 Good morning, everyone, and thanks for inviting me to this Niagara Global Cardiovascular Forum. I'm Dr. Srikanth Konigram, the Director of the Structural Hygiene and VAL Clinic, and Interim Director of the Cardiovascular CDMRI at Texas Heart Institute at Bellas Influenced Medical Center. Today I'm going to talk about the management of mitral and records with bowel disease. I have no disclosures. Let's talk a bit about the mitral valve regurgitation. The prevalence is age-dependent, affecting almost 10% of the patients more than aging more than 75. The etiology is either primary or secondary. It's either a valvular pathology or a ventricular pathology. The excess mortality occurs from the medical management only and delays in the intervention. The surgical risk and the etiology determines the intervention and its timing. The delay in the surgical peripheral and the complexity of the valvular pathology itself can increase the mortality. The rest of my slides will have multiple 3D images, and I want you to familiarize with this. You can see in the primary, which is a valvular pathology, you can see the iodic valve anteriorly at the 12 o'clock and the lipid lipid digit, 9 o'clock and the intratral septum. That's the anti-mitralifid there and the pushy mitralifid there. You can see a flial pushy mitralifid at the center of the scallops causing the etiology of it. Here you have an annular dilation because of the ventricular enlargement causing tethering of the pushy mitralifid and mitral valve regurgitation. Moving on, we know that despite the patients have significant symptoms without qualifying for a class 1 indication, continuing medical management has detrimental effect versus the early surgery. There are multiple percutaneous valve therapies currently available for patients who are at a higher risk. The initial trial which led to this was the Everest 2, which is a 5-year follow-up data showing that though there is no significant difference between patients who are randomized for surgery versus edge-to-edge technique of mitral clay, there was a significant difference immediately after the six months period. The procedure is successful if the mitral clay procedure is successful. There is no significant difference after six months in regards to the re-operation and the repeat mitral valve surgery. That led to the initial approval of a mitral clay for primary mitral valve insufficiency. As everyone knows, it's a co-op trial which is mainly for the secondary MR. It has shown almost 56% reduction in hospitalization when compared to the patients who were treated just with medical management compared with medical management and device group. There was 36% per patient year in the device group compared to 68% in the patient year in the control group. Also, the mortality was significantly differed in patients who were treated with device and medical management compared to medical management alone. You can see here the death from any cause within 24 hours was almost like 30% even in the device group compared to 46% in the control group. Despite optimal medical management and treating with a mitral clay device, one in three patients die showing the higher risk of this patient population and whom we are actually doing it in the current clinical world. Going along, this is just a multiple trans-isophageal echo of use to show how we get on to know where the pathology exists and how we are going to move forward to really treat this. These are all the color-compared views of a four chamber, a two chamber where the commissioners use and know where the pathology is. In this case, it's the partial mitral leaflet. We use 3D essentially to know where the cleft mitral leaflets are or where the flyer segments are to really know which direction we're going to place the clips. And this improvement in 3D technology has really improved our success rate with the mitral clips. Also, in doubt, we use the effective regression to modify areas to calculate the severity of the mitral valve insufficiency, especially in the functional cases where the PISA is less useful given the placental shape of the jet and the EROF more than 0.5 depicts to be severe. And in doubt, we use cardiac MRI to assess the severity of the mitral valve vegetation. As a part of a pre-mitral clip planning, we want to know what the baseline mitral valve area is and if the mitral valve area is more than four, we're pretty comfortable that placing a clip is not going to cause mitral stenosis. So we use the 3D molecular reconstruction to measure the area and we'll make sure this is all amenable for mitral clip. This is a transexual access video just to show that the optimal distance from the annulus is at least like 4 to 5 centimeters because there is a limited talkability of the guide catheter. So we want to have as high as possible so we're not like ending up in trouble reaching the valve leaflet or like overreaching it. This is where like, you know, we judge where exactly to place the clip. We look at it in multiple views and once we are comfortable, we grab the leaflet and once we show that like everything is fine, then we'll check it on the 3D from the atrial side, from the ventricular side as in this top views looking from the atrial and ventricular aspect of things and then we place the color to make sure that we had a good result of the mitral valve regurgitation and this is the secondary MR case where again even though you have a very tethered thin posterior leaflet, you could be able to grasp and cause a very good result. We would make sure that before releasing it, we want the mean gradients to be at least 4 in this case just 1, so we would we're not like really causing any mitral valve stenosis after placing the clip. Now there are multiple cases where the surgical the percutaneous H2H repair is not amenable and they are still high risk because the surgery is not the option. I'll show some of the examples and in this particular case it's a mitral valve a mitral perforation from the medial commissure causing a significant jet going along the lateral and filling all the left atrial appendage in fact and here you can see how the perforation is rising from the commissure medially in this case it's pretty hard to have an H2H repair obviously and anatomical defects like cleft anterior mitral leaflets significant deep ridges in the posterior mitral leaflets and having a very wide prolapsing segment with multiple file florets especially in this particular case with very severe mitral valve regurgitation so to grasp all these cords and the leaflets can significantly under cure the disease and can cause stenosis with a very poor outcomes in the end and in this case like now there's an elderly lady who's got Barlow's valve to start with but