Mitral Valve repair is the gold standard. Unfortunately, not all Mitral Valves can be repaired. Mitral Valve Replacement (MVR) is still a very common procedure. If a replacement is necessary, how do you discuss this with your patient? How do age and the current guidelines impact valve choice? What other factors impact this important decision? This live webinar brings renowned cardiac surgeons and cardiologists together for a case-based discussion on MVR options.
Dr. Mario Castillo-Sang, MD, Surgical Director Mitral Therapies, St. Elizabeth Healthcare, Edgewood, KY
Dr. Tom C. Nguyen, MD, Chief of Cardiothoracic Surgery, University of California, San Francisco, CA
Dr. Robert L. Smith II, MD, Cardiovascular Surgeon, Baylor Scott & White: The Heart Hospital, Plano, TX
Dr. Alan Zajarias, MD, Structural Heart Cardiologist, Washington University School of Medicine, St. Louis, MO
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good afternoon to everybody. Thank you for joining us On behalf of the Panelists, we want to welcome you to the first round table webinar on NVR options For the younger adults, the format will be one of round table discussion. It'll be case based. Our goals are to review the European and American guidelines and mechanical valve replacement. Display the application of these guidelines throughout case based discussions. To exemplify the preoperative decision making discussions mitral valve experts have with their patients prior to surgery, and to provide technical best practices and problem solving techniques by Metropolit. Experts finally to discuss the different alternatives and mitral valve replacement surgery for the young patient. Today I'm very pleased and honored to have with us a panel of friends. Dr Tom Gwen Dr Tom Gwen specializes in minimally invasive mitral valve surgery, and he is the chief adult cardiac surgery and Helen Charles Schwab, distinguished professor of surgery in the Department of Surgery. The University of California in San Francisco. Dr Robert Smith is a cardiothoracic surgeon who specializes in complex robotic mitral valve surgery at Baylor's Cotton White and the Heart Hospital in Plano, Texas. Dr. Zaharias is a director of Structural Heart Fellowship and professor of medicine in a Jonty Millikan Department of Medicine cardiovascular division at the Washington University in ST Louis. And I'm Mario Castillo, san heart surgeon in Edgewood, Kentucky at ST Elizabeth. Health Care Thank you all for joining us today to the Panelists. So these are disclosures. Let's dive in. We're going to talk today about guidelines both the American and European guidelines. And first, we'll start with a new, newly published 2020 h A H EC guidelines for valvular disease as it pertains to the management of the patient who requires a mitral valve replacement. What has changed in these guidelines this year was the incorporation or the change in the age caught off for the patient who requires a mitral valve replacement provided their candidate for oral anti coagulation with Coumadin. This age card have changed from 50 years old since 2017 to 65 years or younger, so that carries a to a indication, um, in both of the guidelines 2017 and 2020 in the European guidelines, very similar to what we have seen in the new American guidelines. The age caught up had been already since 2017 for patients less than 65 years old who were good candidates for replacement to undergo a mechanical valve implantation. Patients who did meet this criteria were given that option for patients who were 65 to 70 years old. That area was a discussion. Recently, European guidelines joined discussion with care Team, so without for the delay. This is the new algorithm, or route that we will take to treat patients based on both guidelines that they are now coalesce into one thought process. Where if the patient is a candidate to undergo or to have Coumadin therapy without contraindications and the patient has a need of a replacement if a repairs failed or is a replacement from the get go, Those who are less than 65 years old become candidates for mechanical mitral valve replacement. And today we're going to talk about three different cases, and we'll get from our Panelists how those patients are managed, what the conversation looks like, and we'll get some pearls from them to inter operative. So our case discussions will present an echo will have the Panelists discussed the findings, will have some polling questions and then we'll have a nice conversation about the case. This is the first case. So the first cases a 40 year old, otherwise healthy female with a history of rheumatic heart disease. B M I of 35 a Bs of 1.8. She has Disney a on exertion with short walks on one flight of stairs. Her left heart catheterization was normal and her echocardiogram will be shown next. Dr Zaharias. Thank you, Mario. So this is a transfer jewel echo, and we have a long axis view of four chamber view. Well, you can see a dense amount of smoke in the left atrium and evidence of left atrial enlargement. You have calcification of the mitral valve, involving both leaflets with chords in the belief that that are retracted and calcified. So this is consistent with significant mitral stenosis. Okay, why don't we have the polling question as a reminder? This is a 40 year old female with rheumatic stenosis. Okay, why don't we go ahead and Dr Smith, what are your thoughts on this eco? Just looking at this eco. So, uh, we got a really nice summary of what's seen there to me. You know when I look at this mitral valve, I think the biggest part of this is this looks like a pretty classic rheumatic valve. And when you look at a classic romantic valve like this in a 40 year old, you need to start thinking. Is this a replacement valve? Um uh, or is this patient have a desire to have Children? And so what kind of replacement is she Still a child bearing age? Is she willing to take birth control pills? The other part. And this is where the heart team is always a big piece of the discussion here is Is this a valve that is potentially intervene, able through balloon mitral valve plastic? And so, based on the discussion points that were brought up about this valve, it doesn't look to be a good candidate, despite the fact that it doesn't have any significant regurgitation, which would be one of the things there's calcium in the leaflet tips. Extreme fibrosis down at the tips of the leaflet going into the popular head. So those would be characteristics where you think that a balloon dog a place you might not do very well, but it's still a discussion point you should have as a team. And then the other big point here is that you've got good right ventricular function, which I think is important, but a gigantic, dilated left atrium with smoke already. So my guess is this patients already on anti coagulation And so more than likely, we're going to be having a discussion about Hey, we want to do a valve for you that's going to try to put you in the best chance for a good long term scenario without another operation. And so in my case and in my thoughts, I would be looking at directing this patient through through active discussion towards mechanical Tom. Anything you want to add to that conversation and perhaps touch on your approach to this. Absolutely. Thank you, Mario. And thank you everybody for joining. Um, I want to expand upon a little bit what Rob said before and what you said about the the ability for anti coagulation in that decision making tree. You know, if you ask people whether or not they want to be uncommon in, most people will say no. He wants to be included in the entire life, But But if you explore low deeply and you have a conversation with them most actually fairly amenable to being on company. So I know that, you know, in that decision tree, whether or not they can be on Cuban and I think a lot of it, it involves a very in depth conversation. And I think now, with, you know, in home testing, uh, it's not as bad as people think. Um, the only thing that I agree with rob on all fronts, um, this patient, you probably get a mechanical valve. One thing I would do addition to work up any time I see a patient with my trichinosis. And in general, I'm actually fairly minimalist and ordering ordering labs or tests or what not? But if I see a patient patient with my diagnosis, I'll often get a C T scan. Um, I usually don't get seats against everyone else, and the reason why I got a CT scan is because I want to see if there's a