In this video, we provide the solution to question number 15 from the practice final exam for math 1060, in which case, given this polar graph right here, supposed to find its correct equation. Now we can see this looks like some type of limouson, right? You have this circular-like object with an inner loop here. You could try to use the basic parameters of a limouson and cardioids and things like that to try to do it, but I'm gonna assume we don't know the general formula here. How can we find the correct equation by process of elimination? Given after all, we have six options we have to choose from. So let's look at specific points on the polar graph. So for example, we look at this point right here. The Cartesian point would be two comma zero, but the polar point we're looking at here would be a radius of two and you're gonna get an angle of zero, so it's kind of funny, it's because it's the same point there, right? So we see that your radius should be two at angle zero right there. So which of these equations have that as a possibility? If angle was zero, notice that cosine at zero is equal to one, so it'd be two plus three, which is five, that doesn't work. Sin at zero is zero, so that's a possibility. Again, cosine at zero is one, so you get three plus two, which is five, three plus three, which is six, three plus two, which would be three in that situation, so that doesn't work. And then you're gonna get three plus three, so just by that one single point, we've actually eliminated all the possibilities and we get choice B. Now, let's suppose it didn't work out so conveniently, some other points we could look at would be like this point right here. In this situation, we see that one, two, three, four, five, if the, so the Cartesian coordinates would be zero comma five right here. The polar coordinate would be, and that's the one we really be looking at here, the radius is five, the angle is pi halves, and let's verify here what happens. Sine at pi halves is equal to one, three plus two is equal to five, so that works out. Again, just for further clarification here, if you look at this point, the x and y coordinates would be negative two comma zero, but the polar coordinate would be two comma, in this case, we're gonna get pi as the angle there. So again, what happens at sine? Sine of pi is zero, and so you'll get the radius is again two, so far so good. And then let's just do one more. If you go down this angle right here, take 270 degrees or three pi halves, right? You have the point, it's kind of hard to see because I've drawn over a couple of times, you get this point over here, the Cartesian coordinates would be zero and one, but in terms of polar coordinates, we wanna think of it as negative one comma three pi halves, like so, which again, when you put three pi halves into sine, you'll get negative one, two minus three is equal to negative one. So that does check out with all four of those points right there. So if you're trying to, if you're given a polar graph and you're trying to identify by process elimination, looking at the four quadrental angles, zero pi halves pi and three pi halves will probably sufficient, but like I said in this example, we actually found it just by looking at what happened at a radiant measure of zero.


Question is from Moe Daywood, how does sleep affect fat loss? Can inadequate sleep hinder fat loss even if macros are correct?  Definitely. Yeah. So, so, um, so here's the main ways that lack of sleep affects fat loss. The main way it affects, uh, fat losses, it changes your eating patterns and behaviors and your activity levels. Okay. Cause you're obviously tired, uh, your body perceives it as stress. So, you know, the way we evolved was if you didn't have good sleep, your body's perceiving that as you need to be alert and awake. Like why would you in nature be up, you know, most of the night or not sleeping? Probably because you're not in a safe environment. So your body's perceiving a stress. Now stressed out body wants to a store more body fat because that's an insurance more often than not. The stress that we were under was either predators or lack of food. So I want more. So what it's going to do is going to make you eat more food as a result. So they've done this in studies and shown that people's appetites tend to increase. It also tends to make you crave foods that give you more of a psychological wellbeing, like feeling of wellbeing, like this temporary feel good effect.  Um, the second thing is your body will lose muscle. Um, in a stressed out, uh, situation, your muscle starts to deteriorate because muscle is expensive. It's expensive tissue. Um, and your body's trying to become it's a luxury. More efficient. Um, so lack of activity or, or ultra activity patterns, more food and take or worse food intake, that's the main way it makes you gain body fat. But the second part of the question was, what if the macros are good? Can it still hinder fat loss? Yes. Um, I definitely think so. I think there's this, your body can lose weight and gain weight in different ways, not always going to be body fat. So what may end up happening is you may end up weighing the same, but you're less muscle and more body fat. So overall weight stays the same, but your, your body composition. What about how, how, how cortisol is affected and your thyroid and things like that, that can be affected. That's what that's, that's what I'm referring to.  And the, and you may store more body fat and lose muscle. Um, I mean calories in versus calories out starts to still obeyed, but you know, and here's the other part, Adam, you're absolutely right. Can hormonal changes alter how many calories your body burns at rest. Absolutely. Oh yeah. You give a man testosterone, uh, don't change his activity levels and he'll just naturally get a little leaner and build more muscle just from the changes in hormones. So I've noticed, I tell you what, um, if my sleep is good, this is an example of where I, I get frustrated with the, the academic. So, you know, when we talked about, with the science, when you talk about calories in versus calories out, and then they try and bash like, Oh, they talk about make insulin a demon. They make cortisol sound like a demon. Those things are all good. Well, no, it's not a demon. It's all part of the body, but absolutely you affect sleep. That changes your hormone profile. Your hormone profile now changes your metabolism, which the rule, the law of thermodynamics still applies, but it's now changed for you. It's now different.  