1
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I THOUGHT WE HAD GOOD 

2
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PRESENTATIONS AND A GOOD 

3
00:00:08,591 --> 00:00:09,725
DISCUSSION YESTERDAY AND WE'RE 

4
00:00:09,725 --> 00:00:10,326
LOOKING FOR MORE OF THE SAME 

5
00:00:10,326 --> 00:00:14,622
TODAY.

6
00:00:14,622 --> 00:00:17,091
THE FIRST SESSION IS ON SURGERY 

7
00:00:17,091 --> 00:00:20,762
AND TRANS CATHETER INTERVENTION 

8
00:00:20,762 --> 00:00:23,364
AND OUR FIRST SPEAKER IS 

9
00:00:23,364 --> 00:00:24,832
DR. MAYRA GUERRERO FROM MAYO 

10
00:00:24,832 --> 00:00:27,335
CLINIC.

11
00:00:27,335 --> 00:00:29,470
>> WELL, THANK YOU VERY
MUCH.

12
00:00:29,470 --> 00:00:31,239
GOOD MORNING.

13
00:00:31,239 --> 00:00:32,140
THANK YOU FOR THIS OPPORTUNITY.

14
00:00:32,140 --> 00:00:40,214
I WOULD LIKE TO TALK ABOUT 

15
00:00:40,214 --> 00:00:42,050
TRANSCATHETER TREATMENT FOR 

16
00:00:42,050 --> 00:00:47,855
MITRAL VALVE PROLAPSE.

17
00:00:47,855 --> 00:00:50,792
THESE ARE MY DISCLOSURES.

18
00:00:50,792 --> 00:00:55,196
THE OBJECT IS TO DESCRIBE THE 

19
00:00:55,196 --> 00:01:02,470
RATIONALE FOR EDGE TO END REPAIR

20
00:01:02,470 --> 00:01:03,237
OPTIONS.

21
00:01:03,237 --> 00:01:08,743
I WAS HOPING TO ILLUSTRATE A 

22
00:01:08,743 --> 00:01:12,046
CASE EXAMPLE OF TRANSSEPTAL 

23
00:01:12,046 --> 00:01:12,747
CHORDAL REPAIR.

24
00:01:12,747 --> 00:01:14,882
I WON'T BE ABLE TO SHOW THAT BUT

25
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WE'LL SEE IF I CAN SHOW OR EARLY

26
00:01:17,418 --> 00:01:20,988
OUTCOMES.

27
00:01:20,988 --> 00:01:25,793
AND AT THE END I'M HOPING TO 

28
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DISCUSS KNOWLEDGE GAPS AND INPUT

29
00:01:29,730 --> 00:01:31,833
ON FUTURE DIRECTIONS.

30
00:01:31,833 --> 00:01:36,070
REGARDING THE RATIONALE, THE 

31
00:01:36,070 --> 00:01:41,109
NEED FOR RE-INTERVENTION AFTER 

32
00:01:41,109 --> 00:01:42,343
TEER IS NOT UNCOMMON.

33
00:01:42,343 --> 00:01:46,914
WHEN IT'S NEEDED IT CAN BE 

34
00:01:46,914 --> 00:01:48,950
CHALLENGING AND REQUIRES SURGERY

35
00:01:48,950 --> 00:01:52,753
AND TRANS CATHETER OPTIONS ARE 

36
00:01:52,753 --> 00:01:56,958
LIMITED.

37
00:01:56,958 --> 00:01:58,693
THESE ARE SOME PATIENTS.

38
00:01:58,693 --> 00:02:03,631
WE KNOW AS A BACKGROUND THAT THE

39
00:02:03,631 --> 00:02:06,033
COMPARISON TO THE TRIALS WITH 

40
00:02:06,033 --> 00:02:07,935
SURGERY PATIENTS WHO WERE 

41
00:02:07,935 --> 00:02:12,940
TREATED WITH TEER SPECIFICALLY 

42
00:02:12,940 --> 00:02:19,814
ILLUSTRATED THEY HAD MORE THAN 

43
00:02:19,814 --> 00:02:20,648
20% REQUIREMENT FOR MITRAL VALVE

44
00:02:20,648 --> 00:02:22,450
SURGERY MORE THAN 20%.

45
00:02:22,450 --> 00:02:24,919
ON THE LEFT YOU CAN SEE WHAT 

46
00:02:24,919 --> 00:02:29,390
THEY WERE ANALYZED AFTER THE SIX

47
00:02:29,390 --> 00:02:32,193
MONTH MARK MOST RECURRED TO SUB 

48
00:02:32,193 --> 00:02:34,428
OPTIMAL RESULTS.

49
00:02:34,428 --> 00:02:37,665
THE BOTTOM LINE IS THE FIVE 

50
00:02:37,665 --> 00:02:42,670
YEARS THERE WAS NOTHING IB MORE 

51
00:02:42,670 --> 00:02:49,877
TAL AND THERE WERE SYMPTOMS BUT 

52
00:02:49,877 --> 00:02:54,916
THE WEAKNESS WAS ISSUE AND WANT 

53
00:02:54,916 --> 00:03:00,855
TO EMPHASIZE THE FIRST TEER WAS 

54
00:03:00,855 --> 00:03:02,823
IN 2003 IN THE U.S. AND THEN 

55
00:03:02,823 --> 00:03:08,930
LATER IN 2013 AND NEXT AND NEXT 

56
00:03:08,930 --> 00:03:09,630
AGAIN.

57
00:03:09,630 --> 00:03:13,134
AND OUT OF MORE THAN 100,000 

58
00:03:13,134 --> 00:03:16,804
PROCEDURES AND WE KNOW A GOOD 

59
00:03:16,804 --> 00:03:21,542
PROPORTION MORE THAN 20% HAVE 

60
00:03:21,542 --> 00:03:26,847
PROCEDURAL IMPACT AND THOSE 

61
00:03:26,847 --> 00:03:31,352
PATIENTS GRADE III OR GREATER 

62
00:03:31,352 --> 00:03:35,990
THE MORTALITY WAS GREATER AND 

63
00:03:35,990 --> 00:03:39,694
SOME REQUIRED SOME INTERVENING 

64
00:03:39,694 --> 00:03:50,238
BUT HAVE HIGH MORTALITY, RIGHT.

65
00:03:50,972 --> 00:03:56,410
SO WE DON'T SEE TOO COMMONLY 

66
00:03:56,410 --> 00:03:58,145
THERE'S MITRAL VALVE PROLAPSE I 

67
00:03:58,145 --> 00:04:00,448
KNOW THE PURPOSE OF THE SESSION 

68
00:04:00,448 --> 00:04:04,118
IS NOT THAT BUT WE SOMETIMES SEE

69
00:04:04,118 --> 00:04:06,053
COEXIST AND OCCASIONALLY WE GET 

70
00:04:06,053 --> 00:04:13,995
A GOOD RESULT.

71
00:04:13,995 --> 00:04:18,733
THIS IS AN EXAMPLE OF A GOOD 

72
00:04:18,733 --> 00:04:20,501
RESULT WITH TEER.

73
00:04:20,501 --> 00:04:30,978
WE KNOW SOMETIMES THIS IS A 

74
00:04:32,813 --> 00:04:37,652
PROGRESSIONAL CONDITION.

75
00:04:37,652 --> 00:04:41,522
LATELY THERE'S BEEN OPTIONS TO 

76
00:04:41,522 --> 00:04:49,530
REMOVE TEER TO ALLOW 

77
00:04:49,530 --> 00:04:55,903
TRANSCATHETER REPLACEMENT AND 

78
00:04:55,903 --> 00:04:56,871
THIS ALLOWS REPLACEMENT BUT THIS

79
00:04:56,871 --> 00:05:05,813
IS CHALLENGING.

80
00:05:05,813 --> 00:05:08,849
THERE'S BEEN A REPORT OF THE 

81
00:05:08,849 --> 00:05:10,418
FIRST IN HUMAN EXCISION AND THIS

82
00:05:10,418 --> 00:05:13,054
WAS PUSHED TO THE SIDE AND THIS 

83
00:05:13,054 --> 00:05:14,989
CASE IT WAS REMOVED.

84
00:05:14,989 --> 00:05:25,466
CHALLENGING BUT CAN BE DONE.

85
00:05:35,409 --> 00:05:39,780
THERE HASN'T BEEN CLINICAL 

86
00:05:39,780 --> 00:05:48,589
TRIALS AND THE MOST RECENT ONE 

87
00:05:48,589 --> 00:05:59,100
AND WE RANDOMIZED FOR ANATOMY.

88
00:06:00,801 --> 00:06:08,175
SOME ARE AT HIGH RISK REGISTRY 

89
00:06:08,175 --> 00:06:12,780
AND FOR THE NEXT FEW SLIDES 

90
00:06:12,780 --> 00:06:14,648
CLICK NEXT.

91
00:06:14,648 --> 00:06:18,119
SO SIMILAR OUTCOMES.

92
00:06:18,119 --> 00:06:22,089
NEXT IMPROVEMENT IN SYMPTOMS AND

93
00:06:22,089 --> 00:06:28,462
THE POINT OF THIS IS THAT IN TWO

94
00:06:28,462 --> 00:06:29,897
DECAD

95
00:06:29,897 --> 00:06:30,398
DECA

96
00:06:30,398 --> 00:06:35,035
DECADES MORTALITY AND SIMILAR 

97
00:06:35,035 --> 00:06:36,404
OUTCOMES AND IT'S HARD TO DO 

98
00:06:36,404 --> 00:06:40,741
THAT WHEN I DON'T HAVE CONTROL.

99
00:06:40,741 --> 00:06:43,511
NEXT, NEXT, NEXT.

100
00:06:43,511 --> 00:06:47,915
SOO T

101
00:06:50,317 --> 00:06:53,621
SO, THE BOTTOM LINE WE HAVE TWO 

102
00:06:53,621 --> 00:06:55,756
DEVICES APPROVED AND MY POINT IS

103
00:06:55,756 --> 00:06:57,625
I THINK WE NEED TO START SEEING 

104
00:06:57,625 --> 00:07:00,060
THAT.

105
00:07:00,060 --> 00:07:03,497
SO THERE ARE MULTIPLE DEVICES 

106
00:07:03,497 --> 00:07:07,234
FOR TRANSCATHETER REPAIR BUT 

107
00:07:07,234 --> 00:07:11,739
MOST OF THOSE ARE SECONDARY THEY

108
00:07:11,739 --> 00:07:16,510
FOCUS ON ANNULUS REDUCTION AND 

109
00:07:16,510 --> 00:07:19,747
APPROXIMATION BUT MAY NOT BE THE

110
00:07:19,747 --> 00:07:23,317
BEST OPTION FOR MITRAL VALVE 

111
00:07:23,317 --> 00:07:24,051
PROLAPSE.

112
00:07:24,051 --> 00:07:28,556
SO I THINK THERE'S ROOM FOR MANY

113
00:07:28,556 --> 00:07:30,357
CHANGES HOW WE APPROACH MITRAL 

114
00:07:30,357 --> 00:07:31,058
VALVE PROLAPSE.

115
00:07:31,058 --> 00:07:32,560
I THINK SOME PATIENTS WOULD 

116
00:07:32,560 --> 00:07:38,566
BENEFIT FOR THE CHORDAL REPAIR 

117
00:07:38,566 --> 00:07:40,901
AND WAS GOING TO SHARE WITH YOU 

118
00:07:40,901 --> 00:07:43,504
AN EXPERIENCE OF A CLINIC AND 

119
00:07:43,504 --> 00:07:44,905
HOPING TO ILLUSTRATE A REAL 

120
00:07:44,905 --> 00:07:45,172
CASE.

121
00:07:45,172 --> 00:07:51,212
THE OBJECTIVES OF THIS EFS OR IS

122
00:07:51,212 --> 00:07:56,650
TO HAVE A TRANS SEPTAL OPTION 

123
00:07:56,650 --> 00:07:59,487
WITH A SHORT PROCEDURE 

124
00:07:59,487 --> 00:08:01,689
RELATIVELY STRAIGHTFORWARD AND 

125
00:08:01,689 --> 00:08:05,226
HAVING THE PATIENTS DISCHARGE 

126
00:08:05,226 --> 00:08:06,861
NEXT DAY LIKE TEER AND EDGE TO 

127
00:08:06,861 --> 00:08:08,329
END REPAIR.

128
00:08:08,329 --> 00:08:09,964
THE REASON FOR WANTING SOMETHING

129
00:08:09,964 --> 00:08:12,066
LIKE LIST IS TO PRESERVE FUTURE 

130
00:08:12,066 --> 00:08:14,668
OPTIONS SO WE DON'T WANT TO 

131
00:08:14,668 --> 00:08:19,507
CLOSE THE DOOR FOR FURTHER 

132
00:08:19,507 --> 00:08:19,773
REPAIR.

133
00:08:19,773 --> 00:08:24,078
SO TRANSCATHETER REPLACEMENT 

134
00:08:24,078 --> 00:08:34,221
OPTIONS.

135
00:08:35,589 --> 00:08:37,825
THIS IS VERY STRAIGHTFORWARD FOR

136
00:08:37,825 --> 00:08:43,864
TEAMS THAT ARE USED TO PERFORM 

137
00:08:43,864 --> 00:08:48,068
PROCEDURES AND GUYEDED LIKE WE 

138
00:08:48,068 --> 00:08:52,473
DO TEER AND YOU PLACE THE CHORD 

139
00:08:52,473 --> 00:08:55,843
ON THE VENTRICULAR WALL AND 

140
00:08:55,843 --> 00:09:01,048
APPLY TENSION AND YOU CAN ADJUST

141
00:09:01,048 --> 00:09:04,752
THE TENSION VARIETY OF THE 

142
00:09:04,752 --> 00:09:12,026
REDUCTION YOU'RE LOOKING FOR.

143
00:09:12,026 --> 00:09:19,366
SO THE EFS LOOKS AT PRIMARY 

144
00:09:19,366 --> 00:09:20,267
PERFORMANCE AT 30 DAYS FOLLOW-UP

145
00:09:20,267 --> 00:09:30,811
AND LOOKING FOR ADVERSE EVENTS.

146
00:09:40,654 --> 00:09:46,460
THIS IS HIGH RISK COHORT.

147
00:09:46,460 --> 00:09:51,165
SO THE EXCLUSION CRITERIA.

148
00:09:51,165 --> 00:09:53,601
AND THE COMPOSITE END POINTS FOR

149
00:09:53,601 --> 00:09:59,406
THE PROCEDURE AS A AND FOLLOW-UP

150
00:09:59,406 --> 00:10:03,243
AT 30 IT'S AN AND LOOK AT OTHER 

151
00:10:03,243 --> 00:10:03,844
TRIALS AND FOLLOW-UP AFTER 30 

152
00:10:03,844 --> 00:10:09,750
DAYS.

153
00:10:09,750 --> 00:10:11,619
UNFORTUNATELY, THE CASE EXAMPLE 

154
00:10:11,619 --> 00:10:16,824
IS A LARGE SIZE AND ALLOWED TO 

155
00:10:16,824 --> 00:10:19,560
SHARE MY SCREEN.

156
00:10:19,560 --> 00:10:22,663
THIS IS JUST THE LEADERSHIP.

157
00:10:22,663 --> 00:10:24,365
I'M ONE OF THE CO-P.I.s AND 

158
00:10:24,365 --> 00:10:25,966
INTERESTED IN YOUR INPUT BECAUSE

159
00:10:25,966 --> 00:10:28,736
WE WANT TO START CLINICAL 

160
00:10:28,736 --> 00:10:32,873
TRIALS.

161
00:10:32,873 --> 00:10:35,175
SO WE HAVE OUTCOMES ON MANY 

162
00:10:35,175 --> 00:10:35,576
PATIENTS.

163
00:10:35,576 --> 00:10:37,511
THIS IS EARLY EXPERIENCE AND THE

164
00:10:37,511 --> 00:10:39,546
CASE I'M SHOWING IS ONE AT MAYO 

165
00:10:39,546 --> 00:10:43,684
CLINIC WHERE WE HAVE SIX-MONTH 

166
00:10:43,684 --> 00:10:43,951
FOLLOW-UP.

167
00:10:43,951 --> 00:10:46,620
IMPRESSIVE RESULTS WITH CHEMO 

168
00:10:46,620 --> 00:10:47,955
DYNAMIC ASSESSMENTS ON THE 

169
00:10:47,955 --> 00:10:50,591
PROCEDURE AND YOU COULD SEE A 

170
00:10:50,591 --> 00:10:56,130
DRAMATIC DROP IN A BIG WAY AND 

171
00:10:56,130 --> 00:11:00,534
REDUCTION OF MITRAL 

172
00:11:00,534 --> 00:11:02,102
REGURGITATION AND THE PATIENT 

173
00:11:02,102 --> 00:11:04,438
WAS EXTREMELY HAPPY WITH THE 

174
00:11:04,438 --> 00:11:07,808
RESULTS AND SO FAR HAVE NOT HAD 

175
00:11:07,808 --> 00:11:13,247
ANY DANGER RELATES TO THE 

176
00:11:13,247 --> 00:11:13,647
PROCEDURE.

177
00:11:13,647 --> 00:11:16,884
SEVEN WERE TREATED WITH A SINGLE

178
00:11:16,884 --> 00:11:17,551
CHORD.

179
00:11:17,551 --> 00:11:24,758
TWO REQUIRES TWO CHORDS AND WE 

180
00:11:24,758 --> 00:11:29,730
HOPE TO HAVE OUTCOMES TO BE 

181
00:11:29,730 --> 00:11:29,997
PRESENTED.

182
00:11:29,997 --> 00:11:31,598
PLEASE KEEP THIS CONFIDENTIAL 

183
00:11:31,598 --> 00:11:34,068
BUT WE MOPE TO PRESENT NEXT 

184
00:11:34,068 --> 00:11:40,741
YEAR, 2025 SOME OF THE 

185
00:11:40,741 --> 00:11:44,044
EXPERIENCE.

186
00:11:44,044 --> 00:11:49,783
SO KNOWLEDGE GAPS AND THE RESULT

187
00:11:49,783 --> 00:12:00,427
S IN THE PROCEDURES CLOSE TO 

188
00:12:03,897 --> 00:12:05,299
TEER AND TEST THE INDEX 

189
00:12:05,299 --> 00:12:06,900
PROCEDURE MAYBE FOLLOWED BY TEER

190
00:12:06,900 --> 00:12:12,072
LATER ON IF AND WHEN IT FAILS OR

191
00:12:12,072 --> 00:12:16,543
COMBINED WHEN NEEDED.

192
00:12:16,543 --> 00:12:17,444
SO FUTURE DIRECTIONS.

193
00:12:17,444 --> 00:12:23,517
I ASK FOR INPUT AND WE NEED 

194
00:12:23,517 --> 00:12:24,818
RANDOMIZED CLINICAL TRIALS.

195
00:12:24,818 --> 00:12:28,055
AND WE NEED TO COMPARE WITH 

196
00:12:28,055 --> 00:12:30,057
SURGERY AND WOULD IT BE FAIR TO 

197
00:12:30,057 --> 00:12:35,062
JUST COMPARE WITH TEER.

198
00:12:35,062 --> 00:12:37,397
SHOULD WE FOCUS ON WHICH 

199
00:12:37,397 --> 00:12:39,733
PATIENTS AND WHAT SHOULD BE THE 

200
00:12:39,733 --> 00:12:42,870
PRIMARY END POINTS FOR THE TRIAL

201
00:12:42,870 --> 00:12:45,339
AND THE DURATION OF FOLLOW-UP 

202
00:12:45,339 --> 00:12:47,307
WE'D LIKE TO SEE IN THE TRIALS.

203
00:12:47,307 --> 00:12:51,411
I THINK THIS IS MY LAST SLIDE.

204
00:12:51,411 --> 00:12:55,783
IN SUMMARY, SO NEED FOR REPEAT 

205
00:12:55,783 --> 00:12:58,452
MVP INTERVENTION IS NOT UNCOMMON

206
00:12:58,452 --> 00:13:00,087
AFTER TEER.

207
00:13:00,087 --> 00:13:04,892
SURGICAL OR PERCUTANEOUS 

208
00:13:04,892 --> 00:13:08,529
EXCISION OF THE FAILED TEER 

209
00:13:08,529 --> 00:13:12,633
DEVICE AND NON-TEER REPAIR DOES 

210
00:13:12,633 --> 00:13:14,034
NOT PRECLUDE FUTURE 

211
00:13:14,034 --> 00:13:17,504
INTERVENTIONS AND TRANS SEPTAL 

212
00:13:17,504 --> 00:13:21,074
CHORDAL REPAIR MAY BE AN OPTION 

213
00:13:21,074 --> 00:13:24,745
AND WE THESE FURTHER STRATEGIES 

214
00:13:24,745 --> 00:13:26,213
AND I'M APPRECIATIVE OF THIS 

215
00:13:26,213 --> 00:13:27,881
OPPORTUNITY AND WOULD LIKE TO 

216
00:13:27,881 --> 00:13:29,850
HEAR YOUR INPUT TO SEE WHERE YOU

217
00:13:29,850 --> 00:13:31,685
WANT US TO LEAD THIS FORWARD FOR

218
00:13:31,685 --> 00:13:32,753
THE NEXT PHASES OF THE TRIAL.

219
00:13:32,753 --> 00:13:42,196
THANK YOU.

220
00:13:42,196 --> 00:13:43,730
>> THANK YOU, DR.
GUERRERO.

221
00:13:43,730 --> 00:13:46,934
ARE THERE QUESTIONS OR COMMENTS 

222
00:13:46,934 --> 00:13:48,902
ON THIS PARTICULAR PRESENTATION?

223
00:13:48,902 --> 00:13:50,370
>> THIS IS FANTASTIC.

224
00:13:50,370 --> 00:13:53,273
THIS IS THE MOST PHYSIOLOGIC 

225
00:13:53,273 --> 00:13:54,575
REPAIR.

226
00:13:54,575 --> 00:13:57,978
REPRODUCING THE ORIGINAL ANATOMY

227
00:13:57,978 --> 00:14:00,180
TO BE CONGRATULATED.

228
00:14:00,180 --> 00:14:01,281
I WOULD THINK ONE OF THE 

229
00:14:01,281 --> 00:14:05,352
CHALLENGES IS THE IMAGING.

230
00:14:05,352 --> 00:14:10,724
I SAW TWO OTHERS ON AND WE 

231
00:14:10,724 --> 00:14:12,426
CERTAINLY WOULD BE INTERESTED IN

232
00:14:12,426 --> 00:14:12,893
PARTICIPATING.

233
00:14:12,893 --> 00:14:14,928
WHAT CHALLENGES HAVE ENCOUNTERED

234
00:14:14,928 --> 00:14:16,663
IN TERMS OF THE IMAGING 

235
00:14:16,663 --> 00:14:17,631
GUIDANCE, PLEASE?

236
00:14:17,631 --> 00:14:18,298
>> THANK YOU.

237
00:14:18,298 --> 00:14:19,666
THAT'S A QUESTION.

238
00:14:19,666 --> 00:14:23,871
WHAT WE DID WAS INCORPORATE THE 

239
00:14:23,871 --> 00:14:24,571
LEARNINGS ON SAFETY ANALYSIS.

240
00:14:24,571 --> 00:14:30,477
IF YOU TWO BACK TO THE VIDEO 

241
00:14:30,477 --> 00:14:36,750
ANIMATION AND WANT  -- I WANTED 

242
00:14:36,750 --> 00:14:40,854
TO SHOW WHERE TO PLACE THE 

243
00:14:40,854 --> 00:14:41,255
CHORD.

244
00:14:41,255 --> 00:14:46,059
I'M NOT A SURGEON I'M A 

245
00:14:46,059 --> 00:14:50,230
CARDIOLOGIST AND FAMILIAR WITH 

246
00:14:50,230 --> 00:14:52,366
THE PROCEDURE AND PLACEMENT OF 

247
00:14:52,366 --> 00:14:56,870
THE VALVE AND I WASN'T FAMILIAR 

248
00:14:56,870 --> 00:15:00,274
ONE WILL THE HYBRID APPROACH AND

249
00:15:00,274 --> 00:15:04,544
WHAT WE DID I ASKED WHERE DO YOU

250
00:15:04,544 --> 00:15:06,947
WANT ME TO PLAY THE END CHORD 

251
00:15:06,947 --> 00:15:17,391
AND THEY SAID BETWEEN THE 

252
00:15:29,002 --> 00:15:30,404
PAPPILARY MUSCLE AND I KNOW THE 

253
00:15:30,404 --> 00:15:35,175
CAMERA ANGLE I NEEDED TO HAVE TO

254
00:15:35,175 --> 00:15:39,646
VISUALIZE THAT.

255
00:15:39,646 --> 00:15:44,718
IN TERMS OF THE LEAFLET IT 

256
00:15:44,718 --> 00:15:49,356
WASN'T DIFFICULT.

257
00:15:49,356 --> 00:15:52,726
ANYTHING WITH GOOD SUPPORT 

258
00:15:52,726 --> 00:15:58,699
SHOULD BE ABLE TO VISUALIZE THE 

259
00:15:58,699 --> 00:16:00,734
PATIENT SELECTION I DON'T SEE 

260
00:16:00,734 --> 00:16:02,903
THAT AS A MAJOR PROBLEM AND WE 

261
00:16:02,903 --> 00:16:04,972
HAVE THE CONCEPT OF LOOKING AT 

262
00:16:04,972 --> 00:16:06,106
THE PRESSURE WHICH I FOUND 

263
00:16:06,106 --> 00:16:07,474
HELPFUL TO NOT JUST LOOK AT THE 

264
00:16:07,474 --> 00:16:09,343
COLOR WHEN YOU APPLY THE 

265
00:16:09,343 --> 00:16:12,646
TENSION, AGAIN, I'M NOT A 

266
00:16:12,646 --> 00:16:16,149
SURGEON, SO WE WERE LOOKING AT 

267
00:16:16,149 --> 00:16:18,285
THE COLOR AND THE FORM IN THIS 

268
00:16:18,285 --> 00:16:20,687
PARTICULAR CASE AND WHEN IT WAS 

269
00:16:20,687 --> 00:16:21,955
REDUCED AND APPLIED TENSION IT 

270
00:16:21,955 --> 00:16:26,126
CAME BACK AND THAT TOLD US THAT 

271
00:16:26,126 --> 00:16:29,329
WAS TOO MUCH TENSION AND 

272
00:16:29,329 --> 00:16:31,598
INCORPORATING THE HEMODYNAMICS.

273
00:16:31,598 --> 00:16:31,865
>> GREAT.

274
00:16:31,865 --> 00:16:32,132
THANK YOU.

275
00:16:32,132 --> 00:16:39,673
>> THANK YOU.

276
00:16:39,673 --> 00:16:42,542
>> MAYRA, I ALWAYS THOUGHT
THIS 

277
00:16:42,542 --> 00:16:45,579
WAS THE REAL FUTURE IF WE COULD 

278
00:16:45,579 --> 00:16:51,985
EVER GET TO CHORDAL 

279
00:16:51,985 --> 00:16:55,389
RESUSPENSION.

280
00:16:55,389 --> 00:16:59,926
I WAS INVOLVED IN A TRIALING TO 

281
00:16:59,926 --> 00:17:01,695
PUNCTURES AND TYING CHORDS BACK 

282
00:17:01,695 --> 00:17:03,363
IN TO THE VENTRICLE.

283
00:17:03,363 --> 00:17:07,401
WE HAD SOME IF RESULTS AND SAW 

284
00:17:07,401 --> 00:17:09,036
PATIENTS SEVERAL YEARS OUT AND 

285
00:17:09,036 --> 00:17:12,172
THE NEXT STEP IS TO GET IT TO A 

286
00:17:12,172 --> 00:17:13,006
CATHETER.

287
00:17:13,006 --> 00:17:14,908
THE SELECTION WAS CRITICAL 

288
00:17:14,908 --> 00:17:16,610
MEANING THAT WE NEEDED TO HAVE 

289
00:17:16,610 --> 00:17:27,154
ENOUGH LINK BETWEEN ANTERIOR AND

290
00:17:28,855 --> 00:17:29,089
P

291
00:17:29,089 --> 00:17:30,557
POSTERIOR AND YOU DON'T HAVE TO 

292
00:17:30,557 --> 00:17:32,993
REDUCE THE ANNULUS BACK TO ITS 

293
00:17:32,993 --> 00:17:33,427
ORIGINAL SHAPE.

294
00:17:33,427 --> 00:17:34,895
MOST PATIENTS BOAT MORE THAN ONE

295
00:17:34,895 --> 00:17:36,730
CHORD LIKE MANY DO IN SURGERY 

296
00:17:36,730 --> 00:17:44,738
UNLESS YOU'RE TREATING AN ELO

297
00:17:44,738 --> 00:17:48,141
ELONGATION AND WHAT WE 

298
00:17:48,141 --> 00:17:49,676
DISCOVERED WAS AND WHAT I'M 

299
00:17:49,676 --> 00:17:50,944
ALWAYS CONCERNED ABOUT AS WE 

300
00:17:50,944 --> 00:17:52,846
MOVE IN THE SPACE SURGERY TREATS

301
00:17:52,846 --> 00:17:57,451
ALL LESIONS OF THE DEGENERATIVE 

302
00:17:57,451 --> 00:17:59,519
POSTERIOR LEAFLET PROLAPSE AND 

303
00:17:59,519 --> 00:18:02,122
WE STUDIED VERY SPECIFIC 

304
00:18:02,122 --> 00:18:05,092
ANATOMIES WITH TRANSCATHETER AND

305
00:18:05,092 --> 00:18:08,161
REWITH RELEASE THEM AND THEY 

306
00:18:08,161 --> 00:18:10,664
GO -- WE RELEASE THEM AND TWO 

307
00:18:10,664 --> 00:18:11,031
INTO EVERYBODY.

308
00:18:11,031 --> 00:18:13,166
HOW DO WE STUDY THE CONCEPTS 

309
00:18:13,166 --> 00:18:14,067
LIKE THIS ONE WHICH I'M 

310
00:18:14,067 --> 00:18:16,770
INTERESTED IN AND EXCITED ABOUT 

311
00:18:16,770 --> 00:18:20,740
BUT THEN RECOGNIZE WELL, MAYBE 

312
00:18:20,740 --> 00:18:24,544
WE SAW 10 OR 15 POSTERIOR 

313
00:18:24,544 --> 00:18:25,745
LEAFLET PROLAPSES AND WHAT 

314
00:18:25,745 --> 00:18:28,748
HAPPENS ONCE YOU DO A STUDY AND 

315
00:18:28,748 --> 00:18:29,883
IT'S APPROVED?

316
00:18:29,883 --> 00:18:32,752
IMMEDIATELY IT STARTS PUTTING 

317
00:18:32,752 --> 00:18:34,588
INTO EVERYBODY POST MARKET.

