 And I'm going to start to talk about, is the last session on medical agitation, all the panelists have actually gone with most of the 2017 guidelines. So I go to the role of actually presenting a couple of cases in MR in hypertrophic obstructive cardiomyopathy patients, and we are going to talk about two different scenarios. We are going to start with one, which is purely associated with some, and another one would you have concomitant valve abnormality. So most of it, I have a couple of competing interests. I was actually granted a couple of grants from the Canadian Society of Anesthesia and from the Peter Montcardia Centre Innovation Committee grant in a study that I'm doing a long ultrason, but nothing that is this close to these case presentations. So the first case, as we talk demographics, like it's a 70-year-old female, like a pretty standard 155 centimetre, 59 kilos, COPD, mild glaucoma. So he come in and that's the report that we got from the pre-op echo. Okay, so they say like preserve gradients up to 160 with balsalva, symmetric septal hypertrophy, and again, moderate MR, but the MR was not well-visualized with severe sum, and the RBS piece estimated at 32 millimeters. So this is one of the multiple choice questions that we will actually discuss at the very end, but one is an anterior might about likely placation recommended in Hocon, going for septal myentomine, the essence of rheumatic or increased segmental bowel disease, and those are the answers. But when you have a floppy or lax anterior leaflet, when you're anterior might actually measure more than three or more than 16 millimeters to the square indexed, or the MR is at least moderate, is the presence of some or all of the above. So I have here a couple of demands from the preoperative transtorothic echo. And as you can see here, we clearly see the hypertrophy on both. But when the time arrives to actually assess the myotermic agitation, so what we mostly see is that so the report again, the MR is not well seen appears to be at least mild to moderate. And that's what we start with. So then is when the patient actually arrived to the OR, and we do our assessment. So internal assessment, again, there is a clear example of sounding this patient, this massive septum, okay, how the anterior might out leaflet is touching the septum and avoiding the LBOD outflow tract to actually provide flow to the aortic valve. In that situation, we are going to go ahead and then assess the interventicular septum. We look for the number four here. There are three measurements that are required. Those measurements are very well reflected in the new guidelines from 2019 from Nikoara, okay, that they have been already exposed. And then again, you want to measure your maximum thickness, you want to measure the apical extent of the septal bulge, which is going to be this measurement up here, the maximum thickness. And then the last one is from the annulus up to the mitral septal contact of the anterior mitral leaflet. So regarding the mitral apparatus, we are going to talk a little bit about that further on this case presentation, but very important, the length of the anterior mitral leaflets and the residual length of these anterior mitral leaflets beyond the co-optation point. And again, susceptibility to some when these leaflet measures more than three centimeters or more accurately, more than 16 millimeters per meter to the square, okay? So just have that in mind when you assess those patients. Okay, so now we are going to talk a little bit about the type of recrutitation. So whenever we have a patient with hypertrophic obstructive cardiomyopathy and we have some, we are going to find a dynamic and posteriorly directed jet, okay? Because the anterior leaflet placates into the LVOT and then it opens a spacer that is going to actually, like a common effect going against the anterior leaflet and then going posteriorly directed, okay? And that's what we look. This is an image of the four chamber view with color compare, okay? And those are the scallops of your mitral valve. So if we can, we keep looking, so again, mitral commissure review is the valve. We see more of it, okay? We go to the two chamber view again a little bit more and we finally arise to the long axis view, okay? Posteriorly directed jet full acceleration in the LVOT, okay? Some clearly contacting to the septum, okay? And then an jet that is walling, pinging into the left entry, okay? Which is consistent with a qualitative assessment of the amount of recrutitation which will be severe and we will go to that in a second. So as we have explained the three main characteristics of this jet, okay? It's related to sun. It's always going to be posteriorly directed and a dynamic jet with a venturi effect of the anterior muscle if they're getting trapped into the LVOT, you're going to have an anterior valve which is going to be a normally, a normally displaced and then you're going to have an abnormal insertion of the papillary muscles with an abnormal attachment. But remember in all those cases there is up to a 10 to 20 percent of patients which the MR is not related to sun, okay? Which is good to remember, okay? So what, what, which type of mitral regurgitation do we have in those cases? So unfortunately those guidelines in 2017 there is no, no actually classification for MR related to sun, okay? Say that there are many papers that the study are always open patients when they have a concomitant mitral regurgitation, all the regurgitations associated with MR, no, we say like 10, 20 percent of them they have