So, today I'm going to try and bring together a few of the previous lectures and discuss a few interactive cases of aortic valve repair and the dilated aorta. And hopefully I'm going to have a panel involvement between Dr. Chung, Dr. Vegas and Dr. Schaefer. So, I've noticed closure of conflicts of interest and we've all seen the panelists here before and I'll be joined on the panel discussion with the faculty here. So, the outline of my presentation today is I will first very briefly discuss some echocardiographic parameters that are required for aortic valve repair. And then we will go on to discuss between three and five cases where we utilize 2D and 3D echo to both direct the surgery and also to help with some clinical decision making during the surgery. So, the objective of this panel presentation is to really highlight the utility of 3D echo in evaluating the aortic valve and to show its superiority over its evaluation with 2D echo. So, when we meet a patient for aortic valve repair, what are the things from an echocardiographic point of view that we as echocardiographers need to be taken into account? Well, first of all, we need to assess the severity of the aortic insufficiency. And there are multitude of ways to assess severity, whether it's beyond 2D with color flow Doppler, looking for holodiastatic flow reversal, pressure halftime or 3D echo. So, aortic valve repair is mainly for patients with at least moderate, if not moderate, severe aortic insufficiency. Then we need to rule out immediate contraindications to repair. And the immediate contraindications would be a stenotic valve that is generally not amenable to repair. And also valves that have acute effective endocarditis that may have significant valvular destruction. And so, these are two contraindications to repair. We then need to look at the etiology of the aortic insufficiency. And echo can highlight this, whether it's a co-optation failure due to dilatation or whether there's an element of prolapse. And oftentimes, the direction of the aortic insufficiency jet will highlight this, whether it's a central jet due to malcooptation or whether it's an eccentric jet due to a prolapse or maybe a leaflet perforation. And it's very important to establish the etiology as this can direct what the surgeon is going to do from a surgical point of view. Next, it's important to highlight the cuspicity of the valve. And while all valves are amenable to repair, valves with bicuspid, unicuspid, and aquacuspid valves may be more technically challenging for the surgeons. And it's important to highlight to the surgeon the cuspicity of the aortic valve that they are going to be dealing with. And then finally, we need to get on to measuring the geometric indices of the aortic valve. And as highlighted in the previous lectures, we know that the aortic valve is a geometrically a very complex apparatus. It is consisting of the aortic cusps and is limited cranially by the SD junction and caudally by the virtual basal ring. And really 2D echo does not do justice to the measuring the geometric parameters for the aortic valve. And this is where 3D echo is really required to make accurate determination of these geometric indices. And when we talk about geometric indices, we've highlighted them in our previous lectures, but we often measure the effective height, the co-optation height and the geometric length, as well as annular measurements. And Dr. Schaefer has co-authored an excellent review article on how 3D echo is utilized to measure all of these geometric indices. So I would advise people afterwards to read this review article on how the geometric indices are measured with 3D echo. So with that, I'm going to get into our first case.  He had a known dilated ascending aorta with at least moderate to severe aortic insufficiency. His ejector faction was preserved and he had a moderately dilated left ventricle measuring 6.6 centimeters. And the question was to do a benton versus a vial-sparing procedure. So I know having spent time working in Toronto General, a lot of these procedures are done here. So I'm going to ask the panel, when you come across a patient like this, what are some of the imaging parameters you perform to direct the procedure and then maybe get the surgical perspective as to how the surgeons interpret these parameters to guide the procedure. So Dr. Vegas, in terms when you are imaging a patient like this, what are the protocol you use or how will you go around directing the surgery? Well, first of all, I never direct surgery. That would be career suicide in Toronto General. But we do, I mean, as you stated earlier, Aiden, I think one of the key principles here is to identify what the mechanism is. So the two, two debuts that you use obviously are the short axis and the long axis. And those will give you information as to whether this is a problem with root geometry or this is a problem with casps or problem with both. So I think you look at both views and identify what is going to be the most likely pathology here. In terms of dimensions, you would measure your root dimensions as the guidelines suggest. So aortic annulus and systole and the remainder in diastole. We don't specifically, as you know, and happened in the past, being requested to provide any other specific measurements for aortic valve sparing procedures. Recently, we've been doing more quantitative measurements, such as we discussed here of effective height, geometric height, and co-optation