In this Penn Presbyterian Medical Center Cardiology Grand Rounds event, Lissa Sugeng, MD, MPH, of the Yale School of Medicine’s Department of Cardiovascular Medicine presents her research and updates around mitral regurgitation from the Yale Echolab.
Atrial Fibrillation Management: Updates and Research from Penn Medicine Amyloidosis Updates from Penn Medicine Twitter @PennMDForum Yeah. All right. Good morning, everybody. Welcome, Thio Cardiology Grand rounds here at Penn Presbyterian Medical Center. We're very excited for today's talk. The CMI code we're just waiting for And so I'll put that in the chat box as we as the talk goes along, and I'll read it out for those on the phone towards the end of the talk a couple of times. So I apologize for the delay in getting to see any code. We're just waiting for that this morning. Um, we're very excited for today's talk. It's going to be interactive, including some poll questions. So for those folks that are on their phone or on the computer, there will be a pull that pops up. And please answer that. But the introduction I'm actually gonna have Dr Royer June do today. And Roy, go ahead. You on a Sure. How's it going, guys? Good morning. Thanks for joining Money's Roy. One of the non invasive cardiologists over Presbyterian eso is my pleasure. Thio, introduce Dr Lisa Su Gang, associate professor of medicine, Metal direct, medical director of quality across Yale and director of the core Lab. Most importantly, she was, uh, actor director for me. My wife, Ashley, is over it, huh? And Ben Vaccaro, who is one of the heart failure attendings at Presbyterian on. And she was really just a great mentor for us. She was like our academic mom, and it's still are sort of academic, Mom, even though we're out of fellowship eso she your m d and Bali at you Don Yana University than nph. Bu trained in residence internal medicine in Massachusetts Medical Center, then did fellowship at University of Colorado under Dr Roberta Lange, where she really went on from there to become one of the major forces in three D Echo. Um, and she'll be presenting on micro segmentation, which is a lot of three d work that Well, thanks, Roy. Thank you, Samir, for the invite to your grand rounds. This is really a pleasure. Thio virtually see everyone. I wish I could be there. Um because I'm sure I would have had a lot more fun with you all. Uh, so I thought it would be a good idea to sort of look at Mike regurgitation as a whole and, um, hopefully the title. You'll understand what this means. A little later on um, this is my the disclosures. Um, the goal here is to, um okay, review and mark quantification using the most recent guidelines for native valve regurgitation. Recognize horizontal my jury meditation on transfer a stick echo in the patterns of em are using three d t and describe how three d echo aids in the determination of mitral valve pathology. So I picked this title because I thought, um, it's a proposal. And then I I love going into history and taking a look at where this, uh, phrase comes from. And so actually a phrase done by Anthony Weldon in his book The Court and Character of King James. And, uh, it was based on Italian proverb. He that deceived me once it's his fault, but twice, it's my fault. Hopefully you'll understand this that by the end of the presentation, to get to where we want to have patients treated for my treat, your irritation, um, either by catheter procedure. And here on the left hand side, you see a doctor Ryan Capel, and the image ing attending is behind the screens. Is Radhika Aggarwal, uh, or with surgery with Dr Gerson with mitral valve repair. Either by Thor Economy or robotic intervention. You need to certainly diagnosis severe mitral regurgitation along with the symptom Atala. Gee, our increase in L V size or decrease in left entrepreneur function. But the key here is identifying my jury agitation. So let's go through Ah case. This is an 82 year old female with a history of rheumatic fever. Ah, severe might regurgitation atrial fib. Relation. Hypercholesterolemia was sent to the Structural Heart Disease Clinic. From a cardiac standpoint, the patient really reports a significant decline in for functional status over the past few months and with significant episodes of shortness of breath, dismay on exertion. Though she's able to do her daily activities, it's at a much slower pace. So here's the personal long access view zoomed in on the mitral valve. You see significant, uh, mitral regurgitation on the right hand side with color Doppler. And certainly we try to measure the Veena contractor, um, at the neck of the jet, though it's very difficult since it's so wide and I get a Vienna contractor of 0.86 I don't show you the LV dimensions here just toe cut time, but the LV dimensions 4.7 and 3.1 with an l A diameter 4.8. So you get a just that this LV diameter has an increased in sized yet, but the L A diameter tells you that there's chronic mitral regurgitation. Now. I would like a mode still, even though I'm a younger generation, but I think there's some value here. On the left hand side is your M modes, and then on the right hand side m o with color. It