 My name is Dr. Ahmada Ombran. I am a staff cardiologist in the Department of Anesthesia and Pain Management, Toronto General Hospital, UHN University of Toronto. And this is a lecture about echocardiographic assessment of prosthetic valves. This lecture is for cardiac anesthesia fellows. In this lecture, I'm going to use a couple of guidelines by American Society of Echo and Society of Cardiac Anesthesia. The first guideline was published in 2009. Recommendation for evaluation of prosthetic valves is echocardiography and Doppler ultrasound. This is a little bit old guideline for assessment of prosthetic valves, but nothing changed compared to that time. And this is a 2020 guideline again by American Society of Echo and Society of Cardiovascular Anesthesia. This is a guideline for the use of chances of facial echocardiography to assist with surgical decision-making in the operating room. This is mainly a guideline about the decision-making in the OR. And the last guideline, that's a 2020 guideline, American College of Cardiology and American Heart Association guideline for the management of patients with valve or heart disease. The first valve replacement surgery was done in 1962. That was after the time that cardiopulmonary bypass pump was invented. That was 1952. Approximately 90,000 valve substitutes are now implanted in the U.S., so in Canada it would be about 9000, and 280,000 worldwide each year. Despite the market improvement in prosthetic valve design and surgical procedures over the past decades, valve replacement does not provide a definite cure to the patient. Instead, native valve disease is traded for prosthetic valve disease. So we are changing one disease to another disease. Outcome of patients undergoing valve replacement is affected by prosthetic valve hemodynamics, durability, and thrombogenicity. Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management follow-up after the implantation. Ecocardiography plays a major role in follow-up of these patients. The type of prosthetic heart valves we have several times type of the valves, and I'm talking about most of the valves that we are using in North America. The biologic valve can be extended. It's a porcine xenograft, pericardial xenograft, a stentless valve, porcine xenograft, pericardial xenograft, a homograft or allograft, autograft, and percutonous valves that are coming and coming. Mechanical valve, biliflet valve that is more common, single-tilted disc valve that was popular in 1980 and after. Now we don't use it usually. And caged ball valve or a started valve valve, that was probably the first successful mechanical valve that was invented. We have to talk about a couple of terminology. Stented valves, when we say stented valves, consist of a radiopec or radionucent base ring or a stent frame covered by a suture cuff from which three stent posts or struts rise to support the valve. A stentless valve used back on close or porcine aortic root as support instead of a stent. Stentless valves provide increased effective orifice area and lower transvalver gradient compared to the stented valves, but their durability is in question. This is an example of the stented valve or magna valve for example. This is swing ring and this is the strut of the valve that supports the leaflet. And the swing ring by the suture will be sued to the annulus of the patient. This is an example of Toronto stentless valve or SPV that was manufactured by St. Jude and this valve was invented by David in Toronto. It was a popular valve in 1990 to almost 2000, but in a long-term run was clear that after seven years or eight years the valve deteriorated now is out of the market. And this is another stentless valve. This is not the valve, it's a root actually, it's a porcine root or freestyle root that is made by Metronik and rarely these days again we use it. When we talk about the xenograft, a tissue graft or organ transplant from a donor of a different species. Xenograft valves are porcine like a pig valve or bovine pericardial valves used for human being valve replacement. Allograft or homograft, a tissue graft from a donor of the same species as the recipient but not genetically identical. Aortic homograft and pulmonary homograft from human cadaver are used for aortic and pulmonary root replacement in cardiac surgery and they still are in use. Autograft, a graft of tissue from one point to another of the same individual's body. In ROS operation for example, pulmonic valve or autograft is taken and replaced the diseased aortic valve of the same person so that is called valve switch or ROS operation. Porcidic valve sizes. Porcidic valve sizes are stated by manufacturer companies are based on outer dimension of the porcidic valves or materials. Porcidic valve size are expressed by odd number like 21, 26, 25 or porcidic ring size, dachron tube, homograft and percutaneous valves are expressed by even number like size 26, 28, 30. These are some of the valves like a ball cage valve or started valve. There is a ball inside the cage. There was a disc and cage as well that is disappeared for a short time. This is a metronic hall tilting disc valve and this is buccially valve. Buccially valve there was a problem in terms of the anchor of the valve and the disc that was broken sometimes but otherwise it was a good valve sometimes. There are mechanical double disc valve. These are the common valve that we are using these days. St. Jude mechanical valve is very popular. Carbon medics mechanical valve and annex valve. Anex