That's what your body burns at rest all day long. And then all of a sudden you have two, three days in a row of poor sleep, your calorie maintenance is no longer 2,500. Your body is perceiving it as under stress. It slows down to conserve energy and save body and produce or save body of fat for energy. And so then your calorie maintenance now becomes 2,200 or 2,000. And so law of thermodynamics still applies. And yeah, if you're macros, but your macros are going to have to have been changed. You can't stay the same as what it was when you were getting great sleep because now you're, you're, it's a good point because I think a lot of times people, they assume that the, that your calorie burn aside from activity, because I don't, they don't assume it for activity, but if everything stays the same, but you change your stress, well, your calorie burn is a fixed number. No, it's not. A lot of stuff affects your calorie. Very, your, this whole idea that we're, we are stuck with a metabolism is hilarious. Yeah. Yes. Your metabolism can shift daily. You don't, you find your calorie maintenance out one day. I mean, in four weeks, it could be completely different. If you add a couple pounds of muscle and lose body fat, you reduce stress, you could, you could see a huge difference. And then we used to measure that with the body gym. Was that called? Yeah. Breathe into it. And I remember like being excited about that device because I was like, wow, you can actually find out like where they're at with their metabolism currently right now. And then, you know, you do it the next day, you do it the next week, you're getting completely different numbers based off of their stress. Yeah, I've had this happen now several, I had this happen to me several times with clients where I would have a, I'll give you an example of one client in particular. She was type A, go, go, go, like just the classic overdo everything type of person. She went, and this was early on in my career. So this actually learned, initially learned this through training her. So I was all about calories in versus calories out, how much you're burning, whatever. I'd have her truck her food. She'd show me her calories. Oh, you want to get leaner? We're just going to increase your activity level. And I would push that for a while. And we got stuck. We got stuck for a little while. And I remember thinking to myself like, okay, if I'm going to push her any harder, I got to give her some time to rest and recoup. So my idea wasn't, it would make her leaner. I thought I needed her to get some rest so we could go after it again later on.  And so she was like, well, what about my calories and what about, I'm not going to burn as much calories. And I said, look, I know we're not burning as many calories. I said, don't worry about it. We'll make up for it later on once I feel like your body's more recovered. Well, here's the crazy part. She did that. Not only did she not gain weight. She lost weight. She started to get leaner. I remember seeing the exact same thing. And it blew me away. I was like, how is this possible? She must be lying to me. And then I started to put it, piece it together, like, oh, her body's working better. She's just healthier. And so, and now what happened, that's happened over a dozen times.   It's all stress. It's all stress. And if you're getting it from all ends, going to the gym and hammering your body, even though you, and this is what was hard to communicate to him, because he's like, I feel good. Yes. He goes, yeah, no, I love to go workout. And I had, and it's like, exactly. And that's the worst thing you could do in that state.  And you don't wanna go hammer the weights out. If you're gonna go to the weights, it should be more recuperative.  And then the day that you feel rested, no stress, everything else. That's the day you get after it. The reason why it's hard to understand for people is because it does feel good. Right. Because cortisol feels good. Here's the thing that people need to understand. We hear all the time about elevated cortisol and too much of it's not good or whatever. And by the way, cortisol has very fundamental roles in the human body. You don't wanna slam cortisol down cause that'll not make you healthy either. But here's the deal with cortisol. It feels good. If I gave you injections of cortisol, you'd have energy, you'd be hyped, it's your stress hormones. It's supposed to do that. So when you're super stressed- I live off that in the morning. Yeah. So it gets me out of bed.  Well, now because you're becoming a cortisol junkie, but eventually like we can become insulin resistant, our bodies stop utilizing cortisol very effectively. We need more and more of it then we start to develop problems.


Inner Sanctum Mysteries Dear friends of the creaking door This is your host to welcome you into the Inner Sanctum once again Come in You know so many people have asked me to explain the significance of the creaking door But I don't really have to You see the door creaks for itself I was going to have a friend of mine here tonight to give you a short explanation Being an undertaker by profession, he's an authority on the subject But he couldn't make it, he's been so busy, poor chap He's literally buried in his work All right friend, let's get dreadful Now remember, don't scream back at the radio, I'd want to hear any kind I'll say it Then listen as we hear our star and see more in the role of Catherine Brine Tell us this story in her own words Flash of lightning, like a giant white electric light Lit up the sky that night as I went up the walk And Brine Mansion looked like a huge gable tomb Standing there on the hill For a moment I wanted to run But much as I hated it, I'd come back Not because I lived there Not because I wanted to be there But because in this house, I should find out if I was going to live Or if I was going to die I let myself in quietly Made my way to the living room There was a rustling of skirts And mother suddenly appeared in the dim, shadowy lights Kathy, Kathy, dear Hello mother Oh you're so late, I was getting worried Was my stepfather worried too? Why yes dear, Mark is still up Here you've got to take your coat off, it's so through Don't you touch me