another concomitant mentions on the mitral valve. But interestingly, and I find from this paper from 2008, they were actually able, they were actually able to, they were actually able to go with all the percentage of people that they were able to find and then up to 70 percent of them showed like a calcification and thickening of the mitral valve up to close to 60 percent and have prolonged with anterior mitral leaflet and a shortened posterior mitral leaflet and up to 31 an excessive motion of the mitral valve, okay? So it's something that you need to have in consideration. So interoperative assessment, so based on the guidelines that we have been studying during the whole morning, okay, so what we normally recommend you have qualitative, semi-quantitative and quantitative. I like quantitative because it's an objective measurement, so I normally use Psi minus studies, you go up with the baseline, you go between 30 and 40 centimeters to the square towards the regurgitan jet and then you freeze the image, you measure your Psi radius, with your Psi radius, your ali-i's in velocity, the one directed on the app towards the regurgitan jet and then with that the computer is going to do your estimation for your effective regurgitan orifice with the max MR regurgitan jet and it's going to give you the MR regurgitan volume with the BTI of the MR regurgitan jet. So it's three steps and you get the measurements. So here you will be able to quantify based on the guidelines, okay, effective regurgitan orifice between 0.2 and 0.4, the regurgitan volume between 30 and 60 millimeters, okay? And if you pay attention here your effective regurgitan orifice will be consistent with moderate, your regurgitan volume will be mostly consistent with severe, so that's where the range actually moves. So other things that we can use instead of using the PISA method, you can use the volumetric method, okay? So for volumetric method it's based on the same things that they use to actually calculate my total regurgitation with MR and then your regurgitan volume is going to be your stroke volume from the mitre valve minus the stroke volume on the LBOT. The stroke volume on the mitre valve you can do it by the annulus of the mitre valve and the inflow of the mitre valve and after that you can calculate your regurgitan fraction rather if you think the regurgitan volume by PISA by volumetric method and you divide it by the stroke volume, okay? So then based on that again between 30 and 50 percent of the regurgitan fraction you actually quantify your mitre regurgitation, okay? So semi-quantitative methods we are all familiar with that already, so benacontractor with pulmonaribin flow if there is a systolic that's a sign of severity, mitral inflow if you have a predominant pattern which is most conscious below CT-molambu into metaspiricons, so this is more consistent with severity and qualitative again. So there is something called flow convergence which basically is if you are able to see your PISA envelope without changing your increased limit and if you have all of the astolic flow convergence, so this is a qualitative sign to actually say that there is continuous with Doppler jet, the density of the jet and the color of the jet area too, if it's more than 50 percent of the left atrium or if it's while impinging into the left atrium, all those are signs of severity. So in the case that we just present, the surgeon decided to go ahead and do a septal myectomy, one centimeter of thickness and then five centimeters into the ventricle and then he actually displaced the papillary muscles to actually try to mobilize a little bit to the posterior part there or pick the mitral annulus, so it will open a little with the LVOT. He performed an orthotomy which is another thing that you can do in those cases when the angle between the aorta and the septum is actually pretty close and it tries to actually help a little bit to open more the LVOT and they didn't perform any mitral valve surgery. So what other surgical options we have here when we actually have a patient with hypertrophic obstructive cardiomyopathy, some of the other options that you can do is an extended myectomy and we will discuss a little bit about that on the second case. Extended myectomy means standard myectomy plus you go past the co-optation point of the mitral valve when you are suspecting that you are at risk of sun after the surgery. The popular and most massive release is exactly what we did in that case is choose to bring the mitral valve apparatus to drop posteriorly into the LVOT, so it released a little bit more of the LVOT. Under your mitral leaflet application, that was the multi-chose question that actually put here at the beginning of the case and it's normally indicated because it shortens the balloon dent under your leaflet and then it takes away the predisposition to sun. Another technique that has been described, edge-to-edge mitral valve repair posterior leaflet sliding plastic or a theory stitch. So this is the post-op image, so the gradients were actually back to normal, the LV thickness like significantly reduced to only 60 millimeters. There was no particular septal defect since we see a couple of septal perforators on the arrows are marking during diastolic flow and we got what we consider residual mitral regurgitation with cordal sun. And the cordal sun, which means when the anterior mitral leaflets pass the co-optation length actually intercedes into the LVOT without touching your septum. Okay, perfect. So again, always remember when we access mitral