valve for aortic and mitral are a different design especially for aortic position. If we use annex mechanical valve we don't use high dose of comedy or we can use other substitutes. Bibocidic porcidic valves, Hancock 2-bibocidic valve that is made by a metronic company. Hancock was first implanted in 1982 by David in Toronto and is very popular valve in our center. Metronic mosaic valve is a porcine valve is a bioprosy valve. This metronic mosaic valve by a one very big methanol study is the best valve for mitral valve replacement. Epic valve in the mitral position has a short strut and if you are worried about the LVUT obstruction after mitral valve replacement because this is short profile we can use it for mitral valve replacement in a patient that there is a risk of LVUT obstruction. Bibocidic bovine pericardial valves again the famous one is Carpentia valve, different type of Carpentia valve. Magna, Magnaese this is a very popular valve in Europe and even in also America. Metronic Avalos valve is a pericardium is made by a metronic company and we use it in our center here. Surin mitral flow was a very good valve sometimes like 5-10 years ago but disappeared from the market because was deteriorating quickly after 2-3 years. Senju trifecta valve again it was a pericardial valve and now is out of the market. So these two valve mitral flow and trifecta are out of the market. These two valve Magna and Avalos we are using now. Socialless Bibocidic valves this is like a competitor for Tavi valves. They don't need sutures so implantation is very fast especially in high risk patient that you want to classical on time be lower less you can use it. It's a self expandable valve first valve is called Perseval made by Surin company doesn't need any suture is a self expandable. It's approved in Europe is not approved in North America. Avalos intuitive valve that's a balloon expandable and need only 3 sutures and metronics 3F enable valve that was popular 5-6 years ago but now is out of the market. One of the problem is this valve is very long and because of the effect of pressure recovery when we do a Doppler gradient across this valve we might overestimate the valve gradient. For example if we call it valve gradient peak 40 or 50 in reality is less than that maybe 30. Percutanus valves or Tavi or Taver valves this is made by metronic companies called core valve and this is by Edward companies called Edward sapien valve and now the generation 3 or sapien series in the market and this is a melodic valve made mainly for pulmonic valve replacement. Aortic and pulmonary homograph these are homographed so these are taken from the cadaver human being aortic homographed is a tube and pulmonary homographed pulmonographed. Now we use it for during the ROS operation for reconstruction of the RVOT aortic homographed is not available very well and rarely we use it. What about anaeroplasty ring there are many rings available now in the market the most famous one is a carpentry ring that is a physio 1 and physio 2 these are rigid or semi-rigid ring. Cosgore of ring is a half a ring and again is a semi-rigid you can call it Cosgore of ring or band is only posterior and this is for tricuspid and this is a simply the band this band was invented by David now is manufactured by metronic company and is not a ring is just a band for anaeroplasty of the mitral and tricuspid. And in our center for mitral valve repair and tricuspid valve repair this is mostly used. There are some other way of repairing the valve like a mitral clip or tricuspid valve clip that is again for a special group of the MR and TR and we should talk about this in a separate lecture. What about criteria to selection the valve so for patient above age 65 we use bioprostic valve so doesn't matter is a mitral aortic position 65 is a cutoff in North America to use the bioprostic valve and 50 is the cutoff for mechanical valve. So below 50 we should put mechanical valve for aorta and for mitral position and above 65 for short bioprostic valve. Between 50 and 65 we make a decision based on the individual and is a shared decision even for all type of valve the decision and preference of the patient is very important. So in a patient above 65 age it is better to use bioprostic valve for aortic and below as I said and in a patient below age 50 who prefer a bioprostic AVR and have appropriate anatomy replacement of the aortic valve by a pulmonic autograph or ROS procedure may be considered. Is it to me and it should be done at the comprehensive valve center or center of excellence for valve replacement like our center and we have many cases now for ROS operation. In European guideline ROS operation is not there also the ROS operation came from UK from Mr. ROS but now is not part of the guideline in European guideline. So this is the algorithm for valve replacement and selection of the valve. What about complications of prosthetic valves? Patient prosthesis mismatch is one of the complications. Geometric mismatch like when we move the pulmonic valve to the aortic position they should match together if it's not matching because of geometric mismatch. The heat sense of the valve is one of the complications usually early the heat sense is because of the technical problem late the heat sense is because of the endocarditis. Primary failure of the valve is sometimes the valve will fail quickly even less than one year especially bioprostic valve. Thrombosis and thrombogenicity it depends on the patient to the host as well. Panus