 So, the topic of my presentation is type 3 mitre regurgitation. I have no conflicts regarding to this topic. And in the next half an hour or so, 25 minutes or so, I would like to describe the classification and mechanism of type 3 mitre regurgitation, discuss a systematic approach for the interoperative assessment of mitre regurgitation, also discuss a little bit of some morphological changes related to chronic mitre regurgitation, and also discuss and apply the last ASC 2017 guidelines in order to quantify the mitre regurgitation, type 3 mitre regurgitation. Okay, so our first case is a 66-years-old male with a past medical history of severe art crystallosis and also an art dilatation, who presented to the hospital with severe heart failure, had a normal angiogram done last year, and also at the same time he had a TEE done that showed a severely dilated left ventricle with an EF of approximately 20% in a low-flow, low-grade art crystallosis. So the proposed surgery for this patient was a tissue AVR, plus or minus ascending art and NMR replacement. So our interoperative TEE assessment showed indeed that the patient had a really bad art crystallosis, as you can see here using the X-plane or the biplane view, we can see the art revolve is pretty calcified, really poor opening. Doing all the measurements, we got an art valve error of 0.6 square centimeters and also a mean gradient of 29 millimeters, probably because of the low ejection fraction. So when we start doing our left ventricle assessment, so we also saw the right ventricles pretty normal in size and normally in function as well, but the left ventricles dilated actually with a really poor ejection fraction. Here we can see in the four chamber view and also in the transgastric view, the medipap transgastric view, how dilated the LVE is and how poor the LV function also is. When you keep moving our assessment and you keep moving the multplane angle, we can rotate the angle to evaluate all the walls, we go to the two chamber view and also to the long axis view where you get the same diagnosis. And also when you look the mitral valve in the long axis view, we can see the mitral valve although looks normal, the leaflets look normal. The function of the mitral valve doesn't look normal. So we can see the mitral valve looks a little bit restricted. The leaflets look a little bit better with poor leaflets co-optation line. In order to improve our assessment, we put some color on, color flow up and on and we can see now is that the patient has some sort of central mitral regurgitation. Probably this mitral regurgitation is related to the poor leaflet co-optation due to the leaflet restriction. So according to Carpegne classification of mitral regurgitation, we have three different types of mitral regurgitation. We have type one with the normal leaflet motion, type two, sorry, with the excessive leaflet motion and type three with restricted leaflet motion. Type three, you can divide in type three A and type three B. Type three A is the one that we have that the valve itself is diseased, which is going to be the second case that I'm presenting today. And type three B is the one that we have the normal leaflets itself, but something else is going on with the ventricle probably some sort of remodeling when we have all the subvalvular apparatus being pulled into the ventricle and the leaflet co-optation gets a little bit better and that's the reason why the patient starts to have mitral regurgitation. This is the case that I'm presenting now. The patient has a really big ventricle, dilated ventricle and that's the reason why the patient is presenting with mitral regurgitation. Following the 2017 ASC guidelines, we should do an integrative approach with all the different parameters in order to get a good assessment of the mitral regurgitation. We should use a morphological assessment. We should look at the valve, see how the leaflets are working. If there is some pathologies in the leaflets itself or it's something related to the mitral valve apparatus, which in this case was the reason why, so we can see here the leaflets are really restricted in motion, especially the posterior leaflet. The leaflet co-optation line is, we have a really poor leaflet co-optation line, especially due to the poor posterior leaflet mobility. We can also look at the, we can also evaluate the LV size and also the LS size, which are indirect signs of mitral regurgitation. Moving forward to the semi-quantitative, qualitative and quantitative assessment of the mitral valve, we can use the color flow in order to identify the mitral regurgitant jet and also with the color flow, we can also, if possible, we can, if we can align the whole jet, we can also measure the vena contracta width and also we can evaluate the flow regurgitant area of the mitral valve, of the mitral regurgitation. We can also use the, like I said, the vena contracta width, which is pretty much the true orifice of the mitral regurgitant lesion. And also we should also, we can also measure the, we can also measure the pulse wave doppel in the pulmonic vein in order to get a good sense of how the receiving chamber is coping, is dealing with the excessive volume that is like, is being pushed forward to the left atron. So when you have a systolic flow reversal in the pulmonic vein, it's really specific for severe mitral regurgitation in about 85% of the cases. So when you move to the quantitative approach, you can use the PISA method to measure the EROA and also measure the regurgitant volume and regurgitant fraction in order to get a better sense of how bad or how bad is the severity of the mitral regurgitation. For our patient using the PISA assessment, we are able to measure an EROA of 0.3 centimeter square and also a regurgitant volume of 35 ccs, which puts the patient in using all the integrative approach that the 2017 guidelines present, put the patient in the moderate range of mitral regurgitation more towards the grade two mitral regurgitation value than the grade three. So if we put all the parameters that I just said, we can like I'm showing you that