again for re-operation. It works more than 20, 30 years. So in this valve he didn't push himself, he replaced it also he repaired at the beginning at the end he decided to replace it and he put the Hancock valve. The case number two is a polyapsodium bicuspid aortic valve that is a little bit more difficult again with normal route. So 50 year old man usually bicuspid they are a little bit younger with known diagnosis of bicuspid aortic valve and severe AR was referred to our center again for aortic valve spading operation. This is a bicuspid aortic valve as you see the RAFE is here. So there's a fusion of the right casp and the left casp. This is the most common form of bicuspid aortic valve. So right casp and the left casp and RAFE is between and this casp that is non-coronavirus casp was always better to be called non-fused casp. This one is a fused casp. So fused casp is right and the left and non-fused one is the other casp. So here when you see again you see the double shadow of the right casp right part and you see a little bit double shadow of the left as well. So we can say the conjoined casp or fused casp has a prolapse of the right part especially and a little bit left part but the other one does not have prolapse. So this is the pathology and the mechanism is again the prolapse and you can see the patient has a severe AR. I'm not going to talk about the grading of the MR already, Annette covered that. So this patient has severe AR and the reason, so mechanism of the AR. So again based on these two terms ideology and mechanism. The ideology is bicuspid aortic valve mechanism is prolapse. So prolapse of the right casp and prolapse of the non-coronavirus casp and AI again is posterior directed shows that the right component of the conjoined casp has more prolapse than the left. So AI went to the posterior directed again some measurement the annulus is 30. So bicuspid aortic valve annulus never is a normal is a little bit high normal or upper limit normal. So 30 and the sinusoidal salva is 3.9 is still in normal range and the tubular aorta is 4.2. This type of dilatation we see it always in bicuspid and all bicuspid aortic valve. So is the prolapse I already showed by echo but again, so double line and double line that's a sign echo sign. I can say echo sign of the prolapse. It applies to trial if it and the bio leaflet as well. What about surgical criteria? Again, we go back to the surgeons. I'm very close to the surgeon more than the cardiologist. So this is a professor Severs from Germany and he classified the bicuspid aortic valve in 304 patient and he classified as a type zero type one type two. This is the type zero it means zero raffae no raffae. So type zero no raffae. This is only 7% of all bicuspid aortic valve. This is called true bicuspid. Two commissure, two cusp, no raffae. So this is a type zero and this is a type one. Type one means one raffae and most of the time is between right and the left. This is surgical view. So surgeon is standing here. This is the most common one 88% of the time. So it's a type one with one raffae and this is type two with two raffae. So one raffae is here between right and the left. And one again, this is surgical view. Surgeon is standing here, right and the left and another raffae is between right and the none. And this is the only commissure. So this valve is two raffae. You can call it bicuspid aortic valve with two raffae or many as Severs called it but many surgeons believe that this is separate entity and we should just call it unicommissural aortic valve or unicuspid aortic valve because we have only one commissure. So it doesn't matter how you classify it. You can say type two Severs classification or just unicuspid, unicommissural aortic valve. This is the example of one of these unicommissural aortic valve. You see it's only one commissure, one commissure here and one cast. And this is MRI of that. So how common is this disease? We saw at the beginning this is not the very common adult. Yeah, we see it in pediatric a lot but in adult this form that has one commissure we see it many times but there's another form we call it unicommissural unicuspid a commissural, no commissure. That one does not come to the adult. Most of the time they will develop severe AS in infancy but the one that has one commissure will come to the adult. Also is like a two in 10,000 general population but if you look at the aortic valve replacement patient the patient that they will come for aortic valve replacement it will consist about four to 6% of all patient that they are going for aortic valve replacement that's a unicommissural aortic valve. What's the importance of this? Most of the time this unicommissural aortic valve is associated with AC in aortic dilation and some of them they come with aortic dissection. What about the repair of my cuspid aortic valve? Again, we owe a lot to three main scholars in Europe, Professor Schaefer and Victor Alchoury himself and Victor Lanzek from Paris and this serious school of my cuspid aortic valve all of them are in Europe because aortic valve repair is not part of the guideline in North America but it is plus one indication in Europe if the valve is repairable in AI we should repair it that is most of this is developed in Europe. Schaefer is emphasizing a lot on this angle the commissural angle. So this commissure and this commissure what is this angle? This angle in ideally when you have a pure or true by cuspid valve this angle is 180 degree but if you have a very severe one maybe even less than 120. So 180 or close to 180 is very good. That's a commissure angle and we can do the same measurement by echo as well. Like this case, we see this commissure angle is about 180 this is one of the example of the true by cuspid aortic valve. This is the like of our patient. It is like 160, 180 this is like our patient. This is a little bit even smaller angle and this is very small angle. This is like a tri-lifflat valve. So looks like that we think, oh, this is very similar to tri-lifflat valve. So maybe this is better for repair but in reality it is not. The one that is very close to tri-lifflat valve is most difficult by cuspid