formation usually panus is developed in a long run like more than five years but sometimes you see the panus formation in aortic or mitral very sooner like two or three years we had the case last week for this. Panus in aortic position is more than mitral position. Soda and ariesom formation endocarditis and hemolysis all of this can happen in a patient that had a valve replacement. So for panus especially I want to emphasize that in aortic valve is more than mitral valve. What the generation of the valve in mitral position is more than aorta. Patient prosthesis mismatch what does mean? Patient prosthesis mismatch is present when the effective orifice area of the inserted prosthetic valve is too small in relation to body size. Its main hemodynamic consequences is to generate higher than expected patient's gradients so normally function in prosthetic valve so gradients high but the function of the valve is good. Parameters used to characterize patient prosthesis mismatch is effective orifice area indexed to the patient's body surface area. Patient prosthesis mismatch is considered to be hemodynamically insignificant if the index valve area is more than 0.85 centimeter square per meter square. It's moderate if it's between 85 and 65 and it's severe if it's less than 0.65 centimeter per meter square that is for aortic position. Prevalence of severe patient prosthesis mismatch is about 2 to 11 percent. In aortic position again is more common and in mitral position is less common because in aortic position surgeon has to put the valve in the size of the annulus. In mitral position usually mitral annulus is dilated if somebody has MR so there is not much limitation. This is an example of a patient has a mechanical mitral aortic valve and developed panacea formation and this valve one is extracted. This is a panacea so in aortic position the panacea will develop both sides but more in LVUT side. In mitral position panacea will develop in LA side. So the evaluation of prosthetic aortic valve. Doppler echocardiographic evaluation of prosthetic aortic valve this is based on the guideline of American study of echo that was published in 2009. So Doppler echocardiography of the valve we should measure the peak velocity and the gradient. Main gradient we should look at the contour of the jet velocity and acceleration time and we should use Doppler velocity index. This Doppler velocity index for aortic position used to be called a dimension less index so we call it Doppler velocity index. Effective orifice area, presence, location and severity of the regurgitation and we should look at the chambers as well like LV size function and hypertrophy. This is an example of a normal aortic valve Doppler and obstructed aortic valve Doppler. In normal aortic valve Doppler we see the mean gradient is 22 millimeter mercury Doppler velocity index is 0.4 that is okay and acceleration time is 75 millisecond. Acceleration time is the beginning of the aortic click to the peak of the aortic Doppler. Overall this Doppler of the normal aortic valve doesn't matter is a bio or mechanical is a triangular shape. It means fast going down and this phase triangular. In obstructed valve this Doppler is parabolic is not triangular is a parabolic shape. So acceleration time increased and ejection time increased. So acceleration time in this case is 180 millisecond and mean gradient is 80 millimeter mercury and Doppler velocity index is 0.18 and I will show you the numbers that is normal. So that's a way to calculate the acceleration time and the ratio of acceleration time the direction time that I will show you later. This is how to measure the LVUT to measure the aortic annulus diameter to be used for continuity equation. So we can use the annulus diameter dimension just below the valve at the junction of the valve and the tissue of the symptom or anterior micro leaflet. The Doppler velocity index it means the velocity of the LVUT to the velocity of the jet of the across the aortic valve. So this velocity to this velocity this is not dependent to any other measurement. So it's a very simple one and we call it Doppler velocity index. This is a phenomenon is called pressure recovery. So I would like to talk about this a little bit. What does mean pressure recovery? Look at this tube. This is the LVUT and this is the aorta and here is the valve as a matter of biopsy valve or mechanical valve. So when the flow is here the velocity is not high. Okay. But the pressure is high. When it reached to the close the valve the velocity increase but pressure will drop. So because the pressure and velocity they have an inverse relation. Then after the valve when the flow goes gradually the velocity will decrease and pressure will increase. That's the reason that we call it pressure recovery. It means pressure will recover. Pressure here is very low here recover to the baseline. So it's called pressure recovery. So when we measure the gradient by the Doppler we are measuring the gradient just at the across the valve just here. When we are measuring the gradient by catheter we are measuring gradient between here and here. So the pressure difference between LV and this point by catheter for sure is less than a gradient or pressure difference that we measure at this point. So always Doppler measurement of the gradient is more than cat measurement of the gradient. That is because of the pressure recovery. This pressure recovery happens more if the aorta is narrow and happens less if the aorta is dilated. So if you