identifies that there's holo, uh, systolic regurgitation, um, with possible prolapse of some sort or flail. And so, based on the mitral valve morphology, you could tell already whether this is mild, moderate or severe. And, uh, the the lack of co optation and possible um, eco density that is mobile tells me that maybe there's a flail leaflet and I'll show you more. The L. A and L V Size also tells me Cronus ity, the LV size being small doesn't mean that it's not severe, but certainly in patients who have dilated left ventricle that will signify the cornice ity of it. And the L A size surely tells you Cronus ity. Here's your LV four chamber of you, as well as to chamber view Thio show left ventricular function. It is still normal, but maybe not so hyper dynamic. Um, the ejection fraction using three dimensional echo is 60% and the end diastolic volumes air ah, little on the higher side, so there's an increase in volume. Here's a four chamber view on the left hand side and just note the directionality of the jet. It's It gives you some clue in terms off the cause of the regurgitation. So, uh, anti rly directed It must be a poster leaflet. That's an issue. On the right hand side is a five chamber of you, and you kind of get a hint that the post yearly foot is the problem with a ah hugging jet. And the fact that the jet is hugging tells you also a severity of the regurgitation. Here's a two chamber of you in this two chamber of you. It seems like the part of the jet is more centralized, and then on the right hand side is a three chamber of you and you can see a nice eco density if I point to it. Um, there's your eco density that's more violent, most likely. Ah, flail leaflet. So the E velocity tells me, or gives me a hint that this is significant might regurgitation either moderate or severe. So the velocity here is 1.8 m per second. On the right hand side is your pulmonary vein flow. And sometimes our Sinaga firs will, uh, more than just doing the right upper pulmonary vein. They'll take a look at the left, upper or other palmeri veins to see if they can see reversal of flow. I would say that I'm not sure if I can convince you, but this is appearing to be systolic reversal of flow, um, or at least blunted flow and the continuous wave. Doppler also hints you about the severity because of the density of the jets. So if you compare the density of this micro grid isn't jet to the mitral valve in flow. It's quite dense. It's more triangular in shape. And so it hints you to the fact that this is significant mitral regurgitation, So color flow jet area. If the jet is more than 50% of the left atrium eccentric, for sure, this this patient has eccentric M. R. I am not sure if it qualifies as the more than 50% depending on the view. Uh, there's flow convergence for sure throughout whole sisterly and with continuous wave Doppler. Hopefully I can convince you this was whole of systolic and against triangular jet. The Vienna contractor was certainly more than 0.7. And if you believe that there was systolic flow reversal, then it's at least uh either moderate because of the blunting or systolic. Reversal indicates that was severe and the mitral valve inflow or e dominance was more than 1.2 meters per second. So in terms of quantification, I think that we at least tried to do Pisa and in this patient was it was very easy. The piece of radios was 1.5, so the ER Roy was quite large 0.8 centimeters square with a regurgitate volume of 1 29 ccs. We do occasionally we'll have the stenographers do pulse wave Doppler for continuity equation as well l v o t stroke volume. But in this particular case, I think it was pretty firm that this was, uh, severe might regurgitation. So just to remind folks try to quantitative as much as possible either with flow convergence method or, um, a continuity equation for regression it volume and regression it fraction. So, if we did a check off list from structure to qualitative Doppler to semi quantitative Doppler and quantitative Doppler, I think this patient was a very easy evaluation for severe mitral regurgitation. Um, and there would be no not much argument about this. Uh, we went on to dio a t e for surgical planning or versus, uh, mitral clip evaluation on the zero degrees. With the aortic valve visualized, you can see that there's a flail portion of the pit poster leaflet. Um, typically in this view, I either determine if it's anti early director or posterior directed to make sure that it's either anterior or posterior leaflet Jet post your leaflet problem. So here the jet is anti really directed. So it's a post yearly foot issue in the bike. Um, Israel view. I decide either if it's a P one or p three. So p one is here. This is P three. Um, there's something above a two. So I'm guessing that this is a P two problem, and the jet, um, is rather, uh, curious. It's kind of more centralized and and just below the A to leaflet when you go to the, um, 90 degree view on the left hand side, I'm deciding more whether it's a P three issues. So you CP three here, but it doesn't seem like it's a P three issue. It's still collapsing. The jet is underneath the the, uh answer leaflet. And on the right