valves, that's the matter. You don't have to stay in a single view. You always go through the whole valve, pre and post-op, okay, because you don't want to miss anything. So in that case, I'm very sure we all agree that the results were only mitral regurgitation. So here we have the pre, here we have the post. So the big question that we have and when we do those cases, is should we go ahead and always do something to the mitral valve? So there is this impressive article from Minnesota where they actually published in 1800 patients and they find that with isolectomyectomy in hypertrophic obstructive cardiomyopathy patients, patients with more than moderate to severe mitral regurgitation from 54%, they went down to 1.7% after isolectomyectomy. And the recommendations and conclusions is you shouldn't touch the mitral valve unless there is something specific into the mitral valve that you want to address. But if it's only because of a hockon, you shouldn't touch it. But then we find this very interesting arguing and an editorial answer to this paper in 2017, which the question was to add or not to add mitral valve surgery to the septal miectomy hockon patients. So the group that actually replied to this article was a group from the states too. They only have like 100 patients compared to the 1800, but they always do different mitral, mitral reverse. And the results were equally good. So that was the question. So for them is if you know that there is always a little bit of an abnormality in the mitral valve, I think you should be treated. But then there is the discussion. If we finally isolate the mitral, you're able to only get 1.7% of the patients with consistent, like considerably like mitral regurgitation, should we do it or we shouldn't. Okay. And then if we do it, which kind of surgery. So there are a couple of articles that are recently published, the most recent one that they was able to find is the one from 2017, okay, where it actually had better survival and less traumatic events when they did repair, obviously mitral valve replacements, okay, in this kind of surgeries. So key points, MRJET is going to be hockon related to some, it's particularly directed and it's dynamic. So when you measure, you try to adjust when you find your maximum, your maximum JET, okay, up to 20% of the patients have MR related to some in this scenario. And the indications or the recommendations for actually do application under a matter of leaflet. So it's when you have a floppy or lax anterior leaflet, when it measures more than three, then there are leaflet or more than 60 millimeters per meter to the square, when you have at least moderate or more regurgitation, when you have sands and when you have an aromatic or an intrinsic matter about the six, that's the format recommendations, okay. So the next case, we are going to talk about MR in hockon patients, but then we have another comorbidity on the mitral valve. So again, different scenario, 74 years old, 174 centimeters, 83 kilos, the patient diagnosed with hockon transatlastic, so 74 millimeters with bad salva, severe salm, moderate to severe MR, with an elongated mitral valve leaflet and an RBSP of 40, concomitant abnormalities, atrial fibrillation, smoker, OSA on the CPAP, and a little bit of GERD. So we don't have pre-op images for this gentleman, but then the multi-choice question before we start the case, it's which of the following are not associated with susceptibility to salm, anterior mitral leaflet of more than three, C-set distance, and we will talk about it in a second, more than 2.75 centimeters, anterior-posterior mitral leaflet ratio less than 1.5, residual length beyond the co-optation point of the anterior mitral leaflet valve, or the anterior mitral leaflet measuring more than 60 millimeters to the meters to the square. So this is the interoperative assessment. In this case, as you can see, there is no form on some, there is only a form of cord on some, but it's very interesting when you go to the long axis to actually pay attention a little bit here, because it seems like there is an excessive movement about the co-optation, the co-optation point. So again, we need more images, so that's what we're going to be doing. So we assess, we already discussed that, the number four here, that's what we want. And then an interesting concept is the concept of the C-set. The C-set was described for mitral valve repair, and the C-set will give you the distance between the co-optation point on the mitral valve up to the septum, if it's less than 275 centimeters, like it was here, which is it was two. So there is a predisposition of some, okay. So anterior mitral leaflet definitely more than three centimeters, and then the posterior mitral leaflet to actually get the ratio, which was in this case more than 1.5, okay. And there is, after the co-optation point, residual length of anterior mitral leaflet. So all these three yellow mark are going to be susceptible of inducing some in that patient, okay. So we go to the color flow to assess, okay, long axis BU, minisophageal long axis BU, the arctic valve, the mitral there, posteriorly directed jet, as we can see here, as we can see here on the vena contracta. Okay, we go to the forward chamber view, modify to the left, focusing on the mitral with color compare. We go a little bit farther in, and then I want you to pay attention a little bit over here, which you're going to see it in a second there, now, okay, seems to be like something that is not okay, even here that it looks normal, that in other two planes, it doesn't