318
00:18:34,588 --> 00:18:39,960
HOW DO WE HAVE LOW RISK 

319
00:18:39,960 --> 00:18:41,728
DEGENERATIVE CLIP WEN THE FDA 

320
00:18:41,728 --> 00:18:43,964
APPROVED IT FOR HIGH RISK 

321
00:18:43,964 --> 00:18:49,903
PATIENTS WHICH IS 5% OF THE 

322
00:18:49,903 --> 00:18:50,203
POPULATION.

323
00:18:50,203 --> 00:18:51,771
HOW DO WE DO THAT?

324
00:18:51,771 --> 00:18:56,743
>> WE FOCUS ON THE SCREEN 

325
00:18:56,743 --> 00:18:59,012
FAILURE RATE.

326
00:18:59,012 --> 00:19:00,981
>> WE SCREEN FAIL IN
TRIALS 

327
00:19:00,981 --> 00:19:02,382
BECAUSE WE HAVE TO BE SO CAREFUL

328
00:19:02,382 --> 00:19:04,084
IN WHAT WE STUDY.

329
00:19:04,084 --> 00:19:06,987
I'M ASKING JUST BROADER TO JUST 

330
00:19:06,987 --> 00:19:08,321
THINK ABOUT ONCE WE GO THROUGH 

331
00:19:08,321 --> 00:19:10,624
ALL THE EFFORT TO APPROVE A 

332
00:19:10,624 --> 00:19:12,325
DEVICE AND VERY DISCIPLINED IN 

333
00:19:12,325 --> 00:19:18,231
SCREEN FAILURES FOR ANATOMY, THE

334
00:19:18,231 --> 00:19:20,667
NEXT PHASE IS EVERYONE'S A 

335
00:19:20,667 --> 00:19:21,334
CANDIDATE IMMEDIATELY.

336
00:19:21,334 --> 00:19:26,973
PEOPLE FORGET TO READ THE 

337
00:19:26,973 --> 00:19:28,742
INCLUSION AND EXCLUSION 

338
00:19:28,742 --> 00:19:33,079
SOMETIMES OTHERWISE HOW CAN WE 

339
00:19:33,079 --> 00:19:36,583
EXPLAIN LOW RISK TEER WHEN IT'S 

340
00:19:36,583 --> 00:19:37,984
FOR HIGHER RISK PATIENTS?

341
00:19:37,984 --> 00:19:44,624
AND SAME FOR ANATOMY.

342
00:19:44,624 --> 00:19:46,526
I DON'T THINK THIS HAPPENS IN 

343
00:19:46,526 --> 00:19:48,128
THE REPLACEMENT WORLD BECAUSE 

344
00:19:48,128 --> 00:19:50,430
YOU HAVE TO PAY ATTENTION TO 

345
00:19:50,430 --> 00:19:54,801
VALVE DISLODGING AND WE HAVE TO 

346
00:19:54,801 --> 00:19:56,303
THINK ABOUT THE CRITICAL THING 

347
00:19:56,303 --> 00:19:57,837
IN VALVE REPLACEMENT BUT IN 

348
00:19:57,837 --> 00:19:59,539
REPAIR THERE'S A TENDENCY TO TRY

349
00:19:59,539 --> 00:20:03,777
EVERYTHING WITH A CATHETER ONCE 

350
00:20:03,777 --> 00:20:08,114
THE DEVICE IS SITTING ON YOUR 

351
00:20:08,114 --> 00:20:09,749
SHELF AND IT'S SO IMPORTANT AS 

352
00:20:09,749 --> 00:20:11,585
WE ARE HELPED TO HAVE THESE VERY

353
00:20:11,585 --> 00:20:16,590
ACADEMIC EXPERT DISCUSSIONS THAT

354
00:20:16,590 --> 00:20:21,228
WE WE'LL HAVE TO REINFORCE THE 

355
00:20:21,228 --> 00:20:22,362
IMAGING EXPERTISE REQUIRED TO DO

356
00:20:22,362 --> 00:20:28,735
THESE AND THE DISCIPLINE OF 

357
00:20:28,735 --> 00:20:32,639
ONES, INTERVENTIONALISTS AND 

358
00:20:32,639 --> 00:20:36,509
EC

359
00:20:36,509 --> 00:20:37,444
ECHOCARDIOGRAPHERS TO LOOK AT 

360
00:20:37,444 --> 00:20:39,713
THE EVIDENCE WE'VE CREATED.

361
00:20:39,713 --> 00:20:45,051
>> THAT EXPLAINS THE
RESULTS, 

362
00:20:45,051 --> 00:20:46,820
RIGHT THAT WE SAW.

363
00:20:46,820 --> 00:20:53,059
IT'S APPROVED FOR PRIMARY MR AND

364
00:20:53,059 --> 00:20:56,730
THERE WAS A LITTLE BIT OF 

365
00:20:56,730 --> 00:21:01,935
THICKENING WE'LL CALL PRIMARY 

366
00:21:01,935 --> 00:21:12,479
AND THEY SUPPORT THE CASES AND 

367
00:21:16,716 --> 00:21:19,085
LOOKING AT POORER OUTCOMES AND 

368
00:21:19,085 --> 00:21:21,321
NOT JUST FOR TECHNOLOGY BUT FOR 

369
00:21:21,321 --> 00:21:22,088
THE PATIENT RIGHT.

370
00:21:22,088 --> 00:21:28,728
THAT'S WHY WE SEE THE POORER 

371
00:21:28,728 --> 00:21:32,365
OUTCOMES.

372
00:21:32,365 --> 00:21:34,567
>> ON THE PAPER WROTE FROM
THE 

373
00:21:34,567 --> 00:21:39,439
TBT REGISTRY AND WHAT WAS SO 

374
00:21:39,439 --> 00:21:41,274
FIRST OF WILL ALL A QUARTER OF 

375
00:21:41,274 --> 00:21:42,575
THE PATIENTS WERE LOW RISK.

376
00:21:42,575 --> 00:21:52,252
I'M NOT SURE HOW THAT HAPPENED 

377
00:21:52,252 --> 00:21:54,988
BUT SOME HAD STENOSIS OR EMR AND

378
00:21:54,988 --> 00:21:58,558
THAT HAD A ONE-YEAR PENALTY IN 

379
00:21:58,558 --> 00:21:59,025
DEGENERATIVE DISEASE.

380
00:21:59,025 --> 00:22:04,731
ONE THING WE HAVE TO DO AND I 

381
00:22:04,731 --> 00:22:07,500
THINK I MENTIONED YESTERDAY WHEN

382
00:22:07,500 --> 00:22:10,103
JUDY MENTIONED AS WE MOVE DOWN 

383
00:22:10,103 --> 00:22:11,838
THE PATH OF TRANS CATHETER VALVE

384
00:22:11,838 --> 00:22:16,810
REPAIR I THINK WE HAVE TO START 

385
00:22:16,810 --> 00:22:19,713
TALKING ABOUT INVESTING IN A 

386
00:22:19,713 --> 00:22:22,215
LONG TERM CORE LAP BY THE NIH 

387
00:22:22,215 --> 00:22:24,718
BECAUSE WE'LL NEED LONGER 

388
00:22:24,718 --> 00:22:27,287
FOLLOW-UP MOST MARKET AND IT HAS

389
00:22:27,287 --> 00:22:29,456
TO BE DONE IN A LAP TO 

390
00:22:29,456 --> 00:22:30,123
UNDERSTAND WHAT HAPPENS AND 

391
00:22:30,123 --> 00:22:32,726
WHETHER THAT DISCIPLINE OF 

392
00:22:32,726 --> 00:22:39,165
SELECTION CONTINUES.

393
00:22:39,165 --> 00:22:40,734
>> THANK YOU.

394
00:22:40,734 --> 00:22:42,202
I COMPLETELY AGREE.

395
00:22:42,202 --> 00:22:44,371
>> THANK YOU FOR THE 

396
00:22:44,371 --> 00:22:48,308
PRESENTATION AND THE IF 

397
00:22:48,308 --> 00:22:48,742
DISCUSSION.

398
00:22:48,742 --> 00:22:50,643
DR. GUERRERO, I APOLOGIZE NOR 

399
00:22:50,643 --> 00:22:52,812
SYSTEM LIMITATIONS.

400
00:22:52,812 --> 00:22:58,518
>> SORRY, I GET EXCITED.

401
00:22:58,518 --> 00:23:00,120
I UNDERSTAND THAT IT PERHAPS TOO

402
00:23:00,120 --> 00:23:03,990
LARGE TO SHOW.

403
00:23:03,990 --> 00:23:04,257
THANK YOU.

404
00:23:04,257 --> 00:23:04,958
I HAVE TO GO.

405
00:23:04,958 --> 00:23:05,692
I HAVE A CASE.

406
00:23:05,692 --> 00:23:06,126
THANK YOU VERY MUCH.

407
00:23:06,126 --> 00:23:15,869
>> THANK YOU.

408
00:23:15,869 --> 00:23:18,138
OKAY.

409
00:23:18,138 --> 00:23:19,205
WE'RE GOING OUT OF ORDER AT THE 

410
00:23:19,205 --> 00:23:25,145
MOMENT.

411
00:23:25,145 --> 00:23:27,113
DR. ADAMS, ARE YOU ABLE TO GO 

412
00:23:27,113 --> 00:23:27,313
NEXT?

413
00:23:27,313 --> 00:23:31,785
>> SURE.

414
00:23:31,785 --> 00:23:41,928
>> OKAY.

415
00:23:43,229 --> 00:23:45,799
>> SO I'M GOING TO TALK TO
A 

416
00:23:45,799 --> 00:23:48,735
LITTLE BIT ABOUT OUR THOUGHTS 

417
00:23:48,735 --> 00:23:52,739
ABOUT VALVE RECONSTRUCTION AND 

418
00:23:52,739 --> 00:23:58,778
VENTRICULAR ABLATION FOR 

419
00:23:58,778 --> 00:24:01,881
PROLAPSE AND SOME ECHOS LOOK 

420
00:24:01,881 --> 00:24:03,650
EXPENSIVE BUT THEY'RE ALL IN RED

421
00:24:03,650 --> 00:24:07,654
AND GREEN AND GIVE COLORS BUT I 

422
00:24:07,654 --> 00:24:10,023
THINK WE'LL GET THROUGH IT.

423
00:24:10,023 --> 00:24:14,127
THESE ARE ALL MY DISCLOSURES AND

424
00:24:14,127 --> 00:24:16,162
I'LL REMIND EVERYBODY I HAVE 

425
00:24:16,162 --> 00:24:18,498
BEEN INVOLVED IN MANY TRIALS OF 

426
00:24:18,498 --> 00:24:20,800
TRANS CATHETER AND ALTERNATIVE 

427
00:24:20,800 --> 00:24:22,302
SURGICAL STRATEGIES.

428
00:24:22,302 --> 00:24:25,905
I ALWAYS REMIND PEOPLE WE'RE NOT

429
00:24:25,905 --> 00:24:27,340
DEFENDING THERAPY WE'RE 

430
00:24:27,340 --> 00:24:28,374
DEFENDING PATIENTS.

431
00:24:28,374 --> 00:24:29,776
I THINK THAT'S WHY THESE 

432
00:24:29,776 --> 00:24:31,945
MEETINGS ARE SO INSTRUCTIVE AND 

433
00:24:31,945 --> 00:24:33,112
FRANK, THANK YOU TO YOU AND YOUR

434
00:24:33,112 --> 00:24:40,487
TEAM FOR PUTTING THIS TOGETHER.

435
00:24:40,487 --> 00:24:41,855
WE'RE GOING TO TALK ABOUT 

436
00:24:41,855 --> 00:24:42,288
SURGERY FIRST.

437
00:24:42,288 --> 00:24:52,365
I WANT TO START WITH AFLAT  -- 

438
00:24:52,365 --> 00:24:53,766
ANATOMY AND WE WANT A MITRAL 

439
00:24:53,766 --> 00:24:57,704
VALVE THAT OPENS COMPLETELY AND 

440
00:24:57,704 --> 00:25:08,214
HAS MULTIPLE SEGMENTS AND THE 

441
00:25:16,089 --> 00:25:19,492
COMMISSURE AREAS AND THE BLOOD 

442
00:25:19,492 --> 00:25:23,096
COMES BACK AND IS LATER EJECTED 

443
00:25:23,096 --> 00:25:25,331
AND WE HAVE CORONARY SCIENCES 

444
00:25:25,331 --> 00:25:28,501
THAT'S FOR PHYSIOLOGY IN TERMS 

445
00:25:28,501 --> 00:25:30,904
OF TRYING TO MINIMIZE ENERGY OR 

446
00:25:30,904 --> 00:25:34,807
MAXIMIZE ENERGY TRANSFER AND TO 

447
00:25:34,807 --> 00:25:38,578
MINIMIZE STRESS AND TENSION.

448
00:25:38,578 --> 00:25:42,982
WE SPENT YEARS TALKING ABOUT 

449
00:25:42,982 --> 00:25:44,651
ISCHEMIC MITRAL VALVE 

450
00:25:44,651 --> 00:25:46,486
REGURGITATION AND THANKS TO BOB 

451
00:25:46,486 --> 00:25:49,022
AND MANY ON THE CALL THERE WAS A

452
00:25:49,022 --> 00:25:52,525
DECADE OF ISCHEMIC MR.

453
00:25:52,525 --> 00:25:55,428
EVERYTHING WAS AROUND THE 

454
00:25:55,428 --> 00:25:56,729
VENTRICLE CAUSING THE MITRAL 

455
00:25:56,729 --> 00:25:59,632
VALVE TO HAVE DYSFUNCTION IN 

456
00:25:59,632 --> 00:26:03,102
TERMS OF DELTATION AND 

457
00:26:03,102 --> 00:26:05,171
REMODELLING AND THE MITRAL VALVE

458
00:26:05,171 --> 00:26:09,008
ANATOMY IMPACTING THE VENTRICLE 

459
00:26:09,008 --> 00:26:10,009
AND THAT'S WHAT WE'RE HAVING THE

460
00:26:10,009 --> 00:26:12,145
MEETING FOR IS TO CATCH UP FROM 

461
00:26:12,145 --> 00:26:22,388
TWO YEARS AGO.

462
00:26:27,393 --> 00:26:29,162
I FIRST DREW THIS FIGURE AND WE 

463
00:26:29,162 --> 00:26:33,833
DREW IT TO HELP SURGEONS 

464
00:26:33,833 --> 00:26:35,435
UNDERSTAND THE DIFFERENCES IN 

465
00:26:35,435 --> 00:26:39,472
ANATOMY AND HOW TO DEVELOP 

466
00:26:39,472 --> 00:26:41,274
REPAIR STRATEGIES BASED ON THE 

467
00:26:41,274 --> 00:26:42,108
TISSUE AND SEGMENTAL 

468
00:26:42,108 --> 00:26:43,343
INVOLVEMENT.

469
00:26:43,343 --> 00:26:47,313
AND OF COURSE NOW AS YOU SAW 

470
00:26:47,313 --> 00:26:48,982
YESTERDAY THIS FIGURE HAS BECOME

471
00:26:48,982 --> 00:26:50,550
VERY USED ALMOST EVERYWHERE AND 

472
00:26:50,550 --> 00:26:52,752
IT'S REALLY BECAUSE OF THE 

473
00:26:52,752 --> 00:26:56,055
CHARACTERIZATION OF VALVE 

474
00:26:56,055 --> 00:27:01,628
DISEASE AND I'LL FOCUS ON THESE.

475
00:27:01,628 --> 00:27:03,196
IF YOU LOOK AT A BOAT AND I 

476
00:27:03,196 --> 00:27:05,898
WANTED TO GO FAST, WHAT DO I DO?

477
00:27:05,898 --> 00:27:10,503
I PUT BIG SAILS ON IT AND USE 

478
00:27:10,503 --> 00:27:15,675
THIS AS A PARALLEL BETWEEN 

479
00:27:15,675 --> 00:27:19,512
BARLOW'S AND I COULD HAVE SAID 

480
00:27:19,512 --> 00:27:25,918
ANTERIOR AND POSTERIOR LEAFLET 

481
00:27:25,918 --> 00:27:28,554
AND THE FIGURE TEACHES US LATE 

482
00:27:28,554 --> 00:27:34,594
ABOUT THE TOPIC AT HAND AND 

483
00:27:34,594 --> 00:27:36,462
MITRAL VALVE PROLAPSE.

484
00:27:36,462 --> 00:27:39,565
THIS IS THE ORIGINAL DESCRIPTION

485
00:27:39,565 --> 00:27:44,137
OF PROTRUSION OF THE POSTERIOR 

486
00:27:44,137 --> 00:27:46,439
LEAFLET BY JOHN BARLOW AND IT 

487
00:27:46,439 --> 00:27:56,949
PRECEDED THE CARDIOGRAPHY AND 

488
00:28:00,553 --> 00:28:01,888
THE FIELD IS BEING REDISCOVERED 

489
00:28:01,888 --> 00:28:03,990
AND I REMAIN EXCITED ABOUT THE 

490
00:28:03,990 --> 00:28:05,591
IMPLICATION FOR PATIENTS WITH 

491
00:28:05,591 --> 00:28:15,768
PROLAPSE .

492
00:28:18,304 --> 00:28:21,974
IN THE TEXTBOOK I HELPED THE 

493
00:28:21,974 --> 00:28:23,443
THREE PRINCIPLES WERE TO RESTORE

494
00:28:23,443 --> 00:28:26,779
THE LEAFLET ANATOMY AND MOTION 

495
00:28:26,779 --> 00:28:27,847
NOT RESTRICTIVE BUT RESTORING 

496
00:28:27,847 --> 00:28:30,717
AND CREATE THE NORMAL, WHICH IS 

497
00:28:30,717 --> 00:28:36,122
VARIABLE BUT A DEEP SURFACE OF 

498
00:28:36,122 --> 00:28:36,556
PRO

499
00:28:36,556 --> 00:28:40,359
PROLAPTATION SO THE VALVE CAN 

500
00:28:40,359 --> 00:28:41,828
FLEX WHEN YOU RAISE THE PRESSURE

501
00:28:41,828 --> 00:28:45,198
AND BECAUSE THE FIBROUS PART IS 

502
00:28:45,198 --> 00:28:48,534
IN CONTINUITY WITH THE POSTERIOR

503
00:28:48,534 --> 00:28:50,737
ANNULUS DILATES AND WHETHER YOU 

504
00:28:50,737 --> 00:28:51,971
DO REDUCTION THE BOTTOM OF THE 

505
00:28:51,971 --> 00:28:54,107
VALVE DROPS OUT AND THE GOAL WAS

506
00:28:54,107 --> 00:28:57,844
TO RESTORE THE NORMAL 

507
00:28:57,844 --> 00:29:02,582
RELATIONSHIP OR KIDNEY BEAN 

508
00:29:02,582 --> 00:29:13,126
SHAPE OF THE AND YOU'LL  -- -- 

509
00:29:17,296 --> 00:29:20,967
ANNULUS AND WE CREATED THIS FOR 

510
00:29:20,967 --> 00:29:22,535
THE VENTRICLE.

511
00:29:22,535 --> 00:29:23,870
WE REVIEWED THE LITERATURE 

512
00:29:23,870 --> 00:29:26,272
DURING THIS CONFERENCE IN TERMS 

513
00:29:26,272 --> 00:29:32,745
OF ALL THE BASIC SCIENCE BEHIND 

514
00:29:32,745 --> 00:29:34,080
THIS I WANTED TO PRESENT CASES 

515
00:29:34,080 --> 00:29:37,383
AND SHOW YOU EXAMPLES THAT WILL 

516
00:29:37,383 --> 00:29:39,552
HIGHLIGHT OUR PHILOSOPHY AS A 

517
00:29:39,552 --> 00:29:39,819
TEAM.

518
00:29:39,819 --> 00:29:45,424
FIRST PATIENT, 48 YEARS OLD, 

519
00:29:45,424 --> 00:29:50,463
LONG HISTORY OF PROLAPSE SHE'S 

520
00:29:50,463 --> 00:29:58,237
GOT EJECTION FRACTION.

521
00:29:58,237 --> 00:30:00,973
SHE'S GET A THICK POSTERIOR 

522
00:30:00,973 --> 00:30:03,309
LEAFLET AND THIS TENDENCY OF 

523
00:30:03,309 --> 00:30:05,945
BOTH LEAFLETS TO GO ABOVE THE 

524
00:30:05,945 --> 00:30:07,413
ANNULAR PLANE AND WHAT IS 

525
00:30:07,413 --> 00:30:09,048
TYPICAL AND I'LL ASK ABOUT IT IN

526
00:30:09,048 --> 00:30:10,650
THE DISCUSSION LATER WITH OTHERS

527
00:30:10,650 --> 00:30:15,154
IS WHETHER PROLAPSE VERSUS 

528
00:30:15,154 --> 00:30:16,022
RUPTURE MATTERS BECAUSE MY GUESS

529
00:30:16,022 --> 00:30:18,124
IS THERE'S MORE TENSION WHEN YOU

530
00:30:18,124 --> 00:30:24,130
HAVE CHORDAL ELONGATION AND HAVE

531
00:30:24,130 --> 00:30:34,674
A WHOLE HISTOLIC MURMUR AND THIS

532
00:30:37,610 --> 00:30:42,248
IS ABOUT 3.9% WITH PBCs AND 

533
00:30:42,248 --> 00:30:43,950
YOU'LL SEE MARK MILLER'S NAME A 

534
00:30:43,950 --> 00:30:46,619
LOT AND HE'S THE 

535
00:30:46,619 --> 00:30:47,453
ELECTROPHYSIOLOGIST THAT DRIVES 

536
00:30:47,453 --> 00:30:49,822
THE PROGRAM TOGETHER WITH ME IN 

537
00:30:49,822 --> 00:30:52,892
TERMS OF THE SURGICAL 

538
00:30:52,892 --> 00:31:03,135
INTERVENTION.

539
00:31:06,138 --> 00:31:12,044
HERE'S THE HYBRID PET MRI AND 

540
00:31:12,044 --> 00:31:14,747
HERE'S A PATIENT WITH LGE IN THE

541
00:31:14,747 --> 00:31:15,047
MUSCLE.

542
00:31:15,047 --> 00:31:16,816
HERE'S THE SURGERY.

543
00:31:16,816 --> 00:31:22,054
LOOK AT THE BILLOWING LARGE 

544
00:31:22,054 --> 00:31:22,622
POSTERIOR LEAFLET.

545
00:31:22,622 --> 00:31:24,156
IN TERMS OF ANY OTHER STRATEGY 

546
00:31:24,156 --> 00:31:26,759
WE HAVE TO REMOVE TISSUE.

547
00:31:26,759 --> 00:31:28,728
LOOK AT THE BULK AND THICKNESS 

548
00:31:28,728 --> 00:31:36,302
OF IT.

549
00:31:36,302 --> 00:31:41,741
THIS IS A QUADGRANULAR RESECTION

550
00:31:41,741 --> 00:31:46,979
AND TAKING A PIECE OF THE 

551
00:31:46,979 --> 00:31:57,490
LEAFLET AND TRIM THIS DOWN -- 

552
00:32:00,793 --> 00:32:05,531
OH, DEAR.

553
00:32:05,531 --> 00:32:07,199
LET'S TRY NOT TO DO THAT SO WE 

554
00:32:07,199 --> 00:32:08,000
STAY ON TIME.

555
00:32:08,000 --> 00:32:09,535
LEAVE THE BUTTON AND WE'LL SEE 

556
00:32:09,535 --> 00:32:15,908
IF IT WILL FINISH.

557
00:32:15,908 --> 00:32:17,543
IT'S IMPORTANT BECAUSE I WANTED 

558
00:32:17,543 --> 00:32:19,779
TO SHOW YOU SOMETHING UNDER THE 

559
00:32:19,779 --> 00:32:20,479
VALVE OF THE PATIENT.

560
00:32:20,479 --> 00:32:24,550
I TOOK IT BACK.

561
00:32:24,550 --> 00:32:35,061
A QUADGRANULAR SECTION -- THE 

562
00:32:40,333 --> 00:32:43,703
POSTERIOR LEAFLET SHOULD BE 

563
00:32:43,703 --> 00:32:45,538
ABOUT ONE CENTIMETER TALL AND 

564
00:32:45,538 --> 00:32:47,707
WE'RE REDUCING THE HEIGHT AND 

565
00:32:47,707 --> 00:32:48,941
RESUPPORTING IT AND DEALING WITH

566
00:32:48,941 --> 00:32:49,742
THE VOLUME.

567
00:32:49,742 --> 00:32:56,749
LOOK AT THE FIBROSIS AND 

568
00:32:56,749 --> 00:32:57,750
CALCIFICATION IN THE PAPILLARY 

569
00:32:57,750 --> 00:32:58,117
MUSCLE.

570
00:32:58,117 --> 00:33:03,689
THIS IS ELIMINATING THE ANNULAR 

571
00:33:03,689 --> 00:33:06,692
DISJUNCTION PLACING IT BACK AND 

572
00:33:06,692 --> 00:33:09,362
TRUE SIZE THE RING AND YOU CARN 

573
00:33:09,362 --> 00:33:12,098
SEE THE NORMAL ANATOMY RESTORED 

574
00:33:12,098 --> 00:33:15,134
WOMAN THE LEAFLET IN NORMAL FLOW

575
00:33:15,134 --> 00:33:17,003
IN THE VENTRICLE AND DIRECTION 

576
00:33:17,003 --> 00:33:23,976
TOWARDS THE APEX AND THE INK 

577
00:33:23,976 --> 00:33:27,046
SHOWS THE AMOUNT OF PROLAPSE.

578
00:33:27,046 --> 00:33:30,516
AND HERE'S THE ONE-MONTH POST 

579
00:33:30,516 --> 00:33:33,819
MITRAL VALVE REPAIR WITH MINIMAL

580
00:33:33,819 --> 00:33:39,925
PVCs AND SOME HAD PVCs RESOLVED 

581
00:33:39,925 --> 00:33:42,128
WITH SURGERY AND THIS PATIENT 

582
00:33:42,128 --> 00:33:43,929
ONLY HAD IT BECAUSE THE BURDEN 

583
00:33:43,929 --> 00:33:44,897
WAS LOW.

584
00:33:44,897 --> 00:33:47,700
HERE'S THE SECOND PATIENT.

585
00:33:47,700 --> 00:33:54,140
SHE'S 68 YEARS OLD AND HAD P

586
00:33:54,140 --> 00:33:57,610
PALPITATION AND HER REJECTION 

587
00:33:57,610 --> 00:34:04,517
FRACTION IS LOW NOW 46%.

588
00:34:04,517 --> 00:34:12,024
HER PBC BURDEN IS 14%.

589
00:34:12,024 --> 00:34:17,563
THERE WAS A STRESS 

590
00:34:17,563 --> 00:34:19,865
ECHOCARDIOGRAM AND HAVING 

591
00:34:19,865 --> 00:34:20,866
VENTRICULAR CUPLETS AND TRIPLETS

592
00:34:20,866 --> 00:34:26,906
ON EXERCISE.

593
00:34:26,906 --> 00:34:32,945
HERE'S HER TRANS ESOPHAGEAL 

594
00:34:32,945 --> 00:34:35,281
ECHOCARDIOGRAM.

595
00:34:35,281 --> 00:34:37,616
MANY HAVE HEIGHT AND HAVE 

596
00:34:37,616 --> 00:34:38,084
PROLAPSE.

597
00:34:38,084 --> 00:34:39,385
THERE'S MANY JETS BECAUSE THE 

598
00:34:39,385 --> 00:34:42,154
VALVE LEAKS IN MORE THAN ONE 

599
00:34:42,154 --> 00:34:44,757
PLACE BUT MOST ARE DIRECTED 

600
00:34:44,757 --> 00:34:48,794
CENTRALLY.

601
00:34:48,794 --> 00:34:51,430
HERE'S HER PVC ORIGIN AND THIS 

602
00:34:51,430 --> 00:34:53,099
IS IMPORTANT AND I'M SURE 

603
00:34:53,099 --> 00:34:54,533
DR. MILLER WILL GET INTO THIS 

604
00:34:54,533 --> 00:35:00,139
LATER WHEN HE SPEAKS BUT EKG 

605
00:35:00,139 --> 00:35:00,806
MORPHOLOGY DRIVES SELECTION OF 

606
00:35:00,806 --> 00:35:02,708
PARTICULAR PATIENTS IN TERMS OF 

607
00:35:02,708 --> 00:35:06,479
AN FOCI TO TREAT DURING THE 

608
00:35:06,479 --> 00:35:11,884
RECONSTRUCTION OF THE VALVE.

609
00:35:11,884 --> 00:35:14,954
HERE YOU CAN SEE YOU DO NEED TO 

610
00:35:14,954 --> 00:35:20,826
WORK WITH AN ELECELECTROPHYSIOLT

611
00:35:20,826 --> 00:35:24,029
AND BIBLE TO GET THE EXPERIENCE 

612
00:35:24,029 --> 00:35:25,231
LEVEL THAT'S REQUIRED TO FORGE 

613
00:35:25,231 --> 00:35:32,738
INTO A NEW FRONTIER LIKE 

614
00:35:32,738 --> 00:35:35,541
PAPILLARY MUSCLE ABLATION.

615
00:35:35,541 --> 00:35:37,476
HERE'S THIS PATIENT'S STUDY 

616
00:35:37,476 --> 00:35:38,177
AGAIN.

617
00:35:38,177 --> 00:35:47,286
LGE POSITIVE, FDG NEGATIVE.

618
00:35:47,286 --> 00:35:52,725
LET'S WATCH THE VALVE REPAIR.

619
00:35:52,725 --> 00:35:54,126
THIS IS A TYPICAL PATIENT.

620
00:35:54,126 --> 00:35:55,661
MULTISEGMENT PROLAPSE YOU CAN 

621
00:35:55,661 --> 00:35:56,195
SEE.

622
00:35:56,195 --> 00:35:58,130
AGAIN, THIS PARTICULAR PATIENT 

623
00:35:58,130 --> 00:36:02,601
WE'RE FOCUSSING ON THE P3 SIDE 

624
00:36:02,601 --> 00:36:04,637
BECAUSE WE HAVE A COMMISURAL 

625
00:36:04,637 --> 00:36:09,875
PATIENT AND THAT'S THE ABLATION.

626
00:36:09,875 --> 00:36:18,751
SO WE'LL CIRCUMFERENCCIRCUMFERE 

627
00:36:18,751 --> 00:36:20,753
AROUND THIS AND WE HAVE PERFECT 

628
00:36:20,753 --> 00:36:24,924
VISION TO DO THAT.