aortic valve to be repaired. So again, back to our patient. If we use that criteria we put the annulus line and measure these two leaflet the leaflet down is the right corner cusp part of the fused cusp. You see this is like a three, four millimeter. So this one has a power lapse. This one is okay. So the non-fused cusp is okay and the right cusp has a power lapse. This is the case most of the time in by cuspid aortic valve AI. The non-fused cusp does not have a power lapse. If that one has a power lapse it's very difficult to repair. So the angle we measured in our patient is this angle. So this is the commissure. Be careful. You have to close it in a, you have to measure it in a close position of the valve. It means in dice to it, not in cuspid, okay? So you freeze the image. You go slowly when the valve is closed you go from this commissure to this commissure and measure this angle. And this angle can be measured by our echo machine is there and you can measure it. So 150 to 160 is not bad. So in summary for this case our finding was this was it by cuspid aortic valve CVS type one right left infusion and type two Elchori classification and severe power lapse of the right cusp and a little bit left cusp as well in the fused cusp. No sign of frustration and commissure angle 150 to 160 and anulus of 30. These two criteria are not in favor of repairability. So anytime angle is more than 160 is very good. So this is a little bit difficult. Every was more than 30 is about more than 28 is a bad sign and we have to reduce it. Surgeon saw everything that we saw and he repaired it. You see? So very nice repair he made the valve like a true by cuspid with 180 degree. And you see it is no AI at all. It's a little bit turbulence but it's a good co-optation height and good effective height. Effective height is like a 1.2 and co-optation height is like a 4.5. So it's a very good repair. And if you see it, annulus he decreased the annulus to 2.5. That's good. So we should decrease the annulus to below 2.5. So there's no AI at all and no gradient. And I followed this patient. There's no AI. This was a couple of months ago. So in terms of the technique of the repair, again, I just go a couple of a slide only. I don't know how is the time. AI is about 13% of all valve of heart disease by European survey. So there are a big number of the patient and ideology as we discussed it in by al-khuri classifications type one, type two and type three. That's a romantic. And so this al-khuri classification shows the technique of the repair. We might do sub-commissioner alloplasty. We might do STJ remodeling, different technique. And I just go quickly. This is a two main way of aortic valve repair with replacement of the root. One was described by Yacoub in 1993 but he described that first in 1987 and one by Tyrone David. So David operation and Yacoub operation. And again, in the tea, we can say all of this measurement pretty up. And this diagram was shown a couple of times before. I'm not describing again. It's the way that the surgeon is measuring the height, effective height. And this is a way that the surgeon is measuring geometric height by a ruler. So post procedure always we check the degree of the AI, effective height, the co-optation height. And there's lots of very good paper if somebody wants to read it, especially this one. A state of the art by Caspid Aortic Valve Repair in 2020. And it's written by three main surgeon in the Europe. Lancet, I visited him as well from Paris. Al-khuri, the person that did the classification. And Schaefer from Hamburg. And this all diagram from them. So in summary, Aortic Valve Repair is a class one indication, level C for the surgical treatment of Aortic Regurgitation based on 2017 ESC guideline. But as I said, it did not come to the guideline of American so far. Interoperative TE plays a major role to define the mechanism of the AR, provide information to guide the repair, interrogate the result and determine the predictors of the durability. The Aortic Valve Repair is feasible in almost all patients. They say 90 times, 90% of patients is either by Aortic Valve in the absence of the valve retraction. The only time that we can repair is the valve retraction. What does mean the valve retraction? The geometric height less than 20 by Caspid and less than 16 in Tricuspid. And the main cause of retraction is the rheumatic disease or old age calcification sometimes. Currently repair is not recommended for patients with a pure type three, that's a refracted, the target leaflet, AR mechanism except in selected patient we are all in a pediatric or in an adult source. So thank you very much. Thank you Dr. Omran for another world class presentation which basically crowns the session and we've had, I'd like to congratulate all three speakers done on a wonderful session and I'll open the floor to questions. You can either post or... I'll ask my question by voice. Thank you Dr. Omran, that was a wonderful presentation. You mentioned the measurements being leading edge to leading edge versus inner edge to inner edge. And my understanding was that historically the leading edge to leading edge measurement was done because it's the most consistent measurement and you have the best definition on the image. So if you're tracking patients over time to see if they're reaching certain criteria for intervention, that's the most consistent way to make measurements but that if you're interested in actual morphologic accuracy for sizing a surgical prosthesis, for example, then the inner edge to inner edge is probably more accurate. Is that a correct statement? Yes, yeah. So for aortic analyst that we use it for valve size is inner to inner, as I was showing. But the leading to leading is recommended for scientists of Valsalva, STJ and the ACE in the ortho and as you said, the reason is leading to leading was there for many, many years in transtersic echo. And because we want to follow these people later again with transtersic echo, leading to leading is recommended. So the only time that inner to inner is recommended is for analyst. That's the size of the valve that we give it to the surgeon. Yeah, that's correct.