length, as well as the angles. So I think that would be my answer. Very good. So just going to move on with the case. So when we performed our echo, we can see here quite a dilated bridge. We can see here a central jet of aortic insufficiency. And then just as Dr. Vegas mentioned, we went on to make some geometric measurements here. And then also a 3D image showing the central jet of aortic insufficiency, highlighting that this is more than likely a co-optation defect resulting in this AI. And then looking at some geometric measurements, we will measure the aortic valve annulus. We measured the sinus tubular junction, which measured 5.4 centimeters. And then also made a measurement of the ascending aorta, which we measured at 5.7 centimeters. We then looked at the cusps, and we could clearly identify a multi-planar reconstruction that there was a significant co-optation defect really involving all of the cusps leading to this central AI. And then when we interlaid the color flow Doppler into this 3D image, we can see here that all of the AI is coming from this co-optation defect. So the question now to the surgeons, is there any other information that you would require from us as ecocardiographers? And is this enough information for you to make a clinical decision as to what might be the best procedure to proceed with? And Dr. Chung, is there any other information that you would require from us? Or do you have all the information that you maybe need here? So I think that having images without color Doppler is also very important so that you can assess the quality of the leaflets. I think that's a key. You don't want to classify thickened leaflets. Ideally, there's as normal as possible. And then all the measurements that Dr. Vegas reviewed very thoroughly for us, we would also ask for. But quite clearly this patient is going to have an intraoperative assessment and we can make those measurements as well intraoperatively. And I think the procedure that we would all propose would be vial sparing replacement at first glance here. Very good. So the patient did, as you just suggested, went on to have a vial sparing procedure. Also known as the David procedure which was really pioneered at TGH. And so this patient went on to have that procedure and had a very good outcome with trivial aortic insufficiency at the end of the procedure. So moving on to another case. And this case is not too dissimilar except in this instance, it was a 41-year-old gentleman. And this instance, he had an acute presentation where he was having chest pain at rest and presented to the hospital with chest pain or shortness of breath. They were worried about a pulmonary embolism so they performed a CT angio. And he was found to have a significant ascending aortic root aneurysm. And a bedside TTE that was done at the time showed severe aortic insufficiency, a severely dilated left ventricle, poor LV function. And so he was brought to the operating room for urgent repair. So in the operating room, we had a massive ascending aortic root aneurysm, severe aortic insufficiency. And this ascending order measured 10 centimeters. We can see that there's very clearly a co-optation defect leading to this severe central aortic insufficiency. And we can see a severely dilated left ventricle with reduced ejection function. So my question to the panel is that this was a similar presentation. And should aortic valve repair or valve sparing procedures always be an option? Or should we consider patient and surgical factors? This case was done over the weekend. It was done after midnight. And so do we think that valve sparing procedures should always be an option or do we need to take into account other factors when making these decisions? Professor Schaffers, if you wanted to. Well, that's a complex question. Number one, I don't think that this case needs to be done after midnight. I mean, he has severe AR, he has had severe AR for the last weeks and months. One might even argue, and this is what we sometimes do with these poor left ventricle, ventricles to start him on entresto and see what happens to the ventricle over time. So we actually postpone surgery in some of these patients with intention for four to six weeks. Should it always be an option? Yes. In my mind, yes, but we need to be realistic. At this point, valve sparing surgery is not yet a routine procedure that every surgeon is familiar with. And this patient will not tolerate well the need for additional clamping if the caspray pair, concomitant caspray pair is not adequate, etc. So we should be realistic. I would have postponed surgery to make sure it's done at daylight hours during the week when you have more competence available that you can ask for help. And in case of doubt, always keep in mind a good replacement is better than a bad repair. We also need to keep in mind the duration of ischemia. Of course, at TGH, he very likely would have undergone a re-implantation procedure. Jen, correct me if I'm wrong. Now, this means and I'm not a slow surgeon. For me, it means roughly two hours of ischemic time. I can do a remodeling in one hour and one additional hour of ischemic time will have a certain effect or may have a certain negative effect on the outcome. So we have to be realistic. We need to consider definitely the competence of the surgeon, the experience of the surgeon. And this is where we have to be realistic. Now, that does not mean that every surgeon who repairs aortic valve is