629
00:36:24,924 --> 00:36:29,795
THEN WE'LL CREATE A LEAFLET 

630
00:36:29,795 --> 00:36:33,799
THAT'S ABOUT A CENTIMETER AND A 

631
00:36:33,799 --> 00:36:35,201
HALF IN THE RIGHT POSITION AND 

632
00:36:35,201 --> 00:36:36,802
SEE THE POST OPERATIVE ECHO AND 

633
00:36:36,802 --> 00:36:40,773
WHAT WE'RE TRYING TO ACCOMPLISH 

634
00:36:40,773 --> 00:36:42,141
EACH TIME IS KNOWING MITRAL 

635
00:36:42,141 --> 00:36:44,777
VALVE REGURGITATION WITH A 

636
00:36:44,777 --> 00:36:48,113
NORMAL FLOW IN THE VENTRICLE AND

637
00:36:48,113 --> 00:36:50,349
SYSTOLIC.

638
00:36:50,349 --> 00:36:52,117
YOU CAN ADVANCE THE SLIDE.

639
00:36:52,117 --> 00:36:56,522
AND THERE YOU CAN SEE THE THREE 

640
00:36:56,522 --> 00:36:57,890
MONTH POSTOPERATIVE EVENT 

641
00:36:57,890 --> 00:37:03,162
MONITOR WITH A 1% BURDEN OF 

642
00:37:03,162 --> 00:37:03,662
VENTRICULAR ARRHYTHMIAS.

643
00:37:03,662 --> 00:37:05,064
THERE'S A ROLE FOR BOTH 

644
00:37:05,064 --> 00:37:05,965
PROCEDURES.

645
00:37:05,965 --> 00:37:08,734
THESE ARE WELL SELECTED 

646
00:37:08,734 --> 00:37:13,272
PATIENTS.

647
00:37:13,272 --> 00:37:15,741
THEN YOU'LL SHOW THE CASE 72 

648
00:37:15,741 --> 00:37:17,176
YEARS OLD.

649
00:37:17,176 --> 00:37:20,346
SHE ALSO HAS PVCs.

650
00:37:20,346 --> 00:37:24,683
SHE'S GOT A 27% BURDEN ON HER 

651
00:37:24,683 --> 00:37:34,326
MONITOR.

652
00:37:34,326 --> 00:37:40,499
HERE'S HER TRANS ESOPHAGEAL 

653
00:37:40,499 --> 00:37:44,570
TRANSFER AND CHORDALATION IS THE

654
00:37:44,570 --> 00:37:46,672
MAIN HERE NEXT TO LEAFLET.

655
00:37:46,672 --> 00:37:48,707
SHE'S GOT TWO DIFFERENT 

656
00:37:48,707 --> 00:37:56,148
LOCATIONS FOR PVCs.

657
00:37:56,148 --> 00:38:02,388
THE DOMINANT PVC IN THE DOMINANT

658
00:38:02,388 --> 00:38:04,723
FOCI AND IN OUR PROGRAM 

659
00:38:04,723 --> 00:38:09,662
DR. MILLER IDENTIFIES THESE IN 

660
00:38:09,662 --> 00:38:12,431
TERMS OF ABLATION.

661
00:38:12,431 --> 00:38:14,166
INTERESTINGLY ENOUGH IN THIS 

662
00:38:14,166 --> 00:38:16,402
PARTICULAR PATIENT, SHE DOES 

663
00:38:16,402 --> 00:38:20,139
HAVE FDG POSITIVELY AT THE LV 

664
00:38:20,139 --> 00:38:21,707
SUM IT WHICH IS THE LOCATION 

665
00:38:21,707 --> 00:38:23,942
WHERE MARK IDENTIFIED THE 

666
00:38:23,942 --> 00:38:32,084
PRIMARY FOCI FOR PVC.

667
00:38:32,084 --> 00:38:34,453
AGAIN HERE'S THE PVC AND THE 

668
00:38:34,453 --> 00:38:36,755
DOMINANT ONE AND THE SECOND IN 

669
00:38:36,755 --> 00:38:41,226
THE POSTERIOR PAPILLARY MUSCLE 

670
00:38:41,226 --> 00:38:43,862
WITH A HIGH BURDEN.

671
00:38:43,862 --> 00:38:46,665
SO HERE'S THIS PARTICULAR 

672
00:38:46,665 --> 00:38:48,167
PATIENT'S PROLAPSE.

673
00:38:48,167 --> 00:38:52,204
AGAIN, THICKENED CHORDS.

674
00:38:52,204 --> 00:38:54,340
USUALLY THERE'S A LARGE MESH OF 

675
00:38:54,340 --> 00:38:54,573
CHORDS.

676
00:38:54,573 --> 00:38:57,076
YOU SEE THE CALCIFICATION AT THE

677
00:38:57,076 --> 00:38:58,177
BASE OF THE VALVE.

678
00:38:58,177 --> 00:39:01,647
AND HERE WE'LL ISOLATE THE 

679
00:39:01,647 --> 00:39:04,049
PAPILLARY MUSCLE, RECONSTRUCT 

680
00:39:04,049 --> 00:39:13,325
THE VALVE LIKE WE'VE SHOWN YOU 

681
00:39:13,325 --> 00:39:22,368
BEFORE.

682
00:39:22,368 --> 00:39:23,502
THESE CREATE TRANS MURAL 

683
00:39:23,502 --> 00:39:33,645
LESIONS.

684
00:39:40,786 --> 00:39:48,794
RECONSTRUCT THE VALVE.

685
00:39:48,794 --> 00:39:51,230
WE'RE CREATING THE SECOND LESION

686
00:39:51,230 --> 00:39:56,502
AT THE LV SUMMIT THROUGH THE 

687
00:39:56,502 --> 00:39:56,702
TRACT.

688
00:39:56,702 --> 00:40:00,506
THERE'S THE POSTERIOR.

689
00:40:00,506 --> 00:40:00,839
NEXT.

690
00:40:00,839 --> 00:40:03,642
THIS PATIENT WENT DOWN FROM 27% 

691
00:40:03,642 --> 00:40:12,184
TO 2% IN THREE MONTHS.

692
00:40:12,184 --> 00:40:17,356
WE PUBLISHED OUR EXPERIENCE IN 

693
00:40:17,356 --> 00:40:20,492
THIS WITH ABLATION IN SELECTED 

694
00:40:20,492 --> 00:40:21,093
PATIENTS WITH ARRHYTHMIC PRE 

695
00:40:21,093 --> 00:40:25,964
LAPSE.

696
00:40:25,964 --> 00:40:28,734
THIS SUMMARIZES OUR CRYO 

697
00:40:28,734 --> 00:40:30,169
ABLATION STRATEGY.

698
00:40:30,169 --> 00:40:32,738
WE DO THREE-MINUTE LESIONS FOR 

699
00:40:32,738 --> 00:40:34,807
THE PAPILLARY MUSCLE.

700
00:40:34,807 --> 00:40:44,116
NEXT SLIDE.

701
00:40:44,116 --> 00:40:51,056
WE HAVE TO BE ABLE TO IDENTIFY 

702
00:40:51,056 --> 00:40:55,661
FOCI AND THOSE WITH GREATER PVC 

703
00:40:55,661 --> 00:40:58,897
AND IN OUR PROGRAM THIS IS NOT 

704
00:40:58,897 --> 00:41:00,732
DONE CASUALLY AND HAS TO BE 

705
00:41:00,732 --> 00:41:02,034
HIGHLY SELECTED AND LUCKY TO 

706
00:41:02,034 --> 00:41:03,035
HAVE A GROUP TO TIE THIS 

707
00:41:03,035 --> 00:41:11,176
TOGETHER EVERY DAY.

708
00:41:11,176 --> 00:41:14,446
WE DID GET AN AWARD TO CONTINUE 

709
00:41:14,446 --> 00:41:17,082
THE JOURNEY HERE FOR THIS AND 

710
00:41:17,082 --> 00:41:17,816
WE'RE GRATEFUL TO NHLBI FOR 

711
00:41:17,816 --> 00:41:27,226
THAT.

712
00:41:27,226 --> 00:41:28,760
THIS WAS SUMMARIZED BY 

713
00:41:28,760 --> 00:41:32,731
DR. TRIVIERI AND WE CAN FOLLOW 

714
00:41:32,731 --> 00:41:35,100
PATIENTS NOT UNDERGOING SURGERY 

715
00:41:35,100 --> 00:41:40,606
AND GIVE CLINICAL FOLLOW-UP FOR 

716
00:41:40,606 --> 00:41:44,576
FIVE YEARS AFTER THEIR MRI AND 

717
00:41:44,576 --> 00:41:46,812
HAVE ARMS FOR SURGERY AND WE'RE 

718
00:41:46,812 --> 00:41:48,514
TRYING TO TAKE AREAS WHERE WE 

719
00:41:48,514 --> 00:41:51,917
IDENTIFIED NATURAL GAS ON 

720
00:41:51,917 --> 00:41:54,186
IMAGING BECAUSE WE ARE TRYING TO

721
00:41:54,186 --> 00:41:59,091
ESTABLISH THE INFLAMMATORY 

722
00:41:59,091 --> 00:42:01,860
ORIGIN.

723
00:42:01,860 --> 00:42:03,462
WE'RE TRYING TO CORRELATE THAT 

724
00:42:03,462 --> 00:42:04,663
AND HAVE FOLLOW-UP AFTER SURGERY

725
00:42:04,663 --> 00:42:06,231
TO LOOK AMOUNT CHANGES IN 

726
00:42:06,231 --> 00:42:15,774
INFLAMMATION AFTER SURGERY.

727
00:42:15,774 --> 00:42:18,176
THIS IS A 67-YEAR-OLD PATIENT 

728
00:42:18,176 --> 00:42:22,714
WITH AFIB AND MR COMPLETELY 

729
00:42:22,714 --> 00:42:24,049
PRESERVED VENTRICULAR FUNCTION 

730
00:42:24,049 --> 00:42:34,126
AND LOW PVCs.

731
00:42:34,126 --> 00:42:38,564
YOU CAN SEE SEVERE MR IN DEEP 

732
00:42:38,564 --> 00:42:40,732
CLEFT AND THIS IS COMMON IN 

733
00:42:40,732 --> 00:42:50,909
BARLOW'S.

734
00:42:51,910 --> 00:43:02,387
HERE'S THE RARE BURDEN OF P  -- 

735
00:43:03,355 --> 00:43:05,557
PVC AS AND THE PET IMAGES BOTH 

736
00:43:05,557 --> 00:43:07,259
OF WHICH ARE POSITIVE.

737
00:43:07,259 --> 00:43:09,227
AND HERE'S THE LAST VIDEO I'LL 

738
00:43:09,227 --> 00:43:11,830
SHOW YOU WHICH IS THIS MITRAL 

739
00:43:11,830 --> 00:43:13,465
VALVE REPAIR.

740
00:43:13,465 --> 00:43:15,500
AGAIN, THICK LEAFLETS ALMOST 

741
00:43:15,500 --> 00:43:21,106
ALWAYS SEEN IN PATIENTS THAT 

742
00:43:21,106 --> 00:43:26,945
HAVE THIS PARTICULAR ANATOMY.

743
00:43:26,945 --> 00:43:29,414
IT'S PART OF THE REFORM FOR 

744
00:43:29,414 --> 00:43:39,725
BARLOW'S DISEASE.

745
00:43:44,029 --> 00:43:47,699
THIS IS DETERMINED BY THE 

746
00:43:47,699 --> 00:43:49,234
PATIENT'S OWN ANATOMY.

747
00:43:49,234 --> 00:43:52,838
WE'LL TAKE OUT THE SEGMENT AND 

748
00:43:52,838 --> 00:43:56,174
WE'RE NOT GETTING IN THE DETAILS

749
00:43:56,174 --> 00:43:58,110
OF WHY WE DO DIFFERENT THINGS 

750
00:43:58,110 --> 00:44:02,314
AND THIS IS A DIFFERENT TYPE OF 

751
00:44:02,314 --> 00:44:02,714
RECONSTRUCTION.

752
00:44:02,714 --> 00:44:04,483
SOMETIMES WE DETACH AND 

753
00:44:04,483 --> 00:44:06,885
SOMETIMES WE ROTATE THE LEAFLET.

754
00:44:06,885 --> 00:44:10,022
THE GOAL IS TRYING TO CREATE THE

755
00:44:10,022 --> 00:44:11,957
SAME SYMMETRIC HEIGHT OF THE 

756
00:44:11,957 --> 00:44:12,791
POSTERIOR LEAFLET.

757
00:44:12,791 --> 00:44:14,926
WE'RE DETACHING ONE SIDE OF THE 

758
00:44:14,926 --> 00:44:21,333
LEAFLET AND WILL MOVE THAT TO 

759
00:44:21,333 --> 00:44:24,169
THE OTHER SIZE AND GETTING 

760
00:44:24,169 --> 00:44:28,740
ACCESS TO THE BASE OF P3 AND 

761
00:44:28,740 --> 00:44:33,311
THIS WE'RE GOING THE BIOPSY.

762
00:44:33,311 --> 00:44:36,348
TO THE BIOPSY IS CORRELATED IS 

763
00:44:36,348 --> 00:44:37,949
WHERE WE SAW THE POSITIVITY IN 

764
00:44:37,949 --> 00:44:40,419
THE MRI STUDY AND THIS THE 

765
00:44:40,419 --> 00:44:41,787
CONTROL SAMPLE IN THIS CASE IS 

766
00:44:41,787 --> 00:44:43,989
BEING TAKEN BY THE ANTERIOR 

767
00:44:43,989 --> 00:44:45,357
SEPTAL WALL.

768
00:44:45,357 --> 00:44:48,994
MANY PATIENTS WE'RE FORTUNATE WE

769
00:44:48,994 --> 00:44:50,996
HAVE A PLACE TO SEE INFLAMMATION

770
00:44:50,996 --> 00:44:53,765
OR IMAGING AND LIGHTING UP SO 

771
00:44:53,765 --> 00:44:55,300
WE'RE INTERESTED TO SEE HOW THAT

772
00:44:55,300 --> 00:44:57,502
WORKS OUT AND THINK IT WILL 

773
00:44:57,502 --> 00:44:58,136
PROVIDE A LOT OF INFORMATION 

774
00:44:58,136 --> 00:45:03,008
REGARDLESS OF WHAT WE FIND ON 

775
00:45:03,008 --> 00:45:04,242
THE HISTOLOGICAL SIDE AND YOU'RE

776
00:45:04,242 --> 00:45:05,043
SEEING THIS ALREADY.

777
00:45:05,043 --> 00:45:07,679
SAME GOALS EACH TIME TRYING TO 

778
00:45:07,679 --> 00:45:10,816
CREATE THE HEIGHT OF THE 

779
00:45:10,816 --> 00:45:11,750
POSTERIOR LEAFLET TO BE 

780
00:45:11,750 --> 00:45:12,317
SYMMETRIC AND CLOSE IN A 

781
00:45:12,317 --> 00:45:22,561
SYMMETRIC WAY.

782
00:45:24,229 --> 00:45:27,099
THE PRINCIPLES ARE THE SAME 

783
00:45:27,099 --> 00:45:28,200
RESTORE NORMAL LEAFLET MOTION 

784
00:45:28,200 --> 00:45:32,304
AND DIASTOLIC FUNCTION OF THE 

785
00:45:32,304 --> 00:45:33,438
VALVE AS BEST WE CAN AN REMODEL 

786
00:45:33,438 --> 00:45:37,642
THE ANNULUS AND THE DEPTH OF 

787
00:45:37,642 --> 00:45:38,610
CLOSURE MATTERS.

788
00:45:38,610 --> 00:45:41,813
THIS IS WHAT IT LOOKS LIKE WHEN 

789
00:45:41,813 --> 00:45:44,082
IT'S PUT IN SURGICALLY.

790
00:45:44,082 --> 00:45:44,983
AND THEN A RING WILL GO IN AND 

791
00:45:44,983 --> 00:45:47,452
THAT WILL SOLVE THAT.

792
00:45:47,452 --> 00:45:49,721
SO AGAIN MANY PATIENTS IN THE 

793
00:45:49,721 --> 00:45:52,290
TRIAL ARE BEING DONE AND IT'S 

794
00:45:52,290 --> 00:45:55,360
INTERESTING THEY HAVE A LOW 

795
00:45:55,360 --> 00:45:57,629
ARRHYTHMIC BURDENS BUT HAVE 

796
00:45:57,629 --> 00:45:58,263
POSITIVITY FOR INFLAMMATION IN 

797
00:45:58,263 --> 00:46:08,507
THE VENTRICLE.

798
00:46:12,244 --> 00:46:22,721
ED -- I THINK THIS IS RELEVANT 

799
00:46:28,794 --> 00:46:32,531
BECAUSE WE SEE PATIENTS WITH 

800
00:46:32,531 --> 00:46:35,033
MITRAL VALVE DISEASE EVERY WEEK 

801
00:46:35,033 --> 00:46:41,873
INCLUDING SYMPTOMATIC AND 

802
00:46:41,873 --> 00:46:43,642
ASYMPTOMATIC AND MONITORING IS 

803
00:46:43,642 --> 00:46:47,078
MORE SOPHISTICATED IMAGING AND 

804
00:46:47,078 --> 00:46:48,113
ABLATION STRATEGIES WILL END UP 

805
00:46:48,113 --> 00:46:51,483
IN THE DISCUSSION OVER THE NEXT 

806
00:46:51,483 --> 00:46:52,450
SEVERAL YEARS IF WE CONTINUE TO 

807
00:46:52,450 --> 00:46:55,353
DO OUR WORK ON THE PHONE CALL, I

808
00:46:55,353 --> 00:47:00,158
THINK ALL THESE THINGS WILL 

809
00:47:00,158 --> 00:47:01,526
BECOME EXTREMELY IMPORTANT AND I

810
00:47:01,526 --> 00:47:02,661
APPRECIATE THE FLOOR, FRANK.

811
00:47:02,661 --> 00:47:03,995
THANK YOU VERY MUCH FOR INVITING

812
00:47:03,995 --> 00:47:04,729
ME.

813
00:47:04,729 --> 00:47:08,400
I'LL STOP THERE.

814
00:47:08,400 --> 00:47:10,168
>> THANK YOU VERY MUCH.

815
00:47:10,168 --> 00:47:12,170
ANY QUESTIONS OR COMMENTS ON 

816
00:47:12,170 --> 00:47:18,710
THIS PRESENTATION?

817
00:47:18,710 --> 00:47:23,481
>> DAVID, OUTSTANDING 

818
00:47:23,481 --> 00:47:24,716
PRESENTATION AND CONGRATULATE 

819
00:47:24,716 --> 00:47:26,284
YOU GUYS ON THE WORK YOU'RE 

820
00:47:26,284 --> 00:47:26,585
DOING.

821
00:47:26,585 --> 00:47:28,720
FOR A LOT OF THE CASES YOU'RE 

822
00:47:28,720 --> 00:47:32,991
DOING THIS CRYO ABLATION AND 

823
00:47:32,991 --> 00:47:37,529
TRACK PATIENTS DOING ANYTHING 

824
00:47:37,529 --> 00:47:40,732
OTHER THAN THE MITRAL REPAIR DO 

825
00:47:40,732 --> 00:47:42,567
YOU SEE IT REDUCED ALONE?

826
00:47:42,567 --> 00:47:45,971
>> I WONDER IF YOU CAN
MAKE A 

827
00:47:45,971 --> 00:47:48,173
BRIEF COMMENT ABOUT THAT.

828
00:47:48,173 --> 00:47:49,941
HE RUNS OUR RESEARCH GROUP.

829
00:47:49,941 --> 00:47:52,143
>> GOOD TO MEET YOU
VIRTUALLY.

830
00:47:52,143 --> 00:47:55,280
WHAT WE DID FIND OUT IS PATIENTS

831
00:47:55,280 --> 00:47:59,618
THAT HAVE SIMPLE NON-COMPLEX 

832
00:47:59,618 --> 00:48:04,055
VENTRICULAR ARRHYTHMIA RIGHT 

833
00:48:04,055 --> 00:48:11,029
AFTER A GARDEN VARIETY ANG

834
00:48:11,029 --> 00:48:13,431
ANGIOPLASTY WITH NO RECURRENCE 

835
00:48:13,431 --> 00:48:18,169
HOWEVER, THOSE THAT HAD NOT 

836
00:48:18,169 --> 00:48:20,739
BURDEN BUT COMPLEXITY AND FREE 

837
00:48:20,739 --> 00:48:24,042
AND UP WAS THE MOST COMMON 

838
00:48:24,042 --> 00:48:28,046
INDEPENDENT PREDICTOR REGARDLESS

839
00:48:28,046 --> 00:48:38,657
OF VENTRICULAR ECTOPY AND IF YOU

840
00:48:39,357 --> 00:48:40,725
HAVE V.P. RUNS WE NEED TO 

841
00:48:40,725 --> 00:48:42,427
REMEMBER THE PATIENTS AND 

842
00:48:42,427 --> 00:48:47,732
INVOLVE THE ELECTROPHYSIOLOGISTS

843
00:48:47,732 --> 00:48:51,169
BECAUSE NOT JUST GOING TO TAKE 

844
00:48:51,169 --> 00:48:52,737
THE REPAIR OF THE MECHANICAL 

845
00:48:52,737 --> 00:48:52,971
PROBLEM.

846
00:48:52,971 --> 00:48:55,674
>> TO SOME EXTENT AT LEAST
FOR 

847
00:48:55,674 --> 00:48:57,242
SURGERY HAS SOME EFFECT AFTER 

848
00:48:57,242 --> 00:48:59,210
REDUCING ARRHYTHMIA BURDEN AS 

849
00:48:59,210 --> 00:49:03,281
WELL AT LEAST IN SOME CASES.

850
00:49:03,281 --> 00:49:05,684
>> AND A REAL KEY HERE AND

851
00:49:05,684 --> 00:49:07,585
INTERESTED TO HEAR THE COMMENTS 

852
00:49:07,585 --> 00:49:08,720
AND SHE'LL TEACH US SOMETHING 

853
00:49:08,720 --> 00:49:10,188
ABOUT WHAT THE NIH TRIAL IS 

854
00:49:10,188 --> 00:49:12,724
GOING BUT I THINK IT'S GOING TO 

855
00:49:12,724 --> 00:49:13,725
TO BE INTERESTING BECAUSE ONE 

856
00:49:13,725 --> 00:49:16,027
ARGUMENT IS THE VOLUME LOAD AND 

857
00:49:16,027 --> 00:49:18,029
THE STRETCH THAT HURTS THE 

858
00:49:18,029 --> 00:49:18,296
VENTRICLE?

859
00:49:18,296 --> 00:49:20,365
THE OTHER ARM THE ONE I 

860
00:49:20,365 --> 00:49:21,700
CERTAINLY BELIEVE AND TRIED TO 

861
00:49:21,700 --> 00:49:28,306
REPRESENT THERE IS THE ANATOMY 

862
00:49:28,306 --> 00:49:29,541
IS VERY UNUSUAL.

863
00:49:29,541 --> 00:49:32,544
IT'S NOT THE WAY MITRAL VALVES 

864
00:49:32,544 --> 00:49:40,952
WERE MEANT TO CLOSE IN SYSTOLE 

865
00:49:40,952 --> 00:49:44,723
AND MID SYSTOLIC LEAKS PROBABLY 

866
00:49:44,723 --> 00:49:49,327
CREATE THE MOST FORCE WITH WE 

867
00:49:49,327 --> 00:49:51,997
DON'T A LOT OF MITRAL VALVE 

868
00:49:51,997 --> 00:49:53,531
MITRAL VALVE WITH THOSE WITH 

869
00:49:53,531 --> 00:49:53,832
DEFICIENCY.

870
00:49:53,832 --> 00:49:59,871
>> I THINK IT'S MECHANISM 

871
00:49:59,871 --> 00:50:00,138
DEPENDENT.

872
00:50:00,138 --> 00:50:01,873
ACROSS THE BOARD THERE SEEMS TO 

873
00:50:01,873 --> 00:50:02,841
BE A MODEST EFFECT.

874
00:50:02,841 --> 00:50:07,379
I THINK THE MECHANISM OF THE PVC

875
00:50:07,379 --> 00:50:09,080
SURGERY PROBABLY HAS LESS EFFECT

876
00:50:09,080 --> 00:50:12,150
IF IT'S PURELY MECHANICAL FORCES

877
00:50:12,150 --> 00:50:13,518
LIKE A FLAILED LEAFLET PROBABLY 

878
00:50:13,518 --> 00:50:15,387
HAS MORE EFFECT.

879
00:50:15,387 --> 00:50:17,155
ONCE YOU DRAW DOWN TO WHAT'S 

880
00:50:17,155 --> 00:50:18,023
CAUSING IT WILL DETERMINE 

881
00:50:18,023 --> 00:50:19,791
WHETHER OR NOT THE SURGERY HAS 

882
00:50:19,791 --> 00:50:20,925
DIRECT IMPACT.

883
00:50:20,925 --> 00:50:22,260
>> I'M GLAD YOU MADE THE 

884
00:50:22,260 --> 00:50:22,627
COMMENT.

885
00:50:22,627 --> 00:50:24,362
>> THE DISCUSSION WE WERE
HAVING

886
00:50:24,362 --> 00:50:28,633
YESTERDAY ABOUT DOING SOME 

887
00:50:28,633 --> 00:50:31,503
TRIALS WITH EARLIER INTERVENTION

888
00:50:31,503 --> 00:50:33,671
AND POTENTIALLY THE EARLIER 

889
00:50:33,671 --> 00:50:35,040
INTERVENTION IS IN THE 

890
00:50:35,040 --> 00:50:36,741
ARRHYTHMIC PHENOTYPE AND THE 

891
00:50:36,741 --> 00:50:39,644
EARLY SURGERY MAY BE THE WAY TO 

892
00:50:39,644 --> 00:50:41,146
REDUCE ARRHYTHMIC RISK IN SOME 

893
00:50:41,146 --> 00:50:41,413
PATIENTS.

894
00:50:41,413 --> 00:50:43,081
>> I THINK IT WILL REDUCE
IT 

895
00:50:43,081 --> 00:50:44,716
POTENTIALLY TWO WAYS.

896
00:50:44,716 --> 00:50:48,219
ONE IS OBVIOUSLY THE DIRECT 

897
00:50:48,219 --> 00:50:52,724
MECHANICAL FORCES AND WE KNOW 

898
00:50:52,724 --> 00:50:55,360
FIBROTIC TISSUE LEADS TO PVCs.

899
00:50:55,360 --> 00:50:59,998
IF YOU CAN REDUCE THE INJURY TO 

900
00:50:59,998 --> 00:51:01,399
THE MUSCLE YOU'LL PROBABLY 

901
00:51:01,399 --> 00:51:04,035
REDUCE THE RISK IF YOU INTERVENE

902
00:51:04,035 --> 00:51:04,569
EARLY ENOUGH.

903
00:51:04,569 --> 00:51:08,740
>> THOSE PATIENTS DO NOT
HAVE A 

904
00:51:08,740 --> 00:51:10,341
SCAR SUBSTRATE ONLY INFLAMMATORY

905
00:51:10,341 --> 00:51:11,976
SUBSTRATE IT CAN INTERVENE IN 

906
00:51:11,976 --> 00:51:14,712
DISRUPTING THE PROGRESSION TO A 

907
00:51:14,712 --> 00:51:15,914
DEFINITIVE SUBSTRATE OF SCAR.

908
00:51:15,914 --> 00:51:26,357
>> THAT'S WHAT WE BELIEVE.

909
00:51:34,099 --> 00:51:39,838
>> THOSE WITH LOW EF -- I
THINK 

910
00:51:39,838 --> 00:51:43,374
A COUPLE HAD NORMAL EJECTION 

911
00:51:43,374 --> 00:51:43,641
FRACTION.

912
00:51:43,641 --> 00:51:49,781
>> YOU HAD THE 57% AND
SYSTOLIC 

913
00:51:49,781 --> 00:51:57,455
42% AND ALL QUALIFIED FOR THE 

914
00:51:57,455 --> 00:52:00,391
DYSFUNCTION AND THEY SHOULD BE 

915
00:52:00,391 --> 00:52:02,293
RESPECTIVE OF ARRHYTHMIA AND 

916
00:52:02,293 --> 00:52:04,028
THIS IS CLASS 1 FOR SURGERY 

917
00:52:04,028 --> 00:52:04,696
BASED ON THE FUNCTION.

918
00:52:04,696 --> 00:52:08,733
SO THE ASSOCIATION OF LV 

919
00:52:08,733 --> 00:52:10,068
FUNCTION AND ARRHYTHMIA IS AN 

920
00:52:10,068 --> 00:52:10,668
IMPORTANT POINT TO TAKE INTO 

921
00:52:10,668 --> 00:52:15,940
ACCOUNT HERE.

922
00:52:15,940 --> 00:52:18,209
>> I LOOKED THROUGH A
DOZEN 

923
00:52:18,209 --> 00:52:20,512
VIDEOS LAST NIGHT AND WASN'T 

924
00:52:20,512 --> 00:52:25,583
PAYING ATTENTION TO EJECTION 

925
00:52:25,583 --> 00:52:25,850
FRACTION.

926
00:52:25,850 --> 00:52:27,685
SOME PATIENTS WE'RE INTERESTED 

927
00:52:27,685 --> 00:52:29,988
IN TRIGGER POINTS AND NEAR 

928
00:52:29,988 --> 00:52:32,724
TRIGGER POINTS THAT'S THE 

929
00:52:32,724 --> 00:52:34,926
DIFFERENCE IN CLASS 2A WHETHER 

930
00:52:34,926 --> 00:52:36,161
IT'S 70 OR 61.

931
00:52:36,161 --> 00:52:41,900
IT'S MORE NUANCED THAN THAT BUT 

932
00:52:41,900 --> 00:52:45,470
I THINK THERE WAS AN EJECTION 

933
00:52:45,470 --> 00:52:51,342
FRACTION OF 70%.

934
00:52:51,342 --> 00:52:53,978
>> AND SYSTOLIC DIMENSION
WHICH 

935
00:52:53,978 --> 00:52:54,279
QUALIFIES--

936
00:52:54,279 --> 00:52:57,348
>> I'LL GO BACK AND LOOK
AT THAT

937
00:52:57,348 --> 00:53:01,786
BUT WE HAVE CLINICALLY I HAVEN'T

938
00:53:01,786 --> 00:53:02,787
REALLY TIED THOSE DOTS TOGETHER 

939
00:53:02,787 --> 00:53:04,689
BECAUSE MANY PATIENTS AT LEAST 

940
00:53:04,689 --> 00:53:09,761
THOSE WE LOOKED AT HAD NORMAL 

941
00:53:09,761 --> 00:53:10,195
EJECTION FRACTIONS.

942
00:53:10,195 --> 00:53:14,899
>> THERE'S CASES WHERE
THERE WAS

943
00:53:14,899 --> 00:53:17,268
LV DYSFUNCTION AND HIGH PVC 

944
00:53:17,268 --> 00:53:19,137
BURDEN AND THE FUNCTION 

945
00:53:19,137 --> 00:53:20,939
NORMALIZES AND NOW LEFT WITH 

946
00:53:20,939 --> 00:53:26,010
NORMAL DIMENSIONS AND NOP VC.

