 Thank you, Dr. Scal. That was a wonderful review of trans-catheter procedures for the mitral valve. It's my pleasure now to introduce Dr. Charles Nyman. He's a staff anesthesiologist at Burgums and Women's Hospital in Boston, where he also serves as the director of the interventional cardiac anesthesia program, as well as the associate director for the adult cardiothoracic anesthesia fellowship program. He's presented at many national and international meetings on anesthesia in anesthesia, as well as echocardiography. And in addition to echocardiography education, he has published in echocardiography and structural heart disease. Dr. Nyman. Good morning. My name is Charles Nyman, and it's a sincere pleasure to be talking to you today. I'd like to thank the organizing committee for the invitation. I'm going to be talking about the essential imaging for mitral valve structural heart interventions. I have no relevant financial disclosures. In terms of objectives, I'm going to describe the pre-procedure mitral valve assessment, describe a step-by-step approach specifically for edge-to-edge repair, and then I'm going to demonstrate a few complications which you can hopefully rule out with TEE. Now, the first rule when addressing these patient populations is to confirm the mechanism of MR. And typically it's going to be just a distinction between primary versus secondary. And certainly certain types of secondary MR would be less favorable to repair, such as someone with mitral rheumatic heart disease. The next step is going to be quantifying the severity. And one follows who are the guidelines in terms of quantifying the severity. But I would encourage you to go more to a quantification rather than just eyeballing it. You really want to avoid the semi-quantitative and go to the truly quantitative. So my personal preference of choice, while if it is a fairly standard discreet lesion, I will calculate a 2D ear away. In my clinical practice, focus primarily on a 3D vena-contractor area. And then the cut-offs as demonstrated per the guidelines. So here's just an example. You can see a patient with a vena-contractor width of 0.7. Certainly they've got a low reversal in the pulmonary veins. You can calculate the 2D ear away and you can see here on the left-hand side, we've got a 2D ear away of 0.24. So not in the severe range despite the appearance of the jet and an MR volume of 34. So the one then goes into a 3D vena-contractor on the same patient. And you can see we've cropped down our blue plane straight onto the origin of this jet. And you can see where our 2D plane was slicing through was the largest portion of the jet. So we did find that area with the 2D image in plane. But if you make the assumption as 2D pizza does of a circle, you miss out all of this additional jet. And so you can see zooming in onto that area and tracing that out. We now have a 3D vena-contractor of 0.74. So certainly well within the category of being severe. The next step, once you've identified the mechanism and these quantified the severity is to identify the location. And while if you look on the image on the left, one could just say this is a P2 flail. Using NPRs, we essentially created our green plane straight down the middle of the valve. And I've put the green plane here on the right-hand side in the same location. And you can see that, yes, it is a P2 flail, but it's actually a P2 medial. And so using NPRs, you can increase your accuracy and focus your target location in the precise location or the precisely desired location for optimal results. In terms of what one's looking for, ideally it would be best if it's an A2 P2 and less ideal, as you can see on the left-hand image in lesions in the commissures, but that is feasible, but slightly less ideal. And certainly unsuitable would be a patient with a cleft or a perforation. So this is a patient that would be best served by going to the operating room. The next step in assessing suitability is to measure the flail gap. And ideally you want a flail gap that's less than 10, and that's the distance between the two leaflets. This is to facilitate grasping. Even though the contemporary devices do allow for independent grasping, one wants to make sure that the device can reach enough of the leaflet so that when it closes to create apposition, you are truly closing in the same location. And then a flail width, the wider the pathology, the less suitable it becomes to clipping, because as one adds more and more clips, you lose significantly more valve area. Leaflet measurements, the ideal situation is to have enough posterior leaflet so that you know that your friction elements have a steady and stable grasp on it. If you've got leaflet lengths that are sort of six millimeters or less, you run the risk that there's not enough leaflet within the device itself to provide you with clip stability. Both short and very tethered leaflets can prove problematic to suitably grasp. Finally, tending height similar to the results seen in surgical repair. If you have a tending height that's less than 10 millimeters, that should be favorable. But once you get a very tethered valve with a significant tending height, as you can see on the right, that can become a bit more problematic. Leaflet calcium, while annular calcification and some leaflet calcification may be acceptable, there have been case reports of leaflet tearing in region of calcification. So there is some tension placed on these leaflets. So that may be a region for concern, but not in and of itself an exclusionary criteria. However, if the calcium is in the grasping zone, as you can see in the right hand image over here, that lump of calcium right on the edge of A2 there, that's going to impede closing of the device and would run the risk of single leaflet detachment. Finally, mitral valve area. Ideally, you want to have a wide open valve with a valve area of greater than 4. If you plan in a multi-clip strategy, some suggest even a valve area greater than 6. And then once you enter the realm of stenosis, certainly once you go below 3 centimeters, or you have a baseline mean gradient that's high and not explained