hand side is your long access view. And, uh, you definitely see the P to issue with the jet and surely directed So, um, even without doing three D, uh, this is an easy one. This is a P two that's flail on three dimensional echo from a left atrial perspective. You see this area? That's, ah, problem on the jet here on color. This is not very useful. Other than, um, you see the regurgitation on the NPR's and, uh, because the cut planus so high up you don't really see the regurgitate jet coming from p two. And so, for those of you who want to do Veena contracted at three d with three d, you should put the cut plane down at the level of the jet and leaflet So this patient certainly went on Teoh A new intervention. Um, there was discussion about surgery, but she was high risk because of her Frailty s. Oh, this is an ideal morphology for this patient. The M R is coming from p two and a two. There is no calcification at the grasping area, the mitral valve area. So I use three D echo to calculate the valve orifice area, and the valve orifice area is 5.2 centimeters square. Um, and the post yearly foot was measured more than 10 millimeters. The flail with should be less than 15, and the gap should be less than 10 millimeters. So I cut this short because otherwise that were very long talk. But this is the end result. I think one of the frustrations, at least I have with mitral clip is at the time of release. Sometimes, um, before the release, the clip looks perfect. But sometimes after the release, the clip slightly moves. And so you can see two jets of might regurgitation, which is difficult to calculate the severity. But we call this mild to moderate. Um, at Max. Here's the result from a three d point of view. So there's a nice, uh, teach the bridge. And certainly you could use three D color to evaluate, uh, regarding or fous. The mitral valve ingredient Post clip was two and 3.1 millimeters of mercury. So this is a perfect result from ah Grady int standpoint. So let's move on to case to this is a 78 year old male with mixed cardio myopathy has a history of alcohol use as well as corn ear disease. Had PC I multiple times, um, atrial fibrillation, hypertension left bundle, branch block and his even post I CD by V placement and has had multiple admissions for congestive heart failure. Um, the ejection fraction at one point was 30 to 35% with mitral regurgitation that was evaluated back in 2017. And the physician who is treating this patient thought that it was a combination of coronary disease as well as a tribulation. They re vast arised. This patient, um, diarist in multiple times adjusted his blood pressure medications because they thought maybe the hypertension also contributed to the m R. But for sure, they thought that atrial fib relation was ah, huge issue and uh, was sent to E. P for this issue. So just to go through the multiple transits off trance harassing echoes that this patient has had in 2017, the E f was 30 to 35% with severe might regurgitation. The cardiologists who treated him did really well and diaries him adjusted. The by VP, sir tried to get him out of a tree for relation and eso the ejection fraction improved to 46% and was called as trace M. R did another one, Um, a year later, same thing. 40 to 45% with trace m r. And in 2019 again, 45 to 50% with trace Anmar. In the meantime, this patient had multiple hospitalizations for congestive heart failure. Um, you could see from the notes that the cardiologists was struggling with blood pressure issues as well as getting a good diuretic regiment. And so I highlight this date because this is the echo that I read, and this is what I saw. So the LV end diastolic dimension, um, currently was 6.9 centimeters and the N l V and systolic dimension was 4.6. His L A diameter was 5.6. And so this was an issue for for this patient because even with a ninja action fraction of 46% previously, the LV dimensions air enlarged. On the right hand side is the This is a true quality of echo. I'm not showing you the best of of, uh, cases and images that I confined in our bank, but the case is interesting. So bear with me. So not much my true your dissertation here. And here's the four chamber view. On the left hand side is a zoom view of the mitral valve. On the right hand side is color flow. Um, um, I promise you that in the previous studies, this is what was called trace might regurgitation. I think here you could say that it is maybe trace mhm. On the left hand side is your two chamber view. And on the right hand side, um, there's a hint of more mitral regurgitation. And unfortunately, this is the a pickle three chamber of you focused on the mitral valve, and I would critique the snog refer here. Luckily, we have this system where we can digitally give them feedback on their reports, and they all do preliminary studies. And so this was called mild mitral regurgitation. From the snog refer standpoint, the continuous wave Doppler you see on the left hand side. Um, not much might regurgitation on continuous wave. Very faint jet here, and, uh, in the middle is Yuri velocity, which is 0.7 m per second or 77 centimeters per second. Um, and on the right hand