lot of calcium on the leaflets and the calcium on the analysts, and if it does, and it might change my approach a little bit, but also it gives me an idea really kind of how long I should put this case for. If it's gonna be like this, it doesn't look like there's a whole lot of calcium in the leaflets will be relatively quick and easy case. If I see a lot of calcium on the leaflets, uh, and all the analysts and I might require some agreement and Patrick Construction or maybe other creative stuff like Tavern Mac, etcetera, etcetera. Nice to be a longer, longer day. So I always go to see the skin. Well, look at a patient with micro cirrhosis, but this particular patient, I'll get a mechanical. I'll steer the patient towards mechanical, uh, mitral valve replacement, Uh, give them to resources that beyond company, it's not the end of the world and a lot of people do it. And we have very productive lives. Uh, and, um, and I would approach this hands down middle invasive approach of the right chest. Alan, let me ask you this looks hilarious. What is your conversation with the patient when you see them? Are you Are you prepping them for that conversation with the surgeon too? I think in this case, Mario, the conversation has to be had early, and it has to be repeated multiple times. Nobody gets excited about card surgery as everybody it pretty much has experienced. But I think patients need to understand that the rheumatic valve stenosis that this patient presents with is associated with. The high risk of thrombosis is associated with a certain amount of complications. And since she's a young individual, we want to make sure we do a lifelong management as opposed to a shorter term treatment strategy. Um, I agree 100% with Rob, but he had mentioned about the candidacy for a mitral valvular plastic, which in younger individuals with the anatomy being appropriate would be the first treatment. However, you know this, uh, this valve is very degenerated, and the Wilkins score is way above eight. So as a result, we do want to encourage the patients to understand that they will get the open heart surgery. They will get a mechanical mitral valve unless there is a frank contraindications to Orlando regulation. And people tend to understand that, uh, the more they hear it, and the more they learn about the safety profile of Cuban or how to manage an active lifestyle with a good dietary and the dietary habits. Um, I think they will take it very, very well. Yeah, I agree. I think these are very, very good points. Looking at the polling questions we had the first person with How would you approach this? And I think Tommy already so that you would have pushed it through the right chest. Um, some, some of the audience, some, some in the audience comment, they would do an open operation. Rob, what would you do? What would be your approach for this operation? So for this, I think Tom's approach, you know, right chest would be very appropriate. I would either do it right chest or robotically, just depending on how the anatomy, um, struck me for best safety profile. But I think both of those are very appropriate approaches. I think an open surgical approaches also, you know, very good as well. And I don't think you're wrong and doing that at all. Um, I think the nice thing about this particular case, we don't have all the echo images, but we're really dealing with isolated mitral valve pathology here. And so it really sets up nicely, particularly even for the beginner and the minimally invasive space. This is a really good case that sets up nicely for doing a minimum straightforward replacement. You know you're going in to do a replacement, particularly you're going to do a mechanical valve. You kind of get your which is downright you. Make sure you clear the pathology of the way of the leaflets, and this should set up pretty nicely for straightforward, a bunch of replacement. Perfect. So, you know, Rob Rob noted that the atrium is extremely left. Atrium is extremely dilated. A lot of smoking left atrium. What would you do? And would you like to the left, in your opinion? Or what would you do about the state pensions? Granted, patients doesn't look like she has a fib, but there's a lot of smoke in there and dilated. Yeah, I think in my hands definitely would would have left atrial appendage legation. I've not been able to do what market is does with that with a V club, so it would be a future future litigation internally for sure. Rob, what's your approach to do you like it all? Atrial appendage is when you do a mitral valve operation. Utah I don't. I'm trying to be pretty thoughtful about each of them in this patient. Let's assume she's not had atrial fibrillation. She's going to be on a pretty hefty dose of anti coagulation as it is. Um, and while generally like getting the atrial appendage are putting a device on it is relatively low risk. It's not zero risk. And so I'm just trying to think of one of the most effective ways to help treat this patient. And for me, it's making sure we really address that mitral pathology. And then, you know, I think in different risk categories for thrombosis. I think we consider doing some of the appendage mint. You know that for me? Anyways, it drops significantly when you start talking about the anti coagulation. You're going to be on when you're already going to be, uh, using correct. So here here are some of the inter operative findings, right, And so this in this circumstance, you can see the severity of the disease process, right? Really, really an ugly valve. What are your thoughts right now, Tom, when you're seeing this, you're faced with this, you know? So it's pretty disease valve, you know, what I what I also see are the paper and muscles are fairly thickened. Uh, disease as well. Um, and obviously the Livingston to go. I'm gonna replace the valve. I'm gonna kind of reserve as much chords as possible. So actually, try not to respect too much and preserve. And I'll try to re anchor, uh, we suspend the Corday, Um, usually at the kind of 10 to 7 o'clock position and then to the four o'clock position. Um, what I what? I also obviously wanna put the largest valve possible, but kind of a pearl that many folks may may not know is, um, you know, the the the Onyx valve. A lot of mechanical valves you actually can spin the way it opens. As you can see here, you know your implant a certain way, but a couple times in the past, implant it. Look at it as the leaflets open as those kind of disc open. Well, hit against the proper muscle. And I'm thinking of crab. You know, I don't want to get stuck there, so sometimes, you know, sometimes you can definitely do it any time, But sometimes it's worthwhile to kind of spin it to make sure it opens in such a way. So it doesn't hit underlying structures because it's a mechanical valve. You have to worry about that particular alpha chapter obstruction. Also, you can kind of do that relatively aggressively. Uh, your, um one thing I would be kind of cautious about is kind of how much really cutting into the papillary muscle. Um, and, you know, I do think that the more you come to the popular muscle and the more you kind of debris that pushed your ambulance, you do run the risk of, um, uh, kind of maybe the social destruction. So I'm a little more conservative about that in this setting. Rob many thoughts on that. Yeah, well, I mean, I think a couple of things. So number one is and you saw it as you were cutting into to the valve and starting to expose this of Advair apparatus. This is why we talk about the Wilkins score and the amount of fibrosis that's there. This is a patient that's going to be pretty high risk for a leaflet tear if we were to do a balloon value capacity. So when again, uh, really emphasized the hard team approach so that cardiologists and cardiac surgeons, even with balloon value plastic, can talk about these kind of different pathologies because romantic valve disease is not all the same. And this really highlights that, because these are there will be times where you know there's a high risk patient. They need to undergo a blue value plastic attempt. But surgery needs to be on standby for some of those because they can get really wicked, uh, terrible. Uh, what Tom was saying, Yeah, I mean, largely. Yeah, I agree. I try to preserve the papillary muscle function and preserving the geometry of the heart. So I I usually use, like a pleasure to Gortex through the papillary tips and bring those out in a way to try to