947
00:53:26,010 --> 00:53:30,215
THEY PROBABLY HAVE AN INDUCED 

948
00:53:30,215 --> 00:53:32,684
CARDIO MYOPATHY ON TOP OF IT.

949
00:53:32,684 --> 00:53:34,152
>> THAT WOULD BE GOOD TO
HAVE 

950
00:53:34,152 --> 00:53:34,385
NUMBERS.

951
00:53:34,385 --> 00:53:35,587
THAT'S INTERESTING.

952
00:53:35,587 --> 00:53:40,858
WE HAVEN'T SEEN TONS OF THOSE 

953
00:53:40,858 --> 00:53:44,729
BUT 

954
00:53:44,729 --> 00:53:52,870
>> IL  -- THEY'LL CALL US
TO 

955
00:53:52,870 --> 00:53:54,239
REASSESS SOMETIMES THEY OFFER 

956
00:53:54,239 --> 00:53:56,808
ABLATION AND VICE VERSA.

957
00:53:56,808 --> 00:53:58,343
>> WHAT WOULD BE
INTERESTING IS 

958
00:53:58,343 --> 00:54:00,044
TO SEPARATE AND I SEE YOU'VE 

959
00:54:00,044 --> 00:54:03,214
BEEN FUNDED TO SEPARATE THE 

960
00:54:03,214 --> 00:54:04,983
EFFECT OF THE CLASSICAL FORM OF 

961
00:54:04,983 --> 00:54:07,285
LV DYSFUNCTION IN MITRAL VALVE 

962
00:54:07,285 --> 00:54:08,720
DISEASE AND THE PEOPLE WHO DO 

963
00:54:08,720 --> 00:54:12,190
NOT HAVE THE SCIENCE MAY HAVE 

964
00:54:12,190 --> 00:54:16,094
FIBROSIS AND MAY HAVE 

965
00:54:16,094 --> 00:54:19,430
ARRHYTHMIA'S AND THE FACTORS ARE

966
00:54:19,430 --> 00:54:21,833
IN A COMPLEX WAY.

967
00:54:21,833 --> 00:54:23,167
>> NOT JUST FUNCTION TO
SEPARATE

968
00:54:23,167 --> 00:54:25,937
THE ROLE OF PROLAPSE AND 

969
00:54:25,937 --> 00:54:28,740
REGURGITATION IN THE ABSENCE OF 

970
00:54:28,740 --> 00:54:30,808
PERCEIVABLE DYSFUNCTION.

971
00:54:30,808 --> 00:54:36,714
BECAUSE THE MAJORITY ARE BEING 

972
00:54:36,714 --> 00:54:38,316
REFERRED BY OF WITH NORMAL 

973
00:54:38,316 --> 00:54:41,119
PRESENTATION AND NO SYMPTOMS.

974
00:54:41,119 --> 00:54:43,321
>> THANK YOU FOR THE 

975
00:54:43,321 --> 00:54:44,055
PRESENTATION AND THE DISCUSSION.

976
00:54:44,055 --> 00:54:47,592
I'M AFRAID WE NEED TO MOVE ALONG

977
00:54:47,592 --> 00:54:48,326
AT THIS POINT.

978
00:54:48,326 --> 00:54:49,927
THERE'LL BE AN OPPORTUNITY FOR 

979
00:54:49,927 --> 00:54:52,730
MORE DISCUSSION AT THE END OF 

980
00:54:52,730 --> 00:54:56,734
THE SESSION.

981
00:54:56,734 --> 00:55:07,245
DR. ELMARIAH ARE YOU READY TO 

982
00:55:13,551 --> 00:55:13,718
GO?

983
00:55:13,718 --> 00:55:16,954
>> YES, I THINK SO.

984
00:55:16,954 --> 00:55:17,855
>> THANK YOU.

985
00:55:17,855 --> 00:55:18,990
>> IT'S A PLEASURE TO HAVE
THE 

986
00:55:18,990 --> 00:55:20,191
OPPORTUNITY TO SPEAK TO EVERYONE

987
00:55:20,191 --> 00:55:21,025
TODAY.

988
00:55:21,025 --> 00:55:23,828
I WAS GOING TO SHIFT GEARS A 

989
00:55:23,828 --> 00:55:24,595
LITTLE BIT.

990
00:55:24,595 --> 00:55:26,898
WE'VE SEEN THE SUPERB IMPACT AND

991
00:55:26,898 --> 00:55:32,303
OUTCOMES THAT SURGERY CAN OFFER 

992
00:55:32,303 --> 00:55:33,237
I WANT TO HIGHLIGHT SOMETHING 

993
00:55:33,237 --> 00:55:36,607
THAT DID NOT COME UP IN THE LAST

994
00:55:36,607 --> 00:55:39,510
MEETING THE TREATMENT OF MITRAL 

995
00:55:39,510 --> 00:55:50,054
REGURGITATION AND THE IMPACT OF 

996
00:55:56,427 --> 00:55:56,561
THAT.

997
00:55:56,561 --> 00:55:57,028
DEF 

998
00:56:03,134 --> 00:56:06,104
I WANT TO LOOK AT THE ADVERSE 

999
00:56:06,104 --> 00:56:08,306
IMPACT OF PATIENTS THAT DON'T 

1000
00:56:08,306 --> 00:56:09,207
RECEIVE THE THERAPIES.

1001
00:56:09,207 --> 00:56:10,441
THERE'S ROBUST DISPARITIES IN 

1002
00:56:10,441 --> 00:56:12,577
THE MANNER IN WHICH WE TREAT THE

1003
00:56:12,577 --> 00:56:14,579
PATIENTS AND TO HIGHLIGHT THOSE 

1004
00:56:14,579 --> 00:56:17,915
AND THEN TO DISCUSS POTENTIAL 

1005
00:56:17,915 --> 00:56:20,718
MITIGATION STRATEGY TO OPTIMIZE 

1006
00:56:20,718 --> 00:56:26,057
MANAGEMENT OF DMR.

1007
00:56:26,057 --> 00:56:29,427
SO FIRST SOME HISTORICAL AND 

1008
00:56:29,427 --> 00:56:30,228
OLDER DATA.

1009
00:56:30,228 --> 00:56:33,264
DR. SERRANO HAS BEEN 

1010
00:56:33,264 --> 00:56:34,232
INSTRUMENTAL IN THE EARLY STAGES

1011
00:56:34,232 --> 00:56:35,967
OF DISCOVERY IN ESTABLISHING THE

1012
00:56:35,967 --> 00:56:38,736
CLINICAL IMPLICATIONS OF MITRAL 

1013
00:56:38,736 --> 00:56:41,072
REGURGITATION AND ONE OF THE 

1014
00:56:41,072 --> 00:56:42,006
FIRST STUDIES IN THE NEW ENGLAND

1015
00:56:42,006 --> 00:56:45,743
JOURNAL WE SEE PATIENTS WITH 

1016
00:56:45,743 --> 00:56:46,811
SEVERE MITRAL REGURGITATION DO 

1017
00:56:46,811 --> 00:56:49,380
HAVE DIMINISHED SURVIVAL AND 

1018
00:56:49,380 --> 00:56:52,016
MUCH OF THIS REDUCTION IN 

1019
00:56:52,016 --> 00:56:52,717
SURVIVAL IMPACTS SPECIFICALLY 

1020
00:56:52,717 --> 00:56:56,421
THE PATIENTS THAT HAVE CLASS III

1021
00:56:56,421 --> 00:57:02,493
OR IV HEART FAILURE OR REDUCED 

1022
00:57:02,493 --> 00:57:03,661
INJECTION FRACTION AND THERE'S 

1023
00:57:03,661 --> 00:57:06,230
OTHER IMPLICATIONS AS WELL SUCH 

1024
00:57:06,230 --> 00:57:08,900
AS INCREASING RATES OF HEART 

1025
00:57:08,900 --> 00:57:10,301
FAILURE AS WELL AS ATRIAL 

1026
00:57:10,301 --> 00:57:11,536
FIBRILLATION OVER TIME WHEN THE 

1027
00:57:11,536 --> 00:57:12,236
PATIENTS ARE NOT TREATED 

1028
00:57:12,236 --> 00:57:18,242
PROPERLY.

1029
00:57:18,242 --> 00:57:21,746
AND WE ALSO KNOW SURGERY WORKS.

1030
00:57:21,746 --> 00:57:25,116
AND THERE ARE MULTIPLE STUDIES 

1031
00:57:25,116 --> 00:57:26,217
THAT DEMONSTRATE THAT SURGERY 

1032
00:57:26,217 --> 00:57:31,289
CAN REDUCE MORTALITY AND REDUCE 

1033
00:57:31,289 --> 00:57:32,156
CARDIOVASCULAR DEATHS IN 

1034
00:57:32,156 --> 00:57:33,458
PARTICULAR AND THAT IS DESPITE 

1035
00:57:33,458 --> 00:57:35,593
THE ASSOCIATED RISKS OF 

1036
00:57:35,593 --> 00:57:38,029
UNDERGOING CARDIAC SURGERY.

1037
00:57:38,029 --> 00:57:42,233
HEART FAILURE IS ALSO DIMINISHED

1038
00:57:42,233 --> 00:57:46,204
AS IS ATRIAL TEE FIBRIL AND 

1039
00:57:46,204 --> 00:57:47,738
REPEATED INVESTIGATORS 

1040
00:57:47,738 --> 00:57:49,307
HIGHLIGHTED THE FACT IF 

1041
00:57:49,307 --> 00:57:54,245
INTERVENTION OCCURS AT AN EARLY 

1042
00:57:54,245 --> 00:57:56,814
STAGE BEFORE DYSFUNCTION 

1043
00:57:56,814 --> 00:57:58,883
DEVELOPS MITRAL VALVE REPAIR CAN

1044
00:57:58,883 --> 00:58:03,221
RESTORE NORMAL LIFE EXPECTANCY 

1045
00:58:03,221 --> 00:58:08,726
AND AS DR. ADAMS SHOWED RESTORE 

1046
00:58:08,726 --> 00:58:11,529
NORMAL ANATOMY.

1047
00:58:11,529 --> 00:58:14,899
SO THE AMERICAN HEART 

1048
00:58:14,899 --> 00:58:16,701
ASSOCIATION AND AMERICAN COLLEGE

1049
00:58:16,701 --> 00:58:23,608
OF CARDIOLOGY PUT TOGETHER THE 

1050
00:58:23,608 --> 00:58:27,245
SYMPTOMATIC PATIENTS WITH SEVERE

1051
00:58:27,245 --> 00:58:30,414
PRIMARY REGURGITATION OR THOSE 

1052
00:58:30,414 --> 00:58:32,717
ASYMPTOMATIC BUT HAVE ELEMENTS 

1053
00:58:32,717 --> 00:58:38,523
OF LEFT VENTRICULAR DYSFUNCTION 

1054
00:58:38,523 --> 00:58:41,392
AS DELTATION OF THE VENTRICLE.

1055
00:58:41,392 --> 00:58:43,861
THE REPAIR IS STRONGLY 

1056
00:58:43,861 --> 00:58:49,100
RECOMMENDED OVER REPLACE MANY 

1057
00:58:49,100 --> 00:58:56,741
A

1058
00:58:56,741 --> 00:58:59,810
AND LIKELIHOOD OF OBTAINING 

1059
00:58:59,810 --> 00:59:01,679
EFFECTIVE REPAIR AND IN PATIENTS

1060
00:59:01,679 --> 00:59:05,883
WHO ARE HIGH RISK OR AT EXTREME 

1061
00:59:05,883 --> 00:59:07,852
RISK FOR SURGICAL INTERVENTION 

1062
00:59:07,852 --> 00:59:08,819
TRANS CATHETER EDGE TO EDGE 

1063
00:59:08,819 --> 00:59:18,930
REPAIR IS RECOMMENDED.

1064
00:59:18,930 --> 00:59:21,132
WE HAVE EFFECTIVE THERAPIES AND 

1065
00:59:21,132 --> 00:59:27,038
PROLONG LIFE AND REDUCE 

1066
00:59:27,038 --> 00:59:28,739
MORBIDITY WITH THE LESION AND 

1067
00:59:28,739 --> 00:59:32,743
IT'S SURPRISING AND SOMEWHAT 

1068
00:59:32,743 --> 00:59:36,781
DISAPPOINTING UNFORTUNATELY 

1069
00:59:36,781 --> 00:59:38,583
DESPITE THE WIDESPREAD 

1070
00:59:38,583 --> 00:59:39,517
AVAILABILITY OF THE THERAPIES 

1071
00:59:39,517 --> 00:59:42,219
WE'RE NOTE AS A MEDICAL 

1072
00:59:42,219 --> 00:59:43,621
COMMUNITY DOING A GOOD JOB IN 

1073
00:59:43,621 --> 00:59:48,726
TREATING THE PATIENTS SO HERE 

1074
00:59:48,726 --> 00:59:51,495
I'M SHOWING DATA FROM HOMESTEAD 

1075
00:59:51,495 --> 00:59:55,433
COUNTY CLOSE TO THE MAYO CLINIC 

1076
00:59:55,433 --> 00:59:58,669
THAT IDENTIFIED 1500 PATIENTS 

1077
00:59:58,669 --> 01:00:00,237
WITH MODERATE OR SEVERE MITRAL 

1078
01:00:00,237 --> 01:00:01,505
REGURGITATION AND WHAT THEY 

1079
01:00:01,505 --> 01:00:03,841
FOUND OVER MEDIAN FOLLOW-UP OF 

1080
01:00:03,841 --> 01:00:05,910
ALMOST FIVE YEARS ONLY 25% OF 

1081
01:00:05,910 --> 01:00:08,446
PATIENTS SO ONE IN FOUR PATIENTS

1082
01:00:08,446 --> 01:00:12,216
WITH AN INDICATION FOR SURGERY 

1083
01:00:12,216 --> 01:00:13,784
ACTUALLY UNDERWENT SURGERY.

1084
01:00:13,784 --> 01:00:17,855
AND THAT OF COURSE WAS 

1085
01:00:17,855 --> 01:00:19,223
ASSOCIATED WITH SIGNIFICANT THE 

1086
01:00:19,223 --> 01:00:22,026
PATIENTS THAT DID NOT GET 

1087
01:00:22,026 --> 01:00:24,762
TREATED HAD A ROBUSTLY EXCESSIVE

1088
01:00:24,762 --> 01:00:26,897
MORTALITY RATE NEARLY DOUBLE THE

1089
01:00:26,897 --> 01:00:29,934
RATE OF MORTALITY AS CAN BE SEEN

1090
01:00:29,934 --> 01:00:31,402
IN THE TIME TO EVENT CURVE.

1091
01:00:31,402 --> 01:00:37,174
AND IT WAS ALSO CLEAR THERE WERE

1092
01:00:37,174 --> 01:00:37,875
DISPARITIES IN DELIVERING 

1093
01:00:37,875 --> 01:00:39,744
EFFECTIVE MITRAL VALVE 

1094
01:00:39,744 --> 01:00:41,712
INTERVENTIONS WITH MEN TWICE AS 

1095
01:00:41,712 --> 01:00:43,014
LIKELY AS WOMEN WITH AN 

1096
01:00:43,014 --> 01:00:43,547
INDICATION TO RECEIVE AN 

1097
01:00:43,547 --> 01:00:46,384
INTERVENTION.

1098
01:00:46,384 --> 01:00:48,719
UNFORTUNATELY, WHEN ONE DOES NOT

1099
01:00:48,719 --> 01:00:52,657
RECEIVE MITRAL VALVE SURGERY THE

1100
01:00:52,657 --> 01:00:54,725
FIVE YEAR MORTALITY WAS ALMOST 

1101
01:00:54,725 --> 01:00:58,095
40% AND NEARLY 50% OF THESE 

1102
01:00:58,095 --> 01:01:00,231
PATIENTS ACTUALLY EXPERIENCED 

1103
01:01:00,231 --> 01:01:06,804
HEART FAILURE.

1104
01:01:06,804 --> 01:01:08,339
THIS IS NOT A PROBLEM UNIQUE TO 

1105
01:01:08,339 --> 01:01:08,773
THE UNITED STATES.

1106
01:01:08,773 --> 01:01:12,743
I'M SHOWING A SIMILAR STUDY THAT

1107
01:01:12,743 --> 01:01:13,678
CAME OUT OF FRANCE.

1108
01:01:13,678 --> 01:01:17,682
IT'S A NATIONWIDE STUDY THAT 

1109
01:01:17,682 --> 01:01:22,953
INCLUDED OVER 100,000 PATIENTS 

1110
01:01:22,953 --> 01:01:27,525
THAT WERE ADMITTED WITH MITRAL 

1111
01:01:27,525 --> 01:01:30,261
REGURGITATION AND 8% UNDERWENT 

1112
01:01:30,261 --> 01:01:31,629
SURGERY FOR THE MITRAL VALVE 

1113
01:01:31,629 --> 01:01:33,464
LESION IN THE FIRST YEAR, THAT 

1114
01:01:33,464 --> 01:01:34,832
IS 1 IN 12.

1115
01:01:34,832 --> 01:01:36,400
OF THOSE UNDERGOING SURGERY LESS

1116
01:01:36,400 --> 01:01:39,770
THAN 40% WERE WOMEN AND OVER ALL

1117
01:01:39,770 --> 01:01:44,041
ONLY 5.7% OF WOMEN ACTUALLY 

1118
01:01:44,041 --> 01:01:45,676
UNDERWENT THE MITRAL VALVE 

1119
01:01:45,676 --> 01:01:48,245
INTERVENTION COMPARED WITH 10.7%

1120
01:01:48,245 --> 01:01:48,713
OF MEN.

1121
01:01:48,713 --> 01:01:51,415
NEARLY TWICE THE RATE OF 

1122
01:01:51,415 --> 01:01:52,516
INTERVENTION IN MEN THAN IN 

1123
01:01:52,516 --> 01:01:54,051
WOMEN.

1124
01:01:54,051 --> 01:01:56,721
THE OTHER THING THAT IS QUITE 

1125
01:01:56,721 --> 01:01:59,623
INTERESTING IS WHEN YOU LOOK AT 

1126
01:01:59,623 --> 01:02:01,892
OBSERVED VERSUS PREDICTIVE 

1127
01:02:01,892 --> 01:02:03,527
MORTALITY RATES THERE IS SOME 

1128
01:02:03,527 --> 01:02:06,230
DEGREE OF EFFECT MODIFICATION 

1129
01:02:06,230 --> 01:02:12,169
SUCH THE OBSERVED IS FAR HIGHER,

1130
01:02:12,169 --> 01:02:15,940
NEARLY TENFOLD AND IN MEN IT'S 

1131
01:02:15,940 --> 01:02:20,711
FIVEFOLD INCREASE IN MORTALITY 

1132
01:02:20,711 --> 01:02:27,651
IN MR WHEN IT'S TREATED.

1133
01:02:27,651 --> 01:02:29,520
UNFORTUNATELY, THIS PROBLEM I'M 

1134
01:02:29,520 --> 01:02:30,888
HIGHLIGHTING AND THE DISPARITIES

1135
01:02:30,888 --> 01:02:34,058
AND TREATMENT IS NOT SPECIFIC TO

1136
01:02:34,058 --> 01:02:34,859
SURGERY.

1137
01:02:34,859 --> 01:02:36,894
IT SEEMS TO BE PREVALENT ALSO IN

1138
01:02:36,894 --> 01:02:40,898
THE TRANS CATHETER SPACE AND TO 

1139
01:02:40,898 --> 01:02:44,935
ENCOMPASS OPTIMAL MANAGEMENT OF 

1140
01:02:44,935 --> 01:02:45,770
VALVE DISEASE IN GENERAL.

1141
01:02:45,770 --> 01:02:50,641
THIS IS A STUDY OUT OF YALE 

1142
01:02:50,641 --> 01:02:56,046
INCLUDING 10 OF THEIR DIFFERENT 

1143
01:02:56,046 --> 01:02:59,917
IN-PATIENT INSTITUTIONS AS WELL 

1144
01:02:59,917 --> 01:03:03,420
AS NEARLY 40 OUT PATIENT 

1145
01:03:03,420 --> 01:03:08,592
INSTITUTIONS WITH THOSE WITH 

1146
01:03:08,592 --> 01:03:09,360
PRIMARY REGURGITATION AND CLASS 

1147
01:03:09,360 --> 01:03:12,229
1 AND GENDER DISPARITIES WERE 

1148
01:03:12,229 --> 01:03:15,399
QUITE PREVALENT IN ALL THE 

1149
01:03:15,399 --> 01:03:16,066
METRICS MEASURED.

1150
01:03:16,066 --> 01:03:20,371
SO ROBUST DIFFERENCE IN REGARDS 

1151
01:03:20,371 --> 01:03:24,708
TO WHETHER THE PATIENT UNDERWENT

1152
01:03:24,708 --> 01:03:28,412
AN EVALUATION AND THE RATES OF 

1153
01:03:28,412 --> 01:03:30,848
TRANS CATHETER REPAIR WERE 

1154
01:03:30,848 --> 01:03:32,116
HIGHER IN MEN THAN WOMEN AND 

1155
01:03:32,116 --> 01:03:33,584
WHILE NOT STATISTICALLY 

1156
01:03:33,584 --> 01:03:34,919
SIGNIFICANT THERE'S A ROBUST 

1157
01:03:34,919 --> 01:03:35,586
DIFFERENCE IN HOW LONG IT TOOK 

1158
01:03:35,586 --> 01:03:37,688
TO GET THE PATIENTS TO TREATMENT

1159
01:03:37,688 --> 01:03:40,724
AS WELL WITH DAYS TO 

1160
01:03:40,724 --> 01:03:42,593
INTERVENTION MARKEDLY HIGHER IN 

1161
01:03:42,593 --> 01:03:44,361
PATIENTS AND WOMEN THAN IN MEN 

1162
01:03:44,361 --> 01:03:48,232
AND A TREND OR A STRONG 

1163
01:03:48,232 --> 01:03:49,133
STATISTICALLY SIGNIFICANT 

1164
01:03:49,133 --> 01:03:50,301
DIFFERENCE IN SURVIVAL RATES 

1165
01:03:50,301 --> 01:03:52,136
DEPENDING ON WHETHER YOU ARE A 

1166
01:03:52,136 --> 01:03:54,138
MAN OR WOMAN WITH MORE FAVORABLE

1167
01:03:54,138 --> 01:03:56,841
OUTCOMES IN MEN.

1168
01:03:56,841 --> 01:03:59,577
PRESUMABLY RELATING TO THE FACT 

1169
01:03:59,577 --> 01:04:00,211
THE PATIENTS RECEIVED 

1170
01:04:00,211 --> 01:04:06,917
INTERVENTION.

1171
01:04:06,917 --> 01:04:08,719
NOW, NOTICE TIER SPACE BEYOND 

1172
01:04:08,719 --> 01:04:11,155
GENDER DISPARITIES THERE'S ALSO 

1173
01:04:11,155 --> 01:04:13,023
ETHNIC AND RACIAL DISPARITIES.

1174
01:04:13,023 --> 01:04:18,295
HERE I'M SHOWING DATA FROM THE 

1175
01:04:18,295 --> 01:04:21,432
SDS ACC REGISTRY DEMONSTRATING 

1176
01:04:21,432 --> 01:04:23,868
82% OF PATIENTS WHO UNDER GO 

1177
01:04:23,868 --> 01:04:27,204
EDGE TO EDGE REPAIR ARE WHITE 

1178
01:04:27,204 --> 01:04:27,938
CAUCASIAN PATIENTS.

1179
01:04:27,938 --> 01:04:29,640
THERE'S BEEN A SLIGHT UPTICK 

1180
01:04:29,640 --> 01:04:31,942
OVER THE YEARS IN PROPORTION OF 

1181
01:04:31,942 --> 01:04:37,481
BLACK PATIENTS WHO RECEIVE THE 

1182
01:04:37,481 --> 01:04:39,183
THERAPIES AND OTHER RACIAL 

1183
01:04:39,183 --> 01:04:40,751
BACKGROUND THAT RECEIVE THE 

1184
01:04:40,751 --> 01:04:42,219
THERAPIES BUT STILL DISCORDANT 

1185
01:04:42,219 --> 01:04:43,187
FROM THE ETHNIC AND RACIAL MAKE 

1186
01:04:43,187 --> 01:04:51,161
UP OF THE UNITED STATES.

1187
01:04:51,161 --> 01:04:52,630
GEOGRAPHICALLY THERE'S ALSO BIS 

1188
01:04:52,630 --> 01:04:58,702
PATRIOTS IN THE AVAILABILITY OF 

1189
01:04:58,702 --> 01:05:02,439
THE ADVANCES THERAPIES AND 

1190
01:05:02,439 --> 01:05:05,643
MITRAL EDGE TO EDGE REPAIR AND 

1191
01:05:05,643 --> 01:05:06,310
ACROSS THE UNITED STATES THERE'S

1192
01:05:06,310 --> 01:05:09,513
SEVERAL STATES THAT DON'T HAVE 

1193
01:05:09,513 --> 01:05:16,153
ANY SITES OR HAVE ONE OR TWO 

1194
01:05:16,153 --> 01:05:19,990
MTEER SIGHT DIFFERENT FROM THE 

1195
01:05:19,990 --> 01:05:21,492
INSTITUTIONS ABLE TO OFFER THE 

1196
01:05:21,492 --> 01:05:23,227
THERAPIES ALONG THE COAST AREAS 

1197
01:05:23,227 --> 01:05:28,699
WHERE THERE'S USUALLY A HIGH 

1198
01:05:28,699 --> 01:05:29,833
DEGREE OF FINANCIAL -- LESS 

1199
01:05:29,833 --> 01:05:40,277
DISADVANTAGED POPULATIONS.

1200
01:05:42,279 --> 01:05:44,748
SOCIO ECONOMIC DISPARITIES ARE 

1201
01:05:44,748 --> 01:05:48,719
CLEARLY PREVALENT IN RECEIPT OF 

1202
01:05:48,719 --> 01:05:52,723
CARE OF DEGENERATIVE MITRAL 

1203
01:05:52,723 --> 01:05:58,696
VALVE AND THE IMPACT OF VALVE 

1204
01:05:58,696 --> 01:06:01,532
REPAIR IN DATA FROM CMS 

1205
01:06:01,532 --> 01:06:02,633
ADMINISTRATIVE DATABASE SPANNING

1206
01:06:02,633 --> 01:06:03,634
2012 TO 2019.

1207
01:06:03,634 --> 01:06:10,307
WE FIND PATIENTS COMING FROM 

1208
01:06:10,307 --> 01:06:12,242
DISTRESSED COMMUNITIES HAVE 

1209
01:06:12,242 --> 01:06:13,210
HIGHER COMORBIDITY AND MORE 

1210
01:06:13,210 --> 01:06:15,412
FREQUENT HEART FAILURE AND 

1211
01:06:15,412 --> 01:06:17,915
UNDERWENT REPAIR AT LOWER VOLUME

1212
01:06:17,915 --> 01:06:18,882
CENTERS.

1213
01:06:18,882 --> 01:06:22,386
NOT CARED FOR BY THE SAME LEVEL 

1214
01:06:22,386 --> 01:06:25,956
OF EXPERTISE DR. ADAMS JUST 

1215
01:06:25,956 --> 01:06:26,757
HIGHLIGHTED ELOQUENTLY.

1216
01:06:26,757 --> 01:06:28,192
THE PATIENTS ALSO HAVE TO TRAVEL

1217
01:06:28,192 --> 01:06:29,727
MORE THAN TWICE THE DISTANCE TO 

1218
01:06:29,727 --> 01:06:32,463
RECEIVE THE CARE THEY NEED AND 

1219
01:06:32,463 --> 01:06:34,932
DESPITE THAT EVEN AFTER 

1220
01:06:34,932 --> 01:06:36,166
RECEIVING THERAPY AFTER 

1221
01:06:36,166 --> 01:06:37,301
RECEIVING REPAIR ARE STILL LEFT 

1222
01:06:37,301 --> 01:06:38,769
WITH INCREASED RATES OF 

1223
01:06:38,769 --> 01:06:40,204
MORTALITY AND INCREASED RATES OF

1224
01:06:40,204 --> 01:06:48,612
HEART FAILURE SO BEYOND PRO

1225
01:06:48,612 --> 01:06:49,680
PROVIDING THE MITRAL VALVE 

1226
01:06:49,680 --> 01:06:51,181
REPAIR THERE'S OTHER ELEMENTS 

1227
01:06:51,181 --> 01:06:52,716
THAT LEAD TO ADVERSE CLINICAL 

1228
01:06:52,716 --> 01:07:01,392
OUTCOMES.

1229
01:07:01,392 --> 01:07:07,264
THE KEY TAKEAWAY IS THOSE WITH 

1230
01:07:07,264 --> 01:07:14,405
REPAIR A THIRD WILL TIE AND FIVE

1231
01:07:14,405 --> 01:07:22,980
WILL DEVELOP HEART FAILURE AND 

1232
01:07:22,980 --> 01:07:24,615
THERE'S SIGNIFICANT DISPARITIES 

1233
01:07:24,615 --> 01:07:26,784
IN CARE WITH GENDER CLEARLY 

1234
01:07:26,784 --> 01:07:28,318
IMPACTING THE RATES OF TREATMENT

1235
01:07:28,318 --> 01:07:30,187
WITH WOMEN BEING NEARLY LAX AS 

1236
01:07:30,187 --> 01:07:33,891
LIKELY TO UNDER GO REPAIR AND 

1237
01:07:33,891 --> 01:07:37,361
BEING LESS LIKELY TO RECEIVE A 

1238
01:07:37,361 --> 01:07:38,128
MULTIDISCIPLINARY HEART TEAM 

1239
01:07:38,128 --> 01:07:39,763
EVALUATION AND HAVING LONGER 

1240
01:07:39,763 --> 01:07:41,198
TIME TO TREATMENT AS WELL AS 

1241
01:07:41,198 --> 01:07:42,633
WORSE OUTCOMES AFTER REPAIR WHEN

1242
01:07:42,633 --> 01:07:48,138
IT IS PERFORMED.

1243
01:07:48,138 --> 01:07:58,682
AND ETHNIC OUTCOMES FOR MITRAL 

1244
01:07:59,616 --> 01:07:59,883
REGURGITATION.

1245
01:07:59,883 --> 01:08:03,921
SO THE QUESTION BECOMES IS THERE

1246
01:08:03,921 --> 01:08:06,223
SOMETHING WE CAN TO ALLEVIATE 

1247
01:08:06,223 --> 01:08:07,691
THE CHALLENGES AND MITIGATE THE 

1248
01:08:07,691 --> 01:08:09,493
DISPARITY EXIST IN THE 

1249
01:08:09,493 --> 01:08:12,029
MANAGEMENT OF DMR?