side, difficult to tell, but for sure, I think it's blunted. I don't see much of reversal of flow. And this is the D wave. We use a contrast echo for evaluation of ejection fraction. So on the right on the left hand side is your four chamber view. On the right hand side is your two chamber view, and this was calculated to be 40 45%. Um, the L A volume certainly is increased its 92.3 ccs per meter square. So certainly this could be diastolic dysfunction due to hypertension. Um, LV dysfunction, atrial fib, relation. So, unfortunately, sometimes chronic l a volume increase doesn't give you a clue about severity because there are also other calamities that could cause the increase in l a volume. So if I stack it up, you know, the l A the L V is in large, but certainly could be due to other causes. The Palmeri vein is blunted. And, uh, the E velocity is 0.8 centimeters square. Sorry. Centimeters per second. I didn't get any, um Jet area. Of course. No flow convergence. I don't have the continuous wave. Doppler was very faint. Um, quantitatively the snog refer Thought it was mild my trade vegetation. So they didn't dio continuity equation in this patient. And of course, there is no Pisa to be found, so the snog refer didn't do pizza so again called as mild my drug vegetation. So what's your assessment? And Linda is going to help me do a poll here, and I'm hoping for your input. Um, tell me what you think. Is this trace mild? Is it moderate or for sure? You know that this is severe or you can say, you know what I don't have. I don't have the inclination thio Judge, this might regurgitation. Um, this is an inadequate study. I'm going to send the patient back to the lab to get a better assessment on. Well, wait a couple of seconds. And Linda, you probably have, ah, better sense of how Maney voted. And so, um, if you think that it's enough, then we can Yeah, we have, uh, 36% voted, So just wait another minute. Yeah. So some of these cases are sometimes easy and straightforward, but I can assure you that this one, um, multiple readers quantitative this as trace my trail vegetation. I'm not deterring you from choosing trace, so, um, and I wouldn't fall to you. I think this is, uh, not easy. Shall we display 47%? So now share results. So good. I'm glad everybody thought that this was not an adequate study. And the majority thought it was unable to be determined. Some set trace. Some said mild, some moderate. And a couple, um, such severe. So, uh, why don't we close the pole and I'll continue and talk about this. So, uh, the General Mike regurgitation is really a common cause of chronic primary M r. Uh, the P two scallop is usually 50% of the time. The reason that a degenerative mitral valve comes to see us. And so it's it wouldn't be wrong that if a fellow or physician with might regurgitation such as this we call it, um p two on you condone Evaluate p to even on a transfer Essick echo either from a short access view Or of course, ah long access view or a pickle. Three chamber views. So, um, it's typical to sort of say, Okay, 50% of time is gonna be p two. Now, if it's this type of lesion, the echo characteristics are pretty standard as I presented before. So, you know, peak velocity of e of more than 1.2. You will have blunting of the pulmonary vein. That's what you would expect and all the quantitative measures that add up to a severe might regurgitation. However, the scope of degenerative mitral valve disease doesn't all encompass. Just be too. Uh, you see, on the left hand side is a by leaflet prolapse, which means it's multi segmental, uh, of all the scallops. And you have a huge, um uh, cleft here. So this is an indentation that goes all the way thio the annual list. And so that could be troublesome in the middle. Here you have a p three scallop that's flail, and on the right hand side is an a three scallop that's flail. So what? I call this non p two prolapse or flail. So because of looking at some of these cases that have this might regurgitation that doesn't go up to the left atrium or doesn't even go and hug a wall, we thought to look at the characteristics of patients with non P two prolapse or flail. And the hypothesis here is that the severity of M. R is underestimated in these non p two prolapse or flail, and um, in those that are non P two, you can also have horizontal M. R. And my thought was that if you have non P two, um, issues, it's going to have horizontal might regurgitation. We also don't know and understand the direction of em are, um, between TTE and versus three d t. E. And so I thought this would be a great opportunity to look at what you see on transfer a stick and what you see on three d t e. So what is horizontal M. R. And that is a definition that we came up with. So the definition here is the jet that hugs the leaflets as you see here but doesn't reach the atrial wallet. Doesn't hug the post. Your wallet doesn't hug the anterior wall. Um, you don't even see it in much in the atrium. But sometimes it just hovers over the leaflets. So if you dio image ing on t e or even transfer asic sometimes but for sure, T e, this is ah, P three. That's flail. And what I've done is using the NPR's. Um