the patient had a dilated LV size, dilated L8 size. He had a vena contracta width of 0.4. He had systolic rebounding of the pulmonic vein flow. He had an EROA of 0.3 and a regurgitant volume of 34 ccs. So the patient ended up getting a bio bento. He had also ascending and ascending ME-R to reconstruction. And what they found was that the Arctic valve was by Cosped with left and right fusion. So here is the patient coming off bypass on a lot of ionotropic support. You can see, you see now the new valve in place. You can see the mitral valve leaflets are opening and closing a little bit better. The patient is hyperdynamic at this point coming off bypass on 10 mics of dog with still a little bit of mitral regurgitation. And the follow-up echo on this patient two weeks after the surgery showed a marginal improvement in the LV function. It was 10 or 15% before. Now it was 25% with no paravolvular regurgitation and tracing mitral regurgitation and normal RV function. So this was to illustrate a type three B, Carpentier classification of mitral regurgitation, type three B is related to the valve itself is normal. What is happening is the LV for some reason is dilated, there is some remodeling that is like pulling back all the subvolvular apparatus making the cause for the mitral regurgitation. Moving forward to our second case. Our second case is a 65 years old female with a 148 centimeters height and 92 kilos. With a really complex history. She has a history of a chronic AFib with a normal LV function, some sort of a diastolic dysfunction. She also has a history of rheumatical mitral stenosis. The mitral stenosis was assessed a few years before but because of the patient's severe chorobesity they declined the surgery on this lady. Also a history of a saccigian hypothyroidism. At this time she presented to the hospital with an exacerbation of heart failure, rapid AFib that needs some assessment, that needs some sort of treatment now. So the trans thoracic examination showed a severely dilated LF atrium, moderately dilated atrium, normal RV and RV size and function. And she also had a severe mitral stenosis due to rheumatic disease with a mean grade of 20 millimeters of mercury with a mitral valve area estimated in 1.3 square centimeters and also some moderate mitral agrogitation. So the patient had proposed a mitral valve replacement, also Maze procedure and also isolation of LF atrial appendage due to chronic AFib atrial fibrillation. So we start doing our intraop T assessment. We can see in the four chamber view the biventricular function is normal. We can appreciate the size of the left ventricle which was really big. We can also see the right atrium was also enlarged and we cannot appreciate in the four chamber view at least in this picture the mitral valve like the way you should assess it. We also can see the transgastric and the mitral transgastric view. We can see the normal biventricular function. When we start moving with our multiplying assessment we start moving and change all the walls and all the mitral valve assessment. We can appreciate the size of the left atrium and especially on the long access view we can see some features related to the mitral stenosis due to rheumatic mitral valve disease due to rheumatic disease. We can see both leaflets are really thickened. The mobility of both leaflets are really restricted but especially the posterior leaflets not moving. The anterior leaflet has some sort of appearance of a hockey stick appearance in the diastolic frame. So this is pretty specific for rheumatic mitral valve disease. When you go to the 3G assessment of the mitral valve using the zoom module looking from the atrial perspective we can see the mitral valve in the center of the screen. We can see the arctic valve on the top of the screen at 12 hours and you can see the poor opening of both leaflets due to rheumatic disease. Talking a little bit about zoom mode that we are using to get this picture is a really good modality for real-time 3G and also multi-beta position. It enables us to focus on a specific 3G image and a specific volume. It's really good for evaluating valve and specific areas of the heart especially valve and inter-intel septum procedures. It allows us to have a really good understanding and live understanding of what's really happening in procedures in real-time. But also in order to get a really good picture of the 3G zoom mode we should like having in mind some tips in order to maximize and optimize those frames and those pictures. So in order to maximize the frame rate in order to maximize the temporal resolution we should also like focus in our assessment in one specific structure. Before that we should have a really good assessment of the 2G picture. You should get a really good 2G picture of the structure that we are trying to image. We don't have... There is no way you can have a really good 3G picture without a good 2G picture and assessment. After we get the 2G picture and we do the assessment we should change the focus to the structure of interested and also trying to get the region of interest of region of the area that we are trying to imagine the smaller as possible in order to get the best frame rate. And also in order to make the temporal resolution better and sometimes the spatial resolution better we can change from the live 3G mode to the multi-beta position. So this is going to improve also our temporal and spatial resolution. So going... And also we can use the NPR, the Multi-planar Reformating which we can like cross all the three different axes the X, the Y and the Z axis in order to slice the valve exactly the point that we are trying to see and it can show us exactly where the disease of the valve is. In this example, I took this example because using the Multi-planar Reconstruction we can have a really good assessment of the disease the P3 disease on this valve. Going back to our patient continue with the micro valve assessment put some color on the micro valve you can see that is a really, really good like a really sederity mitre stenosis on this patient we can see the flow acceleration