1250
01:08:12,029 --> 01:08:18,268
SO SO I THINK WE HAVE TO 

1251
01:08:18,268 --> 01:08:21,939
CONSIDER THE CONTINUUM OF CARE 

1252
01:08:21,939 --> 01:08:24,775
FOR MITRAL REGURGITATION AND I 

1253
01:08:24,775 --> 01:08:28,512
ARGUE IT'S TRUE FOR ALL FORMS OF

1254
01:08:28,512 --> 01:08:32,716
HEART DISEASE AND SHOWING DATA 

1255
01:08:32,716 --> 01:08:34,284
FROM AORTIC STENOSIS AND 

1256
01:08:34,284 --> 01:08:34,918
INCREASING TREATMENT RATES THERE

1257
01:08:34,918 --> 01:08:38,322
AND THINKING ABOUT THE FACT THAT

1258
01:08:38,322 --> 01:08:42,092
DISEASE AWARENESS AND PATIENT'S 

1259
01:08:42,092 --> 01:08:43,427
BELIEFS IMPACT RATES OF UNDER 

1260
01:08:43,427 --> 01:08:45,062
TREATMENT AND THERE'S CLEARLY 

1261
01:08:45,062 --> 01:08:48,031
CHALLENGES IN DETECTION AND 

1262
01:08:48,031 --> 01:08:52,703
DIAGNOSIS AND RECOGNITION AND 

1263
01:08:52,703 --> 01:08:54,238
INTERPRETATION OF NON-EXPERT 

1264
01:08:54,238 --> 01:08:55,506
SITES SUCH AS THOSE REPRESENTED 

1265
01:08:55,506 --> 01:09:00,911
ON THE CALL AND THE STEPS TAKEN 

1266
01:09:00,911 --> 01:09:04,515
TO REFER AND RECEIVE TREATMENT 

1267
01:09:04,515 --> 01:09:05,916
DEPEND ON PHYSICIAN BELIEF AND 

1268
01:09:05,916 --> 01:09:09,386
BIASES AND BARRIERS AND THE 

1269
01:09:09,386 --> 01:09:14,658
DELIVERY OF HEALTH CARE ACROSS 

1270
01:09:14,658 --> 01:09:15,759
SYMPTOMS AND MANY RECEIVING THE 

1271
01:09:15,759 --> 01:09:17,761
MAJORITY OF THEIR MEDICAL CARE 

1272
01:09:17,761 --> 01:09:20,597
ON THE IN PATIENT SETTING.

1273
01:09:20,597 --> 01:09:21,632
SO WHEN SOMETHING LIKE MITRAL 

1274
01:09:21,632 --> 01:09:22,566
REGURGITATION IS IDENTIFIED 

1275
01:09:22,566 --> 01:09:25,669
WHILE THAT PATIENT IS ADMITTED, 

1276
01:09:25,669 --> 01:09:27,104
THERE IS NOT THE APPROPRIATE 

1277
01:09:27,104 --> 01:09:27,938
TRANSITION TO CARE ONCE THEY ARE

1278
01:09:27,938 --> 01:09:30,307
ARE DISCHARGED.

1279
01:09:30,307 --> 01:09:32,709
THOSE PATIENTS PRIMARY CARE 

1280
01:09:32,709 --> 01:09:34,044
PROVIDERS MAY NOT KNOW WHAT 

1281
01:09:34,044 --> 01:09:35,112
HAPPENED IN THE IN PATIENT 

1282
01:09:35,112 --> 01:09:37,047
SETTING AND MAY NOT HAVE ACCESS 

1283
01:09:37,047 --> 01:09:41,018
TO THE SPECIALTY CARE NEEDED TO 

1284
01:09:41,018 --> 01:09:42,319
FOLLOW-UP AND EXECUTE THE 

1285
01:09:42,319 --> 01:09:42,886
REFERRAL TO THE APPROPRIATE 

1286
01:09:42,886 --> 01:09:53,096
SPECIALTIES.

1287
01:09:55,832 --> 01:09:57,868
THE CONVENED A PANEL RECOGNIZING

1288
01:09:57,868 --> 01:10:02,839
THE FACTS ARE BEING UNDER TREAT 

1289
01:10:02,839 --> 01:10:13,283
ED AND THEY FELT IT WAS 

1290
01:10:13,283 --> 01:10:18,655
ACTIONABLE AND PAID PERFORMANCE 

1291
01:10:18,655 --> 01:10:21,658
PROGRAMS AND MITRAL 

1292
01:10:21,658 --> 01:10:22,993
REGURGITATION MADE UP SOME OF 

1293
01:10:22,993 --> 01:10:26,029
THE MEASURES AND ADULTS FOR 

1294
01:10:26,029 --> 01:10:28,599
CHRONIC OR SEVERE MITRAL 

1295
01:10:28,599 --> 01:10:30,634
REGURGITATION AND LOOK AT AND 

1296
01:10:30,634 --> 01:10:32,236
EVALUATE THE PERCENTAGE OF 

1297
01:10:32,236 --> 01:10:34,471
PATIENTS WITH ECHO WITHIN A 12 

1298
01:10:34,471 --> 01:10:36,473
MONTH PERIOD HIGHLIGHTING THE 

1299
01:10:36,473 --> 01:10:37,874
NEED FOR SURVEILLANCE AND 

1300
01:10:37,874 --> 01:10:38,942
DIAGNOSIS AND SECONDLY A METRIC 

1301
01:10:38,942 --> 01:10:41,311
THAT FOCUSES ON THE PERCENTAGE 

1302
01:10:41,311 --> 01:10:45,282
OF EITHER SYMPTOMATIC PATIENTS 

1303
01:10:45,282 --> 01:10:47,918
OR ASYMPTOMATIC PATIENTS WITH 

1304
01:10:47,918 --> 01:10:51,521
REDUCED INJECTION FRACTION THAT 

1305
01:10:51,521 --> 01:10:52,489
UNDER GO MITRAL REGURGITATION 

1306
01:10:52,489 --> 01:10:53,357
WITHIN THREE MONTHS OF 

1307
01:10:53,357 --> 01:10:53,790
DIAGNOSIS.

1308
01:10:53,790 --> 01:10:56,560
THE RATES OF TREATMENT I SHOWED 

1309
01:10:56,560 --> 01:10:59,830
BEFORE WERE INDICATIVE OF SEVERE

1310
01:10:59,830 --> 01:11:03,634
UNDER TREATMENT OUT TO A YEAR 

1311
01:11:03,634 --> 01:11:04,768
AND LOW RATES OF TREATMENT UP TO

1312
01:11:04,768 --> 01:11:08,071
FIVE YEARS IN SOME STUDIES.

1313
01:11:08,071 --> 01:11:11,208
HERE THE METRICS ARE BEING 

1314
01:11:11,208 --> 01:11:14,344
PROPOSED TO HOLD SITES 

1315
01:11:14,344 --> 01:11:15,445
ACCOUNTABLE TO TREAT PATIENTS 

1316
01:11:15,445 --> 01:11:25,922
WITHIN A THREE-MONTH PERIOD.

1317
01:11:30,661 --> 01:11:31,495
UNFORTUNATELY THE CONCERN FOR 

1318
01:11:31,495 --> 01:11:36,333
UNDER TREATMENT IS NOT SPECIFIC 

1319
01:11:36,333 --> 01:11:38,769
TO MITRAL REGURGITATION AND FOR 

1320
01:11:38,769 --> 01:11:46,410
STENOSIS AND HOPEFULLY WE CAN 

1321
01:11:46,410 --> 01:11:48,145
TAKE TIPS FROM THE INITIATIVE 

1322
01:11:48,145 --> 01:11:49,513
AND PATIENTS WITH A CLASS 1 

1323
01:11:49,513 --> 01:11:50,514
INDICATION ARE SIGNIFICANTLY 

1324
01:11:50,514 --> 01:11:53,650
UNDER TREATED PERHAPS NOT TO THE

1325
01:11:53,650 --> 01:11:54,918
RATE SEEN IN MITRAL VALVE 

1326
01:11:54,918 --> 01:11:56,987
DISEASE BUT OVER ALL ONLY HALF 

1327
01:11:56,987 --> 01:12:03,760
OF PATIENTS WITH AORTIC STENOSIS

1328
01:12:03,760 --> 01:12:06,730
TREATED WITHIN THE FIRST YEAR 

1329
01:12:06,730 --> 01:12:08,165
AND ASSOCIATED WITH 

1330
01:12:08,165 --> 01:12:11,635
SIGNIFICANTLY IMPROVED CLINICAL 

1331
01:12:11,635 --> 01:12:14,671
OUTCOMES WITH 72% LOWER ADJUSTED

1332
01:12:14,671 --> 01:12:16,573
HAZARD FOR MORTALITY IN SOME OF 

1333
01:12:16,573 --> 01:12:19,209
THE HIGH RISK GROUPS SUCH AS 

1334
01:12:19,209 --> 01:12:21,044
THOSE WITH HIGH GRADIENT AND LOW

1335
01:12:21,044 --> 01:12:22,546
EJECTION FRACTION AND DESPITE 

1336
01:12:22,546 --> 01:12:25,048
THE ROBUST IMPACT ON SURVIVAL, 

1337
01:12:25,048 --> 01:12:25,849
ONLY HALF PATIENTS ARE GETTING 

1338
01:12:25,849 --> 01:12:33,857
TREATED.

1339
01:12:33,857 --> 01:12:40,263
THEY LAUNCHED THE TARGET AORTIC 

1340
01:12:40,263 --> 01:12:41,865
STENOSIS INITIATIVE THAT SEEKS 

1341
01:12:41,865 --> 01:12:42,933
TO IDENTIFY MEASURE AND REPORT 

1342
01:12:42,933 --> 01:12:45,268
ON THE PROCESSES THAT OCCUR 

1343
01:12:45,268 --> 01:12:51,475
AFTER THE ECHOCARDIOGRAPHIC 

1344
01:12:51,475 --> 01:12:53,143
DIAGNOSIS AND ATTENTION TO 

1345
01:12:53,143 --> 01:12:54,378
MITIGATING THE ETHNIC AND RACIAL

1346
01:12:54,378 --> 01:12:55,579
DISPARITIES THAT EXIST IN 

1347
01:12:55,579 --> 01:12:56,646
MANAGING THESE PATIENTS.

1348
01:12:56,646 --> 01:13:01,218
THIS PROGRAM SO FAR HAS OVER 40 

1349
01:13:01,218 --> 01:13:04,721
HOSPITALS TAKING PART, OVER 

1350
01:13:04,721 --> 01:13:07,758
6,000 PATIENT RECORDS ENTERED 

1351
01:13:07,758 --> 01:13:11,328
AND 21,000 ENCOUNTERS AND THE 

1352
01:13:11,328 --> 01:13:12,596
GOAL IS FOR DOUBLING THE SITES 

1353
01:13:12,596 --> 01:13:14,765
OF THE COMING YEAR AND YOU SEE 

1354
01:13:14,765 --> 01:13:17,067
THE LIST OF CLINICAL METRICS 

1355
01:13:17,067 --> 01:13:17,601
BEING UTILIZED WITHIN THE 

1356
01:13:17,601 --> 01:13:27,811
INITIATIVE.

1357
01:13:29,946 --> 01:13:32,249
AND THE AMERICAN ASSOCIATION 

1358
01:13:32,249 --> 01:13:35,085
RECEIVED A GRANT AND THERE'S 

1359
01:13:35,085 --> 01:13:37,921
OTHER PARTNERSHIPS WITH 

1360
01:13:37,921 --> 01:13:39,489
PROFESSIONAL SOCIETIES TO 

1361
01:13:39,489 --> 01:13:43,427
COLLABORATE AND DELIVER THE M

1362
01:13:43,427 --> 01:13:48,498
METRICS TO SUPPORT THE 

1363
01:13:48,498 --> 01:13:48,799
INITIATIVE.

1364
01:13:48,799 --> 01:13:52,402
AND WE SEE AND CENTERS ARE BEING

1365
01:13:52,402 --> 01:13:54,104
HEAD ACCOUNTABLE FOR WHAT IS INE

1366
01:13:54,104 --> 01:13:55,405
ECHO REPORT.

1367
01:13:55,405 --> 01:14:00,043
THERE'S THE AIM TO ENSURE 

1368
01:14:00,043 --> 01:14:01,244
PATIENTS WITH AORTIC STENOSIS 

1369
01:14:01,244 --> 01:14:06,316
WHEN THEY HAVE ECHOS THERE'S A 

1370
01:14:06,316 --> 01:14:08,952
GRADIENT REPORTED AND VERY CLEAR

1371
01:14:08,952 --> 01:14:11,488
RECOMMENDATION IN THE ECHO OF 

1372
01:14:11,488 --> 01:14:14,024
THE SEVERITY OF THE AORTIC 

1373
01:14:14,024 --> 01:14:16,760
STENOSIS AND HIGHLIGHTING THE 

1374
01:14:16,760 --> 01:14:20,197
NEED FOR FURTHER REFERRAL AND 

1375
01:14:20,197 --> 01:14:24,201
THE KEY METRIC IS TIMELY 

1376
01:14:24,201 --> 01:14:27,871
TREATMENT OF AORTIC STENOSIS 

1377
01:14:27,871 --> 01:14:31,141
WITHIN 90 DAYS AND TIMELY 

1378
01:14:31,141 --> 01:14:31,408
DIAGNOSIS.

1379
01:14:31,408 --> 01:14:34,144
THIS REQUIRES PATIENT TO SEE 

1380
01:14:34,144 --> 01:14:36,213
PATIENTS WITHIN 30 DAYS A 

1381
01:14:36,213 --> 01:14:37,280
DIAGNOSTIC ECHO AND EVALUATE 

1382
01:14:37,280 --> 01:14:38,181
THEIR SYMPTOM STATUS AND 

1383
01:14:38,181 --> 01:14:48,658
CANDIDACY FOR INTERVENTION.

1384
01:14:48,925 --> 01:14:51,394
THE INAUGURAL AWARDING OF THE 

1385
01:14:51,394 --> 01:14:55,899
HONOR ROLE BASED ON ACHIEVEMENT 

1386
01:14:55,899 --> 01:15:00,270
OF 70% METRIC OF TREATMENT 

1387
01:15:00,270 --> 01:15:02,038
WITHIN 90 DAYS OF PATIENTS WITH 

1388
01:15:02,038 --> 01:15:03,406
A CLASS 1 INDICATION.

1389
01:15:03,406 --> 01:15:08,512
FOR 2025, THEY ARE INCREASING 

1390
01:15:08,512 --> 01:15:13,083
THE THRESHOLD TO ENTER THE HONOR

1391
01:15:13,083 --> 01:15:15,519
ROLE TO 75% OF PATIENTS AND 

1392
01:15:15,519 --> 01:15:22,959
FWRAERT  -- THAN 50% BEING 

1393
01:15:22,959 --> 01:15:24,327
DETERMINED TO MEET CLASS 1 

1394
01:15:24,327 --> 01:15:25,529
GUIDELINE PRESENTATION.

1395
01:15:25,529 --> 01:15:28,565
THE HONOR ROLL WILL BE 

1396
01:15:28,565 --> 01:15:29,533
PUBLICALLY REPORTED.

1397
01:15:29,533 --> 01:15:32,102
THERE ARE BY THE U.S. NEWS AND 

1398
01:15:32,102 --> 01:15:35,005
WORLD REPORT AND I DO ANTICIPATE

1399
01:15:35,005 --> 01:15:35,639
ULTIMATELY WE'LL CONTRIBUTE TO 

1400
01:15:35,639 --> 01:15:45,949
HOSPITAL RANKINGS.

1401
01:15:50,487 --> 01:15:52,722
THERE'S ELECTRONIC HEALTH RECORD

1402
01:15:52,722 --> 01:15:53,690
NUDGES TO FACILITATE TREATMENT 

1403
01:15:53,690 --> 01:15:59,162
AND THIS IS A STUDY WE'RE 

1404
01:15:59,162 --> 01:16:00,564
RUNNING FOR AORTIC STENOSIS IN 

1405
01:16:00,564 --> 01:16:01,431
WHICH THERE ARE ELECTRONIC 

1406
01:16:01,431 --> 01:16:04,467
HEALTH RECORD MEMOS ESSENTIALLY 

1407
01:16:04,467 --> 01:16:06,770
SENT IN IN BASKET TO ENSURE THE 

1408
01:16:06,770 --> 01:16:08,405
PROVIDERS THAT ORDERED THE ECHO 

1409
01:16:08,405 --> 01:16:12,342
UNDERSTAND THE GUIDELINES AND 

1410
01:16:12,342 --> 01:16:13,743
HAVE APPRECIATION OF THE 

1411
01:16:13,743 --> 01:16:15,478
SIGNIFICANT FINDING ON THE 

1412
01:16:15,478 --> 01:16:24,554
ECHOCARDIOGRAM.

1413
01:16:24,554 --> 01:16:26,990
THERE'S REFERRAL PATHWAYS WE'RE 

1414
01:16:26,990 --> 01:16:29,492
WORKING TO BUILD WITHIN EPIC TO 

1415
01:16:29,492 --> 01:16:31,227
ENSURE PATIENTS ARE REFERRED AND

1416
01:16:31,227 --> 01:16:40,971
NOBODY FALLS THROUGH THE CRACKS.

1417
01:16:40,971 --> 01:16:45,375
THIS IS DONE IN A SYSTEMATIC 

1418
01:16:45,375 --> 01:16:46,042
FASHION.

1419
01:16:46,042 --> 01:16:48,712
I'VE LISTED HERE POTENTIAL 

1420
01:16:48,712 --> 01:16:51,047
SOLUTIONS TO THE UNDER TREATMENT

1421
01:16:51,047 --> 01:16:55,418
OF MITRAL REGURGITATION BUT FOR 

1422
01:16:55,418 --> 01:16:56,753
THE SAKE OF TIME I'LL STOP THERE

1423
01:16:56,753 --> 01:16:59,155
AND HAPPY IT TAKE QUESTIONS.

1424
01:16:59,155 --> 01:17:00,190
>> THANK YOU.

1425
01:17:00,190 --> 01:17:04,728
DOES ANYONE HAVE A BRIEF 

1426
01:17:04,728 --> 01:17:07,163
QUESTION OR COMMENT?

1427
01:17:07,163 --> 01:17:08,798
>> BRIEF QUESTION FOR YOU.

1428
01:17:08,798 --> 01:17:12,335
THANKS, I ENJOYED THAT AND 

1429
01:17:12,335 --> 01:17:20,977
LEARNED A LOT.

1430
01:17:20,977 --> 01:17:23,446
THE PAPER YOU SHOWED ABOUT 

1431
01:17:23,446 --> 01:17:26,149
HOLDING SITES ACCOUNTABLE WHAT 

1432
01:17:26,149 --> 01:17:27,250
IS THAT?

1433
01:17:27,250 --> 01:17:28,718
THREE MONTHS FROM DIAGNOSIS TO 

1434
01:17:28,718 --> 01:17:30,220
INTERVENTION WHICH I PERSONALLY 

1435
01:17:30,220 --> 01:17:34,524
THINK IT'S TOO EGRESSION IF YOU 

1436
01:17:34,524 --> 01:17:37,894
TWO UP A SECOND FLIGHT OF STAIRS

1437
01:17:37,894 --> 01:17:39,929
I'M NOT SURE YOU NEED MITRAL 

1438
01:17:39,929 --> 01:17:41,431
SURGERY WITHIN THREE MONTHS.

1439
01:17:41,431 --> 01:17:44,267
YOU GO OFF THE ACTIVE 

1440
01:17:44,267 --> 01:17:46,236
SURVEILLANCE AND TALK ABOUT AN 

1441
01:17:46,236 --> 01:17:47,437
ELECTIVE OPERATION BUT I 

1442
01:17:47,437 --> 01:17:49,406
TYPICALLY FOLLOW THE GUIDELINES 

1443
01:17:49,406 --> 01:17:54,711
AND GIVE PATIENT SIX MONTH 

1444
01:17:54,711 --> 01:17:57,213
WINDOWS BECAUSE MANY THEY FIND 

1445
01:17:57,213 --> 01:17:58,882
OUT IN SEPTEMBER THEY HAVE 

1446
01:17:58,882 --> 01:18:00,784
MITRAL VALVE DISEASE AND THE 

1447
01:18:00,784 --> 01:18:02,485
PATIENT DOES TOO IF HE DOESN'T 

1448
01:18:02,485 --> 01:18:05,789
DROP OUT OF THE COLLEGE PROGRAM 

1449
01:18:05,789 --> 01:18:06,222
FOR THREE MONTHS?

1450
01:18:06,222 --> 01:18:08,525
>> THAT'S A POINT.

1451
01:18:08,525 --> 01:18:14,564
A LOT OF THIS STOTT AND AORTIC 

1452
01:18:14,564 --> 01:18:16,766
STENOSIS HAS GOTTEN MORE 

1453
01:18:16,766 --> 01:18:17,200
ATTENTION.

1454
01:18:17,200 --> 01:18:20,136
>> THERE'S A RISK OF
SUDDEN 

1455
01:18:20,136 --> 01:18:20,336
DEATH.

1456
01:18:20,336 --> 01:18:23,940
>> THE LONGER YOU WAIT THE
MORE 

1457
01:18:23,940 --> 01:18:24,874
PATIENTS CAN DIE.

1458
01:18:24,874 --> 01:18:28,745
THE DATA IS NOT AS ROBUST FOR 

1459
01:18:28,745 --> 01:18:29,713
MITRAL REGURGITATION I'LL ARGUE 

1460
01:18:29,713 --> 01:18:32,949
BUT CLEARLY PATIENTS CAN TEE 

1461
01:18:32,949 --> 01:18:34,984
COMPENSATE AND DEVELOP HEART 

1462
01:18:34,984 --> 01:18:43,493
FAILURE AND ATRIAL 

1463
01:18:43,493 --> 01:18:45,662
DEFIBRILLATION AND THE EXPERT 

1464
01:18:45,662 --> 01:18:47,063
PANEL DID SUGGEST TREATMENT IS 

1465
01:18:47,063 --> 01:18:49,299
NECESSARY WITHIN 30 DAYS.

1466
01:18:49,299 --> 01:18:51,167
WHEN I SAY HOLDING SITES 

1467
01:18:51,167 --> 01:18:52,502
ACCOUNTABLE WHAT IS BEING 

1468
01:18:52,502 --> 01:18:55,872
PROPOSED IS THERE IS PUBLIC 

1469
01:18:55,872 --> 01:18:56,873
REPORTING OF THE METRICS.

1470
01:18:56,873 --> 01:18:58,208
SO A PATIENT WOULD BE ABLE TO 

1471
01:18:58,208 --> 01:19:00,110
LOOK IT UP AND WE'RE NOT THERE 

1472
01:19:00,110 --> 01:19:04,714
YET AND I THINK WE'RE FURTHER 

1473
01:19:04,714 --> 01:19:06,249
ALONG WITH AORTIC STENOSIS.

1474
01:19:06,249 --> 01:19:10,754
I WOULD ARGUE THERE'S A NEED 

1475
01:19:10,754 --> 01:19:19,462
FORMUFOR

1476
01:19:19,462 --> 01:19:27,070
MULTI DISCIPLINARY SITES PUT 

1477
01:19:27,070 --> 01:19:27,737
TOGETHER LITERATURE TO 

1478
01:19:27,737 --> 01:19:29,072
UNDERSTAND HOW QUICKLY WE NEED 

1479
01:19:29,072 --> 01:19:29,739
TO ACT.

1480
01:19:29,739 --> 01:19:32,709
>> I DON'T THINK THERE'S
ANY 

1481
01:19:32,709 --> 01:19:36,713
DOUBT PATIENTS WITH SEVERE 

1482
01:19:36,713 --> 01:19:37,614
MITRAL REGURGITATION SHOULD BE 

1483
01:19:37,614 --> 01:19:40,550
IN THE PROCESS OF IT TREATED BUT

1484
01:19:40,550 --> 01:19:44,087
I HAVE A LOT OF CONCERNS ABOUT 

1485
01:19:44,087 --> 01:19:44,921
TRYING TO COMPARE MITRAL 

1486
01:19:44,921 --> 01:19:45,655
REGURGITATION NOW WITH AORTIC 

1487
01:19:45,655 --> 01:19:49,392
STENOSIS WHEN PATIENTS CALL HERE

1488
01:19:49,392 --> 01:19:52,095
THEY HAVE AORTIC STENOSIS AND 

1489
01:19:52,095 --> 01:19:59,702
THE CARDIOLOGIST RISK AND IF ARE

1490
01:19:59,702 --> 01:20:03,673
WINDED NOW AND YOUR CARDIOLOGIST

1491
01:20:03,673 --> 01:20:05,141
HAS BEEN FOLLOWING YOU AND DID 

1492
01:20:05,141 --> 01:20:09,879
ECHO AND YOU IT'S SEVERE MR AND 

1493
01:20:09,879 --> 01:20:13,683
THREE MONTHS FROM THAT STORY TO 

1494
01:20:13,683 --> 01:20:14,350
SURGERY IS EXTREMELY AGGRESSIVE 

1495
01:20:14,350 --> 01:20:15,685
FOR PATIENTS WHO HAVE TO PLAN 

1496
01:20:15,685 --> 01:20:17,954
THEIR LIFE AND DON'T WANT TO 

1497
01:20:17,954 --> 01:20:18,888
MISS THINGS.

1498
01:20:18,888 --> 01:20:21,324
WE NEED SURGERY AND TALK TO YOUR

1499
01:20:21,324 --> 01:20:22,458
FAMILY, LOOK AT YOUR CALENDAR 

1500
01:20:22,458 --> 01:20:26,596
AND FIGURE OUT THE BEST TIME TO 

1501
01:20:26,596 --> 01:20:28,264
INVEST IN GETTING BETTER AND 

1502
01:20:28,264 --> 01:20:29,299
DON'T MISS THINGS YOU DON'T WANT

1503
01:20:29,299 --> 01:20:32,202
TO MISS AND IF YOU HAVE TO WAIT 

1504
01:20:32,202 --> 01:20:34,037
LONGER THAN SIX MONTHS YOU HAVE 

1505
01:20:34,037 --> 01:20:36,706
TO COME BACK FOR A COMPLETE NEW 

1506
01:20:36,706 --> 01:20:37,373
WORKUP.

1507
01:20:37,373 --> 01:20:42,345
I THINK WE HAVE TO BE CAREFUL 

1508
01:20:42,345 --> 01:20:43,379
ABOUT TRYING TO COMPARE MITRAL 

1509
01:20:43,379 --> 01:20:44,280
REGURGITATION WITH AORTIC 

1510
01:20:44,280 --> 01:20:45,615
STENOSIS IN TERMS OF TIMING AND 

1511
01:20:45,615 --> 01:20:46,683
INTERVENTION FOR PATIENTS THAT 

1512
01:20:46,683 --> 01:20:50,386
MAY -- LIKE I SAID, YOUR 

1513
01:20:50,386 --> 01:20:52,722
REJECTION FRACTION IS AT AND 

1514
01:20:52,722 --> 01:21:03,266
ASSIST -- ASSIST  -- ASYSTOLIC 

1515
01:21:05,034 --> 01:21:06,336
AND THAT'S A LOT OF WOK TO TO 

1516
01:21:06,336 --> 01:21:16,846
FOR SOMETHING I THINK WE'RE  

1517
01:21:24,721 --> 01:21:26,689
LOVING THE WORK AND NEED THE 

1518
01:21:26,689 --> 01:21:27,323
DISCUSSION.

1519
01:21:27,323 --> 01:21:30,326
>> I DON'T DISAGREE IT IS 

1520
01:21:30,326 --> 01:21:30,627
AGGRESSIVE.

1521
01:21:30,627 --> 01:21:33,229
THAT WAS MY INITIAL IMPRESSION 

1522
01:21:33,229 --> 01:21:41,104
AS WELL BUT YOU SEE ROBUST ROW  

1523
01:21:41,104 --> 01:21:41,404
PROGRESSION.

1524
01:21:41,404 --> 01:21:43,339
>> I HOPE YOU USE THE SAME

1525
01:21:43,339 --> 01:21:44,707
OPPORTUNITY TO REINFORCE WE 

1526
01:21:44,707 --> 01:21:48,344
SHOULD FOLLOW THE EVIDENCE AND 

1527
01:21:48,344 --> 01:21:51,714
FOLLOW THE HAACC THREE 

1528
01:21:51,714 --> 01:21:54,017
GUIDELINES IF YOU WANT US TO DO 

1529
01:21:54,017 --> 01:21:54,984
SOMETHING IN THREE MONTHS LET'S 

1530
01:21:54,984 --> 01:21:58,121
MAKE SURE IT'S THE RIGHT THING 

1531
01:21:58,121 --> 01:22:00,323
AND LOW-RISK TEER IN TRIALS NOT 

1532
01:22:00,323 --> 01:22:01,524
BECAUSE THE PATIENT DOESN'T WANT

1533
01:22:01,524 --> 01:22:11,768
TO HAVE THEIR CHEST CRACKED.

1534
01:22:11,768 --> 01:22:16,706
>> THANK YOU FOR THE TALK.

1535
01:22:16,706 --> 01:22:19,042
THE ISSUE IS WHEN WE LOOKED AT 

1536
01:22:19,042 --> 01:22:24,047
UNDER TREATMENT WE DON'T 

1537
01:22:24,047 --> 01:22:26,883
UNDERSTAND THE REASON FOR WHY IT

1538
01:22:26,883 --> 01:22:27,850
IS NOT DONE.

1539
01:22:27,850 --> 01:22:30,019
PEOPLE WHO WILL DO SOMETHING 

1540
01:22:30,019 --> 01:22:35,758
GIVE A REASON AND THE PATIENT IS

1541
01:22:35,758 --> 01:22:37,226
SYMPTOMATIC BUT WHEN YOU HAVE 

1542
01:22:37,226 --> 01:22:38,428
SOMETHING NOT DONE YOU FIND NO 

1543
01:22:38,428 --> 01:22:38,795
REASON.

1544
01:22:38,795 --> 01:22:42,065
WE'LL SEE THE PATIENT IN THREE 

1545
01:22:42,065 --> 01:22:45,468
MONTHS OR SIX MONTHS BUT THE 

1546
01:22:45,468 --> 01:22:47,036
NOTE OF THE PHYSICIAN DOESN'T 

1547
01:22:47,036 --> 01:22:48,137
SAY WHY THEY DIDN'T DO 

1548
01:22:48,137 --> 01:22:48,838
SOMETHING.

1549
01:22:48,838 --> 01:22:51,841
I WOULD SAY RATHER THAN PUTTING 

1550
01:22:51,841 --> 01:22:53,876
THE MANDATE IN PEOPLE, IF WE 

1551
01:22:53,876 --> 01:22:57,880
COULD UNDERSTAND THE REASON FOR 

1552
01:22:57,880 --> 01:23:02,218
DOING AND NOT DOING WOULD BE 

1553
01:23:02,218 --> 01:23:04,320
PRELIMINARY TO ACTION BECAUSE IF

1554
01:23:04,320 --> 01:23:05,888
WE PUT A MANDATE, OH, YOU HAVE 

1555
01:23:05,888 --> 01:23:08,191
TO DO SOMETHING IN THREE MONTHS 

1556
01:23:08,191 --> 01:23:10,760
BUT THE PHYSICIANS ARE NOT 

1557
01:23:10,760 --> 01:23:10,994
STUPID.