I aligned the cut plane, this red cut plane here through the micro, regarded in check and on short access. Um, I aligned it as well. So the the orientation here is this is aortic valve. This is inter atrial septum, and this is the left atrial appendage. And so that means that this red plane shows the entirety of the jet, which is at p three. And look how it traverse is the whole aunt Early foot from a three a two a one. So this is by definition, um, a horizontal jet. So the goals are to compare severe m r on T, T E versus T E and those with P two and non p two prolapse and horizontal and non horizontal. I'm are, uh, to describe the differences in the direction of the degenerative mitral regurgitation between TTE and three d t e. And so what we did was we looked retrospectively in our database. We had 2260 t es between 2015 to 2019, and we included anybody who had moderate severe and mar severe m R and also had a trance harassing echo within six months before a t. E. So we excluded the majority of these patients and ended up with 118 patients. Uh, included for this evaluation, we had to investigators analyzed two D t, t e and as well as the three D two d t e um, images to characterize the jet. And so this is how we did it. On the right hand side, you see a three dimensional image of the P two that's flail here, Um, and so you can see this gap in mobile eco density, which is the, uh, Corday. Uh, we acquired images and we do this very systematically, always in patients with Mike regurgitation. So we acquire zero degrees 60 degrees or bike? Um, Israel, 90 degrees, which is P three and 135. Or at least long access view. I always tell my my fellows that long access is between 1. 20 to 1 50. And so this was systematic in all patients that we, uh, did, um so on the left hand side is the color image, and you can see that the jet is anti really directed. When you put this on a clock face, it's about between 12 and maybe two o'clock or one o'clock. And so that's how we determine the clock face. Um, uh, this is a non P two micro regurgitate jet. So, um, again, on the right hand side is the P three that's flail, and we acquired images along this acquisition protocol. And here you can notice that the jet is, um, towards nine o'clock. So here's the same example. So this is the jet. This is the way we, um, judge the direction of the regurgitation. So it was between nine and 10 o'clock. So here the baseline characteristics of these patients, the mean grading the mean age is 70 with 59% of these male, 33% has atrial fib. Relation. Um, in terms of t e, 86% had severe micro vegetation, 14% had moderate to severe Omar. And between the Trans Jurassic and the trans esophageal echo, there was really no difference in blood pressure. And so these are the results if you take a look at all the patients that we have, the majority of patients had P two, so 29% had P two that were affected, and the jet was the majority of the jet really went towards between 11 o'clock and one o'clock. So on T E was and surely directed on trans harassing echo. It was inter medial 59% of the time. And on Lee horizontal 12% of the time, the palm remains a solid reversal was 85% of the patients most of the time. The A one scallop is the most rare scallop to be involved. It's poster immediately directed, um, in these patients on a clock face, the jet goes between 3 to 5 o'clock on TTE. It's post yearly directed. And on this one particular patient that we found, um, there was no systolic reversal if a two is affected, which was 13% of the time. The jet was post yearly directed between 5 to 7 o'clock. Um, on transfer asic echo. Surprisingly, um, the jet was horizontal 40 40% of the time, and 33% of the time was post yearly. Directed with systolic reversal found in 86% of these cases, if you had an A three, which was only 1% of our population, it was post your and laterally directed. So between seven o'clock and nine o'clock is direction of the jet. Um, on Trans arrested Echo Onley 50 Sorry, 50% were horizontal and 50% had poster medial jets on t T. And most or 100% of them had systolic reversal. So I guess because of the location of this scallop and the directionality, it, um, really allowed us to evaluate in the pulmonary veins easily. Here on p three, the jet is an surely directed between nine and 11 oclock and on t t 53% of these patients um, we're horizontal on transfer a stick and 27% where anti remedial. The systolic reversal on lee 60% had systolic reversal of the poor Marine vein. If you had P one, which was only 3.5% of patients, it was anti immediately directed between one and three o'clock. So in this direction and anterior medial on Trans Jurassic 75% of the time and only 25% was horizontal and the pulmonary veins systolic reversal was 75% of the time. In terms of eco parameters, there was not much in terms of differences on eco parameters, but I just highlight that when you look at severe my trigger agitation on T T. That was only 75 cases, whereas if you went on to do t defined certainly more cases of severe mitral regurgitation. Um, when we compared p two and non p two m r, we had a large non P two group. This group had ah, lower e