put them out to the side, you know, So that's usually the kind of 39 10 4. If you look at the way the onyx valve is designed, it's actually got the bigger piece of the flames that goes down, Um, and that's a vascular space, and so that helps kind of protect that out of the way. The other thing I generally do is I usually put it in the anti anatomical position. Very important point. Yes. And then I always you know, the way I do it is I do these, uh, the futures in atrial ventricular fashion. And I always make sure I have a mirror that I can look back up to the outflow track. And this is even port access. This is robotic on my bedside assistant. Put a mirror in there just to make sure that I'm really aligning that with the outflow track because the skinniest part of the device is along the lines of the outflow tract. If you line that up, right and you've got the biggest area now for your outflow track and there are opportunities to create some stenosis and and folks when you're doing mitral valve replacement, not as much in the romantic valve, although they sometimes will have a very small ventricular cavity. But you still can cause outflow tract obstruction, not not profound, but an increase greater out there. So it's something you want to be watchful for us to try to align those things up the best you can and make sure you didn't grab any. Since you're reverting those features, make sure you didn't grab anywhere directly next to the aortic valve. Angels, As you're doing that, you may induce. Uh, yeah. Agreed to I second all those points and great point. One of the things I don't tend to. I don't use a mirror, but I do use a very long endo right angle, um, and probe the limits of the l v o t. To to make sure that my future replacement is going to correspond with that and the valve to an Oriental valentine, Atomic or to these are great points. I also I also want to bring up one of the things that that I that I prefer in the valve is the cage that protects the mechanism of the leaflets. Right. So that's one of the things that we've all done surgeries for, to explain. Valves that are frozen have panels growth on them. And that's one of the things that I fear. I don't want to do to operations in the same patient. And so that's one of the things that I look for and about that has a little more protection of the mechanism. When you implanted. Okay, uh, implantation little bit as well. You know one trick I do. I'm not sure if Rob and tomorrow you do a lot of really invasive. I take the valve, whether it be a ring, mechanical or tissue valve, I take it off the handle pretty early. I have it on the handle to put the sutras through. But what I'm advancing through, I take it off pretty quickly because a lot of times decisions Tiny. You have to put it somewhere. Um, but but you really need to kind of kind of seesawed back and forth to make it seem the analysts, Uh, and the only way to do is take off the handle because the handle kind of restricts that when I do my my my knot tying or corn not It's like a tire. So I usually do it at the one o'clock position first and then the 10 o'clock position in the six o'clock position kind of really anchor it, and then I'll kind of go around the circle and make sure it's nicely anchored. Um, but, you know, I think it's really helpful, and we're not talking about aortic cases now, but same thing for a lot of military bases or even open the order case. I take take off the handle pretty quickly again and really kind of get into seesaw and get it deep down and seek pretty well. And I think you brought up a point that remember, Do you remember that you can actually spin the orientation of the of the leaflets once it's implanted to, which comes in handy if you don't like exactly the way it's seated, that's an important factor. But I think I think this was a great case of this cause and touch upon, um, the different aspects of a rheumatic patient, a young, rheumatic patients. Um, I think we're gonna move onto the next case. The second case is a 55 year old, otherwise healthy male with a history of moderate mitral. Regurgitation in the past has worsened, and he is now with increased dystonia over the last two months. Here's a B M I of 27 b s a of two and his coronaries are clean. No disease there. And we're about to show you the t e of his disease process. So this is his echo. What do you think? I can see what he has. My total vegetation. Uh, this is definitely a valve with the general multiple disease. Uh, this is probably Barlow. So there's my leaflet prolapse, and there's a flail component of the posterior leaflet. The failed gap is very large. Um, you also see potentially some of the anti Leave it at that. Also, we can still look upward. So potentially at least one court, if not to have broken. Um, there is evidence of authentically enlargement, at least in this, Uh um, in this long axis view that you see on the right of the screen and the left atrium appears to be enlarged as well. So classic of the general mitral valve disease. He's clearly symptomatic because of the m r and definitely would meet criteria for, uh, surgical procedure. So, uh, go ahead. Go ahead. Well, yeah, just based off that I think with this echo, I would say, but potentially low fifties, maybe high forties. Now the image on the left is foreshortened. Uh, and we're not really seeing the true long axis view, but I think within 45 to 50% I would say so when you see this patient and you see this at going and obviously the patient symptomatic. Um and I mean, you know, the complexity of the pathology, right? And and not all valves can be fixed or will be fixed. And that's the reality of things. What are you telling the patient? Ellen is a cardiologist when you're referring to Sergent. So I tend to get a trance of Agios echocardiogram in every patient that I'm considering for mitral valve surgery even before I refer to the surgeon. Um, I think sometimes not knowing what the pathology looks like ahead of time puts the patient at a disadvantage and doesn't give the surgeon the tools that that he or she needs to actually have an appropriate discussion of. Is this valve irreparable or is this valve non repairable and having that, he is very, very important. Um, in this in this case, I think the there is big. There is a very complex mental pathology. You have redundancy of both leaflets. You have at least one if not two chords that are torn. Um, so I think upfront, I would say that I would like the patient to be seen by a highly experienced surgeon who specializes in mitral valve, uh, processes because they would have a higher rate of repair. But I would not be surprised if by any chance, this is not something that is successful. I tried to preempt the conversation that way, but I would try to emphasize that there we would like to do a repair strategy first, if possible. Yeah, fantastic. And why don't we cue the questions and polling questions to see what the audience thinks of this? And then we'll go back to the discussion. Those are very good points, Alan. Mhm. Tom, do you Do you always get a T You? Do you always request a T? How about you, Robert? Um you know, I I don't I guess the images here seemed pretty reasonable. And I know that either way, the patient's bought it himself or herself. Trip to the operating room for a couple reasons. One, um, they are symptomatic. Even though they have moderate M r. They do have a dilated left atrium. They do have decrease, uh, LV function, as Allen noted, So I can I'll be able to get the T e in the O. R and make my kind of fine tuning and kind of game time decision there. Um, if I don't have a good TT image, uh, then sometimes I'll get a t E. It's a horrible image, but if I know that the pages had to the O. R. And it's just a matter of kind of making the decision on the, uh, kind of on the line, Then I'll just rely on the T e in the New York. How about you, Robert? Um so for me, I tend to have a pretty, you know, low threshold for getting a t e for a number of reasons. Number one is, uh, so many times in something like this again, this is complex leaflet pathology, on top of which you have somewhat of a depressed LV, and you want to see that from as many angles as possible. You want to see what the curiosity of the ventricle looks like and kind of planning what you need to do. Um, And so for me again, low threshold for getting a T. If it's very straight up p two file disease, I very well may not, because the tea is not without potential risk. You have a patient