by just the increased flow, those patients would not be suitable for a edge-to-edge repair. But how do I measure the mitral valve area? So you can see in the quadrant on the left, this is a patient that'd be suitable. I've moved my short axis plane down to the leaflet tips. And then I can go and trace out this area. And here we have 4.7, certainly suitable. Our institution typically uses a cut-off of 3.5, but we aim for our patients to have valve areas of over 4. And he has a patient with stenosis at 1.6. Certainly, this would not be a suitable candidate. The next step of your echo exam is to rule out challenges. So here's a patient that we had that came for a clip. We knew about this beforehand. Not quite a core triatriotum, but the patient does have an atrial septation. And knowing this in advance allowed us to plan accordingly and plan our targeted transeptile puncture. And here you can see the septation, and we changed our transeptile puncture to facilitate the delivery system going over that septation. The other challenges you may want to identify, like hominidus hypertrophy, an ASD or a PFO, that will create some challenges with your targeted transeptile puncture. And obviously, if one sees a left atrial thrombus, you're going to hit the brakes and bring your patient back another time. So in summary of all the sort of cases that I've been over, you know, if you're new to edge-to-edge repair, you ideally like your patients to meet all of these criteria. And as your center gains more experience, you can consider the patients in the middle. But certainly, patients that you'd want to consider sent into the operating room can see patients out here to the right. You can take a screenshot of this slide if you wish. So in terms of procedural steps, once my patient gets into the room, I'm going to repeat my baseline exam, really keys to look for left atrial thrombus and document your baseline infusion. Transeptile puncture is going to be covered by Dr. Sharkey next. Once you've got your transeptile puncture, you're going to move through your steerable guide catheter, or your delivery system into the left atrium. You're then going to advance the delivery system and position it above the valve. Then you're going to advance the device into the LV, grasp the leaflets, make an assessment, and if everything's gone well, detach the device. So I cannot stress this enough. One really wants to check out your baseline infusion. If you don't have an image where you can see this in the beginning and now you see it at the end, it does create a large amount of anxiety and time wasted watching it to see if it's evolving. As I mentioned, if you see thrombus, that patient's anticoagulation needs to be optimized and they can come back another day. Transeptile puncture, all I'm going to say briefly about it is that depending on where your location is, you may want to change where you puncture. And for the vast majority of patients, we're aiming for mid-faucet, posterior to mid-inferior and posterior. So the aortic valve is your anterior structure and remove posteriority. When advancing the steerable guide catheter, I want to encourage you to use 3D NPR or at a minimum biplane. The reason being is if you just have this 2D image, you're unaware of what associated structures there are. So putting on your orthogonal biplane, you can see that this is directed towards the left atrial wall over here. Or one can simply do it on 3D where you have good spatial awareness. Just make sure that you really expand your frame so that your volume includes as much information as possible so that your tip may not be outside your frame of view. So he has an example just using a sort of well-expanded 3D volume. I've demonstrated the 2Ds below, orthogonal 2Ds where you can see this clip is going into the left atrial appendage and so they just need to withdraw the system and continue the flex down to being above the valve. Here we are positioned in above the target. The 3D does create a pretty picture, but I would challenge you that you can, depending on how you've orientated your 3D, create an error of parallax. 2D was all we used to rely on and while you can align your orthogonal imaging plane directly through the clip and make sure that you're happy above the target, you can put color boxes on this to make sure you're above the target. Real-time NPR has really allowed us to not only set up our imaging planes on the desired target, but it's also allowed us to adjudicate what the trajectory is of our delivery system. So you can see here, this has got a posteriorly directed trajectory and if we would need to make sure that this, as we advance into the LV, stays in the desired location, we would need to adjust our catheter so that this approaching more down the line towards our target. We now advance into the LV and this is where I set up my NPRs and rather than me trying to follow the clip, I tell the procedures to follow my line and we've become a lot more slower and gradual in our advancing process and making our adjustments. As you can see on the fluoroscopy on the right, they really can't tell anything about where they are in the heart and it truly is our echo that guides them safely into the ventricle. Here's an example of a patient that's deviated all the way out towards the medial commissure and this is because the trajectory wasn't well established. You can drop your 3D gain if you really want to see things. This is the same patient where we've deviated out towards the commissure and definitely because of the chordal density when you end up in the commissure you increase the risk of entanglement. Grasp in the leaflets, so I have my NPR plane set up through the clip and you can see here that I can see my device arms and I'm going to watch that the leaflets are right into the angle of the clip and then drop the graspers. Certainly you can see that the spatial resolution is significantly greater on 2D so if in doubt you can sort of raise your grippers and zoom in on 2D my clinical practice is I don't actually try and acquire the clip I just watch it live and once the grippers drop I'll hit the freeze button and roll