velocity. They had less Palmer in vain reversal and in terms of severity of my trigger agitation, um, there was a majority of patients who had more severe my trick vegetation with non p two m. R. So, um, that's comparing with P two. When you look at t E data again, the E velocity is under 1.2 m per second. All the other parameters air really not significant. And so when you take a look at this graph, what it means is when you see P two might regurgitation on transfer ASIC. Um, only a portion of them are are also diagnosed. I should say that a majority and more are diagnosed on t E. But this shows with non P two m r that not many are recognized as severe mitral regurgitation. Um, and more so when you do a t e. So there's more impetus to thio evaluate patients with t e and those with non P two micro accreditation. Um, in terms of the A velocity again just to highlight. Sorry. Um, let me just go through this. This should be the A velocity was significantly increased in the horizontal M r. This is sorry. Horizontal, non horizontal versus horizontal m. R. And the thought was that the velocity would be certainly lower. Um, but it didn't reach significance, but the A velocity was much hired. Um, the E A ratio was lower, and the Pullman vein reversal was less prominent in patients who had horizontal m R When you look at this graph, what's dramatic is that in patients with horizontal might regurgitation, you don't see it as much or defined a severe might regurgitation, uh, Onley 22% of the time. But if you have a t e u diagnoses patients, so we're missing a lot of horizontal and Mars, Um, when we're reading transgressive echo. So let's go back to our patient. This is our patient. Um, it's zero degrees. It's a post really directed jet AM on by commercial. The jet is just below the a two of segment, which is here, and, um, on a P three a three. You see the jet blow the A three scallop, and on the long axis view, you can see that it's mostly under the A two. So this is an A to issue the fact that the anti early foot is not facing up towards the the Left atrium. This is probably prolapse of a to, um, we did do pizza on T E. So we got a 0.46 with a regular volume of 61 and, uh, it's not the most fabulous three d echo, but I'm going to point to the area that this suspect here it's a two. And you can see the jet here, coming from that same area directed between 5 to 7 o'clock. So on a clock face, um, it's between 5 to 7. Um, remember a two on transfer. Acidic. 40% of these patients are are horizontal. M are on the left hand side. You see, true view. I think you can see the A to a little bit better with this true view compared to other original three D, um, rendering. So just to compare and contrast, this is the horizontal M are on the left hand side, and those of you are really astute that you're unable to determine the severity. And I don't fault those who say trace because, you know, this is something that's not really readily recognized in the eco world yet. On the right hand side is your, uh, prolapsed a two with a post really directed jet. So we this patient went on to robotic mitral valve repair. I'm going to try to share a different screen here. Um, so let me just do a new share. And Dr Gerson is our surgeon. He's the chief of cardiac surgery here at Yale, actually was trained at U Penn and his spirit headed the robotic mitral valve repair. Um, you can see that That's the A to that z involved. It's still connected with the cords. Um, he put he put down several Gortex cords for this, a two for the repair eso. He's more of a respect than respect. So he did not respect any of the leaflet. He respected the leaflet and you'll see that he reinforced the mitral valve with ring. So here he is, uh, putting down the suitors, and this is really wonderful to see. It's really wonderful visualization. The camera is actually implanted through the, um, third intercostal space. He tests the valve again, and there's maybe trace regurgitation. But otherwise, that's a really nice repair. And you see the ring, um, that's been placed with the robotic arms. So again, another test after the ring is placed, maybe a teeny, tiny bit of trace regurgitation. But that's ah, fine repair. So I think Dr Gerson, for sharing this video with me and let me just go back to my presentation. So a to prolapse confirmed by the surgeon Ah Gortex cord that was placed for micro repair and a 34 millimeter visual flex annual plastic band. And the end result here is a two millimeter Grady int. This is the intra operative T e that was performed, um, zero degrees on the left. A bike, Um, Israel on the right. And I don't see my dear regurgitation. So keep pearls here. The severity of non p two m r is underestimating a transfer. Asic echo. Remember that the velocity is helpful at least to me to decide whether somebody has severe or significant might regurgitation. But in these patients with non p two m r three e velocity is rather less than 1.2 the pulmonary vein reversal. You really can't stand on that because, uh, it Zaun Lee 40% of the time available for non p two m r. And even with p two, you have to remember that it's only 62% of these patients, at least