Let's Talk, Contemporary Surgery for Primary Mitral Regurgitation
Originally Broadcast: Thursday, September 23, 2021 at 7:00 PM ET
Join us for a case-based discussion with well-known MIS Mitral Valve Surgeons as they discuss considerations for mitral valve repair and replacement based on disease pathology, patient age, guidelines, and clinical trial advancements.
Presenters Mario Castillo-Sang, M.D. St. Elizabeth Healthcare Edgewood, KY Gorav Ailawadi, M.D. University of Michigan Ann Arbor, MI Marc Gerdisch, M.D. Franciscan Health Indianapolis, IN Rochus K. Voeller, M.D. University of Minnesota Minneapolis, MN
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Thank you all for joining us this evening. Perhaps it's evening, Perhaps it's late night um with this webinar, it's our second webinar on the topic of mitral valve surgery. This one is on contemporary surgery for primary mitral valve regurgitation with a focus on minimally invasive approaches. And for that we have but I would like to call a select group of mitral lists uh that I'm proud to call friends and colleagues uh Starting with Dr Rocca's Vogler Doctor across Borders is a director of minimally invasive surgery at the University of Minnesota Dr Mark Kurdish, who is a well known minimally invasive surgeon from Franciscan health care in indiana. Doctor Gore of Al WAdi, who is the chair of cardiac surgery at the University of Michigan and myself from saying Elizabeth Minnich with Kentucky. So with that today we're going to be touching on different points about mitral valve. We're gonna discuss degenerative mitral valve disease predominantly. Uh We'll discuss minimally invasive approach and we'll discuss non re sexual techniques predominantly for mitral valve repair. We will also touch on mitral valve replacement and select cases. So with that we're going to also thank cryolife for putting this webinar up and also for sponsoring what we have created, which is a online course for minimally invasive procedures of the mitral valve bicuspid valve. So thank you. So we're going to project the first polling questions to get a little baseline as to where we are. And uh and get a better idea uh as panelists if you don't mind. The questions are on your screen. Okay, so 20% of our audience today are minimally invasive surgeons already and about a 5050 split perform already neo quarter reconstruction um And 51% are more than five years out from training. Thank you. So with that we're going to start by talking about the minimally invasive approach. And let's let me ask you, let's start with, let's start with Gaurav. Gaurav. What is your red line? Who is the patient that you say? I cannot offer you a minimally invasive approach? That's a good question. Can you hear me? Okay, first of all? Very well. Okay. Alright, great. So I think that evolves over time. Right? When when you're first starting out, you're much more selective looking for the straightforward repairs. A great first one is a replacement that doesn't have a lot of max that you're planning to replace. A rheumatic or something along those lines. And then as your experience grows, so does your selection criteria becomes much more broad. You know, then you start adding try custards. I think at this point as uh you know, once you get mature then it's really going to be the ones that need more significant common procedures in the aortic valve. Although you could conceivably do that through a memory, basic approach as well. Or cabbage of coronary have done one. Unfortunately unexpectedly uh on a redo reduce are also another one where you know, probably takes a little bit more. So I'd say at this point a previous right door economy right parenthesis are cases that I won't do through the right chest. If they have really poor ventricular dysfunction, I'm going to think a little bit harder about it. Although I still personally think there are benefits to the right chest and really they need to comment cava Torrey, right valve surgery or a surgery mark. What about you? What do you think about uh peripheral vascular disease, severe COPD those circumstances which which ones constitute your absolute red line. So yeah I think that over the years I've kind of gotten away from being concerned about COPD but certainly vascular disease. And I see I think you have on their preoperative work of including pre C. T. A. So I don't do the ct for everybody. If people don't have vast jerseys on exam that I usually won't do it. I've gotten very good at looking at the vessels with ultrasound in the operating room and doing perfect a miscalculation. But people who have a burden of vascular disease, I'll get a C. T. On. And if I have concerned there certainly for vessel caliber because I used to I like to use a healthy size cannula that will convert me to a stern anatomy. Um But lung function I think in general they do pretty well with this procedure. The other thing for us though is if somebody's really big if somebody's really obese and has a tremendous amount of chest wall fat. I beg off a little bit because then I find myself having to make a bigger incision and I might not feel comfortable with that. What about you? What are your? I agree with Mark and Gaurav. I think the extreme obese patients uh bigger patient today and it was still very very challenging. So I'm semi selective about extreme obese patients even though they're the ones who really benefit from an instrument approach severe MAC. You know that point we hypertension significantly dysfunction, peripheral disease also comes in flavor. So you know the right excellent combination is an excellent alternative access if the patient has severe really act disease. So I mean it's definitely uh the spectrum of bread line if you call it. So let's look at this video and as we go through the video broke this. I think this is your case. If you can tell us your landmarks are and maybe the rest of the panel can tell us their incision where it's located. Come I set up for a standard. Right me too on comedy endoscopic assisted approach for a normal size 57 year old male. Was this case basically we're gonna have to two inch Caroline your incision in the fourth intercostal space. I like to use the Miami instrument retractor and the soft tissue going retractor. Uh It's almost fairly standard of finding fourth intercostal space but if you have any doubt landmark. I used a lateral border the pectoral muscle insertion site. That's a pretty reliable landmark to find the four. Mark up any location of the incision I. Two things. One as I do get a C. T. On top and everybody but typically and I don't use contrast. Usually a non contrast cT helps guide the key with that is you have to remember that started an inspiration and when the patients are are on the on the table on the ban, of course it's an expiration. So obese patients typically you may have to come up a little bit higher as the diet from will always be in the way and you have to oftentimes diet frame stitch a simple thing that will Ryan told me is take the top of the typhoid and the top of your sternum and find the midpoint and go lateral and that's where you want to be. Even with that simple rule of thumb is often a great spot to start and I agree with staying lateral. Um You