you're giving them anesthesia. You're giving them drugs. And so it's their airways at risk during that procedure. Although it's incredibly rare to have a problem, but it's not zero. So I'm pretty thoughtful with that. But in general, I think anything that looks beyond kind of a straight up pathology, I'll get a TV for okay. So I find go ahead recently and I forget the excitation talking about that, Rob Apparently T e s. They did either e g d s have a patients who got T. E s and a fair number of actually had esophageal injury or erosion. Allen, you probably know about that. You know, uh, I heard about it at least, um, but kind of interesting is not inconsequential, but I think it is going to add value to the decision making is and you know certainly will get. Yeah. So here are the results of the polling questions. These are interesting. I think we should go through them. So how would you approach this case? Repair replacement If you look at it. The majority of the audience poll that they would repair the valve 70 71%. I think we all agree that the general disease we're going to give it a shot, and and we're definitely gonna go for a replacement as a primary goal. Um, if you attempt to repair this was a tricky question. How much time across club are you going to spend? And for two to talk about that question. We go to the next, like, let's see Justin other. It is. This is the next, like, So this is the inter operative finding. I'm sorry. I was feeling that would happen. This is an interpretive finding of the of that valve, particular valve. So yeah. So flail posterior play into, uh, complex. Now, it may turn out to be a longer case, and you have bargained for How much time are you willing to spend? This is for for Tom and Robert in looking at this valve before you say Okay, at this point, I need to start thinking about replacement, you know? So, um, this patient is relatively young and looks like doesn't have a whole lot of other medical problems. I would be very aggressive about doing what I can to repair this valve. I agree. It's complex, but looking at what you've shown here, um, I think it's actually very repairable. I'm of the kind of respect camp, so I'm pretty aggressive about chords. And in fact, because of the entry level prolapse, the only way to really repair it is to use chords, whether whether neo cords or transposition. So I'd be a pretty aggressive by using chords to repair the valve, I I put at least four chords and poster leaflet and probably another at least probably four chords In the Inter leaflet. I repaired that defect. That hole in the answer leaflets. We'll probably kind of primarily close out that hole time wise. Um, I use Del Nido and and most of the time, we can usually get it done within one shot of El Neato. If I have to reduce, Uh, then then I will, um, but I I feel relatively confident should be repaired this within, you know, 60 or 90 minutes of cross from time. Robert, you made it. I agree with Tom. This is a valve that needs to be repaired largely, Um, and and I think this goes to Allen's point at the beginning for a patient who is 50 years of age, he's going to work on Send it to you know someone who has a fair experience with traumatic repair surgery. Um, I think that in, you know, from a time limit standpoint, I think you have a lot of time in a 50 year old with no can accommodate, you know, cardiac disease to get this done. Um, I think the bigger thing is, you know, making sure that you have great imaging of the or so you can do a good assessment afterwards. And then, you know, the next point would be, Well, what if you do all that stuff and then it doesn't look very good point. And I think that's where you start looking at. Well, where's your bailout strategy? But I also am a significant cord user. In fact, I can hardly think of the last, you know, set of valves that unless they had Mac, that required some reception. So it's a pretty infrequent event. And so I would use multiple cords here for the repair strategy. Um, and then and then usually just a posterior band as well. I tend to agree with everything you guys have set for sure. Um, for the surgeon out there who is starting out whether it's minimum basis. We're just simply starting out who ultimately will have to, you know, face a case like this. Um, what would be your best pearl? Your best advice that you could give them when you see a challenging case in terms of exposure. Cardio, please. Jah what do you try first? What? What's your best, bro? I think the first thing here is if you're new and starting out or if you don't have much experience with mitral valve surgery is have humility, right? Have one of your senior partners there. Whether you have done a lot of this, this is You know, we're talking about a 50 year old on the other side, and but degenerate valve disease you are making a gigantic impact on their long term survival right with the repair. So we want to make sure we've got that strategy going, and with a senior partner or someone who has a lot of experience with valvular heart disease, you're now making a combined effort on thoughts on how to make this happen so that hopefully you're speeding the process through. So I think all those are really important. And additionally, and while you're doing this minimum and basically I would do it robotically, Tom, and also do it minimally. Basically, I think that's great. Is open surgical approach if that's your comfort level, and you're going to have more opportunities to give more, please. If you don't use Del Nido like we all do great than making an open approach, it's kind of going for the the repair strategy. The next thing, though, is you know, when do you cut and say, Hey, we can't do this? Guess what? You come off. You know, you really take a look at your valve after the heart's beating. Well, you give it plenty of time to come back and get your electric electricity re polarized everything else. You make those full assessments, and if it's not working and you don't have a great idea of what to do, make sure the hearts rested plenty and then have a quick strategy of going back and maybe doing a replacement at that point. What my recommendations. But this heart more than likely, even though there's some reduced LV function this hard likely can tolerate to pump runs 75 year old eight year old? Probably not, but a 50 year old. I think they could mhm tell them anything with that. Yeah, you know, I'll add, you know, when I have a conversation with patients, I tell them that I have three priorities will do the operation. Um, and they sound pretty basic, but it's important in the order of order of it. First, I want to do the operation safely. So then go back home to their family to I want to address the pathology of why they're there and they're therefore leaky valve. So I want to make sure I leave the operating room with the valve that doesn't leak anymore. And then, thirdly is the incision location, whether it be right for economy robotically strong economy. For the most part, we feel pretty confident that we can do all of that via middle invasive approach. But when in doubt, I always default to those priorities. I wanna make sure I do the operations safely. I wanna make sure I leave the operating room without a leaky valve, and if I'm repairing it and after maybe the second pump run and it's still leaky, then I will go back and and replace right, because that's that's why we're there to begin with and again the city location. I think it's tertiary in that decision analysis, I do want to kind of pose a question to if you repair in this bar lows Martin Rob, would you use a partial ring or a complete ring? Now throw that context and the fact that the patients 55 and if the patient does have a, uh, kind of a failure. And you know, let's say the patients 70 and higher risk than a partial ring is a little bit less accounting for a valve in ring as opposed to a complete ring. So Well, what would you guys put? I'll take a step at that. Um, I I don't use bands. I use full rings and, uh, but it's It's out of training and out of comfort level. There's some data to support that, but at the same time, there's also data to support that bands can do well, too. But I think in my in my situation is more of a comfort, mental and understanding how the valve will react to or interact with that full ring. It's my understanding of how it will turn out to look like um, I don't I'd be worried that if we are planning on a valve in ring in the future with