have a dilated aorta pressure recovery is not happening too much. So it means the cat gradient and Doppler gradient are very similar to each other. But if you have a narrow aorta because of the pressure recovery the Doppler gradient is more than cat gradient. So assume somebody had a aortic valve replacement and replacement of the ACD aorta. If the ACD aorta replacement the Dachron is less than 30 millimeter or 3 centimeter that pressure recovery happens and overestimation of the gradient by Doppler will happen. That is the reason that any time we have a bental operation mechanical valve and Doppler tube when we measure the gradient by Doppler we might overestimate it. So you have to be careful. Sometimes you might get a very high gradient and surgeon might put a catheter here and catheter aorta and say oh there is no gradient. So both of us we are right. We are measuring the gradient at the level of the valve and they are measuring the gradient between LV and the far away from the valve in ACD aorta. This phenomenon of pressure recovery happens when we have a mechanical valve as well but it is more than bioplastic valve because the orifice at the middle has a higher velocity. So we have a higher velocity we have a more pressure recovery. So when we measure the mean gradient peak gradient across the mechanical valve if our cursor line is crossing at the middle orifice or central orifice we might overestimate the gradient. That is the reason that we should put the cursor in a different area and take an average of this gradient. The Doppler parameter of porosity or the valve function in mechanical and extended biopolastic valve if the velocity is less than 3 m per second that is normal more than 4 is civilian stenotic. Mean gradient less than 20 is normal more than 35 is significantly stenotic. Doppler velocity index less than 0.30 is more than 0.30 is normal less than 0.25 is civilian stenotic. Effective orifice area is centimeter squared more than 1.2 is normal less than 0.8 is civilian stenotic in adult patient. Contour of the jet velocity through the prosthetic valve triangular is normal rounded symmetrical or parabolic is abnormal. Acceleration time less than 80 millisecond is normal more than 100 millisecond is significantly obstructed so 80 and 100. Now look at this algorithm sometimes the gradient is high but the valve function is normal. So if we have a velocity more than 3 m per second across the orthic valve doesn't matter by transverse or by T. We take the Doppler velocity index more than 30, 25 to 30 and less than 0.25. If the Doppler velocity is more than 3 and Doppler velocity index is more than 0.30 we look at the jet contour. If the jet contour is parabolic and is more than 100 probably the valve is stenotic. If it's less than 100 valve is not stenotic but the gradient is high because his patient process mismatch or high cardiac output stay. If the Doppler velocity index is less than 0.25 again if it's a parabolic the valve is stenotic. If it's not parabolic is a triangular shape. Acceleration time is less than 100 it means the LVUT velocity is not proper. It means the LVUT velocity sample volume for LVUT is not in right place so it is far away from the valve. For evaluation of severity of prostatic orthic valve regurgitation this is all criteria is very similar to the assessment of regurgitation in native valve and I'm not going to repeat it. Evaluation of prostatic mitral valve. Prostatic mitral valve in terms of regurgitation in transtallocic the mitral regurgitation if the valve is mechanical it might be covered by mechanical valve shadow so we might not see the regurgitation in LVUT. That's the reason that T is better and we'll show it. So again what's the criteria to see the mitral valve is stenotic. We look at the evave velocity of the mitral inflow. If the evave velocity is more than 1.9 like in this case is 2.2. If the VTI in this case is 42 and mean gradient is 7 millimeter mercury so this valve is like the stenotic. So then we go for LVUT VTI and we use this ratio. So the VTI of prostatic valve to the VTI of aortic valve if it's more than 2.2 that make mitral valve is stenotic and I will show you in next slide. So parameter that we use for prostatic valve dysfunction in the mitral position pick early velocity as I said more than 1.9 is abnormal. Mean gradient we have to look at the heart rate as well. Pressure half time we can use it for prostatic mitral valve not for valve area just the number of the pressure half time is important. Doppler velocity index ratio of the Doppler VTI of prostatic valve to the LVUT effective or if it's area we can measure it. Residence location and severity of recogitation and other chamber LV size and function LA size, RV size and pulmonary artery pressure are important. These are two example of the two valve is a normal prostatic mitral valve evave velocity is 1.1 if it's less than 1.9 I said is normal. Mean gradient is 4 usually mean gradient less than 5 or 6 is normal. Pressure half time is 123 so pressure half time less than 120 is totally normal. This valve is stenotic evave velocity is 2.5 is very high mean gradient is 15 very high pressure half time is high. So this valve is stenotic this valve is normal. So this is the criteria to assessment of prostatic mitral valve stenosis. Evave velocity less than 1.9 is normal more than 2.5 is very abnormal. Mean gradient 5 and 10 ratio less than 2.2 is normal more than 2.5 is very abnormal. Effective or if it's area more than 2 is normal less than 1 