know to avoid avoid having to go through the pack, I would mention that I tend to go a little bit more medial and in fact uh for women I'll often use just an area older incision. Uh and my routine is to go through the third intercostal space and I felt that I kind of got in a group of doing that because I didn't like to deal with the diaphragm, especially in the have your folks. So my my preferences generally to be a little more medial and to be going through the third intercostal space. It also gives you a really comfortable access to the or to and I've always been concerned about that or accumulation site. I know that all of you are really great and making sure that that seems static when you have to do the cardio. The other thing is I clamp the order very high. Uh and that allows me great access to the transfer scientists to close the appendage. So for all those reasons I tend to go through the third space. Yeah. What about calculation? I stopped the video here because I know gora I think you you put in an A. Grade sheets too. Put a distal perfusion. Can you on every case using a seven French Red Catheter. One of the anesthesia catheters. And as you see there's a little side port on this this article. Kanye we just ride in so every case that the one ft drop you have hopefully is the last one you ever have. So right because you do cut down this is your case. I do cut down too. But I know mark you do for cutaneous correct? I do we do all them all pre cutaneous and it really kind of started after doing tavern. I just decided that world we can do that. We put that big old thing out there. We can do this. So we do them all pre cutaneous. See I do position though was a little bit odd. I think I position all my wires uh using fluoroscope. P. I do you ultrasound to make my federal sticks in a position of wires with philosophy. Gotcha. Got a very good point. Uh Some of us don't have a quick access toolbar asking what I call floro it may be a little bit uh so t is ubiquitous for us and so I choose that. Um you have an endoscopic assistant approach here. Not everybody uses an endoscope some to do direct visualization. It's important to tell the audience that neither is good is what you feel comfortable with. I believe that all of us sped up very similarly based on all the videos. I've seen anything different that catches your eye here, focuses opening the oblique sinus. Do you routinely open the oblique sinus or do any other distractions? You know my looks the same. I do still rely fairly on direct visualization again, going through the third intercostal space. And I tend to dissect that the inter inter actual groove a bit more. I think that a lot of circumstance I do pretty much similar as what you see here. Yeah, I think the beauty of the scope is maybe for trainees and residents and people in the O. R. you kind of learn more from what you're saying directly, but I agree 90% of this is all direct visual for me as well. So I'm going to fast forward the video to the, to the exposure, there's the arrest across from going up most of us, all of us I think use an integrate needle. Right? And integrate cardio please. A needle mark already talked about the perils of taking that out or putting it in. Well I think you have to be very careful at that point putting it in or taking it down. It's a delicate and part of the procedure. But then the arrest comes. What do you use? What are you using for cardio Malaysia? It's Donita, card ecclesia. Uh every single case. Yeah. I do not, I use Del Nido for any kind of cardiac operation. I do all of them. Yeah, I used El Nido for every case except for a catfish isolated cabins. So, but I think there's probably subtleties into how much, how frequent, you know how to administer that are probably worth discussing. I'll start uh I know this March and I've talked about this. I give 1500 ccs on every case up front. If for some reason somebody has a bit of a I Uh you know, then I might give a little bit more as the upfront dose. You pretty much always get arrest even with modern day. I think everybody either shaking their heads to agree. And so the other thing is I give it every 45 minutes, which I know is probably more aggressive than some people. Um and another subtle thing as we get to testing the valve. I actually used del mito in my suction irrigator. So all those things to prevent the dreaded RV dysfunction. I know for a fact that I do use the need. I do exactly as you're saying, I do that. They'll need to test. I know rock, is that still correct? Do you use the media or sailing and do exactly the same thing. So it's amazing how we've all evolved into that without, you know, just instinctively. Right. And it may have learned the hard way all of us. Right. Right, right, right. Hopefully the audience doesn't learn the hard way. Exactly. So you can see here three different cross times just to show you that there's different ways of skinning the cat in terms of how do you arrest? And and in the Middle East one that I think uh group of users of lower clam bridges, deployable. The chip would climb to the right and that senior clamped to the left. Um So you know, if we try to cover everything minimally invasively would never we would need, you know, two days of conversation. But with that we just go directly to a case. Okay, let's start with P2. Okay, because this is your case. Go ahead. Yeah. So this is a 39 year old, otherwise healthy male asymptomatic, normal ventricle slightly dilated perhaps but preserved. They'll be functional. They'll poster leaflet. You can see a very large tall poster leaflet with obvious flails. Uh reps recorded. I would like to ask, we all want to ask the audience based on that echo, what would you do for this patient? And here's a polling question. At a glance. The majority of the the audience would do a triangular resection which goes along with what what you read in the literature. The majority of people do that. So let's see what road visit here is an interop analysis. Yeah. So you can see I always start off by putting the annual futures in. I think you can get a better visualization assessment of the valve. The analysis done what we should start on the three D. TV multiple flail. Excuse me. A rope recorded from a large P. Two segment that's clearly flail. So I decided to repair this with adjustable cortex. Non reception technique. And uh first implanted three sets of adjustable cortex on the post tomato popular muscle, typical fashion. Uh And then uh so in three sets of uh adjustable course to the failing leaflet edge, starting about right in the middle and working towards the P. Three, I didn't want to cross the midline. And I knew that this is a large broad based P. Two. So I needed more than just three sets of chords. So uh after the three sets from the poster medial side, I decided to anchor down another set of adjustable courts, in the anterior lateral pat muscle. Uh Let me ask you this robust, sorry to interrupt for for Gaurav and Mark, would you have taken the same approach for this case or would you have done a resection or? Yeah, I'll start, I'm a noncommittal first and I don't like cutting things out. I like to use the tissue for co optation. Um There are there cases to do a recession? Yes, there