1558
01:23:10,994 --> 01:23:15,465
IS IT BECAUSE THEY IGNORE THE 

1559
01:23:15,465 --> 01:23:15,765
ECHO?

1560
01:23:15,765 --> 01:23:17,467
WHAT IS HAPPENING IN HOLDER 

1561
01:23:17,467 --> 01:23:18,968
SUBJECTS THEY DON'T WANT TO DO 

1562
01:23:18,968 --> 01:23:23,506
SOMETHING AND HOW CAN WE 

1563
01:23:23,506 --> 01:23:27,377
PALLIATE THAT BY HAVING A VALVE 

1564
01:23:27,377 --> 01:23:29,879
CLINIC REVIEW OF THE PATIENT AND

1565
01:23:29,879 --> 01:23:31,914
WHEN WE LOOKED AT IT THE 

1566
01:23:31,914 --> 01:23:34,717
PATIENTS ARE VERY CLOSE.

1567
01:23:34,717 --> 01:23:36,753
THEY COULD COME BUT NOT REFERRED

1568
01:23:36,753 --> 01:23:38,021
AND WHY.

1569
01:23:38,021 --> 01:23:40,390
IS IT BECAUSE THE WORD MODERATE 

1570
01:23:40,390 --> 01:23:42,492
IS MENTIONED IN THE REPORT OF 

1571
01:23:42,492 --> 01:23:42,792
ECHO?

1572
01:23:42,792 --> 01:23:46,829
IS IT -- WHAT IS THE REASON OF 

1573
01:23:46,829 --> 01:23:49,599
THE -- AND IT'S NOT EXPRESSED 

1574
01:23:49,599 --> 01:23:51,000
DIRECTLY.

1575
01:23:51,000 --> 01:23:52,435
SO IF WE COULD UNDERSTAND WHY 

1576
01:23:52,435 --> 01:23:57,573
IT'S NOT DONE WE COULD PUT THE 

1577
01:23:57,573 --> 01:23:58,808
APPROPRIATE MANDATE TO THE 

1578
01:23:58,808 --> 01:24:00,343
HEALTH SYSTEM TO SAY OKAY, DO 

1579
01:24:00,343 --> 01:24:04,981
THE RIGHT THING.

1580
01:24:04,981 --> 01:24:07,817
BUT NOW WE'RE IN THE DARK AND 

1581
01:24:07,817 --> 01:24:09,419
THROWING MANDATES RIGHT AND LEFT

1582
01:24:09,419 --> 01:24:11,888
WITHOUT UNDERSTANDING WHAT IS --

1583
01:24:11,888 --> 01:24:15,024
WHERE SHOULD THE MANDATE BE 

1584
01:24:15,024 --> 01:24:17,427
GIVEN, HOW SHOULD IT BE DONE TO 

1585
01:24:17,427 --> 01:24:19,062
ADDRESS AN ELDERLY POPULATION 

1586
01:24:19,062 --> 01:24:21,831
THAT IS AT RISK AND PHYSICIANS 

1587
01:24:21,831 --> 01:24:22,732
ARE RISK AVERSE.

1588
01:24:22,732 --> 01:24:25,768
HOW DO WE DO THAT?

1589
01:24:25,768 --> 01:24:28,204
>> THERE IS SOME OF THAT
AND 

1590
01:24:28,204 --> 01:24:29,505
I'LL TRY TO BE BRIEF BUT THERE 

1591
01:24:29,505 --> 01:24:31,407
IS SOME OF THE DATA ON THE 

1592
01:24:31,407 --> 01:24:32,675
AORTIC STENOSIS SIDE WHERE WHEN 

1593
01:24:32,675 --> 01:24:36,345
WE LOOK AT WHY PATIENTS AREN'T 

1594
01:24:36,345 --> 01:24:38,581
TREATED, THERE ARE A MYRIAD OF 

1595
01:24:38,581 --> 01:24:40,183
REASONS FOR EXAMPLE PHYSICIANS 

1596
01:24:40,183 --> 01:24:43,886
IN A LARGE PROPORTION FELT IT'S 

1597
01:24:43,886 --> 01:24:45,555
RELATED TO SOMETHING ELSE.

1598
01:24:45,555 --> 01:24:47,156
SOME DESPITE THE FACT FOR 

1599
01:24:47,156 --> 01:24:49,859
EXAMPLE THERE WERE LOW GRADIENT 

1600
01:24:49,859 --> 01:24:50,960
AORTIC STENOSIS THERE WAS 

1601
01:24:50,960 --> 01:24:54,330
TENDENCY TO ASSUME A LOW 

1602
01:24:54,330 --> 01:24:55,898
GRADIENT CORRESPOND WITH 

1603
01:24:55,898 --> 01:24:56,599
MODERATE DISEASE AND THEREFORE 

1604
01:24:56,599 --> 01:24:58,134
THEY CAN WAIT.

1605
01:24:58,134 --> 01:25:00,103
THERE WERE INSTANCES WHERE 

1606
01:25:00,103 --> 01:25:02,872
SYMPTOMS WERE NOT FELT TO BE BAD

1607
01:25:02,872 --> 01:25:05,074
ENOUGH TO WARRANT CLINICAL 

1608
01:25:05,074 --> 01:25:06,342
INTERVENTION THOUGH THERE'S NO 

1609
01:25:06,342 --> 01:25:07,543
CLEAR THRESHOLD THAT SHOULD 

1610
01:25:07,543 --> 01:25:10,480
GUIDE THAT DECISION MAKING.

1611
01:25:10,480 --> 01:25:12,748
SO SOME OF THE REASONS AT LAND 

1612
01:25:12,748 --> 01:25:14,917
DID NOT SEEM TO MAKE INTUITIVE 

1613
01:25:14,917 --> 01:25:15,118
SENSE.

1614
01:25:15,118 --> 01:25:19,722
THE LARGE MAJORITY OF THE 

1615
01:25:19,722 --> 01:25:22,058
DECISIONS HOWEVER, WERE MADE 

1616
01:25:22,058 --> 01:25:23,960
BEFORE THE PATIENT GOT TO 

1617
01:25:23,960 --> 01:25:25,528
MULTI-DISCIPLINARY HEART VALVE 

1618
01:25:25,528 --> 01:25:27,130
TEAM AND NOT EVALUATED AND 

1619
01:25:27,130 --> 01:25:29,098
CONSIDERED BY THE EXPERTS IN 

1620
01:25:29,098 --> 01:25:30,399
TREATING THE VALVE LESION AND 

1621
01:25:30,399 --> 01:25:32,702
INSTEAD THE DECISION WAS MADE BY

1622
01:25:32,702 --> 01:25:34,804
THE PRIMARY CARE PROVIDER OR 

1623
01:25:34,804 --> 01:25:36,472
SOMEBODY ELSE SOMETIMES THINKING

1624
01:25:36,472 --> 01:25:38,207
THEY WERE TOO SICK NOT 

1625
01:25:38,207 --> 01:25:40,343
RECOGNIZING THEY EASILY COULD BE

1626
01:25:40,343 --> 01:25:42,345
TREATED FOR PERHAPS TRANS 

1627
01:25:42,345 --> 01:25:48,317
CATHETER THERAPIES BECAUSE THEY 

1628
01:25:48,317 --> 01:25:50,486
WERE ELDERLY AND I'LL SAY 

1629
01:25:50,486 --> 01:25:53,089
THERE'S CLEAR IMPACTS FROM 

1630
01:25:53,089 --> 01:25:53,623
SOCIAL DETERMINATES AND 

1631
01:25:53,623 --> 01:25:54,323
FINANCIAL WELL BEING.

1632
01:25:54,323 --> 01:25:58,427
AS YOU MENTIONED EVEN IN CLOSE 

1633
01:25:58,427 --> 01:26:00,096
PROXIMITY TO HIGHLY QUALIFIED 

1634
01:26:00,096 --> 01:26:02,498
CENTERS AND SOME DATA FROM PENN 

1635
01:26:02,498 --> 01:26:03,733
WHERE WEST PHILADELPHIA WHERE 

1636
01:26:03,733 --> 01:26:05,434
PENN IS VERY ACCOMPLISHED 

1637
01:26:05,434 --> 01:26:08,037
SURGICAL CENTER, VERY 

1638
01:26:08,037 --> 01:26:08,638
ACCOMPLISHED INTERVENTIONAL 

1639
01:26:08,638 --> 01:26:12,708
CENTER AND PEOPLE IN DIRECT 

1640
01:26:12,708 --> 01:26:13,609
PROXIMITY TO THE HOSPITAL WERE 

1641
01:26:13,609 --> 01:26:17,380
MOST LIKELY TO BE UNDER TREATED.

1642
01:26:17,380 --> 01:26:18,781
THOSE ARE PATIENTS WHO PERHAPS 

1643
01:26:18,781 --> 01:26:20,516
DON'T HAVE THE ABILITY TO TAKE A

1644
01:26:20,516 --> 01:26:21,250
DAY OFF WORK.

1645
01:26:21,250 --> 01:26:22,518
THERE'S THINGS THAT CONTRIBUTE.

1646
01:26:22,518 --> 01:26:24,720
THE ATTEMPT AT PRESENTING THIS 

1647
01:26:24,720 --> 01:26:26,923
IS A CALL TO ACTION TO PERFORM 

1648
01:26:26,923 --> 01:26:28,724
THE TYPE OF ADVOCATING YOU'RE 

1649
01:26:28,724 --> 01:26:30,626
HIGHLIGHTING AND ALLUDING TO.

1650
01:26:30,626 --> 01:26:31,661
>> OKAY.

1651
01:26:31,661 --> 01:26:33,062
THANK YOU VERY MUCH FOR THAT 

1652
01:26:33,062 --> 01:26:33,362
DISCUSSION.

1653
01:26:33,362 --> 01:26:36,432
WE'RE GOING TO MOVE NOW TO THE 

1654
01:26:36,432 --> 01:26:36,999
FINAL PRESENTATION FOR THIS 

1655
01:26:36,999 --> 01:26:45,908
SESSION.

1656
01:26:45,908 --> 01:26:46,442
>> THANK YOU.

1657
01:26:46,442 --> 01:26:50,780
AS WE PULL THE SLIDES UP I'D 

1658
01:26:50,780 --> 01:26:51,847
LIKE TO COMMENT ON THE 

1659
01:26:51,847 --> 01:26:53,115
PERFORMANCE WILL MEASURES OF THE

1660
01:26:53,115 --> 01:26:54,116
DOCUMENT AND CLEARLY DESIGN TO 

1661
01:26:54,116 --> 01:26:56,752
ADDRESS THE UNDER TREATMENT OF 

1662
01:26:56,752 --> 01:26:58,888
THIS IMPORTANT PATIENT 

1663
01:26:58,888 --> 01:27:00,723
POPULATION AND CLEARLY WE 

1664
01:27:00,723 --> 01:27:03,826
INCLUDED RELEVANT EXCEPTIONS.

1665
01:27:03,826 --> 01:27:05,394
IT'S PERFECTLY POSSIBLE FOR 

1666
01:27:05,394 --> 01:27:06,862
PHYSICIANS TO DOCUMENT THE 

1667
01:27:06,862 --> 01:27:08,364
REASON FOR DELAYING TREATMENT 

1668
01:27:08,364 --> 01:27:09,131
APPROPRIATELY BEYOND THREE 

1669
01:27:09,131 --> 01:27:10,600
MONTHS AND THE LIST OF 

1670
01:27:10,600 --> 01:27:13,769
EXCEPTIONS IS NUMEROUS AND CAN 

1671
01:27:13,769 --> 01:27:15,905
INCLUDE PATIENT PREFERENCE OR 

1672
01:27:15,905 --> 01:27:18,341
OTHER REASONS FOR NOT UNDERGOING

1673
01:27:18,341 --> 01:27:19,475
AN INTERVENTION.

1674
01:27:19,475 --> 01:27:22,011
SO IT'S I THINK AN IMPORTANT 

1675
01:27:22,011 --> 01:27:23,779
STEP HOPEFULLY IN THE RIGHT 

1676
01:27:23,779 --> 01:27:26,682
DIRECTION AND WILL BE UTILIZED 

1677
01:27:26,682 --> 01:27:28,951
TO ADDRESS THE UNDER TREATMENT 

1678
01:27:28,951 --> 01:27:31,754
OF DEGENERATIVE MITRAL VALVE 

1679
01:27:31,754 --> 01:27:32,488
DISEASE.

1680
01:27:32,488 --> 01:27:35,658
I HAVE A LOT OF ANIMATION SO 

1681
01:27:35,658 --> 01:27:38,194
I'LL JUST SAY NEXT FOR THE NEXT 

1682
01:27:38,194 --> 01:27:47,036
SLIDE TO SAVE TIME SO, NEXT.

1683
01:27:47,036 --> 01:27:49,005
NO FINANCIAL DISCLOSURES.

1684
01:27:49,005 --> 01:27:51,707
I'LL TALK ABOUT GUIDELINES 

1685
01:27:51,707 --> 01:27:54,377
VERSUS PRACTICE IN THE PRIMARY 

1686
01:27:54,377 --> 01:27:54,810
TRIAL.

1687
01:27:54,810 --> 01:27:55,111
NEXT.

1688
01:27:55,111 --> 01:27:58,648
FIRST OF ALL WHEN TO REPAIR.

1689
01:27:58,648 --> 01:27:58,914
NEXT.

1690
01:27:58,914 --> 01:28:01,751
YOU HAVE A LADY IN THE OFFICE 

1691
01:28:01,751 --> 01:28:04,153
WHO FEELS FINE AND PLAYS PICKLE 

1692
01:28:04,153 --> 01:28:05,588
BALL EVERY DAY AND A LITTLE BIT 

1693
01:28:05,588 --> 01:28:08,491
FATIGUED AND NO HISTORY OR RISK 

1694
01:28:08,491 --> 01:28:08,724
FACTORS.

1695
01:28:08,724 --> 01:28:13,396
THIS IS HER ECHO.

1696
01:28:13,396 --> 01:28:17,333
SEE THE PT PROLAPSE AND 

1697
01:28:17,333 --> 01:28:17,900
RELATIVELY STRAIGHTFORWARD 

1698
01:28:17,900 --> 01:28:26,008
REPAIR.

1699
01:28:26,008 --> 01:28:28,744
YOU HAVE OPTIONS AND ONE IS TO 

1700
01:28:28,744 --> 01:28:39,221
REPEAT ECHO IN THREE MONTHS.

1701
01:28:43,959 --> 01:28:46,796
AND MAY WANT TO REQUEST STREK 

1702
01:28:46,796 --> 01:28:48,798
ECHO OR LOOKING FOR 

1703
01:28:48,798 --> 01:28:49,799
RECOMMENDATIONS OR WHETHER TEER 

1704
01:28:49,799 --> 01:28:50,800
IS APPROPRIATE.

1705
01:28:50,800 --> 01:28:53,002
AND I THINK YOUR APPETITE FOR 

1706
01:28:53,002 --> 01:28:54,203
INTERVENING ON THESE PATIENTS 

1707
01:28:54,203 --> 01:28:55,771
DEPENDS ON WHAT YOU THINK THE 

1708
01:28:55,771 --> 01:28:58,441
RISK OF MORTALITY, SUDDEN DEATH,

1709
01:28:58,441 --> 01:29:01,077
HEART FAILURE AND STROKE IS IN 

1710
01:29:01,077 --> 01:29:03,379
THE POPULATION OF ASYMPTOMATIC 

1711
01:29:03,379 --> 01:29:03,646
PATIENTS.

1712
01:29:03,646 --> 01:29:04,880
WE'VE SEEN THE SLIDE A COUPLE 

1713
01:29:04,880 --> 01:29:12,021
TIMES NOW.

1714
01:29:12,021 --> 01:29:15,057
THIS IS SURVIVAL FROM SEVERE 

1715
01:29:15,057 --> 01:29:15,624
MITRAL REGURGITATION.

1716
01:29:15,624 --> 01:29:16,158
IT'S NOT GREAT.

1717
01:29:16,158 --> 01:29:20,730
THE PATIENTS ARE AT RISK OF 

1718
01:29:20,730 --> 01:29:30,973
SUDDEN DEATH.

1719
01:29:32,575 --> 01:29:36,045
WE'VE SEEN THE SYMPTOMS AT THE 

1720
01:29:36,045 --> 01:29:43,686
TIME OF MITRAL SURGERY AND THE 

1721
01:29:43,686 --> 01:29:44,854
SURVIVAL OUTCOME.

1722
01:29:44,854 --> 01:29:51,160
THIS IS A STUDY OF MULTIPLE 

1723
01:29:51,160 --> 01:29:51,527
CENTERS.

1724
01:29:51,527 --> 01:29:53,596
STRATIFIED BY WHERE PATIENTS 

1725
01:29:53,596 --> 01:29:56,098
UNDER WENT SURGERY AT THE TIME 

1726
01:29:56,098 --> 01:29:57,500
THEY ARE WENT CLASS 1 

1727
01:29:57,500 --> 01:29:58,701
INDICATIONS OR WHETHER IT WAS 

1728
01:29:58,701 --> 01:30:00,202
DELAYED THREE MONTHS AND THE 

1729
01:30:00,202 --> 01:30:03,305
LOWEST SURVIVAL CURVE IS THE 

1730
01:30:03,305 --> 01:30:11,313
THREE-MONTH DELAY.

1731
01:30:11,313 --> 01:30:12,515
THIS IS THE RATIONALE FOR 

1732
01:30:12,515 --> 01:30:20,723
PATIENTS.

1733
01:30:20,723 --> 01:30:24,260
I'M GOING TO ASK YOU TO CLICK 

1734
01:30:24,260 --> 01:30:25,895
THROUGH THE SLIDES ABOUT ONE 

1735
01:30:25,895 --> 01:30:26,729
EVERY 10 SECONDS.

1736
01:30:26,729 --> 01:30:31,033
THE STRATIFICATION BY SURVIVAL 

1737
01:30:31,033 --> 01:30:36,772
EF AND SURGERY SURVIVAL.

1738
01:30:36,772 --> 01:30:39,341
IN PATIENTS WITHOUT SYMPTOMS DO 

1739
01:30:39,341 --> 01:30:40,776
WE WAIT FOR EJECTION FRACTION TO

1740
01:30:40,776 --> 01:30:42,011
TROP.

1741
01:30:42,011 --> 01:30:44,313
DEPENDS ON WHETHER YOU THINK 

1742
01:30:44,313 --> 01:30:45,881
EJECTION FRACTION IS EFFECTIVE 

1743
01:30:45,881 --> 01:30:50,553
IN MITRAL REGURGITATION AND THIS

1744
01:30:50,553 --> 01:30:58,761
IS A EXPERIMENT HERE YOU CAN 

1745
01:30:58,761 --> 01:30:59,728
CALCULATE EJECTION FRACTION AND 

1746
01:30:59,728 --> 01:31:10,272
THE STROKE VALUM DIVIDED BY 150.

1747
01:31:12,775 --> 01:31:14,944
THIS IS 67%.

1748
01:31:14,944 --> 01:31:18,414
JUST KEEP CLICKING.

1749
01:31:18,414 --> 01:31:19,582
AND THE ACUTE MITRAL 

1750
01:31:19,582 --> 01:31:21,851
REGURGITATION AND EJECTION 

1751
01:31:21,851 --> 01:31:29,024
FRACTION IS 140 DIVIDED BY 170.

1752
01:31:29,024 --> 01:31:32,161
THIS WOULD BE 82%.

1753
01:31:32,161 --> 01:31:34,630
AND THE PATIENT WITH CHRONIC MSH

1754
01:31:34,630 --> 01:31:40,002
AND ASYMPTOMATIC PATIENTS AND 

1755
01:31:40,002 --> 01:31:42,338
EJECTION FRACTION CONTRACTION IS

1756
01:31:42,338 --> 01:31:45,140
79% SO HYPERNORMAL AS WE OFTEN 

1757
01:31:45,140 --> 01:31:46,842
SEE PATIENTS WITH EXCELLENT 

1758
01:31:46,842 --> 01:31:50,145
EJECTION FRACTION AND THE 

1759
01:31:50,145 --> 01:31:52,147
PATIENT WITH MITRAL 

1760
01:31:52,147 --> 01:31:54,283
REGURGITATION EJECTION FRACTION 

1761
01:31:54,283 --> 01:32:00,723
85 TO 65 AND DILATED TO THE 

1762
01:32:00,723 --> 01:32:02,558
VENTRICLE 60% AND WHY WE DON'T 

1763
01:32:02,558 --> 01:32:05,794
WAIT FOR IT TO DROP BELOW 60% 

1764
01:32:05,794 --> 01:32:06,395
AND IN CHRONIC MITRAL 

1765
01:32:06,395 --> 01:32:08,998
REGURGITATION YOU'RE MISSING THE

1766
01:32:08,998 --> 01:32:09,532
BOAT.

1767
01:32:09,532 --> 01:32:20,009
AND IT'S MANAGED BY THE MR.

1768
01:32:20,776 --> 01:32:24,413
WE'RE LOOKING AT THE STRATIFIED 

1769
01:32:24,413 --> 01:32:30,352
40 MILLIMETERS OVER SURGERY AND 

1770
01:32:30,352 --> 01:32:32,054
CLASS I INCLUDES SYSTOLIC 

1771
01:32:32,054 --> 01:32:35,324
GREATER THAN 40 MILLIMETERS AND 

1772
01:32:35,324 --> 01:32:38,193
INCLUDES PROGRESS INCREASE IN 

1773
01:32:38,193 --> 01:32:40,729
SIZE OF THE VENTRICLE FOR THE 

1774
01:32:40,729 --> 01:32:44,967
PARAMETERS FROM THE HYPERTENSION

1775
01:32:44,967 --> 01:32:47,670
AND CLEARLY IDENTIFIES THE 

1776
01:32:47,670 --> 01:32:48,237
REPLACEMENT FOR PROLAPSE IS 

1777
01:32:48,237 --> 01:32:57,079
HARM.

1778
01:32:57,079 --> 01:32:59,281
AND THE AGE MATCH POPULATION 

1779
01:32:59,281 --> 01:33:05,554
THAT DOESN'T RESTORE NORMAL LIFE

1780
01:33:05,554 --> 01:33:16,098
EXPECTANCY AND THE ORDINANCE OF 

1781
01:33:26,342 --> 01:33:33,515
LOW RISK REPAIRS.

1782
01:33:33,515 --> 01:33:37,786
THAT'S WHAT IS BEING ACHIEVED 

1783
01:33:37,786 --> 01:33:37,987
TODAY.

1784
01:33:37,987 --> 01:33:42,591
THIS IS STS DATA OUTCOMES 

1785
01:33:42,591 --> 01:33:43,692
UNSELECTED ALL MITRAL VALVE 

1786
01:33:43,692 --> 01:33:45,194
REPAIRS AT 4% MORTALITY.

1787
01:33:45,194 --> 01:33:47,896
THAT'S INCREDIBLE.

1788
01:33:47,896 --> 01:33:52,234
AND IN MOST OF THE SURGEONS AND 

1789
01:33:52,234 --> 01:33:53,202
CENTERS WITH THE EIGHT YEAR TIME

1790
01:33:53,202 --> 01:33:54,837
FRAME THERE WAS NO MORTALITY.

1791
01:33:54,837 --> 01:33:56,772
THE VAST MAJORITY OF PATIENTS IN

1792
01:33:56,772 --> 01:34:04,780
THE U.S. ARE LOW RISK PATIENTS.

1793
01:34:04,780 --> 01:34:07,516
HOW TO REPAIR THE VALVE?

1794
01:34:07,516 --> 01:34:09,284
AGAIN IF YOU CLICK THROUGH THIS 

1795
01:34:09,284 --> 01:34:12,354
ONE, THIS IS GIVING YOU A SENSE 

1796
01:34:12,354 --> 01:34:15,924
OF THE SPECTRUM OF MITRAL VALVE 

1797
01:34:15,924 --> 01:34:16,225
DISEASE.

1798
01:34:16,225 --> 01:34:17,993
THIS IS A PROLAPSE.

1799
01:34:17,993 --> 01:34:24,933
YOU SEE THE LEAFLETS ARE 

1800
01:34:24,933 --> 01:34:30,372
EXTREMELY FLIMSY IT GIVES YOU A 

1801
01:34:30,372 --> 01:34:33,909
SENSE THAT YOU'VE GOT 

1802
01:34:33,909 --> 01:34:37,413
ESSENTIALLY A PROLAPSE AND THAT 

1803
01:34:37,413 --> 01:34:38,447
IS VERY DIFFERENT.

1804
01:34:38,447 --> 01:34:39,882
WHAT YOU SEE HERE ON THE 

1805
01:34:39,882 --> 01:34:42,351
FOLLOWING WHICH IS THE VIDEO WE 

1806
01:34:42,351 --> 01:34:46,588
STARTED WITH.

1807
01:34:46,588 --> 01:34:48,691
AGAIN THE PROLAPSE AND LOOK AT 

1808
01:34:48,691 --> 01:34:50,859
THE QUALITY OF THE LEAFLETS IN 

1809
01:34:50,859 --> 01:34:51,827
THIS SURGICAL VIDEO.

1810
01:34:51,827 --> 01:34:54,763
YOU GET A SENSE THIS IS A 

1811
01:34:54,763 --> 01:34:55,664
COMPLETELY DIFFERENT LOOKING 

1812
01:34:55,664 --> 01:35:01,637
MORPHOLOGY OF THE VALVE.

1813
01:35:01,637 --> 01:35:02,204
IT'S PERFECTLY POSSIBLE TO 

1814
01:35:02,204 --> 01:35:07,476
REPAIR THESE.

1815
01:35:07,476 --> 01:35:10,713
IT WOULD HAVE GIVEN YOU THE 

1816
01:35:10,713 --> 01:35:18,387
RELIEF IS THINGEN -- THICKENED 

1817
01:35:18,387 --> 01:35:28,931
AND CALCIFIED AND AND THIS IS A 

1818
01:35:45,247 --> 01:35:47,149
VIDEO OF A LEAFLET REPAIR AND 

1819
01:35:47,149 --> 01:35:51,153
GIVES A SENSE WHEN YOU SEE THE 

1820
01:35:51,153 --> 01:35:53,889
VIDEOS TEER IS VERY GOOD AT 

1821
01:35:53,889 --> 01:35:56,725
APPROXIMATING LEAFLETS BUT CAN'T

1822
01:35:56,725 --> 01:35:58,227
DEAL WITH THE PROLAPSE AND 

1823
01:35:58,227 --> 01:36:04,032
SURGICAL REPAIR IT'S POSSIBLE TO

1824
01:36:04,032 --> 01:36:14,243
EFFECT THAT.

1825
01:36:16,178 --> 01:36:18,380
WE TALKED ABOUT RECOMMENDING 

1826
01:36:18,380 --> 01:36:18,614
TEER.

1827
01:36:18,614 --> 01:36:19,948
WE DIDN'T TALK ABOUT EXAMINING 

1828
01:36:19,948 --> 01:36:21,750
THE PATIENT AND FINDINGS LIKE 

1829
01:36:21,750 --> 01:36:24,119
THIS HELP YOU UNDERSTAND THERE'S

1830
01:36:24,119 --> 01:36:25,320
A SPECTRUM OF FRAILTY AND 

1831
01:36:25,320 --> 01:36:35,798
ABILITY TO TOLERATE SURGERY.

1832
01:36:48,110 --> 01:36:53,315
AND YOU CAN SEE THIS SCANS PAST 

1833
01:36:53,315 --> 01:36:57,486
THE ANNULUS AN IF THEY WERE 

1834
01:36:57,486 --> 01:37:01,156
ASYMPTOMATIC YOU'D GO DOWN THE 

1835
01:37:01,156 --> 01:37:01,623
SURGICAL ROUTE EARLY.

1836
01:37:01,623 --> 01:37:07,663
IT SPEAKS TO THE POINT ABOUT 

1837
01:37:07,663 --> 01:37:08,864
PERFORMANCE MEASURES.

1838
01:37:08,864 --> 01:37:17,472
NOT ALL PATIENTS WOULD GO TO THE

1839
01:37:17,472 --> 01:37:19,808
BASKET OF PROHIBITIVE RISK AND 

1840
01:37:19,808 --> 01:37:24,880
HEART FAILURE AND IT'S CURRENTLY

1841
01:37:24,880 --> 01:37:31,153
THE CRITERIA FOR TEER AND 

1842
01:37:31,153 --> 01:37:34,456
RANDOMIZED TRIAL OF 466 PATIENTS

1843
01:37:34,456 --> 01:37:40,729
AND FUNCTIONAL MR AND TEER AND 

1844
01:37:40,729 --> 01:37:51,573
PROCEED KATE--PREDICATED ON SUR 

1845
01:37:52,774 --> 01:38:03,252
AND MANY CLAIM IT'S FUNCTIONAL 

1846
01:38:04,786 --> 01:38:07,856
AND DEGENERATIVE.

1847
01:38:07,856 --> 01:38:10,959
A QUARTER ARE LOW RISK OF 

1848
01:38:10,959 --> 01:38:21,370
MORTALITY LESS THAN 2.5.

1849
01:38:29,511 --> 01:38:33,782
AND SOME HAVE MITRAL 

1850
01:38:33,782 --> 01:38:39,154
REGURGITATION AND STENOSIS AND 

1851
01:38:39,154 --> 01:38:42,057
EVEN MODERATE AORTIC STENOSIS OR

1852
01:38:42,057 --> 01:38:45,827
MITRAL REGURGITATION HAD WORSE 

1853
01:38:45,827 --> 01:38:48,931
OUTCOMES IN ONE YEAR AND 

1854
01:38:48,931 --> 01:38:49,798
MORTALITY IN ONE YEAR.

1855
01:38:49,798 --> 01:38:52,834
THE ABILITY TO RESTORE NORMAL 

1856
01:38:52,834 --> 01:38:58,674
ANATOMY AND HUMAN DYNAMICS 

1857
01:38:58,674 --> 01:39:00,976
SAFELY IS CRITICAL IN THE 

1858
01:39:00,976 --> 01:39:01,310
PATIENTS.