in diastole but also when you get a good frame we can see also that is some sort of mitre regurgitation. This patient has a mixed valve lesion she has some sort of... She has a really bad actually mitre stenosis and also some sort of mitre regurgitation. In order to quantify this mitre regurgitation first before that this patient because of the mitre stenosis the mitre valve is restricted due to like taken in due to the rheumatic calcification this patient is a type 3A carpentry classification the first example that I gave was a type 3B classification which was related to LV dilatation to do some remodeling and this patient has a type 3A mitre regurgitation due to restricted mobility of the leaflets due to the thickening caused by the rheumatic disease. Using the 2017 severity assessment guidelines we should like try to integrate all the informations that we get with the G assessment. So for this patient we have a really thick anemobial mitre valve leaflets we also have a really big, really dilated left atrium using the quantitative, semi-quantitative and qualitative assessment of the mitre valve we can see we are able to get a vena contract on this patient of 0.5 centimeters calculating the EROA and the bi-pizza method we had a really good assessment of the pizza radio we are able to get a regurgitant volume of 34 cc 34 millimeters which would put this patient in the same range as the patient before in the modern range of mitre regurgitation she had like a pretty bad disease in the mitre leaflets pretty restricted leaflet mobility she had a really, really big left atrium she had a variable color jet area and she also had a 0.4, 0.5 vena contracta width with an EROA of 0.3 and a regurgitant volume of 34 cc so this patient ended up getting a tissue valve she also had a maze procedure and also pulmonary vein isolation she came off by pass on some support so this is the long gaxes view of the mitre valve post replacement she had a tissue mitre valve the mitre valve, the prosthesis looks fine both leaflets are opening and closing well we don't see any degree of mitre regurgitation anymore when you calculate the gradient across this valve was below five millimeters of mercury and when he did the 3D assessment of the mitre valve looking from the left atron side we could see the mitre valve on false view opening and closing wells the leaflets opening and closing wells and I would like to end this presentation with a few key points first of all, we should integrate approach of all the different parameters in order to have a more accurate assess of mitre regurgitation severity there is no single Doppler or single 2G modality that is precise enough to quantify the severity of mitre regurgitation in individual patients so we should always try to get some quantitative assessment of mitre regurgitation severity especially when the dagginals of mild or severe mitre regurgitation is not that clear and we also should have in mind that when we are using colorful Doppler we are going to discuss this in the afternoon on the questions we should always have in mind that using colorful Doppler for mitre valve assessment can be very misleading because sometimes although the patient has a really like a small jet error for example a sanctuary jet that goes and hugs the wall area the wall atrium area this patient may have some sort of moderate or severe mitre regurgitation when you use colorful Doppler to assess mitre regurgitation colorful is really important to identify the jet but we should then emphasize the importance of colorful Doppler only we should pay attention to vena contracta width which is much more specific for mitre regurgitation and we all should have a good understanding of the regurgitant flow and the convergence area in order to have a really good assessment of the mitre regurgitation I'm going to stop it there if you have any questions and thank you very much thank you Fabio for the amazing presentation back-to-back-to-back great presentations does anybody have any questions for Fabio well I'll ask you a question with in that first case if you have a patient with severe aortic stenosis and a functional MR when do you decide when do you decide to actually do something to the mitre well I'll actually replace it sorry sorry because could you repeat severe AS and concomitant functional MR and you're going to move from and you're going to and it gets more difficult to deal with the MR after the aortic valve replacements when do you decide to intervene on the mitre valve well that's a that's a good question so it's hard to tell and we should like have a like a patient we should like do a really photo assessment on the patient so for our patient so we didn't we are not expecting to have this this sort of mitre regurgitation beforehand because the transoracic echo didn't show that so when he put the trans the transophageal echo and they saw the echo and we saw the picture so we did a an assessment because the surgeon was asking us should we change this mitre valve should we do something this mitre valve or not so the patient she had a he had sorry he had a my like a more towards the mild regurgitation mild to moderate regurgitation so the patient and end up not doing anything on this valve because he said oh we are going to change them the aortic valve so probably this this is going to allow the latrine to go to remodeling and to get better hopefully the mitre mitre regurgitation is going to go away in a few weeks and that was exactly what happened but for patients we thought like some sort of more than moderate mitre regurgitation is is a hard assessment so we should like have like a see patient by patient see what they they do normally here at the hospital they they try not to touch the mitre valve unless the valve the valve has some sort of organic disease if it's functional and it's caused by probably severe aortic stenosis they they tend to just touch the aortic valve and let the mitre valve alone and in hoping that the mitre the latrine is going to remodel and it's going to get better and the degree of mitre regurgitation is going to improve.