are. But in my personal preferences to to use that as really only cases I'm really worried about sam. So I I would use coral repair as well. Mhm. That's exactly what I did as well, right? Yeah, I would. It's exactly the same reasoning, you know, more tissue more to work with. I think we should stress the point that was just made about not crossing the midline every time you think it's gonna work crossing the midline, it doesn't. So as he pointed out, he only went to the midline. Once you cross the midline to the other popular muscle, you're you're committing a little bit of a sin because you'll pull down that end of the leaf and no matter how well you think you've got it figured out super, super important point. So you're saying you always restrict you always end up with the restriction in the far end of your quarter if you Yeah, I agree. So here's is postoperative echo is a nice result. And. And just to the question that the audience just answered. This is a comparison to our sectional technique. It's a good result. There's no leakage, but there is a much smaller ring compared to the, to the non recessional technique and you can see the alias saying of the turbulence of the inflow compared to a normal sexual technique. And I think there's something to be said about that. Um, let's go, let's go look at your case. Mark. Well what size ring? I think that's also important and I find that people were set. They tend to put smaller rinks. Right, what size ring did you use? 36 U annual plastering you? Yeah, very common when you do non recessional techniques to use bigger rings for sure. So Mark, this is your case. So yeah, this is actually, this is not a 47 year old guy, is that who's, that's my case. Yes. Yes. I think that he is just wrong. Yeah. Yeah. It's actually an 82 year old guy I think. And and He, you'll see what he has got a file P two. so I'm, I'm curious to see what the audience is going to say here too. It's very similar case. Uh, so the majority would again do a reception technique for this and adjustable cortex new records for this is second place for this. That's interesting too. Okay, so, so you were saying about this case 87 year old with AP two. Right, right. He's an older guy. He's in pretty good shape. Um, and I really want economy of motion in time for this because this is, this is an older gentleman. Um, so I didn't, I'm not going to get real fancy and the post relief to lower its shape reshape it, it's got a reasonable contour. It's a little excessive but not huge measuring the court. Of course. This is kind of an important move. Right? So when I use pre measured cores and I pretty much use them all the time to be honest because I'm lazy. If you, if you just look at two things, one is just measure from your intended popular muscle to just below the Angelus and that will be your length or, and or measure adjacent normal courts because you're invariably the same length. So you find the normal cords fine. If you don't just measure for the path to just below the and the annual, it's, that's the length that you use, uh advice mark not to interrupt you. But this is the device that is part of the set that comes through that port is correct. So the pre measured chords come with this adjustable device that hooks in and you can look on the handle and I think in one of the other videos you'll see the handle and you can see how it tells you what size you're using. So you're doing pre measured cortex here. Right? And I'm looking at both the patients made of course that are good. And then measuring and then put the chords in pretty straightforward again, want to move along. He's an old guy as you'll see I think on this one I'll land these chords on the interior side of the peppery muscle. You and I talked about this the other day. This just makes it easier not to get tangled in the native chords and to drop your stitch in and get its own down to the pathway muscle head. And you can actually kind of adjust the length a little bit based on where you implant on the muscle, on the pathway muscle head. And then when you go through the through the leaflet tissue, kind of depending on the texture of the leaflet tissue, how redundant it is. It was a little bit redundant. You might take some bigger bites. You can travel a little bit on the leaflet to gather the tissue a little bit. All that kind of becomes second nature after you use these a fair amount of time and you start to kind of see what you think are the prettiest looking repairs. Um In this case this guy's pampering muscle head lined up perfectly to dress this P. Two prolapse. And it only took these three set at cords. And this is testing, we're using Del Nido here of course the test as we described before. We see that we've got great co optation right off and I just size. He was 34. I agree we stay as big as we can. Um and uh this guy I used the physio flex which is my go to ring now. It has been for quite a while. Oh and then I closed the class just because I felt like he had the opening there. We usually use cardio. No for that nice soft future. Uh huh. And close the clash between P. Two and P. One. Very good. Very good. I see here you also clipped the appendage, closing those fellas. I kind of wish we used your routine on all cases. I do. I close everybody's appendage. We've got some data now looking at prophylactic closure not just for michael disease. So you'll be seeing that that getting published in but that's the the clip going through the transverse sinus. Okay grew up this is your case. Walk us through it. Uh Yeah this was a younger lady. As you could see with a bit of by leads to prolapse the central M. R. Maybe the postal, it looks a little bit more redundant than the answer. And so I guess I do a little bit different in the sense are we doing a survey first? You can tell me about what people do this survey. Yeah for sure. Serving question. Uh huh. So just as a as everybody's answering it notice how I think everybody also has regressed to or divers to the same 10 point where all of this looks like we put our annular features in first is particularly helpful I think for mental invasive cases but I do that also not open cases. I think it helps present the valve and display the valve and you can see kind of it in its entirety. That's especially helpful for minimally basis. So in your case, yeah. Again the same the same distribution except this time I think most responded that they would do adjustable court. That's interesting. It changed from one case to another. So here's, here's what you did if you want to tell us. Yeah. So uh if you go back to just the test, uh maybe about 10 seconds before that. The first thing I do after I put my entire citizen is I feel the ventricle and I think everybody does the same thing and I end up marking the areas that I want to put cores in. And I think I noticed that on focuses as well and that helps me then decide where to put the paper muscle. We just talked about not crossing midline. The other component is there are cords all along every pet muscle. And so you don't want to necessarily cross even cords going to the same section of P. Two or P three. You want to really stay in order. So here I am I use a a valve replacement size or to expose it on. I think