automatically a better class surgeon. They simply have a special area of expertise. This is like we have surgeons who experience surgeons who are good at repairing mitral valves and experience surgeons who simply have difficulty with the 3D imaging and the 3D conceptual work involved. Let's be realistic. The goal is to have an alive patient. I think Dr. Vegas has a question as well. Yeah, Aiden, if I'm not mistaken, the patient presented with chest pain, which is symptomatic. I don't know if there was any prior imaging to suggest what the size of this in-ears was before. So how do you know it's not, say, acutely dilating? And how would that change the surgeon's perspective of things? So we did not have any prior imaging. We were not sure whether this was acutely dilating or whether this was a chronic event. Going down his past history, he had been complaining of kind of progressive shortness of breath and chest pain. So we made the assumption that this was an evolving process over the three years. Can I make a comment? Of course. Out of the last few thousand root aneurysms that I've treated, the only ones that had a more acute and dynamically evolving process were the ones with subacute or chronic dissection. All the other ones were relatively stable. And the fact that his ventricle was dilated and so poor, in my mind, indicates that this was an end stage of chronic aortic regurgitation rather than acute regurgitation. Dr. Vegas, would you agree? Obviously, there are features that would suggest chronicity. But I guess when we're presented with an acute on chronic event where the surgeons may push us to say, look, this is a surgical emergency. Jan, perhaps you can weigh in. What would your thoughts be on timing in this particular case? So I feel that chest pain especially can be quite difficult to evaluate. It could have gone on for a while. It's what's the nature of the chest pain. Is it related? For sure, here we would attribute it to this 10 centimeter aneurysm. When it's such a large aneurysm, I think we all agree that there is an urgency to it. So in this particular scenario would be one that's done on this admission. Whether it's one that's done at midnight, I don't know about that. I think that at TGH we would have likely not and done it in the morning. So in terms of actually rapidly expanding aneurysms, which is the question that there are can be tricked with limited intimal terrors. I have seen that where that can cause the the aneurysm to grow very quickly. And then that would be an emergency. But that the case that I'm thinking of right now was able to for sure wait until daytime hours to do. As you know, sometimes it's not dissimilar to thoracos that are symptomatic. So we do admit those thoracos and we put them in the CVICU, make sure there are blood pressure and heart rates well controlled. But we're not going to do that. A symptomatic thoracol in the middle of the night that's asking for poor outcomes. So that one we would wait until morning to do. And so I think that would be similar for this case where we would do it first thing in the morning. Very good. Okay, we're going to move on to this. So this patient went on to have a ascending aorta repair and a mechanical aortic valve. In this case, the surgeon was not used to do an aortic valve repairs. And so we felt that the safest option was to do a mechanical valve replacement in this case. So good moving on to the the next case. We have a 71 year old gentleman who has a good functional status and was investigated for a murmur two years previously and was found to have moderate aortic insufficiency on a TTE. He now presented with worsening shortness of breath and exertion. And the most recent TTE has shown that his aortic insufficiency had now gone to severe. He had a mildly dilated left ventricle with preserved function. And he was brought to the operating room for aortic valve repair versus replacement. So our first images we can clearly see that there is a prolapse of one of the aortic valve leaflets. And then when we use color flow Doppler, we can see that there is a very eccentric jet of aortic insufficiency. The left ventricle is mildly dilated. However, there is preserved function. Looking at a 3D image, we can see here there's a lot of redundant tissue on the non-current recusp. And when we used our multi-planar reconstruction, when we do this, we tend to use 3D markers to to mark all our cusps. And we can clearly see that there is prolapse of the the non-current recusp, which is resulting in a mild co-optation and also a reduced effective height. And then when we interlay our color flow Doppler between in this image, we can see that there is a very eccentric jet of aortic insufficiency. So questions to the panel. Do we feel that this aortic valve is repairable? And then what other information are we required? So Dr. Schaefer, do you think that this is a good patient for aortic valve repair? I think this is a possible patient for aortic valve repair. You showed us the some nice 3D reconstruction images. I was not perfectly convinced of the substance of the non-coronary cusp to be absolutely certain that this is okay. Principally at the age of 71, he would also have a good prognosis with a biologic valve. So if I was to operate this patient tomorrow, I would plan him for aortic valve repair. I would expect that repair would be possible with a probability of 80%. But there may be findings in the operating room. And this is where the echo images