an interior leaflet that's intact, that we could get in trouble. I know their techniques to end, you know, to to mitigate that. And perhaps Alan can can touch on those. But I'll be I would use a ring just out of habit or practice, right? Yeah. So I I use bands here. I particularly don't like limiting or freezing the anterior annular motion that occurs during Sicily. So I like to see that thing get as eight realized as possible with its during Sicily where it kicks and it drives leaflet co optation. And I think that the the more a leaflet co optation that you can drive, the more you reduce some of the degenerative capacity over time because you're getting a lot of good liquid co optation. You're taking some of the pressure off this fabulous structure. So that's kind of my you know, uh, theory on how how to choose about bands. And not now, if there is considerable left ventricular dysfunction and you've got more of this mixed, functional component that goes into a longstanding dm our patient with mark angular enlargement. Then sometimes I'll use a ring. But it is. It's a more rare occurrence to do that. Regarding down down the road, valve in valve, you're you're absolutely right time. I think that's one of the issues is you take out that valve in valve option. However, you still potentially have trans Catherine mitral replacement option. Uh, you know, you're talking about a 55 year old who hopefully now be 75 before that's an an issue, or you're also looking at therapy and now a really big ambulance, and so you have a little bit more room to work with. So I think you haven't really eliminated all your trans catheter options. You've really just minimized the opportunity for doing a valve and ring or taking that off the table. But you still have some trans catheter options down the road. You know, when we look at, you know, fixing this complex about pathology. We talked about number of surgeons who do enough micro work to really get something like this done really, really well, in a short period of time, you start shrinking some of the numbers down mitral valve surgeons. When you start talking about the number of interventional teams that feel really comfortable dividing an anterior leaflet for valve in for valve in ring, you really even shrink that number considerably further than you than you would. So that is not a straight up easy procedure to do. It's it's doable, you know, and Alan comment on this. But it is, uh, it's it's not. It's not an everyday in the cath lab or an eventual sweet, but it's a basilica procedure. Is that what it is? It's the lampoon basilicas for the aortic valve to minimize the amount of coronary obstruction. But the Lampoon is what's, uh, device to electrifying a guide wire and cutting or severing the Enter micro leaflet. And I think the discussion is, you know, is incredibly powerful. Uh, you, as the surgery team, I think understands that not every bring is created equal. The interventional cardiology team is learning that at a very fast pace. Choosing the right ring that potentially is flexible enough to circular arise when you put a valve inside. It is, uh, is something that we're learning because not all of them do that. Um, and as a result, Trying to force a decision for something that's going to happen 10 to 15 or even 20 years from now makes it even more complicated. You know, this patient should potentially have their LV shrink. And one of the main caveats that we have for the valve and ring type of procedures is the risk of LGBT obstruction, as Robert had mentioned, particularly the anti relief that is very large or potentially if the angle between the aorta and the mitral is very acute, or or not not up to us, to say the least in. As a result, you definitely pose a risk of ele bot obstruction, so it's great that we can be set up for the future. But sometimes the future is pretty difficult to predict. Uh, So, um, I think the the ability to place a clip on a previously repaired valve also will depend on the length of the posterior leaflet, which is one of the major determinants of appropriate leaflet insertion into the current generation clips. So that's also something to consider in this case. Both leaflets are pretty redundant, so it is likely that potentially in the future we would be able to clip something. Or maybe in the future, some of these other courts that were not replaced may actually tear and cause the severe remark that that have caused the original pathology. This time around, I want to ask a quick question. You brought up clips and you and you brought up, you know, d m r. So this patient is going to go on the Internet and say, Hey, you know, I want to micro click because the best way to do it she can be seen my cardiologist. Cardiologist. Okay, look, those those leaders are graspable. There's the orifice. Area is big. I can clip it. Uh, what would you what? The conversation you would have the patient about clip versus surgery on this. This particular case, I think with the with the information that Mario was kind of to present, this is a low risk patient. Low risk patients should have therapy. That is until until proven otherwise is considered the gold standard. And for the low risk patient, the successful mitral valve repair will be incredible. There will be long lasting and they will have very little residual m r. Uh, these patients well in in the Everest child. If you remember, almost a decade ago, patients were randomized to either surgery or the procedure. Uh, the biggest advantage for the micro clip for the low risk patients was less risk of bleeding, as opposed to residual micro vegetation, which was always higher in the clip patient. So this patient should be considered for a surgical repair to begin with. And that's one of our upfront conversations. Unless he would be considered for a clinical trial that would compare the efficacy of one versus the other, but not a commercial implant. Yeah, very good points, Tom, Thanks for bringing that up on that same vein. I think it would be valid to ask if this patient was between 60 and 65 years old. Um, and the person starts getting into that question of, um, biological valve. What is your conversation with the patient and the prospect of a valve involved in the future? I think at age 60 or 65 it is likely that, uh, people outlive his a bio prosthetic valve. However, it's not necessarily an unreasonable option, Uh, you know, 10 years from now, or 15 years from now, if that valve degenerates. You're talking about somebody who would be now in their upper seventies and as a result, would like to be a higher risk individual. Um, we have good data to support high risk patients. Undergo mitral valve in valve. The moderate data set is currently being captured. There is a registry that we are fortunately part of it's the partners we might develop involves trial, uh, registered for intermediate risk Patients were actively enrolling, Um, but we'll have that information available later. There is a TV T registry data that's been published that shows that in patients who have an STS around 11% the 30 day mortality for mitral valve valve was 4%. Uh, in the one year mortality was supposed to 13% or so, Um, in the wallpaper, you can see that patients who had read much about surgery in the intermediate Risk or intermediate age group had an operative mortality of 14%. And so Michael Evolve is definitely a good procedure for patients who would meet the indications for it, Not quite yet for everyone, but definitely for patients who would meet the indications for it is a very good a good venue okay. I think one other piece to bring up there, though, is whether they're 60. I think 60 and 65 0 young still, but particularly this age, and we're talking about, you know, failed at the repair. We need to do something else. You're looking at replacement strategy. One of the things this is going to be a big valve, but you really need to make sure you're putting in a big valve if you're looking at it down the stream valve in valve option because one of the issues is even though the trans catheter valves balloon expandable trans Catherine valves when they go in there, you have extremely low profiles and they fill up the valve area. They're still limited by the same framework, and now they're taking up similar rooms. So small valves do not do well with valve in valve. And so, if you're thinking on the line of hey, I want to plan for the future somewhere, make sure you're putting that in your calculation. The nice