it's worth talking about that Mario. I noticed um raucous use a different device as well and I think it is helpful to do that, but the one I use is clear so I can see where my marks on the on the leaflet. So I can tell where do I want to put the course and I put all the chords first at the paper muscle level and then I bring him through the The week. But here you can see there are still some redundancy. I thought around p. one Uh it's gonna hold, I just want to 39, we want to give her you know the best shot at least likelihood of needing anything else. You can see this is a very big valve. We did not have to do anything to the end to relief although I was prepared to and I end up using uh use free free hand chords if you will obviously is in corn nut and here it's a matter of testing and measuring it and so I do the final test and tying after the annual after the angioplasties down because sometimes you get some modifications or changes. The other thing I'll do is you can see I end up clipping, putting a little clip just to decide on height and I can adjust that if needed. That's just a five millimeter indo clip. And then of course removing it at the end. But here you can see then once we do that and do our final test, we've been able to Get the right height, I believe for the ring. Even then you can see this lady, you probably could even use the larger rink if they made one. But it was a 4040 ring, which is the largest physio to. And do you think that we'll see the echo? There's good communication as well, yep. It is. There's a ton of computation there. So even with, I mean this is a 40 ring, it looks like we're going to use a larger rank. Well, that that's me too. Why don't we head to eight two interior leaflet and talk a little bit about the interior leaflet. Uh this is a case of mine, 68 year old female and your flail large left a term. But other than that function was preserved. Uh This is how it looked, owning properties as you said. Gaurav. I also do the same thing. The ring stitches go first and then and then we inject the valve. We do pressurized testing to see what the problems are and what other things may be missed by echo. Here's a polling question for the audience to see what they think are they would handle this. Of note. The the answers for the three cases of poster leaflet had different different answers or different incidents of resection versus uh preservation of the, of the leaflet as we learn along. Okay, we'll go back to the case. And so what we see here was Pre measured courts, we measured Cortex, Freehand PTF 41 And adjustable Neil Cordial Cortex 33%. Uh no. All theory stitches. We're not in italy I guess. But that's very interesting survey there. So this is what I ended up doing. I think you you could tell based on what we've shown here that it was going to be a minimum. It says repair. We're using adjustable cord as you can see the rupture cord right there. It's amazing how one court a damage four. so the inter lateral muscle would be my go to for an interior leaflet. And this is an adjustable cortex system. And I basically perform the same rhythm that Gaurav and and broke his showed before where you want to be able to adjust the height of the leaflet. I do so by using a locking stitch in each one of the arms and then you can adjust to hide. I think this video shows that well, because one of the things that happened here is I did the first adjustment. I tested it and it was still prolapsed. So I adjusted it again. And then that was the final result again. Big rings, right? Uh There there are clearly, you can use bigger ranks when you, when you do non re sexual techniques. So you can see here that you lock the future and then that's that you can not point forward just grab the future and grab the leaflet and just push down and that will give you, that's the adjustment right there, how you tested and there's still a prolapse. So it's just a matter of then push it down again. Uh and I perhaps you can, you can all a pile in this, but I don't finalize the repair until the ring is in. Do you do you do it differently? Mark or brokers go off. No, I Oh yeah, I made the same comment. I put the ring on first because the final height is a little different. Yeah. Uh, I think another good point to make is if you're a non reception guy, you get comfortable with this, you know, and really repaired traditionally start to be a much more complicated repair, but it's the technique is so reproducible and simplify that. You know, this is not harder than doing a post release repair. Non reception technique. I agree. I agree. Very much so. So, um, you know, we're, we uh we're going we're making good progress. We have a lot of cases to this cause and I hope that we can cover all aspects of the valve and go around the valve, let's start Barlas, Hey, what do you think? Stop Marlowe's my comment about that really. You know, I felt like with the answer, leave a lot of times that what determines the repair is what the post relief, it looks like this really for shortened, You know, that's a, that's a tough one of course and then you really kind of have to downsize the analysts more than what we talked about earlier for for post really proposed to you really kind of criticizing it. Of course, you don't think the risks of SAM are much much less with a true answer. Leave the polar caps or fail compared to a large post to relieve the pro app. So, or a bar lows, of course, but that's something I've noticed that I've wanted to go back to look at my anterior versus poster and I suspect my interior repairs or maybe size or two smaller in terms of the ring size compared to a post relief repair. If that's something you guys have noticed. Yeah, I would definitely agree. I think that, you know, because we don't respect a lot. Also, we use these big rings, we eat the potential for moving the co optation Playing anti really with a redundant poster leaf, that of course, is much greater. But if you've got a fairly normal poster leaflet, you end up with your co optation line moved mysteriously and therefore, as you say, you just have to establish a ring, that's the right size for the anti r leaflet. And I would I would echo also, um, the raucous comment earlier that once you're comfortable with chords, the entire leaflet becomes just part of the repair. And it's really something that people can move into pretty easily once they're comfortable with it. Absolutely, absolutely. So this is uh this is the first part of this case indeed an ugly down. Uh So yeah, moving on. A little more complex pathology. This is a 56 year old male by leaflet prolapse. Think Barlow is pretty redundant. Big leaflets by leaflet prolapse more interior than the post earlier, but complex yet. Let me stop you there. And let's get let's get the polling question. Going to see what the audience would do about this case. Clearly, a more complex. Although I will say that that the case you put it for uh in the P. Two graph was also a by leaflet write it clearly was a by leaflet prolapse. Uh and you did not have to touch the interior legal, just uh the ring took care of the interior lighting. Yeah, sometimes it does. Right. Okay. Mhm. And in the case we have, We measured Cortex 24%,, three hand PTF 28% Adjusting McCord ex 24%. And quadrangular resection with lining plastic? 