Kathy darling Don't start sniveling over me again mother I can't stand it I was just trying to help you Always trying to help me Why didn't you think of helping me before you married that man upstairs? But no, you're such a pretty woman mother You couldn't possibly be without a husband What would people say? Catherine please, you can't go on like this No I can't I can't go on very much longer without destroying myself You must not say such things And why not? But make you and Mark very happy if I should die Wouldn't it? Catherine No one in this house wants me to go on living Good evening Catherine Mark, I didn't know you were here I'm aware of that, I heard you Mark, she didn't mean it, she didn't mean a word of it No but I did Now that you're both here there's something I must find out tonight It's very important What is it? What is it? Ten years ago my father died Catherine we can't discuss that now We must, I've got to know certain things Why? Because if I don't, something quite dreadful might happen to me Now Catherine, you're exaggerating Dr. Wells doesn't think so I've been going to him for months now He knows there's grave danger that I'll go completely out of my mind If I don't find out about this my poor darling Don't pity me mother, help me Tell me how my father died You know you were there But Catherine there's nothing to tell Your father was killed in an accident He was a doctor That will be enough Laura Mark We'll call Dr. Wells the first thing in the morning And discuss the matter with him Why don't you let her tell me What have you got to hide? We are not going to discuss this Until I speak to Dr. Wells Ah Laura, I suggest you come upstairs As soon as possible Good night Catherine Mother, he's gone You are going to tell me Where was this accident? How did it happen? Who was involved?  What is it?  If you look at it long enough she said A strange thing will happen You'll find yourself able to talk with the dead See them wherever they are Catherine, I'm going to talk to my father You can't be serious You won't tell me what I want to know Then maybe the dead will Mother left the room And I sat down in front of the fireplace Just as I used to when I was a child I looked at the tile At the design The parallel lines and dots began to dance Before my eyes Stay at it It seemed to hold Control my gaze And then almost at once I felt an icy chill And the design vanished In its place there was black Infinite space Filled with shadows and Still shadows beyond shadows Then I noticed a speck of gray Come out of that blackness There was a strange, sulfurous odor in the air As it came toward me At first very slowly And gradually faster and faster As though it were coming to me Through endless years of space Suddenly there was an ear-shattering Thunder clap A streak of lightning zigzagged Through the room in an insane dance And I heard the front door close I heard footsteps approaching I turned around Faced the doorway And then I saw him Don't scream Who are you? You are Kathy Kathy Brine You know me? I did Ten years ago Where did you come from? Tell me How do I appear to you? How you appear? Yes Please You have white hair White beard But your eyes No, it can't be What can't be?  Did you know my father? Dr. Brine Very well Very well indeed How did they die? I want to know that He was murdered Murdered? Yes, murdered How do you know? I saw it all You? I was punished for it You murdered him? No I didn't kill him He was the only friend I had in the world That's why I came back here tonight Didn't you ever know how your father died? No Would you like to know? More than anything in the world He was the kindest of men And that's what led to his destruction He took a man under his care A man who had been given up as a raving maniac And rather than see this man placed in an institution He kept him in the guest cottage of his house Wait Wait, I remember now The man was a poet Yes His name was Dennis the Moor Your father believed this man was a great poet And struggled to save him Did this man murder my father? No One evening when your father came in to treat the Moor There was a third man in the darkened cottage This man leaped at your father and drove a knife into his back The poor madman, frightened Ran over the countryside until he was caught by the police And he was charged with the murder of your father You... You said you saw all this I did Then you are... The madman Dennis the Moor You... You're dead? Perhaps I am The murderer Who was the person who murdered my father?  Your father is the only one Who can prove this My father Can you bring him back here? Bring him back? You came back If you could only bring him And prove this Prove it? Perhaps I can Perhaps I will bring him back Tonight Just then There was a tremendous thunderclap And the electric lights failed I tried to see him by the firelight But He wasn't in the room I ran to the door Stumbling over furniture and the shadows And screaming for him to wait I opened the front door But he wasn't there Cassie, we heard you screaming Did you, mother? What happened? I... I found out how my father died Really? How? He was murdered Laura, did you tell her anything? No, not a word, Mark I swear Cassie, how did you find out? I told you how I'd find out That... That tile? Yes It worked That's impossible Of course you'd say that But I discovered tonight That you, Mark, murdered my father That you cleverly arranged That a poor patient of his named Dennis D'Amour Would be arrested for the crime that you committed Who told you this? Dennis D'Amour D'Amour? Was he here? Yes He told me everything And you believed him? Why shouldn't I? Why the man's a maniac I don't know how he ever got here He should be at the state institution For the criminally insane Number, please Hello, operator Will you put through a call to the state institution For the criminally insane at Blighton? I wish to speak to whomever is in charge And call me back as soon as you get them It's urgent Yes, sir, I understand Thank you Now, Catherine You claim you actually spoke to this man Yes, Mark He told me he saw you murder my father Why, you're lucky you escaped with your life The man is a homicidal maniac I find it shocking that you should even begin To believe this fantastic story But it seems to be true, Mark, doesn't it? My father was murdered And Dennis D'Amour was sent away for the crime Yes, yes, that part