is very abnormal. Pressure half time 130 not 120 I said 130 is normal and more than 200 is very abnormal. So these are the number that for assessment of prostatic mitral valve stenosis you should measure it. For regurgitation is very similar to the stenosis. Again we use the evave velocity the ratio of the VTI mean gradient TR velocity. If somebody has a mitral regurgitation TR velocity goes up and the stroke volume calculated by Doppler and by 2D. There are big difference and systolic flow conversions might be seen. Echocytography and Doppler credibility of prostatic MR using findings from TTE and TE. This is the whole criteria that you can read it. And these are the one that we should remember always the area of the MR to the area of the LA. Flow conversions and the shape of the mitral inflow. Evaluation of prostatic pulmonic valves again is very similar to uortic valve. So peak velocity and peak gradient is important. Mean gradient Doppler velocity index effective or if it's area presence location and severity of regurgitation. Some of these criteria are not very validated. Related cardiac chamber or V size function and hypertrophy. So the one that we use mainly is the peak gradient and mean gradient. Finding suspicious for prostatic valve stenosis. Casp-oliphate sickening. Narrowing of forward flow. Peak velocity more than 3 meter. In a prostatic valve and more than 2 meter in homograph. Increase in peak velocity on serial studies that's very important. Impaired every function. So the peak velocity is the most important one in assessment of prostatic pulmonic valve dysfunction. For pulmonic regurgitation again the criteria are a little bit similar to the uortic regurgitation. But some number are different. And like pressure halftime for example less than 200 millisecond in AI severe. In pulmonic regurgitation less than 100 is severe. Tri-cast width valve again is very similar to the mitral valve. Peak early velocity is important. Mean gradient and pressure halftime and the ratio. This is an example of the case with prostatic tri-cast width valve stenosis. You can see the turbulence here and you can see the mean gradient is high. So the peak velocity more than 1.7 meter per second is abnormal for tri-cast width valve. Prostatic valve mean gradient more than 6 is compatible with severe TS. Pressure halftime more than 230 millisecond is compatible with significant stenosis. And effective orifice area and the ratio are not very validate. So these three are important. For tri-cast width regurgitation again all of you know it. The jet area it is the most important part that we use it. And venal contractor. So jet area, venal contractor. What about the guideline of T guideline in the OR interrupt T guideline? A couple of issues almost we reviewed all of this. But for aortic valve replacement for example in the OR assessment of prostatic valve in the aortic position. We should identification of the swing ring and evaluation of the proper functioning of the valve leaflet. It's important exclusion of presence of pathologic regurgitation, intra or paravvalor. And establishment of the hemodynamic profile of the newly implanted valve. Evaluation of prostatic valves in the aortic position includes several view at the midisophageal trans-gastic view. The entire circumference of the swing ring should be visualized in short axis view. And the measured gradient of an aortic valve prosthesis depends on the ventricular contractility, loading condition and type and size and location of the prosthesis. Immediately following implantation, the prosthetic valve should be evaluated for pathologic regurgitation. Intravvalor regurgitation is a common finding in normally functioning bioprostatic valve 10% of time. And it's often seen as a small central or commercial AI, especially pericardial valves that we see every day in the OR. Mechanical valves have a specific pattern of washing jet that minimize blood stasis in the hinge mechanism, preventing thrombosis formation. These washing jets are seen within the swing ring, occur early during valve closure and are of short duration and length. Simultaneous multiplying imaging permits easier identification and characterization of these jets. Regurgitating jet features that may suggest more than mild regurgitation include wide jet origin, multiple jet, jet path that is visible around the stand or swing ring and a visible proximal flow convergence. These are all criteria shows that the regurgitation is significant. The ACE guideline does not recommend the use of jet lengths or jet area for prosthetic valve to assess the degree of regurgitation. Values of quantitative indices that may indicate significant valve obstruction include the peak aortic prosthesis less than more than 3 meter. It's abnormal in the presence of an elevated acceleration time more than 100 and low Doppler velocity index less than 0.27 is abnormal and acceleration time to ejection time more than 0.4 is also consistent with prosthetic valve obstruction. This is mainly in the American study guideline. It did not come in 2020 guideline. As patient prosthesis mismatch can lead to diminished LVM mass regression and poor long-term outcome after the aortic valve replacement, the effective orifice area of the newly implanted prosthetic valve should be calculated using the continuity equation. The effective orifice area should be compared with other Doppler parameters for concordance and reasons for discordance. Mitral valve replacement assessment of prosthetic valve in the