24%. Okay. I'm curious to see of uh this is obviously wrong in this case, but Gaurav or or mark, what would you have tackled this ass? So I tend to uh you know obviously I mentioned already just using uh my own course. Not not any pre measured course of any kind. I do think, you know. Oftentimes as as uh in the literature. And so let's say the P one is a reference point. So presuming that's not prolapsed here, you know that that could be used as a reference point. I find it's always better to set your into relief it first before tackling that both believe that if you're putting course on both sides using often times the annual says a reference, this is one where you may have to do a few different things. You know, you may have to close some class, you may have to do other things to lower the height. May have to uh really restrict that post relief further if this great ever done it or potentially have to lower the height with with some reception technique which we can talk about their probably some simple ways to do it in a triangle reception. Let's let's see what the inter up now let's just look like focus, you know, so we're testing the valve from the left ventricle is sailing and you do know, have a uh testing under your pressure here and you can see the main pathologies Andrew with the A two with the rupture court. And actually in this case I decided to do repair using a set of adjustable cortex and six quartets fix cortex. And actually decided to repair the Australians the first, Which is possible that we maybe didn't have to touch it at all. But uh I decided to use I think 60 millimeter Products to the P two. Just so I have a better reference point to fix that obviously with a two segments. Well, so that's what I'm doing there? That was a little bit out of kind of you there, but I think it comes to you in just a second. So you're anchoring those and a poster leaflet. The pre measures are the pre measured, correct pre med records going to the T. Two. And uh of course they're going on the top of the screen on the adjustable course and now they're going to be playlet to segment using the figure of a lock and stitch that Mario just showed him. You're actually flipping there. All right. So you can still manage these cases uh Mark, what comes to you have you can still manage these cases without having to do every sexual technique. Yeah. Right. I and I would tend to start with the poster leaflet as well and then test the anti early foot and determine where I want to put it. Uh and I probably would do what was done here, which is kind of go with a simple approach on the poster leaflet and then do adjustables on the anti relief because that's the that's the most complex part of this particular repair for me. As far as for section goes, you'll see in the case, I'm going to do, we're going to do some reception in this Barlow. I kind of think of it as a continuum, you know, there's five more elastic disease and there's everything else. And so Angeles leaflet court a what are the things that need to be approached with that? Um So this this is actually one of my cases. Right? All right. This is your case. Yeah. So, and I sent you, this is a P. Two. You moved it over to Barlow and I have to agree. So what I have to say again, it's kind of this continuum in my mind. Uh in this case I knew this anti leaf that was going to work. So this was about managing the post really fit, which was really P two P three. It is a Barlow esque valve. The posters leaflets tall. It was a young woman, fairly healthy otherwise and wanted the ideal repair. So I will reduce the height of this post nearly foot and then I'll put plenty of chords on to address the entirety of it again, not crossing the midline. I use pre measured courts here, I'd say probably I do pre measured 70% of the time and adjustable the rest of the time. Uh This is really felt like I said I needed a little bit lower so I lowered it and you can see the ruptured cord there and here we can see the adjustable are the pre measured courts and I lay them out so that in my head. I know where they're going to how they're going to land when I drop them in. So they're on a towel. And as I as I put the futures through the pampering muscle in my head, I know how those are going to drop in and then they can put them up through the leaf it quickly. I know I know their orientation in this case. I think I actually put them on the back side of the papillary muscle. I don't do that anymore. This is an old case when you stay back side, you're talking about the orientation of where the chords are coming off. That happened muscle. Right. Yeah, correct. Yeah. Tell me what you do now. Yeah. So I tend to put on the interior li I may have put them into really on this one. I know that on a couple of my video, their interior, their interior. Yeah, I kind of play it by ear a little bit. I think if I'm worried about collect ation, I let him answer. If I'm worried about sampras and I go post your, I do the same. I don't know if it makes that much of a difference, but subtlety. That's also why I lowered this post relief to get away from SAN potential. And then after I got it, of course I've got a pressurized now high pressure and all my futures are in and I just want to establish what my co optation overlap is going to be like and in size according to that. This is what I was using complete rings And so for the audience, I think Mark brought up a very important point is that you're seeing all this work happening at the atrial level of ventricular level and uh what you're not seeing is what's happening outside with all the courts. Right? So keeping that order outside of the chest is paramount if you're using pre measured uh cortex or, or adjustable cortex, because you could really get into into a pickle if you, if you start twisting them going in there and you spend all this time on twisting them for sure. Um, let's see if we have a little bit of time. Let's go, let's go and talk about a commercial case. A quick commercial case. This is this is going to be the quick case because I think this is your case. Yeah. So uh, 68 year old female, otherwise healthy male symptoms. Natural lateral commercial flail and I think it's pretty obvious here preserved LV function. Yeah, very centric jet. You can see there's a obvious lateral anyone or commercial flail. So for the audience, I'd like to see what the audience has to say about the commercial polling question. We're trying to cover the valve going around the valve completely and I think we're getting there. That's good. We'll have some cases left over that. We can discuss it. We have extra time. Alrighty. Let's take a look with what the audience has to say. So magic stitch, Commissioner plastic. Okay. Yeah, Does anybody disagree with that with that? That trend here? That's probably what, what's expected. So what did you end up doing robert? Yeah, it's I took the unusual approach actually. I think the magic statue and closing the commerce, she would have been totally okay. It's not a tiny valve and I don't think the grading would have been an issue would have been quick quicker. But I took a more an atomic approach to actually use uh fixed