of it is true But to accuse me Laura, we tolerated her in this enough But this is Hello Hello, supervisor of state institution Oh, yes, hello, Dr. King This is Mark Weldon speaking Has one of your patients A Dennis D'Amour escaped? What? Yes, that's right, a homicidal maniac He hasn't escaped, Mr. Weldon He was one of the patients who was killed In a fire that broke out in this place Two years ago What's that? Didn't you hear me? Yes Yes, I heard you Thank you Goodbye Mark What is it? Dennis D'Amour is dead He was killed two years ago Oh, friend How'd you like to have a little Chinese tile That can produce dead men for you? Or don't you think the Dennis D'Amour is a ghost? Perhaps you think he's just an old Popeye Poltergeist? Well, we'll know in a moment As we hear Catherine Brine Tell us the second half of her weird story My stepfather's hand trembled as he hung up the phone And even in the red glow of the firelight I could see his face that suddenly turned snowy white It's impossible The dead can't come back Unless you're making up this whole thing, Kathy Why should I invent a story like this?  Isn't it?  No, Mark I didn't invent it Dennis D'Amour was here He couldn't have been He's been dead for two years Then how would I know the things I told you? I don't know And that's what you've got to explain Mark, why does this upset you so? If you didn't murder him What difference does it make about D'Amour? Why are you so frightened? I'm not frightened I'm just determined to get to the bottom of this thing What was that? Just the thunder, Mark Laura Why are you looking at me like that? Like what?  Do you think I murdered her father? I... I just remembered certain things, Mark I can't help it if I think of them now What things? Tell me what things?  I thought I was mistaken, especially since you claimed you were at home that night Oh, Mark, don't be angry with me I can't help it thinking of these things now It's only natural Natural? Is it natural for a man's wife to accuse him of a crime like murder? And on the basis of what? The word of a psychopathic girl who should have been confined long ago She talked to a man who's been dead for two years I suppose you believe that too And who is this man even assuming that he's alive? A madman, a homicidal maniac who took your first husband's life When your husband tried to cure him Well, I've had enough of this Mark, what are you taking out of that drawer? Cathy, come here Why?  No Very well then Where is this man you saw? I'd like to see him too I don't know Of course you don't because he doesn't exist He does He appeared when I looked at the Chinese tile The Chinese tile?  Nothing but the design Yes, and that's all you're going to see No, the design is fading It's getting dark Nothing but blackness I heard the front door Someone just came in Yes Those footsteps That's just how he came in the last time Perhaps, but I doubt if it's good evening Oh, it is, Demor You remember me, Laura Yes, you've changed a great deal But it is you Mr. Weldon, it's been ten years since I've seen you Demor, then you're not dead There must have been some mistake when I identified you Not dead, you escaped Someone must have been identified instead of you That's the only explanation It depends on what you choose to believe, Mr. Weldon I brought a guest with me My father Dr. Brine, I'm sure you know these people quite well Of course you do What's he saying? He's talking to my father That's right, Kathy Unfortunately, you cannot see him But he's here, aren't you, doctor? Demor, what are you up to? What do you think? If you come back here to make trouble Double? No I've come back because someone wanted to know the truth And I've brought the doctor back for the same reason Doctor, before these others I want you to tell us Who murdered you? Who murdered you? Mark, you shot him Yes Why? Why? He's dangerous, a maniac That's not the reason It's because you murdered my father And you don't want us to know All right, Kathy I did kill him Mark He doesn't make any difference now This maniac has planted suspicion in your minds You would have found out sooner or later Mark Yes, I killed him For you, Laura I love you But that's over now It's been over for a long time I know what to do now And it's going to be very simple Thanks to our friend lying there What are you going to do?  D'Amour Do you think those shots will stop me? Don't you come near me Stand back Nothing will stop me, Weldon The gun is empty Now don't let go of me Yes Well, it's strike, D'Amour They hit him, but they didn't stop him From lurking toward Mark And seizing him by the throat As they fell to the floor The kerosene lamp fell off its table It might have been the wind But I believe otherwise I'm almost certain it was my father In a moment the drapes were on fire And the whole place was blazing I screamed to my mother to leave She ran with me out of the blazing building Into the storm that raged outside Two weeks later My mother came into the hotel room Where we were staying I've just come from the police, Kathy Well, mother Only one body is positively identified Whose? Mark's The other body? They haven't been able to find it In the rubble I don't believe they ever will But, Kathy, the police checked With the authorities at the state institution It seems that some of the patients Did escape at the time They had the fire there two years ago It's possible that the more was among them It's possible But I doubt it You think the more died Two years ago?   Well, there's only one way to find out If ghosts really exist Just ask one to haunt you some time You'll be sure to listen, won't you? Until next week then Good night Pleasant dream Inner sanctum has come to you Through the worldwide facilities Of the United States Armed Forces Radio And television service


Hey everyone, I'm Genie. So when I annotate, I like to have the printed article or book in front of me. I get my favorite colors, a pen, a few post-its, maybe some blank paper too. Symbols help me mark the page without making it messy. It's kind of like when you pin things on a map to help you find things later. A star means cite this passage. An exclamation point means pay attention. A question mark says what does this mean? And a square bracket means review this later. Circle numbers also help me list out key themes. I like to mix and match these symbols for any kind of reading. Good luck.