mitral position by 2D and 3D. The interop environment provides unique challenges for the assessment of prosthetic valve due to possible acute and frequent changes in hemodynamic. A prosthetic valve in the mitral position should be inspected for adequate functioning of the mechanical disc or bioprosthetic leaflets and the presence of intra or paraviral leak. Adequate motion of the prosthetic valve disc can be examined after removal of the aortic cross clamp. Excaution of prosthetic valve disc leaflet may be limited by interposition of subvalver tissue or in the presence of low flow across the valve in a partially filled LV. Comprehensive evaluation of prosthetic valve should be performed after complete separation from bypass. The entire sewing ring of the mitral prosthesis should be imaged at the mid-isovusional level by sweeping the multiplane angle from 0 to 180 degrees. Off-axis view sometimes is needed. Color flow Doppler should be used to locate abnormal intra and paraprosthetic flow. The normal washing jets of mechanical prosthetic valve should be identified and differentiate from pathological regurgitation. By providing a fast view of the mitral valve, 3D echocardiography with or without color can evaluate the location and characteristic of the paravavular regurgitation. E-Mobile leaflets in the presence of adequate loading condition and moderate or severe paraviral leak should trigger surgical intervention while the management of a mild paraviral leak is controversial and can be left from the war. The decision for immediate correction requires a team approach within imaging. Cardiac anesthesia and the cardiac surgeon should be tailored to each patient and critical situation and the weight against the risk of prolonged surgery if the LV function is not good. Ormonic valve replacement. Again, we should check it for PS and PR. And for tracheal, the same. We should check the gradient and any paraviral leak. So now I'm going to show you a couple of case examples. Very short. This is a patient that had a mechanical mitral valve replacement. As you see, the two discs are anti-anatomic because anatomic anterior disc should open this but still should this. So this anti-anatomic position of the mechanical mitral valve. This valve has a small paraviral leak as the arrow is showing. And when you do 3D, you see it. Always try to get the 3D of the mitral valve. It's a little bit aortic valve that you can say from where the leak is coming. Early paraviral leak is common and if it's less than mild, we just leave it. This is another case with aortic valve replacement by a plastic valve. You see a leak here. When you see a leak also is mild, but you have to say from where it's coming. You put the X-plane. You see the leak is inside the swing ring and is mild and lifted. So this is seen mainly in pericardial valve. And this paper shows that the paraviral leak or cough leak in magna valve is about 2% of all valves. And we see it more in our center here. This is another patient that has a leak like this. In the war, we said, okay, this is a mild leak. We can leave it. We left it. And it was a transvalvular. And next week the leak increased. And main reason for increase was this calcification. Because the valve was sitting in the calcification. After a couple of days, the calcification will be absorbed a little bit and leak will be more. So this week increased and we had to bring the patient back to the war. So always be careful. If the leak is more than mild in the war, we should not accept. This was a case that we had to do a re-do it the week after. This is another case that had an aortic valve replacement one year ago and now has a severe part of our leak. So this is really severe. And this patient had to re-do AVR and no leak anymore. This is another case under a bio AVR with root enlargement. You see there's a turbulence here. We should not have it and we have a leak. This leak is more than mild. Two jets. So we should not accept it. But sometimes the surgeon are pushing us to accept it in the war. The gradient was high. This patient came to ICU. The degree of the AR increased. And we took the patient back in three days to the war. And what the surgeon expected, they saw the patch that they put it for root enlargement was interfering with the function of the valve and valve was leaking. This is another patient had a mild valve repair, not replacement. But the Doppler gradient, you see these two shadows. I showed many of you in the war that we take only the dense shadow. That might have a repair or replacement. And this is one of the paper that shows that these two shadows mainly because of the effect of the Doppler. That we call it Doppler effect. And we should always take the dense shadow. This is a patient that had a bio positive mild valve. That was a small like a part of our leak here. But this patient came the year after. And it was not part of our leak. It was actually the circumflex. It was damaged. They had to coil the circumflex. And this is the reason. So if the patient has a right left dominant, the chance of damage to the circumflex is more than right dominant. Because especially this area, the circumflex is very close to the discommission and appendage is here. So during the appendage closure or during the valve repair and replacement, damage to circumflex might happen. It's not very common, but it can happen. And this is a paper. So this is the end of the talk. Thank you very much. And I will answer the question when we see each other in the class.