cortex actually to 60 Very lateral flail segment there uh with a good result, took a little more time. But obviously there's more one way to fix this, wow. Yeah, but it worked out very nicely in this particular case. So it's a very versatile technique. I mean, no quarter reconstruction, you can really go around the valve and fix different things or combo problems for sure. I would add that sometimes the conventional prolapse is they're not as big as, you know, these other values that we talked about, the poster leads with the Barlow. Right. So honestly, right, because I do the same thing, We'll use P. T. F. E. As the first strategy if there's still some residual leak. So I decided to put a little magics that you're not. I think that's a good approach. Let me get back to the to the power point here. Mhm. So let's let's talk about this case. And I think this case is uh dramatic case is a random case? There's no age or anything associated with this necessarily. But this is a younger person with rheumatic heart disease. And just out of curiosity because I do tend to see a lot of dramatic disease where I'm at, well you see a lot of rheumatic disease where you're at Gaurav, so we'll probably see about 8-10% of our mitral cases are dramatic, maybe maybe a little less so in Michigan that I saw in Virginia. But we actually looked at it statewide in Virginia was is right at about 10% and it's been pretty consistent over the years. Hasan't really changed, hasn't dropped. How about you, Mark? Yeah, we're solidly in the 10% or excess of their in in Indiana and I'm absolutely amazed at how much we see to tell you the truth Barajas. You see a lot of in the twin cities smart, but say at least 10% more than you think. Hopefully more than I ever thought I would see. But this is the intra op analysis. Right? And I want to pause it there and I want to ask, well there's no question for the audience here but I but I get based on what we see in this valve interrupt and also Um on Echo, I think this is a clear replacement in a 50 year old and I my choice here would be to use an onyx valve and everybody will have a preference in terms of the valve they use. But I've been through different iterations of different valves and struggled with the mechanism and I it it pains me to see the mechanism so clear, so clearly close to either corny or remnants of popularity muscles. So I think I like that of the of the onyx valve. Um So what what are you thinking when you're seeing a valve? Like this one from the beginning and when you make the incision on the answer delivery and you see you know ahead of time that this is a very ugly valve and then there's complete fusion. Are you respecting everything? Are you trying to preserve something or mark? You know, I pretty much will always preserve the poster leaflet under almost every circumstance I'll debris to the bulk. But try to keep those coral attachments in romantics as you know often the court er so mad at that. You don't have to really kind of worry about re suspending the anterior components because it's all fused together. You just got to get it out of the way of the valve. So in cases of rheumatic disease I often am not re suspending the anterior components. Anybody else that I replace the valve on? I will re suspend those anti r components of their family muscles somehow. Whether I have to put gortex in or if I have to, what I typically will do is use the remnants of the anterior leaflet directed poster laterally and poster immediately. I see you put the valve in exactly the right orientation for this for this particular device. So let me yeah you bring up a very good point because we have talked about this before about the don's right and so I wanted to put the slide here of these are actual two cases. I think one is robust. One is mine of having to take out a mechanical valve. Uh For whatever reason it was implanted this way anatomically. And I think that's uh you should try to to to place it anti anatomically. Um That said hey Mario I just want to extend Mark's point about how much to preserve. You know obviously there's been a big push from uh both bench top as well as you know the C. T. S. Central to this coral preservation mystique which as I I agree with market you know and the right patient that's important. And ischemic ventricle functional. M. R. Maybe an endocarditis but in a dramatic patients are very different. I've actually had three patients that have been sent that had early failure of a bio prosthetic valve for rheumatic disease. What they actually had a sub valvular stenosis or some valuable or fusion or continued fusion of their answer most relief because somebody decided to preserve all their courts. So it was quite and then there's no inflow to the vegetable and of course their valve failed that too. So when you take it out and you see cut all this stuff out and just like Mark said I d bulk a lot lot of it on the rheumatic and you don't see quite the same LV LV dilatation in the romantics as you do. And of course in other pathologies. So I'm pretty aggressive about taking the interleague and it's getting a lot of the thickened calcified pat muscles out trying to preserve post early. But I want to make Mario is uh it's more format than just developing rheumatic tissue. But I think the ultrasonic aspirated er the Coosa or the sonic. Pick something that I'm really helpful and more recently and I like using that if you're interested in shaving off parts of it but not completely calcified analysts uh it can be helpful and safe to use. Yeah I'd like to I like to use this as a segway to Mark to tell us a little bit about product nitro. Yeah this is actually pretty exciting. Um You know and I would say kind of lead into this one of the things that I presented recently for the asian society and I looked at kind of some of the numbers around the world. And interestingly enough folks are putting in more tissue valves in the mitral position without any data. So I think that we have to be careful about migrating the age down and tissue valves in the micro position. Especially because tissue valves just don't have great durability dmytro position and it makes sense right because they're exposed to higher pressure, higher tension in that position. Uh we don't have the we don't have the off ramp that we have perhaps with tissue aortic valve. My point I bring that up because we have to think seriously in folks that are up to 70 years old about using a mechanical valve if they have some reasonable longevity. And we did the Proact study of course with the aortic valve and demonstrated that we could run that valve at an I. N. R. 1.5 to 2. We just finished and have submitted data for the pro ac mitral which is an iron are of 2 to 2.5. So what we saw in the article heart was that we reduce the incidence of bleeding events by 65% which essentially normalized it because people with the issue about the bleeding events too. And uh we saw strong data which will be further revealed later for the product Metro. But my point is that the characteristics of the valve which are pure carbon coating laminar flow, they exist also in this device, like they do in the aortic valve. Uh and I think we're probably going to enjoy the same kind of benefits