In this video, we provide the solution to question number 11. For practice exam number 1 for math 1050, we're given the graph of some function f. And we're supposed to identify on what intervals is f increasing. And so how do we identify where it's increasing? Well, when you read a graph, you always read it left to right. We always start from the smallest number in its domain. And we move towards the largest number in the domain. We always read graphs left to right. Now, in that direction, if you're reading it left to right, increasing indicates that the y-coordinate is increasing. Decreasing would mean that the y-coordinate is getting smaller. So as we go from left to right, where are we increasing? Well, if we start over here at x equals negative 6, that's the x-coordinate there, you're at y equals 0. As we progress forward towards x equals negative 4 right here, we'll notice that the y-values are actually getting smaller. So that's not increasing. That's decreasing. So we won't include that. Then as we go from negative 4 to negative 2 right here, we'll notice that the function's getting bigger. That is the y-coordinate's getting bigger. So that's definitely part of it. After negative 2, that was just an x-intercept, it continues to increase coming up here to x equals 0, like so. And so this portion's in green. This would be part of where it's increasing. It's increasing. So what we see here, it's increasing from negative 4 to 0. Now we're gonna put parentheses on it because the function was not increasing at negative 4, because on one side it was going down. On the other side, it was going up type of thing. That's actually what we call a local minimum. It's neither increasing nor decreasing at a minimum. Same thing as the maximum at x equals 0. You'll notice that when we hit x equals 0 though, the function starts to decrease. Again, the y-coordinates are getting smaller until we hit x equals 2. At x equals 2, it then switches a sharp corner, mind you, but it switches, and that starts going up again until we reach x equals 3 right here. So we're gonna throw that into our interval here. It was increasing from 2 to 3, like so. And then you'll notice that for the rest of the graph, as we go from 3 to 6 over here, x equals 6, the function was in fact decreasing again. So we're not gonna worry about that one. So it was decreasing from negative 6 to negative 4 from 0 to 2 and from 3 to 6. We don't want those. We want where it's increasing. So that happened from negative 4 to 0 and from 2 to 3. And it was increasing nowhere else. And so we look for that response amongst the choices and we see that's exactly choice F. So the function was increasing on those intervals right there. And I should point out here that when you're working on these questions of where is the function increasing? Where is the function decreasing? Where is the function concave up? Where is it concave down? We're always referencing the x-coordinates, not the y-coordinates, on which x-address will we be going up? That's what's being asked here. And so the domain, the intervals in the domain that make the function go up is negative 4 to 0 and 2 to 3.


Good morning. I'm Stephanie Coulter and today we're going to speak on imaging in structural heart disease What does the interventionist need to know? So we're going to start by discussing three main Pillars of of structural heart disease for which we're conducting You know patient-centered trials and as part of a regular clinical medicine here at Baylor St. Luke's Medical Center and the Texas Heart Institute We do interatrial septal Closure devices left atrial appendage Exclusion devices and we're going to talk a little bit about valve disease and what opportunities are available so for interatrial septal defects a simple review reminds us that the most common type of interatrial septal defect is really the PFO which can be based on embryology and may be acquired due to atrial enlargement or acquired due to Interventional procedures as well but in the embryological type of interatrial septal defect the succundum is the most common and you can see pictures on both the left and the right Revealing the venosus type the succundum type the premium type An unroofed coronary sinus which is very rare The ASD Can be imaged very beautifully by trans esophageal echocardiogram and you can see there's evidence of a succundum ASD in this view on the left You'll see at the base of the heart the aorta as your landmark and you see the septum Primum above and a hole in the interatrial septum and on the right you can See again a defect in the center of the interatrial septum During part of the succundum septum and in another view you can with color Doppler You can see clearly that there is a good amount of flow From the left atrium into the right atrium which suggests that the left-sided filling pressures are higher than the right Which are common and are associated with over circulation of blood flow to the right heart Which leads to the manifestations of an ASD we can size the ASD by TE by 3d we can size an ASD as well by CTA or by MRI Real-time imaging in the cat lab is available only by TE and you can see that the defects here Have unique shapes some round some elliptoid some distorted and these distortions are related to the pressure differential That expose the interatrial septum to different forces Indication for interatrial septal intervention include ASD's and PFO's and in Asymptomatic children ASD should be closed if there's evidence of right-heart dilatation if the ASD measures more than five millimeters and If the child grows and there's no spontaneous closure in older patients hemodynamically significant ASD's are defined as a QPQ s greater than 1.5 These should be closed particularly if there is elevated pulmonary artery pressure or if there's pulmonary vasoreactivity due to Induced changes in the vascular bed due to pharmacologic challenges or if there are reversible changes on lung biopsy We also now have an indication for closing hemodynamically insignificant ASD's or PFO's or those with QPQ s less than 1.5 if the patients had a cryptogenic stroke The closure device that's most useful and most utilized is the amplacer device which is seen here, which is really Basically two discs and the measurements are on the right and the delivery catheter system is on the bottom left and it can be easily deployed from venous access and This is the respect trial which fed us with the proof that closure of a PFO or a small ASD Benefited patients who'd had a cryptogenic stroke in this landmark study There were 980 cryptogenic stroke patients aged 18 to 60 with a PFO And they were randomized to device closure versus medical management and followed for nearly six years and the endpoint was recurrent stroke There were low serious adverse event rates procedural Adverse risk were low at 2.4 percent And in the end there was a 45 percent reduction risk reduction In reducing recurrent ischemic stroke in those that had the closure device and a significant 2% relative risk reduction in favor of PFO closure for reducing recurrent cryptogenic stroke There was technical success in this study of 99 percent and 96 percent procedural Success and based on this trial the amplacer device was FDA approved for PFO closure During the