thing about mechanical vows is they are very large, even in the smaller sizes. So, um, that that brings up, you know, making sure you've got good human dynamics and how it works out very rough. That's an excellent point about the size of the bio prosthetic. And I think it's super important to emphasis that we have to focus on the internal diameter of the valve, not of the sewing ring of the valve and not everybody. A prosthetic valve is created equal, so a 29 millimeter from one company is not the same as 29 from another company. And it's really important to really focus on what that internal diameter is like. I would I would close this discussion by this particular case by saying that just like the Panelists have said, Rob and Tom, I've mentioned that if you're in your second clamp and it doesn't look good replacing this valve in this young individual, giving a mechanical valve will give them durability and good humor dynamics that will carry them on to old age. Okay, let's go to the last case. That was a great discussion, guys. The last case this one gets a little. I think it's gonna get a little stickier. This is a 60 year old male with a history of C A D, but has had prior standing and PC, and it presents to the surgeon when he's been diagnosed with severe mitral regurgitation. It appears to be ischemic in nature, and we'll take a look at the echo. His heart cat last was done when they revascularization and everything looked open and we'll show you the echo. Next. Whoever wants to take a stab at that, I can do it if you want. So there's definitely evidence of severe, um, are it appears to be post clearly directed. The mechanism is likely Leaflet restriction of poster leaflet restriction. Probably coming from that informational aneurysm that you had mentioned. Um and that is the mechanism of of this M R. Okay, why don't we go ahead and give the polling questions for this last case? So, Robert, what are you thinking here? What you're seeing this patient just showed up in your office. I know that the conversation probably has changed a little bit since January, right since the circulation of the 2020 guidelines. But what are your five process right now? So I mean, first off, when I see a patient like this in my office, I, uh, usually will have reevaluated their T images and I will have sent this patient to our mitral valve clinic where we actually have a hard team approach for looking at these patients. So we actually see everybody together. We have echocardiography, interventional cardiogram fee, and, uh, interventional cardiology and cardiac surgery see patients together. And this FMR patient, which is what this case is a perfect example of something that needs, um, you know, multidisciplinary thought. So that's first thing. The second thing is, I want to make sure that this patient, as we look through them and are pre screening them, has already been looked at and evaluated for guideline directed medical therapy. And I'll let Alan kind of get more into this discussion. But, you know, guideline, guideline directed Medical therapy is the basis for everything we do in these patients with functional mitral regurgitation. So I think the key thing that just to start out with as a surgeon, going into seeing a patient like this is number one. Don't think that surgery is the right thing to start with. And number two, grab your colleagues who deal with this a lot more than you do all the pieces and parts around the heart right in the medical therapy piece, because that's the basis of everything we're going to do next. So this is a hard team patient, and that's the first thing that I would do. And then, as we get into what are our options down the road? We can talk about the trans catheter options, surgical options. But really, it's doing all that and making sure we really knocked out and zoned in on your guideline director medical therapy because that valve in the setting of optimization, which includes CRT when required, can look a lot different. Great Tom, A lot of thoughts. Um, I think, um, you know, we as surgeons and clinicians need to recognize that m. R isn't m r is an M r, and we use the term very loosely. But we need to dig deeper and caught and and kind of find out the ideology of the M R. And in your case scenarios, you you did a really good job. You highlighted dramatic the d m R and kind of the ischemic functional M. R. Uh, it's important because the treatment options are very different. Analogy is that cancer use cancer kind of sort of loosely. But there's a big difference between pancreatic cancer versus kind of basil skill set basil skin cancer, right? Because I think that that's important when you say you get a cardiology consult, consult cardiology patients. M r. I dive deeper and say, Hey, what's the ideology of the M R? What the pathology, Where's it from? Because that helps dictate my decision a little bit. We know that in ischemic m r the Aker paper in New England, Journal of Medicine, that there is an increasing trend towards replacing these, uh, these cases because there's a higher risk of recurrence. Uh, and and that's kind of the kind of the approach that I've been doing recently, Uh, and and the reason why I think is is pretty straightforward. And even the AJ guidelines kind of help to divide this. You call it primary MRV secondary M R. Because the pathology can either be the leaflets or it could be in the ventricle and the pathologies and leaflets, and you fix the pathology and leaflets, Then the patient is doing well, but the pathologies of the ventricle and all the other stuff you're fixing the leaflets. We still have 99 other things that's going on, the patients don't do very well. That's why it's really important. So in this particular patient, recognizing all that, I would actually air towards replacing the valve. But also, as Rob alluded to make sure they've really been optimized from a medical therapy standpoint, Um, I know we're kind of going close on time, but I just want to touch on something that I think is controversial. But it's settled. There's a recent micro clip indication for potentially clipping patients who are FMR before is only DM our patients. But the irony to me. And I think it's this huge kind of discrepancy because in the surgical world we're moving towards Hey, it's OK, if not preferred to replace patients, the replacement of patients who have FMR. But in the cardiology world, we're going okay, it's okay. Repair them and put a clip on. We don't have a whole lot of data. I know I'm open that can of worms, but I do think it's kind of important kind of discrepancy in the way we're looking at the pathology, and I'd love to hear all your thoughts on that. So let me let me take it from there for one second because I want to go over the polling questions. The first one is I find it very interesting that we are 50 almost 50 50 split. If you were 59 41% of the audience that would replace to a mechanical 69% biological, 41% if the undertook it as an operation. Uh, and then we and I think that the that the New England paper on a schema Kmart is really percolating, like, just like you're saying it in the in the audience of surgeons in the areas of surgeons where you can see in the answer is 71% of the audience would replace this valve, and only 29% would repair it. But, um, one of the things that I would like Ellen to comment is exactly what you said. I mean, I know that there are criteria for these to be treated with, uh, trans catheter, edge to edge repair. What can you tell us about those criteria? And how does this one fit into that? Not your muted Allen, sir. Sorry. Echoing what Robert and Tom had mentioned, a multidisciplinary is key. Um, and we learned that when the aortic valve and we've we've adapted that as we treat patients in the heart failure arena or even in the EP Arena with refractory arrhythmias. So in this case, these patients have to be innovative locker. They have to be a good guideline, directed medical therapy at least for a period of three months. And make sure that your update during these medications appropriately, um, I think the beta blocker risky. I think the use of interest to uh instead of an S R and A R V is also very important. If you can tolerate a doctrine that's great considering patients for CRT, as a fair portion of them may improve, it may not need your your surgical services or my interventional services. Um, guiding therapy is there for a reason, and it's totally fine not to operate. Or it's totally