with this device. I will add. I mentioned earlier that you had that valve position perfectly. The one thing about this valve you can see it has a fairing that goes down into the ventricle a little bit and it's important to recognize that it's a little bit different than the other valves and the reason that's there is because it creates laminar flow which is lower resistance and therefore a lower gradient. But you should orient the valve like you hit at it, which was with the with the hinges so that the hinges are on a diagonal in the outflow track, just like when you put a tissue valve in or only Less important. Less complicated because the tissue value can really start a problem just oriented the way that you did. But it has had solid performance obviously and um, and you know, we're right now in the uh we're in the 10 a trial for the aortic valve. I don't know if you ever get that to that for the mitral valve but it gives you an idea of the performance characteristics of the device that in the order position. We're doing a study with eloquence. Um, and uh we've, you know, we're a year into that study. It's fascinating and I think that that makes managing these patients a lot easier. I can tell you I get at least two phone calls a day from my office about i in ours. So it's it's important to be able to have a smaller target and be able to hit that bullseye easier, faster if I want to go to the last case that we have scheduled to talk about when we start getting into the woods of Mario. There's a question. Okay. Already them out since I'm not sure if you have them up the versus is it still recommended for they already valve. This is still recommended to keep patients on aspirin When targeting an iron are 1.5. Uh The answer is yes but not globally. So uh they're still debating on on the planet with respect to whether or not we should have astral onboard and it actually various nations and nation. So my party line though is yes aspirin. We included it in the original study. Uh So at 1.5 to 2 for the aortic valve, we recommend that people take a low dose aspirin And and pursuing that's the same for the mitral for the 2-25. Yeah. Study be great. I mean it would be certainly uh practice shifting lens he stated come out correct. So let's go to ischemic mrk. So this is a The case of the 56 year old male with a history of an inferior steamy uh underwent PCI years before and then is referred for severe m. r. Um And so like I think this is more of a discussion of What do we do for this patient? Right. And so at 56 ischemic um are already revascularization. I'd like to see what the audience has to say. I wonder how this and this answer Mario would be different if this was a revolt cardiologist. You think yes. I think that would be very different for sure. So no question. All right, let's get back to the case. Uh And it is Downsizing angioplasty 30%. So a lot of people would repair the valve and 52% will perform a mechanical mitral valve replacement. Uh Smaller number of people would do a popular Mosul approximation. I would like to talk to those who do the popular muscle approximations and have a conversation. I'm I'm very interested in that technique. Um But let's go back to the case curious just with the panelists, any of you guys also involved in your my triplet program? We are and actually it's pretty fascinating how effective it can be in these situations. I would go after the papillary muscles in this case but I am just really I am really amazed at how well my triplet performs in this scenario and I have some theories on why it's good but this is the internal testing. Obviously this vision went to surgery but we don't show what we did. There's a league, it was a posterior restriction media. Um So Gaurav tell us about where do we stand in this at this point in time to this. Yeah. So as you know, there's been a randomized trial from the C. T. S. N. Looking at severe skin like mars this patient fits in looking at repair versus replacement and certainly what we know in terms of recurrence at M r it's substantially less with replacement. You know, we're talking about less than 5% of patients have any degree of more than mild amar after replacement versus with Repair at two years. It's roughly it's up to almost 50%. So pretty substantial differences. There are sub populations. If you really look carefully. We did tease out of sub population of patients that do not have what we call a basil or aneurysm, which really is a thicknesses of the base right underneath the post to release the great. You got the picture there for you. Yeah. Yeah. So what we found is roughly half the patients in the cts and trial had, you know, call it an aneurysm but it's even a keynesian. Not really disconnection, not truly out patching like a truly aneurysm that a Tunisia of the base right underneath the post relief it and that's a strong predictor of failure with the downside stating last. So you have the other point to make, you know, if the patients willing to be an anti coagulation, you know, this this is the definitive operation. Mechanical metropolitan faces would be a defender. I think the whole thought process of course has evolved now with with coop, you know, recall coop was a randomized trial might not to surgery, but the medical therapy. Medical therapies that to be indication, we've never done a randomized trial comparing it to medical therapy. So it's sort of been left out on the street, surgery becomes left out on the street when it comes to thanks Omar and especially ischemic mitral regurgitation Prior to co act less than five isolated mitral valve surgery was to the functional M. R. Less than five africa. We haven't seen the data yet, but I'm sure it's even even you know, so it's very unusual, at least in my practice to be referred a patient like this for surgery where we're not discussing much best option. Yeah. We've surgically I really enjoyed great success with not just the pamphlet muscle approximation but actually putting a sling on that medial popular muscle and then bringing that up toward the midline of the poster angelus is really remarkable how you can change the contour that basal posterior LV. I don't I don't know if we'll ever get a dramatic shift to that in surgery, but it works is very definitive way of addressing that pathway muscle dysfunction. Yeah. I I think in the recent probable year there's been some more publications on papillary muscle approximation or or slinging the papillary muscles with a with a true size animal plastic as opposed to downsizing under plastic with pretty decent result, both humans and animal studies. So I think that there's something to that. And and I think uh surgeons like you Mark and joe Lamelas and others are working on on that. Um And crown of course. Uh Remember when he published that paper on on basically realigning reposition and muscle, right? Yeah, reposition the muscle, particularly, you know, the scarred uh, pat muscle after high. Yeah. Okay. So we have like two minutes and I think the minutes is enough to perhaps ask the audience if they would like to see another case. We have all flavors in terms of pathology. Yeah. This is like the young core. I want to take this opportunity to say Mario, you did an absolutely