interventional procedure the TE is useful for guidance because of its you know Advantages one their superior image quality to trans thoracic imaging You can use 3D techniques to evaluate the interatural septum. You can evaluate the anatomy. You can exclude thrombi and you can help the Interventional cardiologist or the interventional Radiologists I guess in some centers with device positioning and guidance and we can assess for Residual shunting at the end of the procedure of course the disadvantage for all TE procedures is that it requires esophageal intubation requires some additional sedation and The risks include aspiration and mainly esophageal trauma, which is really quite rare and reported to be less than one in 3000 Intubations so here is what a device looks like on FOS on the right and you can see The left atrial disc on the right protruding into the left atrium and the disc motion This slide shows a case that we actually had at our facility that was a transfer from an outside central Texas facility Where the patient had been previously treated for a PFO? Which was thought to be the cause of their interatural shunting and a PFO closure device was applied to the patient But lo and behold the shunting did not end TEE done here in our facility demonstrates a superior venosis defect and surgical Intervention was required at which time two branches of the right-sided pulmonary veins were anonymously Shunted into the SVC So these veins had to be re Allocated to the left atrium and the venosis defect closed So in fact if more careful imaging of the interatural septum had been done The patient probably wouldn't have needed the PFO closure device that you see on the right side of the screen this patient underwent The surgery as I said and then this slide actually shows a little bit of residual Color abnormality abnormalities around the interatural septal device Which is common because the interatural septal occluder device is a bulky device and it causes color Abnormalities which are not related to a recurrent or a residual hole when you look at intra cardiac Contrast injections so we also are a big center for left atrial appendage exclusion and We are using currently the watchman and we also are using the lariat device and the lariat device was developed here at the Texas Heart Institute under the direction really of doctors Billy Cone and Abdi Rasak and I think we've done the largest Series at in the world today using the lariat and I'm going to explain it as we go so during these procedures the Imaging is quite important Pre-procedurally we look at the left atrial appendage shape Documenting whether or not there's a large chicken wing or they're not it's a windsock We can make very detailed measurements of left atrial appendage size And we can make sure there's no thrombus in the left atrium or in the left atrial appendage Inter-procedurally we are there doing TE guidance To help with the transeptal puncture and for real-time imaging during device placement We assess the position of the device we look for complications including pericardial effusion and importantly We do follow-up Surveillance of these devices before we withdraw the anticoagulation to look for success of closure Looking for residual flow and we are also looking for residual post closure thrombus on the device Which in the watchman is currently thought to occur in about two and a half percent of the cases So this is a case of a TE pre Watchman and you can see on the scan on the left We are measuring the left atrial appendage at the waist where the device will sit and and at its depth and On the right side as well by x-plane technology is very helpful because you can get one picture you can get two pictures at one time and And shorten the length of your exposure into the cath lab Here you can see that There's a biplane picture again of the interatrial septum and we use this biplane imaging to help the interventionalists Puncture the interatrial septum and the goal is to puncture the septum both inferiorly and posteriorly So that there'll be plenty of room to maneuver into the left atrium So you can get the device across the watchman looks like this on the left it looks like a little parachute and we lodged that into the left atrial appendage and It sits should be flush With the os of the appendage and it should form clot on the back side of it and Exclude the appendage so blood clots can no longer form in the appendage this slide shows the post or Intra positioning of the watchman and on the left you can see the watchman with the catheter still Attached to the center of the watchman and we're imaging to make sure there's no residual flow on either side and in real-time Imaging on the right you can see that there's no color flow on either side of the watchman So it appears to be pretty well placed and Here you can see post procedural imaging on the left shows a very successfully deployed watchman and on the right You can see the residual interatrial septal defect which is common and which should spontaneously close over time And it's important to do follow-up imaging and this was a follow-up imaging done a month after the insertion of the watchman and you can see evidence of a thrombus with a long sinewy tail in The first image and in the second image the patient was antiqued kept on the anticoagulation And and follow-up imaging The thrombus went away. So this patient was maintained long-term on A NOAC which you know was kind of contra the reason for getting a watchman But it's a rare complication only two and a half percent But yields really of a good success rate at over 97 percent the Lariat system is another type of system for excluding the atrial appendage and This one literally causes permanent exclusion of the left atrial appendage because literally a lasso is threaded extra cardiac through the pericardium and that's what you can see on the the demonstration in a On the screen you can see a catheter is placed across the inter atrial septum And it has a magnet on it and that magnet enters the left atrial appendage From the inside of the heart and from the outside of the heart a pericardial tap is done dry and a catheter is positioned with the magnet near the lateral wall and the two magnets are attracted to one another and This is the way that we use to guide the Lariat into the left around the left atrial appendage From the magnet inside the heart So you can see here that this ligation results in a permanent Transmural lesion and we think this is the reason that people that get the lariat Have sustained reduction in atrial fib burden long term So keys to successful left atrial appendage ligation is careful pre-procedural planning which includes both echocardiography and CTA pericardial access by careful Interventional cardiologists the proper placement of the endocardial magnet wire Orientation of the lariat and alignment of the snare over the left atrial appendage and then confirmation of closure We're going to move on to valvular disease and Valvular heart disease or structural heart disease is increasing with age for both Mitral and aortic disease and now it's considered to be at least nine and a half percent for patients or people Over 75 years of age So what do the interventionalists need to know from the imaging physician during taver