simply lacked in clarity of definition of structure. Maybe some surprise in the operating room. And at the age of 71, I would then have a medium low threshold to switch to replacement. Perfect. And then so for this case, we went on to do some geometric indices to try and aid with the decision making. And so for this, we obviously need to take a 3D data sesh. And then in the 3D data sesh, we will measure our aortic valve annulus, which we measured at 2.6 centimeters in this case. We measured the central co-optation length, which was adequate. And then we went on to measure the effective height and the co-optation length between all of the various cusps. And here we find using the 3D markers in cases like this is very good as it takes away the ambiguity of knowing which leaflets you are looking at. So here in this case or in this image, we can see we measured the effective height and the co-optation length between the right and the left coronary cusps and also between the non and the left coronary cusps. And then also we changed around our multi-planar planes. So now we were able to measure between the right and the non coronary cusps, as well as the non and the left coronary cusps for this patient. And then we went on to measure the geometric height of all of the non left and the right coronary cusps. And so for this case, all of the indices, all the geometric indices suggested that this patient may be amenable to repair and that the surgeon would make his decision when he did a visual inspection. However, the question that I would like to ask the panel is in terms of performing an annular plasti, when do you consider doing an annular plasti and the difference between a suture versus a ring annular plasti for these cases? Jen, you want to comment first? No, please go ahead. Okay, maybe one comment first before I answer your question. We speak of the length of a football field and the height of CN Tower. Why do we call it co-optation length when we mean co-optation height? I had this discussion with Alain Beruby, who the summer in Rome, who finally agreed that he would reword and speak of co-optation height. In addition, I find it very difficult to measure co-optation height precisely. It's always two millimeters more or less because the lower part of this co-optation zone is very difficult to determine. How much geometric height did you have and the annulus you went through the images so quickly? Can you answer? I apologize. So the annulus was measured at 2.6 centimeters and the geometric height was I think over nine millimeters. Geometric height over nine. No, sorry. It should be 20 or a somewhat less. I don't have the precise numbers here. I mean just visually. It looks to me like partial prolapse of distal prolapse of the non-coronary cusp and the others look again visually normal. So I would expect an echo geometric height of maybe 18 millimeters, which in the operating room will be 20 or 21. Probably an annular plasti is advisable beyond 24-25 millimeters. Even though in our retrospective analysis we have not yet found that annular plasti in an isolated tricuspid repair has been the game changer. So if we have an adequate geometric height and actually you did not state the numbers, I didn't miss them. Repair yes. I personally feel comfortable with the suture annular plasti. Maybe Jen can make a comment. How about ring? So yeah, we can cut the bottom end off of a dachron and to do the ring, we don't have the commercially available one. And we also do actually have the suture annular plasti and I have used it when the muscle does come up too high and the dissection is too precarious for valve sparing. So in this case I would do an annular plasti because I think that 26 is not normal. So we're trying to bring this patient back to what we consider a more typical geometry and so I think that if it was 24 or more we would try and at least stabilize it. I don't think the method is as important as doing it. Very good. So this patient underwent an annular plasti and he on the surgeon visually inspected the valve and he confirmed that there was prolapse of the non-carnary cusp and he underwent a placation of the non-carnary cusp in this case. And so post bypass the patient had trace aortic insufficiency and good co-optation between all the leaflets. So I think we are just coming up to 11 so we'll finish with this case and if there's any other questions from the audience or the panel I would encourage people to ask questions. There are a couple of audience questions I feel like we I think sort of one person deleted it but they wanted to know the the vendor that you're using for the 3D reconstructions. Oh so that is a GE and GE and Tomtech allow you to place markers within your within your 3D image and so yes it's quite useful for especially for aortic valves it's quite useful for for performing MPRs. I noticed that you snuck in a heart ring just at the end of the sessions but anyway another audience question if this is for Dr. Schaefer such as what are what are you looking for on TE that will convince you to reclamp and re-repair? Another simple question with a complex answer. I definitely look at jet size. I definitely look at jet eccentricity. I also look at the patient. A 50 year old patient requires a better repair to bring him to the rest of his life than a 75 year old so if there was an eccentric jet of more than grade one or if there was billowing and this is something that we discussed before billowing of more than