incredible job of putting this together. This is one of the best that I've been able to participate in. So, congratulations of this setup of this interface that you've developed. It's pretty, Pretty stabbing. It, it's really cool one. All right. Let's you are the audiences. Oh, it's type 19, and 35. So Barlow another borrows. Okay, Okay, we have to. Barlow is one is bilos like, uh, forgive me for that, but we'll go to that one. Um, we have a true violence, which is March, March, maybe we'll do yours and you cannot read it. So this is Mark's case. Sure. So this is actually a case from a long time ago and I just pulled it up and send it to you because I only had it as slides, but I think it's an important case because it is a true Barlow and we're going to do a lot to this valve. Uh, Barlow runs this kind of spectrum from just to annular dilatation that address with a ring and That it may be an Alfieri to this where entire valves involved except I think maybe T1 wasn't, I don't remember. So actually, here I am, I think I'm measuring chords on uh, to the bottom of the analysts. I do a substantial reception on the post your leaders because it's enormous. But everything, all of the chords in this valve are elongated. So I'm gonna put all new chords in basically, I think, and I'll address the opposed to relief at first, I think sliding plasticky uh, and establish my level of cooperation. So, I've taken out a pretty big chunk of that valve to get myself to a reasonable height and post your lead foot. All new chords and the post your lead foot. Uh, and then I'll use that. Now is my reference point for the anti relief. It and how to set up a reputation. I see the overlap there, uh, and then put in and these are all this entire case was done with pretty much recorder because they fit well, we ended up with a with a nice result. Sorry about that. Let me let me find you again. All right. So, yeah, there is an answer. Yeah. And that's the one we did earlier. So, I like, I like the concept. You bring up mark. And this is what I tend to do a lot with Barlow, XYZ, you combine the reception with Kordell repair even in the same target area in the post relief that, so what I often do is I'll put my chords in first and then just respect, sort of near the base of the leaflet. And that way I've set, I've got a smooth edge of that post relief it and now I'm just using the resection to downsize and so we're avoiding sam and getting the co optation like poster. I didn't want to leave you hanging there and all the cords on the anti leaflet, both family muscles. And uh, and you know, the one nice thing about the, one of the nice things about the measured chords is once you're comfortable with the sizing, uh it goes fast because you just bang them up through there and tie him down and you're finished and you can see we had a nice result. Yeah. So you're, you're absolutely right in terms of the speed of, of uh, pre measured cordage is, it's right. Once you get the sizing right, it flows, it just flows. The thing is the key. And I think you get a great, I know Mark talked about size and you have any other insights on that for people that haven't used pre measured chords. Um yes, let me, let me pull up a couple of videos actually that we did not get to show the first one, is this one that, you know, this is happening inside and it's something we already talked about. You see all these courts happening going down the shaft out on the outside. You have to have some measure of control. And so Mark spreads them out. I use one of these Gabby freighters and I locked him in there and I just parachute them down. I have my assistant parachute them down as I go into the shaft. But it's an important concept to keep that control. Um, um, I also wanted to put this here to remind people that this is a very effective way I took it from your video of exposing the popularity muscles. If you don't have other forms of exposure, right? Uh, and and there are many commercially available different forms of exposure, some disposable, some not in terms of the, the cortex, how to, how to measure again. This is the picture of how it would be airplane down into the shaft as you go down to anchoring the popular muscle. Um, here on the, on the left, we can see, I agree with Mark. I try not to measure at the very tip because realistically it's very hard to, to not tangle the native courts if you are anchoring really close to the top. So I would do it very similar to what's in the picture and I would usually go to the normal court a adjacent to that segment. That would be my measurement and I size twice if not three times because it's awful to have to take the system down to resize it again, I don't know because you have any other comments on that. Yeah, pretty much the same technique. Although I'll be honest I do use adjustable core is a lot more than fixed cords. So you know, on that technique you really rely on visualization and filling the ventricle of cardio pleasure to and using your reference point against the other leaflet to kind of customize the length. Uh and the beauty of the justice of course as you can do that with all three individual new of course they're not all set. So there's a little flexibility in that, you know, you don't have to commit to 12 millimeters or 16 millimeters. But somewhere in between or some cases it can be a little longer. So um but either way it really works. I think there's one other point that we should make about Kordell repair, non reception will repair in general and that is you know, you were fixing to a chord length today and I've had two patients that have positively remodeled and now that like this long. So I especially look at the LV dimension at the beginning of the case. I talked to our eco folks are anesthesiologist and if it's an enlarged ventricle I'll actually try to over tighten it. You typically don't over tighten it so much that you get. Um are but I want to prepare that chord to be for the right length and maybe this is a learning that when, as I've heard experiences with with the accord and with harpoon that over tightening is actually okay because as the LV remodels becomes the right length, you're absolutely right. I think total was have seen at least one failure like that where the ventricle remodels and in fact at the sts market, you remember Mark Guillen off brought that up that that he has had a failure as such where the ventricle positively remodels and then your lengths are off. Um so I agree with you. I think that you have to factor that into the equation perhaps restrict the poster leaflet a little bit more than you want to initially and factor the size of your ring with active Because if you if you're trying to put that 40 ring and you're trying to restrict the poster leaflet, you may end up losing co optation by by really keeping that 40, maybe it's a 38 and restrict more of the poster and leaflet. That's just a thought, that's my algorithm. I see these things. I think the time is up and it's been awesome and fun. I need to do this again for sure. So on behalf of my palace, my friends, thank you so much for attending this webinar and uh hope to see you soon again. Thanks everybody. Thank you guys. Thank you Mario Cryolife for this. Thanks thank you