she has continued to have significant valve stenosis with sorry like valve calcification with a file segment right there where the arrow is pointing out these particular cases placing a mitral clip can cause mitral valve stenosis and these are not an ideal cases for proceeding with H2H repair this is another final example of papillary muscle rupture even though it's amenable for clipping it's going to be a really difficult and challenging case to proceed with it in these cases the new percuteness valve devices have been developed which to completely replace the mitral valve with the new bioprostic valve the multiple types have been developed there a lot more to be shown these are some of these examples now many of these devices use a different mechanism for anchoring some uses the left ventricular apex like a tendon valve or some use the radial force like interpret valve and some has the anchors around them to show these anchors can give the support a radial strength for the devices to sit on and so on and so forth and we currently have Apollo trial which is an interpret device from Edwards it's a very elegant design with an outer ring which sits nicely into the complex annulus of the mitral valve and there is an inner ring which contains a 27mm pilot thread bioprostic pericardial valve and it gives an elegant way of dealing with the complex annulus and then still having a decent olfize to overcome the mitral stenosis and parallel leaks the study design is currently we have a one-to-one randomization and a single arm itself and this has further a valve into patients who also have mitral valve calcification and now a current generation transeptile deployment has has come up as well which is going to which is going to completely revolutionize the current technique this is an interpret DMVR system which is an Apollo trial again I want to show the animation of this which is self-expandable you can see once you unsheathe the device it's going to adhere to the annulus the outer skirt and takes the shape of the annulus and then releases the inner device with no significant parallel leaks or like any major compression of the inner stent so there's a lot of pre-procedure planning goes along with this cardiac with the cardiac CTs to make sure that the device is right sizes and what not and this is just to show the way to go with the septal lateral and the commercial to commercial distance and the area and the perimeter we go with the three different sizes currently available for us to use and we use one of them with the suitable upsizing this is an elegant way to show that in a baseline normal height you have an LVOT which is the narrowest portion of the area in the outflow track and once you place the prosthetic device in B you have now have a new narrowest portion which is now called as a new LVOT and that's the area of interest right now for any of the prosthetic devices to be placed because you could lead to a significant narrowing of the LVOT causing significant LVOT gradients so the way we go across is we model the valve at different phases of the cardiac cycle and we average the areas to work the cardiac cycle and if the average systolic area of more than or equal to 1.5 centimeters scale we're good to go and proceed with the valve requirement this is just an example of an intrepid valve going through trans-epical route and once it goes to the center of the valve we kind of like label so that it's easier for the surgeons and interventionists in the room to know where exactly the device is placed and once it's placed unsheating the device will make it land right at the center of antiposturally and the laterally and once we are comfortable we'll go ahead and start unsheating and you can see this the valve the bioprostic valve start to function in this case with only trivial central leak and no significant leak also in the 3D see the outer skirt sitting very nicely around it and the inner stand showing a nice valve with a very trivial central maternal valve registration so what we're supposed to do with the valve in Mac and this is an example of showing what happens when we do a model valve in the rinse which is a valve in valve or a valve in a prior bioprostic valve and you do have significant near-LVOT reduction and it's a concern and as is the case with a native valve where you have a decent near-LVOT but however with patients with mitral valve stenosis as you know the LV is smaller in these cases the near-LVOT is significantly smaller and there is a higher risk in this patient population that this can lead to a very narrow LVOT and LVOT gradients can occur so the planning for these cases of the valve the plastic particular valve in the Mac is very challenging this is the case where you can see there is a significant concrete at mitral valve severe mitral valve calcification of the annulus and then you also have a mitral valve stenosis so you got to deal with this and obviously the surgical risk is extremely high in these patients dealing with both the valves and the pump time is going to be higher and so is the risk of the surgery and this is just to show a photorealistic light to enhance the 3D view and showing where exactly is the calcium so the surgeons can really know and the interventionist to predict the parallel release and the outcomes so the previous case which I was showing we dealt with a tower core valve in heriotic valves and then we modeled an Edward Sapien valve in the Mac and we know that significant issues with the parallel release during the extent of calcification and whatnot so we proceed with a surgical, a minimally invasive surgery where you have a direct deployment of the Edward Sapien valve the suturing and flipping and suturing the mitral valve around the Edward Sapien valve to overcome the parallel release with a very excellent result and this is just an example at the baseline on the top and the bottom showing that you have an Edward Sapien valve within that Mac and here an example of that with color and some reasons not playing but you would have a significantly lower risk of parallel release and summary you know initially you got to assess the morphology and determine the etiology of MR when you have a doubt of MR you need to get to a disproportionate MR to treat and especially the functional MR cases if in doubt use cardiac MRI the mitral flip is approved for both primary and secondary MR and patients with with higher risk and not suitable for edge-to-edge repair the newer forgiveness devices coming into a and also don't forget that it's a complex pre-procedure of planning with multiple multiple device sizing prediction of complications everything and then in a very high risk patients with MAC there are a few centers which offers minimally invasive