in our cohort that have systolic reversal. The direction of them are on t E is really discarded, compared toa Transkaryotic echo. So even if you don't see it in the left atrium, you really need to be mindful of horizontal m r. Because horizontal m r is underestimated and it's severity on transfer asic echo. Um, only 22% of the time. Do we recognize it as severe. And if you go on to t, you can actually find 89% of those patients have severe might regurgitation the E velocity, similar to non P two is less than 1.2. Um, though it didn't reach significance. And but for sure, the polling vein reversal is very low. Um, in terms of frequency in those patients with horizontal might regurgitation, whether it be on transgressive echo or trans esophageal echo. So this quote of fool me once, shame on you, fool me twice. Shame on me. But hopefully we don't get full a third time. Um, because it would be shame on both of us. Right. Um So thank you so much for listening to my lecture. And thank you for the invite from Sameer and, uh, Roy, um, I'll take questions from here and Allah, I think my share. All right, Lisa, thank you very much. Fantastic talk today. We really appreciate you coming online for this before we get to the question unanswered session. I just want to read off the CMI code. For those of you that are on the phone line or on the computer, it's 66529 again. 665 to 9. At least I'm gonna start with a couple of questions for you. And there are a couple that air coming in through the through the Q and A. Tabas. Well, this actually has to do with two patients that I recently saw. Um, patient number one was kind of middle aged gentleman I'd been seeing for years for some hypertension. It's a mild m r sum Hyperloop Kadhimiyah and comes in and says, I'm sure to breath There's a distinct change than how I felt, you know, 3 to 6 months ago on examining clearly here. He's got mitral regurgitation now, which is new. So we do an echo, um, and a stress test. And the echo comes back, you know, mild to moderate M. R. Um, dimension to normal. His stress test mildly abnormal, Which is what prompted the Captain further evaluation. Another patient, similar symptoms very short of breath goes to their primary care doctor, who hears a very loud murmur gets an echo and an outside local cardiologists who comes back mild to moderate. M. R. Goes back to the primary care doctor. Goes to the cardiologists who says everything's fine goes back to their primary care doctor because they're getting more and more short of breath and then comes to us for a second opinion. And both of these cases, um, the m r by a thorough ASIC echo significantly underestimated it. One. How often does this happen? And I know you showed some correlations between T e and Jurassic Echo And are there things that we could do either Sinaga furs or for our echo readers to try to minimize this? Because I think this is, ah potentially for patients of a big deal if it's missed and it delays the recognition of the m r. Yeah. No, I, um I agree with you. I think I'm sorry. Um, that I think this is a recurring issue, not not that it occurs frequently. Um, but in the specific cases that are not straightforward p two, you have to have in the back of your mind that maybe this is a non P two issue and the hints of or recognition of, this horizontal m R or M R that you don't see, But you hear it, you don't see it then should should go on for a t e just to make sure. Because there there are some cases like this, um, that are totally missed. And this patient went two years on, you know, from being severe and Maher and they diaries, they diaries and the Sinaga furs have to really pan through. So when you're in a para sternal, you have to pan through. When you're a pickle, you have to pan through. And, um, it's it's the acquisition is is key here and also the recognition of mighty regurgitation that may be so severely eccentric. But because of the history and the physical you need thio send them for a T e. So acquisition, meaning that fanning through that's really important. Trying to always get a pizza is also very important. And continuity equation, the photographer on the second case, I thought, Okay, this is trace again and never even thought to dio continuity. So I mean from a maybe a standardization standpoint, he should have done it because historically you know it was severe. So the reader from the past also, you know, if in 2017 it was severe, it was missed in 2018, and the reader should have thought, Well, severe. Amar doesn't just go away automatically. Um, so I think, Ah, heightened suspicion is a good attitude to have. If you already treated the corner disease, you treated the heart failure, the blood pressure and the patients still short of breath. Then there must be else something else structurally wrong. No, great for that insight. Thank you. Um, a couple of questions on horizontal mitral regurgitation. Um, question number one. Do you have a suggestion to better visualize the Pisa dome on a thoracic echo? And the second part is this horizontal mitral regurgitation. Really Doppler splay. Is it due to high velocity signal causing it an artifact? So to acquire