two to three millimeters and would reclamp and try to improve the repair. Okay thank you very much. Azad? Azad is in the break already mentally? No no no sorry headphone problems. So Dr. Schaefer is that was in the absence of any AI if there's billowing and if the measurements of durability are not what you would prefer you would still go back and redo the repair in that situation? Yes 10 years ago I would have accepted that now I have a few patients that developed early failure probably related to excessive stress on this billowing cusp and if I have five four to five millimeters of billowing I will go back. Now the question key question is how much billowing is billowing and there you have to be careful. A 2d mid is of a gl view may give you projection artefact so what we always do is 3d and we double check by a deep trans gastric view to make sure we don't have a projection artefact but indeed billowing. So the measurements that we've been traditionally trying to look at is that as a co-optation height which we unfortunately measure in two lengths mostly which obviously should be done ideally in three lengths in 3d and that co-optation height took from the annulus to the tip but as you say that's the ventricular side of that as point is quite difficult to identify. Wait a second from annulus to tips is effectified. Co-optation height is because you just say co-optation height from annulus to tips. Annulus to tips is relatively easy even though you may be in mistaken you may run into projection artefacts if you determine the annular plane just by 2d so you have to make certain that you determine the annular plane right and this you can best do by 3d multi-planar reconstruction and then effective height is very easy to measure plus minus one millimeter that's the error of margin. Co-optation height you know for a co-optation height of three to four millimeters you have an error of margin of maybe two millimeters which I think makes this less dependable. The question of co-optation height again goes back to the Brussels publication though the one I took the table from that I showed in my presentation and ever since it has remained in the discussion even though we have never seen an independent effect of co-optation height on the durability of the repair so this is why I'm a little I always skeptical if I cannot reproduce a question a problem or whatever I I try to question whether this is really relevant or we can forget about it I'm not as provocative as saying forget about co-optation height all I'm trying to say is be a little skeptical because it's very difficult to measure precisely and I'm not I don't I don't know any surgeon who would go back in and reclamp just because co-optation height is a millimeter or two below the recommended range. Okay so the two key variables are billowing and the effective height yes the two primary measures. Dr. Vegas. So Dr. Schaefer you know as a reference surgeon with years of experience you're pretty flexible to go back on pump and aim for I guess in many respects perfection. What about you know patients where the post pump echo is showing say that type of finding is it up to the echocardiographer you think or the surgeon to sort of decide whether it's reasonable to go back on pump who would put the weight on here. At the end of the day the surgeon of course has to decide number one now I do my own TEs I'm not so good with 3D but give me any patient with a 2D TE and I can do a full assessment myself but in that I'm not representative of the average surgeon so the the echocardiographer must give the surgeon some guidance and maybe one correction or or modification. It's not about going back on pump the hardest test phase for any repaired aortic valve is the first three to five minutes of reperfusion when you're when you're on the pump you're cannulated you're stable and and you usually see more AI in that phase and then you will see 10-15 minutes later when you come off pump. If in that phase you you see something it's not about clamp it's not about cannulating going back on pump and so forth it's all about reclamping and giving cardioplegia so in to come back with these considerations I think the echocardiographer should give the surgeon the adequate clear and adequate information at the end of the day the the way responsibilities are distributed it will be up to the surgeon whether he listens to you or whether he goes his own way. So professor shapers the geometry looks good on echo you're happy with your effective height you're happy with the the billowing minimal there's mild central AI. I will very likely leave it I will very likely accept it because this is like in mitral repair if we completely eliminate prolapse and there is mild residual leak because of a fold somewhere the prognosis of that repaired mitral valve is very good you know even if you have a 10 to 20 percent chance of having to re-operate within 10 years that's not a whole lot so for the aortic valve it's very similar we haven't done the systematic study but simply going back simply looking at my experience I've had very few aortic valves with perfect form mild AI that I had to re-operate within 10-15 years. Thank you very much that was a wonderful session thank you very much Dr. Chang and Dr. Gregory, Dr. Vegas and professor shapers for a wonderful discussion and excellent lectures and we're running a little bit late so we'll take a shorter 10 minute break and we'll return at 1120 for the next session