1859
01:39:01,310 --> 01:39:05,080
WE LEARN FROM SURGICAL SERIES 

1860
01:39:05,080 --> 01:39:06,415
HERE ARE FOUR WITH LONG-TERM 

1861
01:39:06,415 --> 01:39:08,650
OUTCOMES AFTER SURGICAL REPAIR 

1862
01:39:08,650 --> 01:39:12,254
AND THE FREEDOM FROM MR IS GOOD 

1863
01:39:12,254 --> 01:39:15,390
GREATER THAN 95% EIGHT TO 10 

1864
01:39:15,390 --> 01:39:18,961
YEARS WITH THE EXCEPTION OF ONE 

1865
01:39:18,961 --> 01:39:19,828
SURGICAL EXPERIENCE BY THE GROUP

1866
01:39:19,828 --> 01:39:22,497
AND THAT'S THIS ONE AND THE 

1867
01:39:22,497 --> 01:39:25,400
DIFFERENCE IN THIS WAS EDGE TO 

1868
01:39:25,400 --> 01:39:28,704
EDGE REPAIR FORMED IN 

1869
01:39:28,704 --> 01:39:30,672
DEGENERATIVE PATIENTS AND THAT 

1870
01:39:30,672 --> 01:39:32,507
HAS OBVIOUS IMPLICATIONS FOR 

1871
01:39:32,507 --> 01:39:41,583
EDGE TO EDGE REPAIR.

1872
01:39:41,583 --> 01:39:44,753
THIS IS ONE OF THE REASONS TIER 

1873
01:39:44,753 --> 01:39:49,024
FAILS AND HERE'S A SECOND REASON

1874
01:39:49,024 --> 01:39:59,334
WHY TEER FAILS WITH THE RESIDUAL

1875
01:39:59,334 --> 01:40:01,470
PROLAPSE.

1876
01:40:01,470 --> 01:40:06,375
IT'S POSSIBLE TO REREPAIR THE 

1877
01:40:06,375 --> 01:40:07,142
FAILED TEER.

1878
01:40:07,142 --> 01:40:08,710
IT'S NOT APPROPRIATE TO TELL 

1879
01:40:08,710 --> 01:40:10,946
PATIENTS THEY ARE CAN GET A TEER

1880
01:40:10,946 --> 01:40:15,751
AND THEN REPAIR BECAUSE 95% OF 

1881
01:40:15,751 --> 01:40:16,318
THE PATIENTS IN THE UNITED 

1882
01:40:16,318 --> 01:40:20,555
STATES WILL END UP WITH A 

1883
01:40:20,555 --> 01:40:20,856
REPLACEMENT.

1884
01:40:20,856 --> 01:40:24,393
THEY'RE TECHNICALLY DEMANDING 

1885
01:40:24,393 --> 01:40:34,036
REPAIRS.

1886
01:40:34,036 --> 01:40:36,371
WHY THERE'S VARIABILITY IN 

1887
01:40:36,371 --> 01:40:39,307
SURGICAL REPAIR ON THE LEFT IS 

1888
01:40:39,307 --> 01:40:41,276
NEW YORK CENTER PROGRAM IN 

1889
01:40:41,276 --> 01:40:43,545
DEGENERATIVE REPAIR IS DOWN TO 

1890
01:40:43,545 --> 01:40:45,580
30% AND THE VARIABILITY IS 

1891
01:40:45,580 --> 01:40:48,350
DRIVEN BY INDIVIDUAL ON ABILITY 

1892
01:40:48,350 --> 01:40:50,485
TO REPAIR THE VALVE CONSISTENTLY

1893
01:40:50,485 --> 01:40:59,428
AND THE RED DOTS ARE INDEPENDENT

1894
01:40:59,428 --> 01:41:02,431
SURGEONS.

1895
01:41:02,431 --> 01:41:08,703
AND DURABILITY VARIES BY SURGEON

1896
01:41:08,703 --> 01:41:10,172
AND THE MITRAL VALVE MORE THAN 

1897
01:41:10,172 --> 01:41:14,476
25 TIMES A YEAR AND 1% FAILURE 

1898
01:41:14,476 --> 01:41:17,946
RATES COMPARED TO THREE TO FOUR 

1899
01:41:17,946 --> 01:41:19,981
TIMES THAT OF LESS EXPERIENCED 

1900
01:41:19,981 --> 01:41:20,248
SURGEONS.

1901
01:41:20,248 --> 01:41:22,684
AND ECHO WHICH WE RELY ON TO 

1902
01:41:22,684 --> 01:41:25,720
GIVE US AN IDEA WHETHER A 

1903
01:41:25,720 --> 01:41:27,155
PATIENT IS APPROPRIATE FOR 

1904
01:41:27,155 --> 01:41:29,724
SURGERY IS NOT ENTIRELY RELIABLE

1905
01:41:29,724 --> 01:41:33,695
WITH DISCORDANT GRADING THAT CAN

1906
01:41:33,695 --> 01:41:35,464
CHANGE OUTCOMES AND THIS 

1907
01:41:35,464 --> 01:41:38,467
REMARKABLE SERIES IS OVER 80% OF

1908
01:41:38,467 --> 01:41:42,370
PATIENTS WITH DISCORDANT GRADE 

1909
01:41:42,370 --> 01:41:45,240
ANTHAD PROCEDURE CANCELED AND 

1910
01:41:45,240 --> 01:41:47,209
SURGE I HAVE WAS REQUIRED WHICH 

1911
01:41:47,209 --> 01:41:48,610
WOULD HAVE OTHERWISE BEEN 

1912
01:41:48,610 --> 01:41:49,277
INDICATED AND HUGE VARIANT IN 

1913
01:41:49,277 --> 01:41:51,513
ECHO AS WELL.

1914
01:41:51,513 --> 01:41:55,817
AND ESSENTIALLY WE'RE VERY 

1915
01:41:55,817 --> 01:41:58,053
UNSURE WHETHER THIS KIND 

1916
01:41:58,053 --> 01:42:00,388
TRANSLATES TO POORER SURVIVALS 

1917
01:42:00,388 --> 01:42:09,030
AFTER TEER VERSUS SURGERY IN 

1918
01:42:09,030 --> 01:42:10,265
TATE AND QUESTION BY A 

1919
01:42:10,265 --> 01:42:11,133
RANDOMIZED TRIAL.

1920
01:42:11,133 --> 01:42:13,435
THE PRIMARY TRIAL IS WORTH A 

1921
01:42:13,435 --> 01:42:21,977
MINUTE OR TWO TO TALK ABOUT.

1922
01:42:21,977 --> 01:42:24,212
AND THIS IS FOCUSSED ON HIGH 

1923
01:42:24,212 --> 01:42:32,654
RISK PATIENTS ON THE INFERIORITY

1924
01:42:32,654 --> 01:42:36,124
END POINT AND PRIMARY WHICH IS 

1925
01:42:36,124 --> 01:42:38,927
AN IMPORTANT NIH FUNDED 

1926
01:42:38,927 --> 01:42:43,932
INITIATED TRIAL FOCUSSED ON ALL 

1927
01:42:43,932 --> 01:42:50,639
COMERS OVER 60 WITH THE DESIGN.

1928
01:42:50,639 --> 01:42:51,773
THE REGURGITATION OF PATIENTS IS

1929
01:42:51,773 --> 01:42:55,477
60 YEARS AND ABOVE.

1930
01:42:55,477 --> 01:42:59,614
THE NEXT SLIDE IS RAN BY THE 

1931
01:42:59,614 --> 01:43:03,151
NETWORK SPONSORED BY THE NIH AND

1932
01:43:03,151 --> 01:43:05,854
EFFECTIVENESS OF THE SAFETY OF 

1933
01:43:05,854 --> 01:43:06,655
MITRAL REGURGITATION REPAIR BY 

1934
01:43:06,655 --> 01:43:09,157
THE APPROACH AND ESSENTIALLY WE 

1935
01:43:09,157 --> 01:43:13,495
ARE RECRUITING ALL PATIENTS WITH

1936
01:43:13,495 --> 01:43:17,966
REGENERATIVE MRH OVER 60 AND THE

1937
01:43:17,966 --> 01:43:18,600
PRIMARY ELIGIBILITY COMMUNITY 

1938
01:43:18,600 --> 01:43:19,768
SHOULD GET A GOOD RESULT WITH 

1939
01:43:19,768 --> 01:43:26,441
THERAPY.

1940
01:43:26,441 --> 01:43:28,543
AT LEAST THREE YEARS AND UP TO 

1941
01:43:28,543 --> 01:43:31,813
SIX YEARS AT FOLLOW-UP IS 

1942
01:43:31,813 --> 01:43:34,849
ALL-CAUSE MORTALITY.

1943
01:43:34,849 --> 01:43:36,718
ANY MITRAL VALVE INCLUDING 

1944
01:43:36,718 --> 01:43:40,355
REPLACEMENT HEART FAILURE 

1945
01:43:40,355 --> 01:43:44,192
ADJUDICATED BY A PRIMARY 

1946
01:43:44,192 --> 01:43:47,495
COMMITTEE AND REGURGITATION AND 

1947
01:43:47,495 --> 01:43:50,565
YOU HAVE TO BE ALIVE THREE TO 

1948
01:43:50,565 --> 01:43:52,601
SIX YEAR WITH A MITRAL REPAIR 

1949
01:43:52,601 --> 01:43:57,305
AND NO HEART FAILURE OR 

1950
01:43:57,305 --> 01:44:03,311
HOSPITALIZATIONS AND TO THE 

1951
01:44:03,311 --> 01:44:06,648
PRIMARY END POINT.

1952
01:44:06,648 --> 01:44:09,150
AND THE SEQUENTIAL TRIALS 

1953
01:44:09,150 --> 01:44:10,518
THERE'S ALREADY THE DEGREE OF 

1954
01:44:10,518 --> 01:44:11,486
EQUIPOISE AND TRIALS WOULD TAKE 

1955
01:44:11,486 --> 01:44:14,022
OVER A DECADE TO PERFORM THE 

1956
01:44:14,022 --> 01:44:14,556
DATA.

1957
01:44:14,556 --> 01:44:19,694
THE PATIENTS ARE ASKING ABOUT 

1958
01:44:19,694 --> 01:44:23,698
NOW AND THE EXPERT TEER IS SAFER

1959
01:44:23,698 --> 01:44:26,234
AND ABLE OF BETTER RESULTS AND 

1960
01:44:26,234 --> 01:44:28,136
THE TIME THE TRIALS STARTED AND 

1961
01:44:28,136 --> 01:44:30,138
WE HAVE THE FUND BEING FROM THE 

1962
01:44:30,138 --> 01:44:32,707
NIH TO DO THIS AND THAT'S 

1963
01:44:32,707 --> 01:44:35,510
IMPORTANT FOR TWO REASONS.

1964
01:44:35,510 --> 01:44:36,711
ONE IT'S ALLOWED INVESTIGATORS 

1965
01:44:36,711 --> 01:44:39,014
TO COME UP WITH THE APPROPRIATE 

1966
01:44:39,014 --> 01:44:43,451
TRIAL AND THERE'S A PHENOMENAL 

1967
01:44:43,451 --> 01:44:45,353
SUPPORT WE'VE HAD AS A RESULT OF

1968
01:44:45,353 --> 01:44:46,388
SUPPORTING TRANSLATIONAL 

1969
01:44:46,388 --> 01:44:53,862
RESEARCH TO THE UNRAEANSWERED 

1970
01:44:53,862 --> 01:44:56,931
QUESTIONS AND THE FIRST IS 

1971
01:44:56,931 --> 01:44:58,700
SURGERY AND UNDERSTAND SUDDEN 

1972
01:44:58,700 --> 01:45:00,402
DEATH WITH PATHOPHYSIOLOGY THAT 

1973
01:45:00,402 --> 01:45:03,705
CONTRIBUTE TO THE PATIENT 

1974
01:45:03,705 --> 01:45:04,205
POPULATION.

1975
01:45:04,205 --> 01:45:05,006
PERFORMING MONITORING BEFORE AND

1976
01:45:05,006 --> 01:45:11,613
AFTER REPAIR TO LOOK AT MITRAL 

1977
01:45:11,613 --> 01:45:12,414
REGURGITATION AND AORTIC 

1978
01:45:12,414 --> 01:45:18,753
STENOSIS AND COMPARING SURGERY.

1979
01:45:18,753 --> 01:45:24,426
WE'LL ALSO CREATE DIGITAL TWINS 

1980
01:45:24,426 --> 01:45:31,900
BY MECHANICAL SIMULATIONS TO 

1981
01:45:31,900 --> 01:45:37,105
EXAMINE AND RISK STRATIFY MORE.

1982
01:45:37,105 --> 01:45:40,809
AND TAKING BIOPSIES AT THE TIME 

1983
01:45:40,809 --> 01:45:44,646
OF SURGERY TO LOOK AT FIBROSIS 

1984
01:45:44,646 --> 01:45:52,721
AND CONDUCTING TRANSCRIPTIONAL 

1985
01:45:52,721 --> 01:45:57,692
ANALYSIS ON MITRAL CHORDAL AND 

1986
01:45:57,692 --> 01:46:02,163
LOOK AT GENE SIGNATURES AND 

1987
01:46:02,163 --> 01:46:03,098
PHENOTYPES AND WE'RE GRATEFUL TO

1988
01:46:03,098 --> 01:46:04,866
THE CAROL FOR SUPPORTING AND 

1989
01:46:04,866 --> 01:46:07,168
ALLOWS US TO TAKE LESSONS FROM 

1990
01:46:07,168 --> 01:46:08,803
INDUSTRY RUN TRIALS SUCH AS THIS

1991
01:46:08,803 --> 01:46:12,207
ONE PUBLISHED TWO WEEKS AGO IN 

1992
01:46:12,207 --> 01:46:16,244
THE NEW ENGLAND JOURNAL OF 

1993
01:46:16,244 --> 01:46:26,755
MEDICINE AND I THINK IN THE 

1994
01:46:28,623 --> 01:46:30,425
ACCOMPANYING TRIAL SHOWS THE 

1995
01:46:30,425 --> 01:46:31,426
SUPPORT OF THE NHLBI IN THE 

1996
01:46:31,426 --> 01:46:31,693
SPACE.

1997
01:46:31,693 --> 01:46:36,831
IF WE'RE GOING TO ANSWER THE 

1998
01:46:36,831 --> 01:46:39,401
QUESTIONS WITH NEED THESE KINDS 

1999
01:46:39,401 --> 01:46:40,001
OF TRIALS.

2000
01:46:40,001 --> 01:46:43,271
THE PRIMARY TRIAL IS ENROLLING 

2001
01:46:43,271 --> 01:46:45,306
IN 65 SITES AND COUNTRIES IF.

2002
01:46:45,306 --> 01:46:47,909
WE CONTINUE TO ENROLL THE TRIAL 

2003
01:46:47,909 --> 01:46:49,911
WILL BE COMPLETED BY DECEMBER OF

2004
01:46:49,911 --> 01:46:50,578
NEXT YEAR.

2005
01:46:50,578 --> 01:46:51,446
THANK YOU VERY MUCH AND I'M 

2006
01:46:51,446 --> 01:46:59,087
HAPPY TO TAKE ANY QUESTIONS.

2007
01:46:59,087 --> 01:46:59,587
>> THANK YOU.

2008
01:46:59,587 --> 01:47:01,856
WE HAVE A COUPLE MINUTES FOR 

2009
01:47:01,856 --> 01:47:04,726
QUESTIONS IF ANYONE HAS A BRIEF 

2010
01:47:04,726 --> 01:47:15,069
QUESTION OR COMMENT.

2011
01:47:19,374 --> 01:47:20,141
THANK YOU AGAIN.

2012
01:47:20,141 --> 01:47:22,911
>> IF I CAN ASK A QUICK 

2013
01:47:22,911 --> 01:47:23,178
QUESTION.

2014
01:47:23,178 --> 01:47:28,249
THE MECHANICS, JOE, THAT'S 

2015
01:47:28,249 --> 01:47:29,217
FASCINATING.

2016
01:47:29,217 --> 01:47:31,219
TELL ME MORE ABOUT THE SPECTRAL 

2017
01:47:31,219 --> 01:47:35,123
AND IMAGING TRYING TO LOOK AT 

2018
01:47:35,123 --> 01:47:37,358
POST REPAIR FUNCTION BETWEEN 

2019
01:47:37,358 --> 01:47:40,929
TEER AND MITRAL VALVE REPAIR.

2020
01:47:40,929 --> 01:47:42,397
>> WE'RE LOOKING PRE AND
POST.

2021
01:47:42,397 --> 01:47:47,602
IN ABOUT 200 PATIENTS IN THE 

2022
01:47:47,602 --> 01:47:50,505
TRIAL WILL GET HAVE BEEN GETTING

2023
01:47:50,505 --> 01:47:53,775
MIRs IN ADDITION TO THE STANDARD

2024
01:47:53,775 --> 01:47:58,112
WORKUP PRE AND POST INTERVENTION

2025
01:47:58,112 --> 01:48:00,114
AND THE GROUP ARE INTERESTED IN 

2026
01:48:00,114 --> 01:48:01,983
TRYING TO IDENTIFY EARLY MARKERS

2027
01:48:01,983 --> 01:48:04,719
OF FIBROSIS, PROGRESSION OF 

2028
01:48:04,719 --> 01:48:08,656
FIBROSIS AND TO TRY AND GET A 

2029
01:48:08,656 --> 01:48:12,427
BETTER READ ON PRE AND POST 

2030
01:48:12,427 --> 01:48:16,564
MITRAL REGURGITATION BECAUSE 

2031
01:48:16,564 --> 01:48:18,800
IT'S DIFFICULT TO QUANTIFY AND 

2032
01:48:18,800 --> 01:48:20,068
PARTICULARLY AFTER TEER.

2033
01:48:20,068 --> 01:48:22,036
WE WANT TO ADDRESS THE PRACTICE 

2034
01:48:22,036 --> 01:48:22,570
VARIATIONS WHERE YOU GET 

2035
01:48:22,570 --> 01:48:25,640
DISCORDANT ECHOS AND SEE IF CMR 

2036
01:48:25,640 --> 01:48:28,042
CAN GIVE US A BETTER IDEA AND 

2037
01:48:28,042 --> 01:48:32,714
CORRELATE THAT WITH THE 

2038
01:48:32,714 --> 01:48:36,384
PREVALENCE OF VENTRICULAR 

2039
01:48:36,384 --> 01:48:38,953
ARRHYTHMIA AND ALL THE PATIENTS 

2040
01:48:38,953 --> 01:48:45,193
ARE MONITORING IN TERMS OF THE 

2041
01:48:45,193 --> 01:48:46,861
IDEA AND HOPEFULLY WE'LL GET A 

2042
01:48:46,861 --> 01:48:49,297
BETTER SENSE OF WHAT 

2043
01:48:49,297 --> 01:48:54,435
NON-INVASIVE IMAGING CAN TELL US

2044
01:48:54,435 --> 01:48:56,638
ABOUT WHICH PATIENTS ARE AT RISK

2045
01:48:56,638 --> 01:48:58,806
AND WE COULD BE MORE TARGETED.

2046
01:48:58,806 --> 01:49:04,712
SOME PATIENTS ARE HIGHER RISK 

2047
01:49:04,712 --> 01:49:07,215
AND SOME I SUSPECT TEER DOESN'T 

2048
01:49:07,215 --> 01:49:11,686
OFFER THE KIND OF MECHANICAL 

2049
01:49:11,686 --> 01:49:13,121
IMPROVEMENTS SURGERY IS IT AND 

2050
01:49:13,121 --> 01:49:18,726
WE'LL SEE MORE FIBROSIS AND 

2051
01:49:18,726 --> 01:49:19,027
ARRHYTHMIA.

2052
01:49:19,027 --> 01:49:21,763
>> IT MAY TAKE TIME BUT I
AGREE.

2053
01:49:21,763 --> 01:49:22,830
I'M GLAD YOU'RE DOING THAT 

2054
01:49:22,830 --> 01:49:24,332
BECAUSE I THINK WE'RE GOING TO 

2055
01:49:24,332 --> 01:49:25,800
LEARN SOMETHING THAT'S 

2056
01:49:25,800 --> 01:49:26,067
IMPORTANT.

2057
01:49:26,067 --> 01:49:28,903
THE OTHER QUESTION REAL QUICK, 

2058
01:49:28,903 --> 01:49:33,141
JOE, YOUR PAPER LOOKING AT THE 

2059
01:49:33,141 --> 01:49:33,675
REGISTRY.

2060
01:49:33,675 --> 01:49:35,843
MY THEORY AND THE QUICK COMMENT 

2061
01:49:35,843 --> 01:49:37,946
I WANT IS MORE SITES CLULGD OURS

2062
01:49:37,946 --> 01:49:39,013
I THINK THEY UNDER REPORT 

2063
01:49:39,013 --> 01:49:40,582
OPPOSED TO OVER REPORT.

2064
01:49:40,582 --> 01:49:44,052
I DON'T BELIEVE -- I THINK WHILE

2065
01:49:44,052 --> 01:49:48,456
IT'S REPORTED MY GUESS IS FOR 

2066
01:49:48,456 --> 01:49:50,525
MANY PATIENTS IT'S WORSE.

2067
01:49:50,525 --> 01:49:52,427
AND MITRAL STENOSIS AND I DON'T 

2068
01:49:52,427 --> 01:49:54,796
THINK WE'RE OVER READING THEM I 

2069
01:49:54,796 --> 01:49:56,698
THINK PEOPLE ARE UNDER READING 

2070
01:49:56,698 --> 01:50:06,808
THEM.

2071
01:50:09,911 --> 01:50:15,149
ISN'T IT STRANGE HOW A SURGEON 

2072
01:50:15,149 --> 01:50:17,619
ALWAYS WANTS TO SHOW YOU THE 

2073
01:50:17,619 --> 01:50:18,886
WORSE VIEW AN INTERVENTIONIST 

2074
01:50:18,886 --> 01:50:21,356
WANTS TO SEE THE BEST VIEW.

2075
01:50:21,356 --> 01:50:24,359
>> I SAW A LOT OF TIER
CASES AND

2076
01:50:24,359 --> 01:50:27,028
I ALWAYS NOTICE I GET ONE QUICK 

2077
01:50:27,028 --> 01:50:28,396
VIEW AND SOMEONE TELLS ME ABOUT 

2078
01:50:28,396 --> 01:50:29,831
A V WAVE.

2079
01:50:29,831 --> 01:50:34,869
YOU DO A SURGICAL REPAIR I 

2080
01:50:34,869 --> 01:50:36,704
GUARANTEE THEY'RE CALLING YOU 

2081
01:50:36,704 --> 01:50:39,440
BACK FOR EVERY CORPUSCLE AND 

2082
01:50:39,440 --> 01:50:40,675
WILL BE INTERESTING TO SEE FROM 

2083
01:50:40,675 --> 01:50:43,044
THE TRIAL.

2084
01:50:43,044 --> 01:50:51,219
THANK YOU FOR THE PRESENTATION.

2085
01:50:51,219 --> 01:50:54,055
>> SORRY, I'M DRIVING HOME
TO DO

2086
01:50:54,055 --> 01:50:57,792
MY PRESENTATION FROM HOME FROM 

2087
01:50:57,792 --> 01:50:59,394
THE INTERNET CONNECTION IS 

2088
01:50:59,394 --> 01:50:59,627
BETTER.

2089
01:50:59,627 --> 01:51:00,928
BRILLIANT PRESENTATION AS 

2090
01:51:00,928 --> 01:51:01,396
ALWAYS.

2091
01:51:01,396 --> 01:51:02,797
I WANT TO MAKE ONE COMMENT ABOUT

2092
01:51:02,797 --> 01:51:04,198
THE PRIMARY TRIAL.

2093
01:51:04,198 --> 01:51:05,266
I DON'T THINK WE SHOULD THROW 

2094
01:51:05,266 --> 01:51:08,503
THE BABY OUT WITH THE WATER AND 

2095
01:51:08,503 --> 01:51:09,070
SAY ALL INDUSTRY SPONSORED 

2096
01:51:09,070 --> 01:51:12,140
TRIALS ARE BAD.

2097
01:51:12,140 --> 01:51:14,042
THE INDUSTRY SPONSORED TRIALS 

2098
01:51:14,042 --> 01:51:16,244
ARE DONE FOR A NEW INDICATION.

2099
01:51:16,244 --> 01:51:20,982
AND WE'VE LEARNED A TREMENDOUS 

2100
01:51:20,982 --> 01:51:22,050
AMOUNT FOR EXAMPLE FROM THE 

2101
01:51:22,050 --> 01:51:24,352
INDUSTRY SPONSORED TRIALS.

2102
01:51:24,352 --> 01:51:27,088
IF THERE IS NO POTENTIAL 

2103
01:51:27,088 --> 01:51:28,256
INDICATION OR IF THE INDUSTRY 

2104
01:51:28,256 --> 01:51:31,592
ALREADY HAS A DE FACTO 

2105
01:51:31,592 --> 01:51:32,694
INDICATION THEY'RE NOT GOING TO 

2106
01:51:32,694 --> 01:51:33,461
DO THE TRIAL.

2107
01:51:33,461 --> 01:51:35,096
THAT'S ONE OF THE THINGS I WAS 

2108
01:51:35,096 --> 01:51:37,398
ARGUING FOR STRONGLY AT THE 

2109
01:51:37,398 --> 01:51:38,633
INITIAL STAGES WHEN YOU FIRST 

2110
01:51:38,633 --> 01:51:42,470
PROPOSED THE TRIAL AND AS YOU 

2111
01:51:42,470 --> 01:51:47,008
REMEMBER THERE WERE MITRAL VALVE

2112
01:51:47,008 --> 01:51:48,209
SURGEONS IN AMERICA HESITANT TO 

2113
01:51:48,209 --> 01:51:49,844
START THE TRIAL.

2114
01:51:49,844 --> 01:51:51,279
IS THAT THE THING THAT SEPARATES

2115
01:51:51,279 --> 01:51:53,347
THE TYPES OF TRIALS SUPPORTED 

2116
01:51:53,347 --> 01:51:57,018
FROM THE NIH FROM THE INDUSTRY 

2117
01:51:57,018 --> 01:51:59,287
TRIALS IF A GOOD STRONG CLINICAL

2118
01:51:59,287 --> 01:52:02,123
TRIALIST CALLS THE MVP OF A 

2119
01:52:02,123 --> 01:52:04,592
COMPANY AND SEE A NEW INDICATION

2120
01:52:04,592 --> 01:52:06,294
YOU HAVE A PROTOCOL WRITTEN THE 

2121
01:52:06,294 --> 01:52:09,764
NEXT DAY AND ETHICS APPROVAL 

2122
01:52:09,764 --> 01:52:10,798
SHORTLY THEREAFTER.

2123
01:52:10,798 --> 01:52:12,133
WHEREAS THE STUFF WE DO INDUSTRY

2124
01:52:12,133 --> 01:52:14,402
IS NOT INTERESTED IN IS LONG 

2125
01:52:14,402 --> 01:52:17,305
DIFFICULT WORK SUPPORTED, THANK 

2126
01:52:17,305 --> 01:52:20,942
GOODNESS BY BODIES LIKE THE NIH 

2127
01:52:20,942 --> 01:52:24,378
BUT WE HAVE A THREE-YEAR THEY 

2128
01:52:24,378 --> 01:52:25,046
ARE TO CATCH UP.

2129
01:52:25,046 --> 01:52:26,481
IT WAS SO IMPORTANT TO PUSH WITH

2130
01:52:26,481 --> 01:52:29,350
THE TRIAL, THE PRIMARY TRIAL 

2131
01:52:29,350 --> 01:52:33,488
INSTEAD OF ALWAYS TRYING TO 

2132
01:52:33,488 --> 01:52:35,456
CATCH UP WHEN SUCH AU TRIAL MAY 

2133
01:52:35,456 --> 01:52:39,594
NOT BE MORE RELEVANT OR NOT DONE

2134
01:52:39,594 --> 01:52:42,096
BECAUSE THE INDUSTRY HAS THEIR 

2135
01:52:42,096 --> 01:52:44,332
DE FACTO INDICATION WITH LOW 

2136
01:52:44,332 --> 01:52:47,568
RISK MR PATIENTS THEY PLAY START

2137
01:52:47,568 --> 01:52:51,572
TO FROM THE REPAIR MR RESULTS 

2138
01:52:51,572 --> 01:52:54,509
ONCE THE APPROVAL COMES YOU GET 

2139
01:52:54,509 --> 01:52:56,043
THE INDICATION CREEP LEADING TO 

2140
01:52:56,043 --> 01:52:57,712
THE MORE RISK PATIENTS.

2141
01:52:57,712 --> 01:52:59,747
THEREFORE JUST WANTED TO 

2142
01:52:59,747 --> 01:53:03,484
CONGRATULATE YOU ONCE AGAIN OR 

2143
01:53:03,484 --> 01:53:04,418
SPEARHEADING THIS AT FIRST 

2144
01:53:04,418 --> 01:53:05,653
CONTROVERSIAL BUT NOW I THINK 

2145
01:53:05,653 --> 01:53:06,020
ACCEPTED TRIAL.

2146
01:53:06,020 --> 01:53:07,388
THANKS A LOT.

2147
01:53:07,388 --> 01:53:11,092
>> I APPRECIATE IT,
MICHAEL.

2148
01:53:11,092 --> 01:53:12,226
>> A SHORT QUESTION.

2149
01:53:12,226 --> 01:53:22,136
CONGRATULATIONS FOR THE EFFORT.

2150
01:53:22,136 --> 01:53:25,907
THE WHOLE IDEA OF SPECTO 

2151
01:53:25,907 --> 01:53:28,609
TRACKING WE KNOW THE MECHANICS 

2152
01:53:28,609 --> 01:53:31,078
BEFORE AND DURING THE SEVERE MR 

2153
01:53:31,078 --> 01:53:32,079
AND WHAT HAPPENS WITH THE ACUTE 

2154
01:53:32,079 --> 01:53:33,047
CHANGE AFTER REPAIR.

2155
01:53:33,047 --> 01:53:36,017
WHAT DO WE THINK IS THE UTILITY 

2156
01:53:36,017 --> 01:53:39,287
OF ADDING THIS TO THE PRIMARY 

2157
01:53:39,287 --> 01:53:41,589
TRIAL ON SOMETHING WELL KNOWN 

2158
01:53:41,589 --> 01:53:44,725
AND WELL ESTABLISHED REGARDLESS 

2159
01:53:44,725 --> 01:53:47,595
OF HOW YOU WORK THE VALVE?

2160
01:53:47,595 --> 01:53:50,064
>> YOU'RE THE EXPERT HERE.

2161
01:53:50,064 --> 01:53:53,901
YOU KNOW WAY MORE ABOUT THE 

2162
01:53:53,901 --> 01:53:55,002
PECTO TRACKING THAN I DO.

2163
01:53:55,002 --> 01:53:56,704
IT GOES BACK TO TRYING TO PICK 

2164
01:53:56,704 --> 01:53:58,673
THE PATIENTS TO OPERATE AND THE 

2165
01:53:58,673 --> 01:54:00,708
RIGHT TIME TO OPERATOR THE RIGHT

2166
01:54:00,708 --> 01:54:01,742
TIME TO INTERVENE.