and mitral clip? Well, in fact the imaging is the bread and butter of patient screening We primarily use the echocardiogram In an outpatient setting to identify patients who have significant aortic or mitral valve disease based on primary screening by the physical exam MRI and CT are complimentary techniques to evaluate both the structures involved and MRI certainly for quantification Purposes for taver. Dr. Crazier is going to speak about taver today, and I'm going to kind of Breeze past taver interventional imaging because it's pretty routine and we're doing about 15 tavers in our center every week We're pretty streamlined on the imaging for taver This certainly the interventional cardiologists use the fluoro Dr. Crazier and his colleagues here are doing tavers with very limited amount of Coronary dye and certainly that's beneficial to our patients. We are using gradients calculated by Doppler we identify stroke volume index and LVEF by echo In patients that have severe and symptomatic aortic stenosis. We're also looking as progress trial at Patients with moderate aortic stenosis and certainly we're using imaging to discern Trileaflet versus Bicuspid aortic pathologies for the mitral clip pre procedural screening is first performed by trans thoracic and then by trans esophageal echocardiogram the TE is required because detailed mitral anatomy is Required as well as measurement of the mitral valve annulus by 3d for plenometry the echo is also extremely beneficial for determining whether or not the etiology of the mitral regurgitation is primary or secondary and as I said before We have to determine the mitral valve area before we plan how to fix the valve because if the valve area is too small then Percutaneous Interventions are not going to work and finally we use the echocardiogram to quantify the severity of the mitral regurgitation here's a pretty picture of a taver and I'm going to move to mr. So mr. Is very common Increasing amounts of mr are found in our population and the pathophysiology of mr. Is such that it's a It's a circular Problem where you have a little bit of mr. That increases the load and the stress that causes muscle loss and damage and dysfunction to the left Fentrical which leads to dilatation of the left ventricle which leads to increasing levels of mitral regurgitation With one-year mortality for significant mr. Up to 57 percent medical management of mr. Defined by functional status or degenerative status on the left and on the right and You can see that the mortality In five years for medically managed mr. Is 50 percent So we're not doing a great job with therapies for mr Because many of the patients are not good surgical candidates. So for mitral clip technology. It started first with clipping organically abnormal or innately abnormal mitral Anatomy and you can see that with patients that have a flail leaflet or severe mr from degenerative mr Class three or four heart failure is associated with the mortality of up to 34 percent per year compared to those that have only class one Or two symptoms only four percent per year the mr. Severity also predicts progressive worsening prognosis in Patients that have functional mr. And heart failure and you can see here that the degree of mr. Increasing Decreases the likelihood of survival and increases the likelihood for mortality in Follow-up and this is data from the co-op trial the mitral clip is the only approved mitral device at this point And you can see on the left How it looks like a clip with arms and this is what the device looks like when you are Using it in the cath lab, and that's the delivery catheter and the device so in general the mitral clip requires a lot of detailed and Really kind of expert imaging in order to successfully complete the procedure the imaging is really really important And the imager has to be a companion to the interventional cardiologist to be effective you can see on the left that The first step of this procedure is to help guide the Transseptal puncture then we use the echo the TE to steer to the right Spot in the mitral valve, and we use both on-foss three-dimensional imaging as well as Two-dimensional explain imaging to see where the grasping arms are and you can see that Following the spot once we get the leaflets gras we make an assessment about how hemodynamics have changed with the clip and then we look to see afterwards how successful we are what the gradients are and Here we can see that we use the TE to define the mitral valve anatomy before the procedure The plenimidered mitral valve area must be greater than four square centimeters by 3d plenimetry We look carefully to make sure that there are not large mitral valve clefts that there are no Vegetations and perforations which are exclusion criteria for mitral clip and we also look for Areas of abnormal calcification which would make clipping more difficult the TE is also useful to define Defendant of Lee what the etiology is whether it's primary or secondary And we look at the link of the leaflets because you're going to need enough Link of the leaflet to get into the clip and you need of at least a nine millimeter length of a leaflet particularly of the smaller posterior leaflet leaflet in order to make a good grab The width of the mr. Jet is important because it's going to help to define which kind of clip you're going to want to use and then we can measure the flail gap and a flail segment width and A gap less than 10 millimeters and a segment with less than 15 are ideal for clipping You can see here There's a 3d on phospho of the mitral valve which shows the aortic valve in the surgical position Which is so confusing to me as an echocardiographer and I've gotten used to it over time But you can see unfortunately for you know it seems backwards to us that the medial commissure is now lateral and the lateral commissure is now medial and This gives you the clock view with the enter leaflet on top and the poster leaflet on bottom It looks like a smiley face and here you can see that smiley face on an echocardiogram that I TE that I did this week and you can see that you've got the Two-dimensional images in a biplane Imaging plane on the left and then the 3d in the middle and you can see this is a relatively normal ish looking mitral valve and Again, you can do a lot of fancy imaging and I've shown you a technique that people are really kind of happy with called glass imaging Which may be useful in certain search of circumstances pre procedural hemodynamics are important and Assessment of the trans mitral gradient is important and looking at the pulmonary veins is also very important for the Assessment of mr. We quantify the mr In some cases by the ever is to criteria where you need at least three of the four or the color jet area of a Central jet is 30% of the left atrial area You look at the pulmonary veins to make sure that there is Cystallic flow reversal or blunting of that systolic flow to indicate significant hemodynamic Mitral regurgitation you measure the vena contract a width and hopefully it's greater than 0.5 a Regurgent volume needs to be at least 45 mils and in the US. We really kind of like 50 mils per beat Which should correspond with a regurgent fraction over 40% and a regurgent orifice at least greater than 0.3 and Hopefully near