my trackball back and confirm that the leaflets adequately in the clip arm. Our practice is to close under color and we've just partially closed this clip and then we're going to gradually close it under color and we want to see over time as we close in the impact that we have on the valve and the impact we have on the leak. Now that you've got your leaflets grasped you then need to do your pre-release assessment and so we grade the MR we determine whether we want to reposition if there is residual MR or are we going to choose a multi-clip strategy and for me the way I adjudicate this is I go and measure a venicontractor area ideally we're aiming to leave people with a venicontractor area of less than 0.2 but based on the information we have it appears that a cut point of 0.27 venicontractor residual area may be sufficient. Look at the pulmonary vein flows it's lovely when you can see normalization of this pulmonary vein flows and I always say you're an anesthesiologist look at the hemodynamics you see a big jump in your blood pressure you know that your forward cardiac output has gone up once we've assessed the MR we need to assess the gradient ideally a good ballpark target is a gradient of less than 5 and I will always go the route of measuring or calculating the valve area if my gradients are around 5 or greater so here's assessment of the residual MR as a patient with a venicontractor area of 0.74 and we then attached our device pre-deployment we down to 0.14 so this is an excellent result and a clip that we're going to accept and release but before we release you want to make sure that you've got a suitable valve area so here we've moved our blue plane onto the medial orifice and we measure out this valve area at 1.2 and then we measure the lateral orifice here we go measured down to a total valve area of 2.4 another 1.2 so this is a valve that we're quite happy with and we will let this clip go here's a valve area that's 2 but I want you to take note that the blue plane is measured not at the leaflet tips but higher up in the valve and so if you add these valve areas you got a great end of 2 this patient had 2 clips and you might be fooled into thinking that this is an acceptable result however if you move the blue plane and you need to do this on each orifice down to the leaflet tips as shown by the dotted line here this valve area was well under 2 at 1.7 and so this was actually a second clip that we did not deploy how many vein flow patterns we're all happy when we see normalization but it's not always the case gradients you can measure your gradient through either orifice but I will say don't use pressure halftime to measure matrivalve area it has not been validated in these patients so in deciding whether or not you're going to add that extra clip I really think you want to take into account your entire situation of your patient if you're planning a multi-clip strategy like I said ideally you want to be starting off with a matrivalve area of greater than 6 but for a single clip and possibly a multi-clip strategy certainly over 4 you definitely want to leave your patients with a valve area of over 2 a valve area of less than 1.9 is an independent risk factor for worse outcomes you ideally want a mean gradient of less than 5 and you're aiming for like I said mild or less MR once you're happy with everything you can then repeat that entire assessment post-release unfortunately sometimes these clips can be held rigid by the delivery system and it's not uncommon for the degree of MR to change post-release here on flora you can see that this clip is nice and stable not moving so this is reassuring that your clip is well attached this nice tissue bridge and tension on the leaflets is another good sign in terms of ruling out complications every time you've crossed this interatural septum you leave an iatrogenic ASD and here we have a patient still with left to right shunt across this but this is the case of mine from Wednesday of this week and you can see that now that we've addressed the MR the severe TR was leaving us with a significant right to left shunt this patient wasn't a candidate for tricuspid edge-to-edge repair and so we simply closed this hole with the gore device to facilitate us being able to go into the left side of the heart in the future should we need to once again want to make sure that there's no perforation rule out a fusion and if there is one compare it to the clips you obtained prior and then I'm going to show you the dreaded complications so here we've got a nice view of the clip arms coming up this one we actually did dropping the grippers under rapid pacing and you can see the leaflet lying there nicely the gripper arm came down we're all feeling happy we're happy with the result you can see minimal leak on the left there but in hindsight we haven't released this device I've put my orthogonal beam on here notice how much leaflet is out this clip arm and I'm going to go back to the the pre-release device see this long leaflet I missed the fact that this leaflet as you can see here despite the appearance this leaflet lens still appears that a significant portion of that leaflet is out this clip and so when we let this go you can see now that there's a whole bunch of movement this is single leaflet detachment and unfortunately that great result that we had while still attached is no longer the case so in summary start off by characterizing your mechanism of MR actually go to the point of quantifying the severity and like I said my personal preference of choice beyond the guidelines is to focus on the vener-contractor area have a systematic approach going stepwise as the co-procedure list definitely use your real-time MPRs to not only increase your accuracy but to guide the procedure pitfalls and complications and then embrace your role as the co-procedure list to really strive to optimize the outcomes I'd like to thank you for this opportunity and if you have any questions feel free to email me directly or I look forward to answering your questions in the Q&A session to follow Dr. Nyman those were great cases and some very valuable pearls in there