fine to just prescribed medications that actually are very helpful in life saving. Um, if this patient has finished their G d. M t and is still quite symptomatic, um, then I think the next important big step is knowing what the LV function is like, what the overall dimensions are like if the left ventricular dimensions are very large or the lvs period in seven. Uh, then it is unlikely that a repair, even if successful, may impact their survival. As you know, there's, uh, there. There are two good, um, micro clip trials, one is called, might try far, and the other one is caught for this patient population. And the results are vastly different, mostly because of the type of the patient populations that were enrolled, the success of the procedure and the medical therapy that was applied prior to. So that's actually the key to a good, successful, uh, edge to edge repair from a catheter perspective. So this patient used to close the loop on this patient in this patient, underwent an operation and Micromax replacement, not a repair, to close the loop on the questions to the audience to um, it wasn't mechanical about by by virtue of a conversation with the patient, I think what you what you all have touched on. Ellen. If you want to take over, this is This is the new guideline that has been put out, by the way, with a to a indication for trans catheter H two h repair for those who have secondary m r And then it is important that, um, we tease out which of these patients are going to really benefit from a trans catheter at Schuette vs an operation once they've failed GMT. And and that's where Robert was very well, saying that hard team approach is extremely important because, arbitrarily, you cannot come up and say that he will benefit or she'll benefit from an operation clip. It's really a conversation and really analyzing the case on a case by case basis, uh, to to Tom's point, um, to be, uh, indication was that replacement versus a repair in secondary Amar and probably based out of the New England paper. And in fact, it is based on the New England paper, Um, from years past. Alright, Ellen. Yes, thank you. So it is critical when we assess these patients with secondary, um, are to one. Make sure they are in Guilin directed medical therapy. And just like their senior cardiologist for senior surgeons, you could ask for help. There's hard figure specialist. There's a seasoned cardiologist that are willing to help and to make sure that these patients are following the appropriate treatment guidelines or algorithms. You know, M R has become very difficult to understand or diagnosed, and we first of all want to make sure that your patients are symptomatic. They have severe M r by good eco choreographic criteria, and we have to understand the loading conditions. Sometimes patients come in with very little m r in a couple days later. If you re imagine if their blood pressure seems to be out of control, their M R will be very, very elevated. So please make sure that they're inappropriate medications that are required and then a previous patient was already results arise. But if the patient needs to be revamped authorized, there is no doubt that revitalization, uh, with with the surgical potential strategy and a micro valve surgery at the same time is key. Now, if the patient does not need to be re vast arised, any rejection fraction is is appropriate or greater than 50% and you still have a fib or significant symptoms, then a surgical approach is key for success now in those patients who now have all the dysfunction who still persist to have symptoms even on G. D. M. t who have a favorable anatomy, which means that the rejection is fraction is greater than 20 in less than 50. Who's in systolic dimensions are less than 70 millimeters and who do not have severe pulmonary hypertension. And I would add to this who do not have severe or moderate to severe trick hospital vegetation because that is also a harbinger of worse outcomes. Trans catheter edged dis appropriate. On the other hand, if the anatomy is not appropriate or not conducive for good, edge to edge, it's having a non successful procedure doesn't help patients either. That is basically the what we found out about the failed medical procedures in my tree farm. Um, so that's why selection is critical and the selection is done, as Robert had mentioned with the team approach of echocardiography for a cardiologist and cardiac surgeon, Valve in valve is something that's incredibly attractive. We have heard about valve in valve aortic in the past. Mitral valve in valve is currently gaining a fair amount of momentum. I think the idea of doing a transept of procedure, uh, is very exciting. Um, the outcomes are likely better with a transept and a transit vehicle procedure, unfortunately, but they're still very, very, very successful. You can see here in data from the TV T registry who are patients who have a previous mitral valve surgery, who's estimated operative mortality with the STS promise around 11% for redo NVR. The procedures, uh, were 96.8% successful with a 30 day mortality of 5.4% which gives it an artery ratio of less than five, which is spectacular with a relatively low risk of stroke and a relatively low risk of valve thrombosis. At one year, the mortality increases to 16% probably because of the type of patients that we're seeing. The risk of stroke does increase as well, and it is very important to understand that patients who have trans catheter mitral valve in valve procedure should undergo oral anti coagulation therapy in order to prevent valve thrombosis and what Robert mentioned earlier about the possibility of doing placing a large valve. It is very important to make sure that the valves that are placed are larger. It is rare that are almost impossible for anybody to do a micro valve in valve procedure in place, a 20 or 23 millimeter balloon expandable valve that that would give patients significant stenosis and may not a system in any good shape or matter, but 26 29 millimeter balloon. Expandable valves are highly effective for the appropriate patient population, and the CT scans are key to make sure you will not have any obstruction. Um, I know that we're pressed for time, but I do want to echo that both tissue and mechanical prosthesis are safe, and the patient population that they are applied on will depend on their efficacy and the longevity of the patients. Uh, so, as you can see here, these survive occurs are parallel, but mostly they're parallel there. They're parallel, just potentially for the age group in which patients are being treated and likely, according the wallpaper that was mentioned earlier in the micro valve. Specifically, you can see that it's only in the lower risk population, where there appears to be a larger difference in survival in patients who were treated with a mechanical prosthesis. But at the end of the day, you are basically choosing which type of mobility you're gonna you're gonna expose your patients to mechanical prosthetics at a 15 year survival are very similar in this middle age group. How are your stroke rate is? 14%. You're bleeding. Rate is 14%. Uh, bio prosthetics don't necessarily have that bleeding rate, but they have a risk of re operation of almost 50%. So you have to decide if it's worth it to pay the risk up front, the risk in the future. And that's where the lifetime discussion of the lifetime management is incredibly important. And the multidisciplinary discussion comes into place as well. Sure, So if you want to click on the next call, I retain control. There we go. Thank you. You know, I think it's let me go back one. Yeah, I think with that last like that, you talked about the risk of thrombosis and bleeding. You know, I know that the Onyx obviously looked at for a lower iron are indication at least the data is being submitted to the FDA. I think by next year, and I was more to be learned about this. But how would lower indication for nine out of 2 to 2.5 impact your decision process? Uh, in these patients, conceivably lowering the risk of bleeding and making it easier to get to a target I nr in a shorter period of time. I think that's something that's very thought provoking. And it it could change some of the decision process and the conversations that we have with our patients. Yeah, Mari I I completely agree. I think that's a critical piece here, and we'll find out more to come. But you know, most of these patients who come in with functional mitral regurgitation are