alert nearer to 0.4 mr. Comes in two types Really mr. Is incompetent mitral valve closure which leads to retrograde Cystallic flow from the left ventricle onto the left atrium and subsequently into the pulmonary veins Which is what causes pulmonary edema and it comes as a primary problem when the leaflet itself is diseased But the ventricle is not the problem in this case one leaflet is prolapsed or flail and It's usually a problem with a leaflet and the cordal structures or the sub-valvular apparatus Our secondary mr. Which is much more common is secondary to left ventricular dilatation Which is often related to ischemic heart disease But it's also very common in patients with non ischemic cardiomyopathy The common problem here is that the ventricle is the problem the ventricle is enlarged which displaces the Papillary muscles pulls on the cordae and pulls the mitral into an apically tethered position Which prohibits proper leaflet adherence and closure So here in this case on the left is a primary Mitral valve problem of the posterior leaflet and a secondary problem on the right and again The top left is the posterior mitral valve on the right the anterior mitral leaflet on The bottom left is a flail posterior leaflet with P1 cord rupture because you can see the aorta in that position and in the bottom right is a bi leaflet Myxomatous typical Barlow type mitral valve regurgitation patient so the criteria for mitral clip or are included here for Perfection but we really want to see patients with significant greater than moderate to severe regurgitation that are symptomatic with pre-existing co-morbidities that are that do not proclaim them from living at least a year To benefit from the reduction in MR. They patients are currently being Included if their surgical risk is prohibitive. So at this point for primary disease, you know some young people with Mitral regurgitation and a ruptured cord in their 30s. These people really should have very low STS scores and really should still go for an open or Robotic mitral valve repair, which has long-term durable outcomes, but for those that have high STS scores for a mitral valve Replacement or repair or those that have porcelain aortas or hostile chest with radiation or severe pulmonary hypertension or Other pre-existing problems like cirrhosis or AIDS or severe dementia these patients really need to have a careful analysis the important thing too is that they need to be at goal-directed medical therapy and still have Symptoms and significant mitral regurgitation. So For secondary MR, you have to have moderate or severe MR According to the ASC guidelines Symptomatic MR persists despite as I said goal-directed medical therapy, but the EF is between 20 and 50 percent Okay, the stroke in systolic dimension needs to be less than 70 millimeters and a multidisciplinary team must be involved for the imaging you can see here on the very far right with the clip actually looks like and then you can see the echocardiographic view on the left and the fluoroscopic view on the right and The interventionalists will be watching both of the screen. So you need to have the echo TE images on the screen for the interventionalists and the first thing we're gonna watch is for the Transceptile puncture and here you can see an x-plane of the interatrial septum Which shows you a superior to inferior dimension and an x-plane which shows you an anterior and a posterior dimension and Again, you want to be inferior and slightly posterior in your puncture And you want to have about four to five centimeters of height from the puncture site as A distance to the mitral annular plane and this four to five centimeter Dimension gives should yield enough room to maneuver the device and to give you enough movement room to be able to steer The device toward the mitral valve appropriately as you can see here I've shown these beautiful 3d markers that can be applied to structures During a TE and then they can be followed in Subsequent imaging planes so that you always know what the structure is Very helpful in some of the technology For mitral valve clipping the transeptal again, you look at a bicable and a short axis view You measure the proper height from the annulus and you can assess whether or not your puncture site has been appropriately Directed for positioning you're gonna see in screen number one on the left an intercomissural two-chamber view looking at proper medial and lateral alignment and in Phase two you'll see the LV outflow track and again you look for anterior and posterior alignment So you can use 2d imaging to get to proper alignment or you can do a 3d on Foss view with a good amount of the atrial tissue and you can see where your catheter is diving Toward the mitral valve and align it in that regard and for clip positioning in this slide You can see on the left the clip arms are down and the 2d imaging in the x-plane of the clip At 60 degrees and x-plane you can see the grabber arms of the clips And you can see the mitral leaflets as they come down into the clip And that's how the interventionalist steers the guiding catheter system to the right position and the echocard The echocardiographer is certainly very involved because any motion of your wrist or of the probe will distort the imaging that the interventionalist is needing So it is a patient and time-consuming procedure you can see in three and four and four particularly you can see the on-foss view with the clip and its orientation and so the echocardiographer and The interventionalist can see you know what orientation You want to achieve In order to get the clip in the correct position based on the anatomy of the position of the patient and Here you can see the clip arms are perpendicular to the line of co-aptation The gripper arms are taken down the full length of both clip arms are visible at 180 degrees and the clip arms are available Once the clip is inserted you can assess to see whether or not the leaflet length is the proper length by echo views and Also by this on-foss tissue bridge view you can see where you've created, you know a Tissue bridge between the anterior and the posterior leaflet and you can also use this exact view to assess for regurgitation and it may be useful to help reposition the clip in order to get more Mitra regurgitation here is a clip case from this morning and a clip case from last week and The first five views on the left are from the clip last week and you can see the first two upper slides show significant Functional mitra regurgitation There's one clip in place and you can see that there's very Mitigated mitra regurgitation and a restriction of the motion at the clip and a very successful with one XTW clip The second case is done from this morning a functional mitra regurgitation patient that had left atrial pressure average in the middle 30s with V waves into the 70s the patient had torrential MR and pulmonary hypertension as expected the patient was quite symptomatic and The patient required two clips first lateral and then one medial and the left atrial pressure fell to 12 the mean gradient on the right went to 2.4 and Hemodynamically we thought it was a raging success and hopefully the patient will benefit Thank you so much for your attention and I appreciate the opportunity to present today