hybrid tower and Sapien valves in MAC so evaluating tricuspid valve for interventions and you can see the tricuspid valve is extremely complex much more complex than the mitral valve this is just an anatomical process when showing the septal leaflet and anterior leaflet and the posterior leaflets and we're lucky enough to have a much developed 3D processing giving us an anatomical view of how these leaflets appear and where they are situated and where the jet is originating for us to know however that's not enough with Dr. Hans in publication showing that there are multiple different subtypes of tricuspid valve the majority being the classic type 1 having 3 leaflets and then the type 2 which is like a bi-fit anterior and posterior leaflets and the type 3 ABC are most interesting where you have a deep bridge in the anterior deep bridge in the posterior and septal and then you have deep bridge in both anterior and posterior for the dividing the different valve morphologies majority of it as we see only 54% is the common tri-leaflet and the remaining has much different complexity the remaining 50% so when we're dealing with this we have to keep all of these morphologies in mind before moving forward for an edge test repair for the tricuspid valve once again the majority of the tricuspid valve regurgitation is secondary to left front left side pathology or because of the problem we have to mention more than 85% of the time and the less common primary TRs are because of the rheumatic heart disease myxomatitis disease, absence anomaly endocarditis or because of the hydrogenic basmic elites and Arvibioxis etc however the pathological MR can itself pre-model the mitral analogue enlargement and Arvibioctomy this is an example of showing like how the natural course of patients who has a heart failure with reduced EF and this is just a mortality curve of the severity of the venocontractor effective regurgitation of the area and regurgitation volume over time and then again like you know ensuring that the survival probability of patients who has significant venocontractor area, effective regurgitation of the area and regurgitation volume the worst the worst the mortality Arvibioxis is one of the most important aspect when you're dealing with tricuspid valve like the LVE for the mitral valve and we always have a very keen interest on looking at the right particular size and function in our valve clinics we this is like a routine for us for all of the valve cases whether they're going for surgery or for percuteness valve therapies this is just an example of showing in patients with significant tricuspid valve regurgitation at different stages of heart failure determines their outcomes like stage one being normal RV function stage four being a very severe reduced RV function and showing the survival curves so RV function is very important sometimes we tend to use cardiac MRI to precisely assess the RV size and function so we know the reserve the patients has moving forward so coming to the different tricuspid landscapes there will be trials which are used to tackle the co-optation co-optation devices the few which deal with suture and loblasties and heterotropic valve the cable valve implants and the ring and loblasties and the direct tricuspid, tricuspid valve replacements we're not going to go through every single aspect of it let's just go with the tricuspid valve edge to edge repair so we're fortunate that it's a right timing the multiple end reconstruction the live multiple end reconstruction came up with the 3D so we can really understand better how and which valve leaflets are really involved and zoom that valve up in a short axis to know the anterior subgroup and the posterior leaflet and I showed before the complexity to understand better the complexity of the tricuspid valve and placing the color we know between which leaflets that does the majority of the valve the tricuspid valve registration is originating and currently we are part of a class TR trial with a Pascal device and we plan in a way that where we should be placing these devices beforehand and once we get in there we'll plan accordingly to know whether we should place septal anterior and septal posterior leaflets for a better result this is one of those cases we're dealing with that like you know you want to align them right in plane and then when you get in there to make sure that both the leaflets are right under the grasping areas and once you plane it where you want to grasp you've got to make sure that both the leaflets are in the arms and before we confirm that everything is in place we'll make sure that there is a reduction of tricuspid valve registration and there is significant tethering of these leaflets so we know that they are within the clips and then we'll release the clip and look at the stability currently anything more than less than moderate we consider it as successful and the patients are showing significant improvement in symptoms once we do even reduce it to a moderate moving forward to a heterotropic valve implantation again CT plays an important role we measure it right above the first hepatic plane and we have a minimal upsizing of these ones and once we know the exact position we calculate the circumference in the area and select the device these are some of the device the tricval which is again showing nicely in the CT the valve leaflets sit right at the RAUC junction stopping the revision flow back to the systemic organs and then this is the sapient valve sitting right at the RAUC junction this is a try a navigate valve which is many of the trials were done this is from the Cleveland Clinic it's a very deployment of the valve in the animal models and we're waiting for the true human trials to come out and this is an a work system which is an adverse trial which is currently been going on for much more complicated and a complex tricuspid valve morphologies where it's difficult to do a try edge to edge repair we're anticipating this trial to come to our center in due course in summary the tricuspid apparatus is much more complicated than mitral and the secondary TR is almost more than 85% and the medical management leads to higher mortality compared to treating these patients and there is a really high risk of isolated tricuspid valve surgery is almost close to 10% and this goes up to 20% if it's a reduced surgery the edge to edge technique is rapidly getting there it's very popular improving the symptoms of this complex patients and the multiple transcarter devices are in trials right now and we hope for the best suitable tricuspid valve therapy to come up in due course to overcome the complexity of these diseases thank you so much for your time and we're happy to take any questions and thank you