a good pizza? Uh, I think that the one thing that I've I've asked the stenographers to do is to do one. And so also looking for that dome by looking for the dome. That means that you need to really fan looking for the largest piece of radius. The second question, it's It's not artifact it is truly. And let me just go back to the the slide that I think is most representative, um, is that it truly hugs the jet because of the way Um ah, the way that the leaflet is flail. Right. So, um, let me just show this, So if I can share one more time here, um, So, uh, this this jet on three D shows how it comes from p three, but then, uh, it's directed for some reason. P three doesn't let the jet go up. It hovers over the valve itself. So I don't think it's artifact. I think it's just the trajectory of of this, uh, particular, uh you know, flail. Oh, our leaflet. But what I think was surprising for me to find out is that it's not just p three or eight or ah ah, com assure a lesion. Uh, it can also happen on anterior leaflet jets, too. So I think that we just need to be a little bit more aware of non P two type lesions. Next question has to do with the physical exam. You know, taking this back thio the basic ostentation skills. If the exam so How much does the exam help, I guess, is the question when the thoracic echo shows mild m R. But the exam is suggestive of more. Is that something that you know? How do you use exam? In that case, Yeah, that's that's a very good question, because when you take a look at the notes to this patient when it was defined a severe in 2007, uh, the cardiologists noted that there was a murmur. Um, remember that if it's severe, my trigger agitation, the murmur might not be that loud. And the record in orifice might be huge. So there's, you know, more laminar flow. I would say So, um, but if you have a smaller or fous the murmurs loud and it's easier to define, um, I think we just should, um, what I would say is that if you do hear a murmur and put the history together with the Echo, then I think that helps you make the decision. I don't think there's one particular symptoms sign that that tells you we need to do a T E and have to go further or, um, so on. So is there a role for cardiac Marie to better quantify my trigger station. I would agree with that. I think that particularly in patients who are moderate or moderate to severe the only reluctance that I had sometimes is that sometimes m r I tends toe underestimate course. The US keep paper, um tells us the opposite that echo overestimates. So the way that I use Emery is Thio Thio correlate What I see on transfer asking to transfer, salvage ill and confirm that so if it was, you know, moderate on eco Um, it probably is going to be moderate by Emory. Um, so I do use it from time to time. I think it's more useful for ejection fraction as well as, um, tissue characterization. Could you come? I know you didn't focus. Your talk was not about you know so much primary and secondary m r. But can you comment a little bit about proportionate and disproportionate m R. So let's say you have a patient with a mildly reduced ejection fraction or low normal ejection fraction, but with severe m r. And how you differentiate whether it's it's a primary valve problem or in that case, secondary. Amar. Yeah, this disproportionate M R is quite an interesting fields. Um, it's sort of tries to explain, um, the function of the ventricle with the severity of em are that we have right and that, um, we tend to end Underestimate. E think there's just not enough pressure to generate significant Mitra regurgitation. We see that we really do. And so, um, was the question more off? How to understand that or what? Determine whether with disproportionate markets actually severe Amar. Yeah, I guess if you could comment on both of those. Yeah, So, um, I think it starts with symptom Atala. Gee, and also the fact that in a patient who has some symptoms and those who have delectation of their left atrium right and starting to dilate their left ventricle, they may not exhibit significant mitral regurgitation with with a lower stroke volume or, um, a lower workload. So what needs to happen is to increase that workload. Thio challenge the ventricle to see if there is more mitral regurgitation. I think that we don't do that enough, um, to challenge the ventricle so that it actually exhibits, might regurgitation and explains the symptom mythology off that patient. Um, at one point. The ventricle just can't generate that pressure. All right, um, let me see if there are any more questions or comments that have come through here. Well, fantastic. I think we hit on the mall, and so again, thank you very much. We truly appreciate you spending the time with us with us this morning. I know we had initially hoped for you to come down to meet us, live in Philadelphia, but this was equally fantastic and so very insightful. Very helpful for all of us to better understand Michael Regurgitation. Thank you. Thank you very much. All right. Have a good day. Thanks. All right. Thank you. All right. And for everybody one last time. The CMI code is 665 to 9. All right. Thank you. Have a good day.