look normal, okay. So we went in and we did a 3D echo, and then what we were able to find in the 3D echo, and it's much more clear in the 2D images, and that's why I'm advocating for that, okay. You should be able to actually expose your whole valve, and if you can all see here posterior leaflet, okay, this is an M-phase, this is the arctic valve, this is the mitral valve, left atrial appendix, pulmonary valve, tricuspid valve, okay, and you can perfectly see the posterior ring here, the anterior ring over here, and even the anterior ring here is actually hiding below this, okay. And if you pay attention here in the color, you have the classic posteriorly directed jet, but you have another jet that goes anteriorly, okay, which it makes us think was wrong with this patient, no. So we mentioned to the surgeon, we think the patient may have a prolapse of the P1 segment, just have a look, let us know what you think, okay, because we are seeing those jets here. So again, in this case, we know like mitralic rotation associated with some is not described at this classification, but in this case, there was certainly like the posterior segment, and it will be included in the type 2, okay. So the surgeon did a septal myectomy, pretty big, they did a mitral valve repair, and we are going to comment on that in a second, he did a closure of the left atrial appendix, and a restriction for shortening of the ascending order, okay. So that's the post-op image. So interestingly, we go here, the septum is reduced to 15 millimeters, but the C-set distance, which we go there, it's only 1.4 centimeters, okay. But interestingly though, there is only very, very minimal residual MR, no. Why? It's because of the type of surgery that we choose performing that patient, and there is more images of the type of surgery. So this is in the 4th chamber view, this is going to mitral commissure, B1 gain, minimal residual MR, and I'm very sure that you guys all agree that this is only mild MR, what is left there, less. So if you look at the 3D images, it is very clear here that you can see actually between A2 and P2, something binding those two, this is there, those scabs, okay, and the 3D color assessing that. So what the surgeon did was an inferior stitch, A2 to P2, not all the surgeons like to actually do a fierce stitch, the durability of the repair is not as great, but in this case, I think it was actually a good case to actually place here, because I knew my other partners were actually exposing cases of mitral valve replacements and repairs, okay, in a different way with an alloplastis. So in this case, we changed completely the subject and we need to assess for mitral stenosis, okay, so we check for velocity, more than 2.5 is severe, the normal velocity should be below 1.9, and this is a little bit borderline, okay, mean gradient between 5 and 10, more than 10 severe, less than 5, and then again, the gradient is a little bit high, so we do pressure halftime, what is going to the last pressure halftime, so if it's more than 200, it's going to be tight, it's going to be a tight valve, if it's less than 130, and then this is in the degree of probably a little bit moderate, okay, so you tell the surgeon, and that's actually important when you assess this kind of valves. So k-points on this case, you want your c-set distance after the surgery, not in the case of an alveolar stitch, but when you do a repair on the mitral valve, to be actually more than 275 centimeters, to avoid some, and you are, you're an intelligent posterior ratio to be more than 1.5, so you can avoid some, okay, again, 20, up to 20 percent of the patients have mRNA related to some, so you need to look like in all the views to this mitral valve to be sure that you don't miss anything, and always perform a full assessment, okay, and that's it. Thank you again, Jacobo, for a great talk. There's a question on the board here, would it be acceptable to do pressure halftime in a repair in mitral valve? Yeah, well, as we saw there, pressure halftime is part of the recommendation for actually assessing any prosthesis or repairs in mitral valves, so it's part of the guidelines, again, so the main things that you need to look is first the velocity, then you go to the main gradients, and then the recommendation is to go with the DBI or the BTI, the relationship between the BTI in the LBOT and in the mitral valve, and if it's more than 2.5 on the mitral valve compared to the LBOT, then it's actually increased, and then that's a sign of this mitral valve to be too tight for the patient, and again, the other things that we are going to look, if it's effective for this area, which is less than 1, it's again going to be a significant stenosis of this repair and a pressure halftime of more than 200. Thank you, Jacobo. One more question for you. The Vina contract is typically measured at 120 mitral valve geo view. I noticed in your slides, you calculated the PISA at zero degrees in one slide or in four chamber, in another picture, there was a long axis view. Where is the typical place to measure PISA? PISA recommended for chamber view. PISA is always recommended for the four chamber view, at least that's by the guidelines, but remember, it's like the guidelines are mostly described for transtorothic, so it will be your apical view, that's the one that they actually use, but the PISA, if we can, we should measure in the four chamber view, and then the Vina contract in the long axis view, which is your equivalent to the parasternal long axis in your transtorothic, and you're completely right.