generally not healthy, right? And oftentimes there past medical histories are complicated by the number one thing that complicates people with mitral regurgitation, which is atrial fibrillation, and they are generally on some sort of anti coagulation regimen and in the setting of atrial fibrillation, if you're in a committed regimen, you're running right in that range. Just put you into that range and maybe doc down some of those other potential complications now and also will eliminate your risk or your ability rather to get into a no act therapy. At least as of right now, we haven't seen that to be applied to a mechanical valve situations, so it broadens the discussion. It makes it a deeper discussion when having you know when talking with your patients, particularly about if this trial ends up showing safety at a lower iron are it's a It's a really important piece particular for that younger patient you presented with functional functional ischemic regurgitation. Very good. These are been fantastic discussions in all the cases, and I think I wanted to have the audience leave with something. And so, Alan, if you go ahead and give us your take away points, thank you. I think my key takeaway point is that whenever we approach patients with valvular heart disease, we do have to plan for a lifelong management. We can't just plan for a very short term therapy. Uh, it's not like treating in central stenosis. If that re occurs. We want to make sure that lifelike management is discussed, and we want to make sure that the patients are managed both by the team of individuals that address their care. Heart surgeons, cardiologist echocardiography is that basically will allow us to decide what the right management would be. Um, I always would prefer medieval riveria as long as it's durable and successful. Um, I think the idea of trying to keep the patients with a lower range of anti coagulation if deemed safe will be spectacular as the higher the the anti coagulation level, the higher the risk of bleeding complications. Um, I think trans catheter edge to edge repair is FDA approved, as you know, for high risk or, uh, individuals who have a favorable anatomy from a general perspective, uh, in for patients who otherwise are discussing a multidisciplinary fashion with the hard team approach for those health. FMR and I do think that bio prosthetic valves have a good role in patients who are older than 65. And I think the mechanical prosthetics are spectacular for longer for patients who are younger that you just wanted to one long term therapy for Robert Your music. Robert. Immunity. I'm sorry. Number one. Thanks for having me. I really appreciate it. Number two. It's been a really fun conversation to have with all these guys. Uh, and hopefully everyone is getting a lot from this. I'm going to be briefed on the top one. Yes, it's a shared decision making process, and you're planning for lifelong management number two. I think it's not only about the medical part of this. But there's an an atomic part that always goes into this, um, and so for those patients who are 65 to 70 or even a little bit above if you're already on anti coagulation, you know you may be a good candidate for a mechanical valve, particularly if you have inappropriate anatomy for valve valve in the future, based on the way current tissue valves are constructed. So that needs to be a very thoughtful discussion with the patient and with a lot of kind of engineering discussion to go along with that so that you're helping guide along the pathway of what's really possible in the future. Next, patients who have narrow mitral valve and Eli, um, and by way of natural anatomy or prior congenital heart surgery. Guess what you want, a valve that's going to provide you the biggest opening area. So again, there's a lot of times other prohibiting factors that may limit their ability to take an IQ regulation that needs to be addressed in the conversation. But oftentimes I'm using mechanical valves there for patients who are otherwise young. Mechanical valve is to go to for me, Um, and oftentimes the discussion is not that difficult to have when you're talking about this, unless the patient's female and desire to be pregnant and the complications that go into trying to manage and regulation, particularly the fact that they should not be uncommon in for that, Um and then also patients who have very limited access to health care and the difficulty of managing communities patients, I think is a very important piece to be brought up when you're having these discussions. So anyways, to me, it's it's it's kind of a shared decision, but you have to bring a lot of important information to that conversation and make sure the patient understands what your discussions about. Excellent, Tom. Thanks, Mara. I think I covered most of the talks the points, uh, in the park conversations, but I want to add a couple things. One, Uh, it's a conversation with you and the patients again. That shared decision making concept is important. It's a conversation with you in the heart team, right? And it should be a multidisciplinary collaboration in productive conversation. Number three. I think you have to know the data. Uh, and in some ways I believe surgeons kind of have to know the data better than other, especially seeing the cardiologist. So I think we need to know the data increasingly for myself. I I find myself doing replacements, uh, mechanical valve replacement, probably or replacements at a younger, younger age than before, knowing that there are trans Catholic options in the future. Number four. You know we're surgeons, but I always kind of any soap box I get. I think it's important for us to stay involved, be the Rob Smith of the world and be involved in trans captain therapies because it's at the end of day, it's here to stay. But in the light of knowing the data, I think it's important for us to also recognize that there's only one randomized controlled trial comparing micro clip versus surgery. That's Everest, too, in high risk patients. So you know, I know it's a different kind of conversation for a different time point, but I personally believe that the A c A. A. C C H A guidelines with that to a recommendation for FMR is a bit premature. It's not a whole lot of data for that again, that's going back. We need to know the data and do it best for our patients. Thank you, Mario. Thank you. Robin and Alan Inquire Life. Yeah, I was There was lots of fun doing this. Number one and I thank you all for putting all this time into this. My points are going to be very similar to yours. It's a It's a conversation with the patient and their families, and they're referring cardiologist and and finding out what's best for them. It's, uh, in my practice. It's going to be a solid for less than 60 years old. They get a mechanical valve in between between 60 and 65. It will be a definitely a conversation for those who are older than that. I definitely air on the side of a biological valve, and, uh, exceptions are few and far between. But the patients who, like Rob said who have no reliable means of adhering to the therapy for those who have a history of drug abuse notwithstanding, the age will get a biological valve. But with that, I think we end all our cases in our discussions, and it was so much fun. Um, and I think we're open to the conclusions here which I think if we summarize it all, we talk about a rheumatic patient that is in need of surgery. Um, you have the option of a biological and mechanical valve, and the age products are very clear. I think the European and American guidelines have now aligned in terms of the age card of There should always be a conversation for those who have FMR. We have two new to a indication for trans catheter edge to edge hard team approach with guideline. Director uh, medical therapy should be absolutely the first go to and then the discussion of whether they have favorable anatomy and the discussion of about replacement with replacement favoring repair in the case of surgery and then for degenerative muscular disease repair. Of course, number one. And if you cannot repair the breakdown into replacement or mechanical or biological based on age with a good conversation with the vision prior to and then for those who are high risk, uh, trans catheter edge to edge for degenerative disease, I think that summarizes what we've discussed today, and I thank you all for coming in. I think the panels and I thank the audience for for tuning in