2167
01:54:01,742 --> 01:54:04,712
THERE'S DEFINITELY A COHORT OF 

2168
01:54:04,712 --> 01:54:08,549
PATIENTS HIGHER RISK THAT DRIVE 

2169
01:54:08,549 --> 01:54:13,154
THE MORTALITY YOU SEE WITH 

2170
01:54:13,154 --> 01:54:14,322
UNTREATED MITRAL REGURGITATION 

2171
01:54:14,322 --> 01:54:15,156
AND WE'RE CONFIDENT NOT EVERY 

2172
01:54:15,156 --> 01:54:18,426
PATIENT SHOULD BE OPERATED ON 

2173
01:54:18,426 --> 01:54:20,027
WITHIN THREE MONTHS BUT IF YOU 

2174
01:54:20,027 --> 01:54:24,098
CAN BE MORE SOPHISTICATED IN WHO

2175
01:54:24,098 --> 01:54:29,971
IS AT RISK OF VENTRICLE 

2176
01:54:29,971 --> 01:54:30,771
DECOMPENSATING AND PICK THE 

2177
01:54:30,771 --> 01:54:34,775
PATIENTS MORE ACCURATELY I THINK

2178
01:54:34,775 --> 01:54:37,712
IT WOULD IMPROVE TREATMENT AND 

2179
01:54:37,712 --> 01:54:38,913
OUTCOMES AND SPENTO TRACKING IS 

2180
01:54:38,913 --> 01:54:43,951
PROBABLY NOT GOING TO BE THE 

2181
01:54:43,951 --> 01:54:51,926
ANSWER BUT I SUSPECT MRI MAYBE 

2182
01:54:51,926 --> 01:54:54,028
AND THAT'S THE HOLISTIC VIEW OF 

2183
01:54:54,028 --> 01:54:58,866
WHAT WE'RE TRYING TO DO HERE.

2184
01:54:58,866 --> 01:55:00,501
STRATIFY AND PICK OUR PATIENTS 

2185
01:55:00,501 --> 01:55:00,735
BETTER.

2186
01:55:00,735 --> 01:55:10,344
>> THANK YOU.

2187
01:55:10,344 --> 01:55:12,146
>> THERE'S A QUESTION
THERE'S 

2188
01:55:12,146 --> 01:55:16,717
BEEN A SUB GROUP OF PATIENTS 

2189
01:55:16,717 --> 01:55:18,319
WITH MYOCARDIAL BIOPSY TO 

2190
01:55:18,319 --> 01:55:20,521
MAPPING ABNORMALITIES ON CMR.

2191
01:55:20,521 --> 01:55:22,823
>> WE CAN'T DO THAT IN
TEER BUT 

2192
01:55:22,823 --> 01:55:25,927
IN SELECTED PATIENTS WITH 

2193
01:55:25,927 --> 01:55:31,098
CONSENT WE VERIFY WHAT WE SEE ON

2194
01:55:31,098 --> 01:55:35,870
CMR AT THE BASE, AT THE APEX OF 

2195
01:55:35,870 --> 01:55:36,437
THE VENTRICLE.

2196
01:55:36,437 --> 01:55:37,405
>> THANK YOU VERY MUCH FOR
THE 

2197
01:55:37,405 --> 01:55:38,973
PRESENTATION AND DISCUSSION.

2198
01:55:38,973 --> 01:55:39,674
WE'RE RUNNING A LITTLE BEHIND AT

2199
01:55:39,674 --> 01:55:41,709
THIS POINT SO WE'RE GOING TO 

2200
01:55:41,709 --> 01:55:42,777
TAKE A BREAK UNTIL 15 MINUTES 

2201
01:55:42,777 --> 01:55:44,712
AFTER THE HOUR.

2202
01:55:44,712 --> 01:55:54,989
THANK YOU EVERYONE.

2203
01:56:13,793 --> 01:56:17,030
AND A PAPER SHOWING INTRABASAL 

2204
01:56:17,030 --> 01:56:20,333
FIBROSIS AT THE REGIONS HE 

2205
01:56:20,333 --> 01:56:23,169
SHOWED IN HIS PRESENTATION BUT 

2206
01:56:23,169 --> 01:56:27,007
IN FACT IF WE GO ON USING DARK 

2207
01:56:27,007 --> 01:56:29,376
BLOOD IMAGE AND T1 

2208
01:56:29,376 --> 01:56:31,344
QUANTIFICATION AS MICHAEL BORGER

2209
01:56:31,344 --> 01:56:33,346
HAS DONE YOU CAN SEE FIBROSIS IN

2210
01:56:33,346 --> 01:56:39,319
UP TO 89% OF PATIENTS WITH 

2211
01:56:39,319 --> 01:56:41,955
ARRHYTHMIC MITRAL VALVE PROLAPSE

2212
01:56:41,955 --> 01:56:44,324
CORRELATING WITH HISTOPATH LOGIC

2213
01:56:44,324 --> 01:56:45,959
VERIFICATION DURING SURGERY.

2214
01:56:45,959 --> 01:56:48,995
IN FACT IT'S A COMMON THING IN 

2215
01:56:48,995 --> 01:56:59,506
PATIENTS WITH ARRHYTHMIC MVP.

2216
01:57:12,052 --> 01:57:15,221
AND LINKED WITH THAT A DOWNWARD 

2217
01:57:15,221 --> 01:57:20,393
MOTION FROM THE PAPILLARY MUSCLE

2218
01:57:20,393 --> 01:57:23,530
LEAFLETS WITH THE UPWARD MOTION 

2219
01:57:23,530 --> 01:57:29,869
OF THE POSTERIOR ANNULUS AND 

2220
01:57:29,869 --> 01:57:31,571
THIS IS CALLED CURLING AND THIS 

2221
01:57:31,571 --> 01:57:39,913
IS FROM A PAPER SHOWING THE SAME

2222
01:57:39,913 --> 01:57:41,815
ANIMATION AND SEEING THE SAME 

2223
01:57:41,815 --> 01:57:46,419
ABNORMAL MOTION OF THE PAPILLARY

2224
01:57:46,419 --> 01:57:51,491
MUSCLES WITH EXPANSION OF THE 

2225
01:57:51,491 --> 01:58:01,267
MITRAL ANNULUS AND THERE'S ONE 

2226
01:58:01,267 --> 01:58:02,836
IN THE VENTRICLE AND PAPILLARY 

2227
01:58:02,836 --> 01:58:05,939
TRACTION AN UPWARD MOTION OF THE

2228
01:58:05,939 --> 01:58:07,440
ANNULUS AND THE SYSTOLIC 

2229
01:58:07,440 --> 01:58:10,443
CONTRACT OF THE ANNULUS.

2230
01:58:10,443 --> 01:58:13,046
AND AS SOME HAVE SHOWED THERE'S 

2231
01:58:13,046 --> 01:58:17,117
AN EXPANDED SKWAJ RATED LATE 

2232
01:58:17,117 --> 01:58:19,586
SYSTOLIC SUSPENSION OF THE 

2233
01:58:19,586 --> 01:58:20,587
ANNULUS IN PATIENTS WITH MITRAL 

2234
01:58:20,587 --> 01:58:22,355
VALVE PROLAPSE AND THAT WILL 

2235
01:58:22,355 --> 01:58:24,758
INCREASE THE FORCE EXERTED ON 

2236
01:58:24,758 --> 01:58:27,327
THE VENTRICLE BECAUSE THAT FORCE

2237
01:58:27,327 --> 01:58:29,863
IS THE PRESSURE TIMES THE 

2238
01:58:29,863 --> 01:58:31,598
ANNULAR AREA.

2239
01:58:31,598 --> 01:58:34,134
IF THE ANNULAR AREA WILL FORCE 

2240
01:58:34,134 --> 01:58:38,605
MORE ON THE PAPILLARY MUSCLE AND

2241
01:58:38,605 --> 01:58:40,473
UNDERLYING VENTRICULAR WALL WE 

2242
01:58:40,473 --> 01:58:45,912
PRESUME STIMULATING FIBROSIS.

2243
01:58:45,912 --> 01:58:51,384
AND THERE WAS TALK EARLIER AND 

2244
01:58:51,384 --> 01:58:54,621
TALKING ABOUT THE ANANYNULAR 

2245
01:58:54,621 --> 01:58:56,556
DYSFUNCTION AND TEE COUPLED IT 

2246
01:58:56,556 --> 01:58:59,492
FROM THE ANNULUS AND CAN 

2247
01:58:59,492 --> 01:59:03,530
INCREASE THE SYSTOLIC ANNULAR 

2248
01:59:03,530 --> 01:59:03,830
DISJUNCTION.

2249
01:59:03,830 --> 01:59:05,999
IT STANDS TO REASON THIS WOULD 

2250
01:59:05,999 --> 01:59:10,503
ALSO BE ASSOCIATED WITH 

2251
01:59:10,503 --> 01:59:11,571
INCREASED FIBROSIS.

2252
01:59:11,571 --> 01:59:15,108
WE HAVE THIS HYPOTHESIS THAT MVP

2253
01:59:15,108 --> 01:59:17,610
DRIVEN MECHANICAL STRESS 

2254
01:59:17,610 --> 01:59:22,749
INCREASED LOCALIZED FIBROSIS BY 

2255
01:59:22,749 --> 01:59:27,353
EXPANDING THE ANNULUS SO THE 

2256
01:59:27,353 --> 01:59:28,621
MYOCARDIUM IS STRETCHED IN BOTH 

2257
01:59:28,621 --> 01:59:29,022
DEGREES.

2258
01:59:29,022 --> 01:59:30,657
THIS WAS STUDIED AND THEY'RE 

2259
01:59:30,657 --> 01:59:32,258
SUPPORTING PAPERS RECENTLY ABOUT

2260
01:59:32,258 --> 01:59:33,560
THE HYPOTHESIS.

2261
01:59:33,560 --> 01:59:35,495
FIRST THE LOCALIZED NATURE OF 

2262
01:59:35,495 --> 01:59:40,533
THE FIBROSIS THAT WAS SHOWN BY 

2263
01:59:40,533 --> 01:59:42,902
JORDAN MORNING STAR AND CHIP'S 

2264
01:59:42,902 --> 01:59:44,871
GROUP WITH INFLAMMATION AS WELL 

2265
01:59:44,871 --> 01:59:47,207
BOTH IN PATIENTS STUDIED IN 

2266
01:59:47,207 --> 01:59:49,976
MICHAEL BORGER'S GROUP AND 

2267
01:59:49,976 --> 01:59:51,478
TRANSGENIC MICE AND WE WORKED 

2268
01:59:51,478 --> 01:59:54,547
WITH JOE WU SHOWING IF YOU 

2269
01:59:54,547 --> 01:59:57,016
INDUCE MVP IN VITRO IT INCREASES

2270
01:59:57,016 --> 02:00:00,220
THE TUGGING FORCE ON THE PATHWAY

2271
02:00:00,220 --> 02:00:02,989
MUSCLES AND FINALLY BOTH 

2272
02:00:02,989 --> 02:00:07,594
FIBROSIS AND ABNORMAL MECHANICS 

2273
02:00:07,594 --> 02:00:09,929
INCREASED COMPLEX VENTRICULAR 

2274
02:00:09,929 --> 02:00:10,230
ARRHYTHMIAS.

2275
02:00:10,230 --> 02:00:14,100
WE CAN SEE THE SPECKLE TRACKING 

2276
02:00:14,100 --> 02:00:18,238
IN A PATIENT WITH MVP WITH A 

2277
02:00:18,238 --> 02:00:20,039
MARKEDLY ABNORMAL MOTION IN THE 

2278
02:00:20,039 --> 02:00:22,275
INTERIOR BASE WHICH SHOWS UP ON 

2279
02:00:22,275 --> 02:00:24,410
THE RIGHT IN THE TRACINGS.

2280
02:00:24,410 --> 02:00:26,346
MOST THE SEGMENTS CONTRACT 

2281
02:00:26,346 --> 02:00:30,817
NORMALLY AND SHORTEN WITH THE 

2282
02:00:30,817 --> 02:00:35,588
CURVES GOING DOWN AND LENGTHEN 

2283
02:00:35,588 --> 02:00:38,024
IN DIASTOLE AND THERE'S 

2284
02:00:38,024 --> 02:00:48,468
POST-SYSTOLIC CONTRACTION.

2285
02:00:50,236 --> 02:00:55,141
IN MID SIS STOLEE THE SHORTENS 

2286
02:00:55,141 --> 02:01:06,386
BUT IN LATE SIIN LATE SIS  SIS  

2287
02:01:16,162 --> 02:01:19,032
LENGTHENINGS AND LOOKING AT THE 

2288
02:01:19,032 --> 02:01:25,905
FIBROSIS BY MRI IN THE SAME 

2289
02:01:25,905 --> 02:01:27,373
PATIENTS PREDICTED VENTRICULAR 

2290
02:01:27,373 --> 02:01:28,575
ARRHYTHMIAS OF THE COMPLEX TYPE 

2291
02:01:28,575 --> 02:01:30,076
AND THERE'S AN ADDITIONAL VALUE 

2292
02:01:30,076 --> 02:01:32,345
TO THE MECHANICS ABOVE AND 

2293
02:01:32,345 --> 02:01:35,615
BEYOND THE PREDICTIVE VALUE OF 

2294
02:01:35,615 --> 02:01:39,052
THE ENHANCEMENT FIBROSIS.

2295
02:01:39,052 --> 02:01:41,087
BOTH TOGETHER PROVIDE A STRONG 

2296
02:01:41,087 --> 02:01:47,594
PREDICTIVE CONSTELLATION FOR 

2297
02:01:47,594 --> 02:01:49,228
SUBSEQUENT VENTRICULAR 

2298
02:01:49,228 --> 02:01:49,829
ARRHYTHMIAS.

2299
02:01:49,829 --> 02:01:51,464
NOT ONLY IS THE FIBROSIS AS 

2300
02:01:51,464 --> 02:01:57,003
OTHERS HAVE TALKED ABOUT A 

2301
02:01:57,003 --> 02:02:00,807
SUBSTRATE FOR ARRHYTHMIA BUT THE

2302
02:02:00,807 --> 02:02:07,580
MECHANICAL MOTION CAN BE A 

2303
02:02:07,580 --> 02:02:09,015
TRIGGER.

2304
02:02:09,015 --> 02:02:15,788
THE CENTRAL HYPOTHESIS MVP HAS 

2305
02:02:15,788 --> 02:02:19,592
ASSOCIATED ELECTROPHYSIOLOGIC 

2306
02:02:19,592 --> 02:02:23,296
CHANGES AND IN ORDER TO 

2307
02:02:23,296 --> 02:02:24,263
DEMONSTRATE WHETHER THIS IS THE 

2308
02:02:24,263 --> 02:02:25,732
CASE WE THOUGHT IT WOULD BE BEST

2309
02:02:25,732 --> 02:02:31,170
TO PROVIDE A MODEL TO START WITH

2310
02:02:31,170 --> 02:02:33,272
THE NORMAL HEART AND SEPARATE 

2311
02:02:33,272 --> 02:02:36,909
OUT THE EFFECTS OF MECHANICS AND

2312
02:02:36,909 --> 02:02:41,347
ANTONIO VAN CAMPEN A FELLOW FROM

2313
02:02:41,347 --> 02:02:42,615
LEIPZIG DEVELOPED AND CHAMPIONED

2314
02:02:42,615 --> 02:02:45,985
THIS MODEL MAKING IT A 

2315
02:02:45,985 --> 02:02:47,253
REPROTUESDAYABLE LARGE ANIMAL 

2316
02:02:47,253 --> 02:02:51,090
MELD TO STUDYING THE EFFECTS OF 

2317
02:02:51,090 --> 02:02:57,230
MECHANICS AND AWARD THE VIVIAN 

2318
02:02:57,230 --> 02:02:59,599
A. THOMAS CAREER AWARD AND THIS 

2319
02:02:59,599 --> 02:03:03,002
IS A COLLABORATION WITH MICHAEL 

2320
02:03:03,002 --> 02:03:05,371
BORGER AND CHIP NORRIS FOR THE 

2321
02:03:05,371 --> 02:03:07,106
BASIC SCIENCE PART OF IT.

2322
02:03:07,106 --> 02:03:08,641
WE ARE GRATEFUL FOR THE CAROL 

2323
02:03:08,641 --> 02:03:11,177
ACT FUND WILL OF THE NIH AWARD 

2324
02:03:11,177 --> 02:03:15,448
FOR STUDYING THE NEXT SLIDE 1:  

2325
02:03:16,949 --> 02:03:18,918
STUDYING THIS.

2326
02:03:18,918 --> 02:03:21,187
REVERSING THE EFFECT OF A MITRAL

2327
02:03:21,187 --> 02:03:23,022
VALVE REPAIR AND THE CREATE OF 

2328
02:03:23,022 --> 02:03:25,858
THE PROLAPSE IN A CONTROLLED 

2329
02:03:25,858 --> 02:03:28,428
MODERATE WITH MODERATE NOT 

2330
02:03:28,428 --> 02:03:29,095
SEVERE MITRAL REGURGITATION AND 

2331
02:03:29,095 --> 02:03:33,499
SIX MONTHS LATER THIS INDUCES 

2332
02:03:33,499 --> 02:03:35,635
FIBROSIS AS WE'VE SEEN IN SOME 

2333
02:03:35,635 --> 02:03:39,505
PATIENTS SHOWN TODAY.

2334
02:03:39,505 --> 02:03:41,841
UNDERLYING THE MEDIAL PAPILLARY 

2335
02:03:41,841 --> 02:03:45,545
MUSCLE SOMETIMES EXTENDING UP 

2336
02:03:45,545 --> 02:03:51,851
TOWARDS THE INTRAVENTRICULAR 

2337
02:03:51,851 --> 02:03:55,621
SPECTRUM AND IN THE CONTROLLED 

2338
02:03:55,621 --> 02:03:58,424
REGION WITHIN THE HEART THERE'S 

2339
02:03:58,424 --> 02:03:59,592
LITTLE INTERSTITIAL TISSUE AND 

2340
02:03:59,592 --> 02:04:01,461
INCREASED IN THE SUB PAPILLARY 

2341
02:04:01,461 --> 02:04:05,298
REGION AND THIS OCCURS 

2342
02:04:05,298 --> 02:04:07,133
CONSISTENTLY.

2343
02:04:07,133 --> 02:04:12,705
THIS IS IN THE MITRAL VALVE 

2344
02:04:12,705 --> 02:04:23,249
LINKED REGION THERE'S FIBROSIS 

2345
02:04:23,649 --> 02:04:31,090
BY CONTROL NORMAL.

2346
02:04:31,090 --> 02:04:33,059
ELECTROPHYSIOLOGISTS HAVE SHOWN 

2347
02:04:33,059 --> 02:04:39,031
THAT IN THIS FIBROTIC REGION 

2348
02:04:39,031 --> 02:04:42,201
THERE'S FRACTIONATION WE THE 

2349
02:04:42,201 --> 02:04:45,505
MUSCLE ELECTROGRAM INDICATING A 

2350
02:04:45,505 --> 02:04:50,076
PRE DISPOSITION TO CARDIAC 

2351
02:04:50,076 --> 02:04:55,648
ARREST AND RESTITUTION SO IT 

2352
02:04:55,648 --> 02:05:03,790
REMAINS AQUI -- ACQUIESCENT TO 

2353
02:05:03,790 --> 02:05:06,893
ARRHYTHMIAS AND LOOK AT BULK AND

2354
02:05:06,893 --> 02:05:10,997
NUCLEAR RNA SEQUENCES WITH CHIP 

2355
02:05:10,997 --> 02:05:11,597
NORRIS' GROUP AND THE BULK 

2356
02:05:11,597 --> 02:05:12,565
SEQUENCING IS CONFIRMED.

2357
02:05:12,565 --> 02:05:15,201
THE PRESENCE OF FIBROSIS WHICH 

2358
02:05:15,201 --> 02:05:17,904
IS OBVIOUS AND POTENTIAL 

2359
02:05:17,904 --> 02:05:19,572
MECHANISTIC LEADS LEADING TO 

2360
02:05:19,572 --> 02:05:23,376
THIS FIBROSIS AND WE'VE SHOWN 

2361
02:05:23,376 --> 02:05:29,348
THAT GENETIC MARKINGS CAN ADD TO

2362
02:05:29,348 --> 02:05:30,249
THE REGIONS.

2363
02:05:30,249 --> 02:05:34,687
LET'S TALK ABOUT INTERVENTIONAL 

2364
02:05:34,687 --> 02:05:36,322
STUDIES AND WHAT HAPPENS IF WE 

2365
02:05:36,322 --> 02:05:39,525
REMOVE THE MECHANICAL STIMULUS 

2366
02:05:39,525 --> 02:05:40,393
AND THIS IS SOMETHING AN 

2367
02:05:40,393 --> 02:05:45,531
ADMINISTRATIVE SUPPLEMENT TO THE

2368
02:05:45,531 --> 02:05:49,101
FANTASTIC STUDY DR. CHIKWE 

2369
02:05:49,101 --> 02:05:51,671
DESCRIBED AND THE SURGICAL 

2370
02:05:51,671 --> 02:05:54,540
VERSUS THE TRANSCATHETER REPAIRS

2371
02:05:54,540 --> 02:05:59,612
OF MITRAL VALVE PROLAPSE.

2372
02:05:59,612 --> 02:06:02,114
THE AIM HERE IS TO LOOK AT THE 

2373
02:06:02,114 --> 02:06:05,184
OPTIMAL REPAIR NOT ONLY IN TERMS

2374
02:06:05,184 --> 02:06:10,957
OF THE VALVE BUT VENTRICULAR 

2375
02:06:10,957 --> 02:06:16,295
MECHANICS AND THIS IS BEING 

2376
02:06:16,295 --> 02:06:20,600
STUDIED PROPOS  -- PROSPECTIVELY

2377
02:06:20,600 --> 02:06:26,172
AND THIS IS AN EXAMPLE FROM 

2378
02:06:26,172 --> 02:06:27,573
STUDIES HERE SHOWING THE 

2379
02:06:27,573 --> 02:06:28,841
ABNORMAL MECHANICS ON THE LEFT 

2380
02:06:28,841 --> 02:06:31,577
AND UNTREATED MVP AND THE 

2381
02:06:31,577 --> 02:06:32,812
NORMALIZATION IN TERMS OF NOT 

2382
02:06:32,812 --> 02:06:36,115
ONLY THE VALVE BUT THE SPECKLE 

2383
02:06:36,115 --> 02:06:38,217
TRACKING AND ON THE LOWER RIGHT 

2384
02:06:38,217 --> 02:06:40,453
THE DOUBLE PEAK PATTERN IN THE 

2385
02:06:40,453 --> 02:06:46,859
BASAL AND POSTERIOR REGION PRE 

2386
02:06:46,859 --> 02:06:47,994
OPERATIVELY IS NORMALIZED.

2387
02:06:47,994 --> 02:06:50,396
THIS IS COMING DOWN THE ROAD BUT

2388
02:06:50,396 --> 02:06:52,031
WOULD BE FASCINATING AS 

2389
02:06:52,031 --> 02:06:54,000
DR. ADAMS WAS TALKING ABOUT THE 

2390
02:06:54,000 --> 02:06:56,769
DIFFERENTIATION BETWEEN THE TWO 

2391
02:06:56,769 --> 02:07:02,174
APPROACHES IN TERMS OF 

2392
02:07:02,174 --> 02:07:03,576
NORMALIZING VENTRICULAR MECH

2393
02:07:03,576 --> 02:07:11,017
MECHANICS AS A TRIGGER OF 

2394
02:07:11,017 --> 02:07:11,317
ARRHYTHMIA.

2395
02:07:11,317 --> 02:07:14,186
WE'RE COMBINING THE STUDIES AND 

2396
02:07:14,186 --> 02:07:16,856
PRIMARY TRIAL STUDY TO ACHIEVE 

2397
02:07:16,856 --> 02:07:22,795
THE AIM OF IMPROVING PREDICTION 

2398
02:07:22,795 --> 02:07:24,764
THROUGH IMAGING AS OTHERS TALKED

2399
02:07:24,764 --> 02:07:27,233
ABOUT AND WE'LL TALK ABOUT.

2400
02:07:27,233 --> 02:07:31,203
AND THE PREVENTION OF FIBROSIS 

2401
02:07:31,203 --> 02:07:35,574
IN ARRHYTHMIAS.

2402
02:07:35,574 --> 02:07:39,078
AND AS RECENTLY WRITTEN RISK 

2403
02:07:39,078 --> 02:07:39,712
STRATIFICATION IS STILL IN ITS 

2404
02:07:39,712 --> 02:07:43,549
INFANCY.

2405
02:07:43,549 --> 02:07:45,418
AND A WORKING HYPOTHESIS WOULD 

2406
02:07:45,418 --> 02:07:49,422
BE BASED ON THE DATA THAT MAJOR 

2407
02:07:49,422 --> 02:07:51,157
RISK FACTORS FOR ARRHYTHMIC MVP 

2408
02:07:51,157 --> 02:07:53,626
INCLUDE AND SHOULD INCLUDE 

2409
02:07:53,626 --> 02:07:57,296
MECHANICAL DEFORMATION AS WELL 

2410
02:07:57,296 --> 02:08:00,399
AS THE FIBROSIS WE CAN SEE FROM 

2411
02:08:00,399 --> 02:08:04,637
CMR AND THE PRESENCE OF 

2412
02:08:04,637 --> 02:08:05,371
ARRHYTHMIA PATIENT ALREADY 

2413
02:08:05,371 --> 02:08:06,772
ACHIEVING THE END POINT.

2414
02:08:06,772 --> 02:08:10,276
IN SUMMARY, ARRHYTHMIC RISK IN 

2415
02:08:10,276 --> 02:08:11,444
MVP RELATE TO THE VALVE 

2416
02:08:11,444 --> 02:08:15,481
INTERACTS WITH THE VENTRICLE AND

2417
02:08:15,481 --> 02:08:15,715
ANNULUS.

2418
02:08:15,715 --> 02:08:19,585
THE ABNORMAL MECHANICS ARE 

2419
02:08:19,585 --> 02:08:21,587
ASSOCIATED WITH MYOCARDIAL 

2420
02:08:21,587 --> 02:08:23,222
FIBROSIS AND ARRHYTHMIC RISK AND

2421
02:08:23,222 --> 02:08:25,958
THIS SUGGESTS THERE MAY BE TWO 

2422
02:08:25,958 --> 02:08:28,294
WAYS OF REDUCING RISK BOTH 

2423
02:08:28,294 --> 02:08:30,596
STRUCTURAL IN TERMS OF 

2424
02:08:30,596 --> 02:08:32,331
SUCCESSFUL REPAIR AND SURGERY 

2425
02:08:32,331 --> 02:08:35,201
AND BIOLOGICAL INTERVENTION TO 

2426
02:08:35,201 --> 02:08:38,104
UNDERSTAND WHY THE MECHANICS 

2427
02:08:38,104 --> 02:08:39,338
INDUCES FIBROSIS IN ARRHYTHMIA 

2428
02:08:39,338 --> 02:08:40,639
AND HOW WE MIGHT BE ABLE TO 

2429
02:08:40,639 --> 02:08:42,875
PREVENT THAT.

2430
02:08:42,875 --> 02:08:51,650
THANK YOU VERY MUCH.

2431
02:08:51,650 --> 02:08:52,785
>> THANK YOU, BOB.

2432
02:08:52,785 --> 02:08:53,719
DOES ANYONE HAVE QUESTION OR 

2433
02:08:53,719 --> 02:08:58,324
COMMENTS ON THIS PRESENTATION?

2434
02:08:58,324 --> 02:08:59,158
>> I HAVE A QUESTION.

2435
02:08:59,158 --> 02:09:02,828
THAT WAS A GREAT PRESENTATION, 

2436
02:09:02,828 --> 02:09:02,995
BOB.

2437
02:09:02,995 --> 02:09:04,897
IN TERMS OF OTHER PARAMETERS 

2438
02:09:04,897 --> 02:09:05,898
EVALUATED IN ADDITION TO THE 

2439
02:09:05,898 --> 02:09:09,602
DOUBLE PEAK WILL THERE BE AN 

2440
02:09:09,602 --> 02:09:13,439
ASSESSMENT OF MECHANICAL 

2441
02:09:13,439 --> 02:09:15,141
DISPERSION OR I'M INTERESTED IN 

2442
02:09:15,141 --> 02:09:16,675
THE BIOPSIES AND CORRELATION 

2443
02:09:16,675 --> 02:09:19,578
BETWEEN STRAIN AND FINDING OF 

2444
02:09:19,578 --> 02:09:23,749
BIOPSY AND WE PUBLISHED HOW 

2445
02:09:23,749 --> 02:09:33,325
POSTMORTEM  -- THE DES PERSIAN.

2446
02:09:33,325 --> 02:09:36,328
>> THE FIRST PAPER THE 

2447
02:09:36,328 --> 02:09:37,063
MECHANICAL DISPERSION WHICH 

2448
02:09:37,063 --> 02:09:38,364
CHANGES IN PARALLEL WITH THE 

2449
02:09:38,364 --> 02:09:39,698
DOUBLE PEAK PATTERN.

2450
02:09:39,698 --> 02:09:41,067
SO THERE ARE MULTIPLE MEASURES.

2451
02:09:41,067 --> 02:09:44,570
I WAS JUST FOCUSSING ON THE 

2452
02:09:44,570 --> 02:09:46,072
TRAUMATIC TROUBLE PEAK FINDING 

2453
02:09:46,072 --> 02:09:48,040
BUT MECHANICAL DISPERSION IS 

2454
02:09:48,040 --> 02:09:48,307
IMPORTANT.

2455
02:09:48,307 --> 02:09:49,909
AND THERE ARE OTHER MECHANICAL 

2456
02:09:49,909 --> 02:09:50,142
CHANGES.

2457
02:09:50,142 --> 02:09:51,944
YOU CAN MEASURE THE PATHWAY 

2458
02:09:51,944 --> 02:09:55,681
MUSCLE DISPLACEMENT.

2459
02:09:55,681 --> 02:09:58,484
FOR EXAMPLE, THERE WAS JUST 

2460
02:09:58,484 --> 02:10:00,519
PUBLISHED THIS YEAR SOME 

2461
02:10:00,519 --> 02:10:03,589
PATIENTS HAVE MORE PATHWAY 

2462
02:10:03,589 --> 02:10:05,424
MUSCLE DISPLACEMENT AND 

2463
02:10:05,424 --> 02:10:07,893
ARRHYTHMIAS AND THOSE WITH NO 

2464
02:10:07,893 --> 02:10:09,595
ARRHYTHMIAS DON'T HAVE MUCH 

2465
02:10:09,595 --> 02:10:11,097
PAPILLARY MUSCLE DISPLACEMENT.

2466
02:10:11,097 --> 02:10:12,431
THERE'S A NUMBER OF MEASURES AND

2467
02:10:12,431 --> 02:10:14,633
WE SHOULD BE MEASURING ALL OF 

2468
02:10:14,633 --> 02:10:14,867
THEM.

2469
02:10:14,867 --> 02:10:15,868
NOT ONLY IN GENERAL BUT IN THE 

2470
02:10:15,868 --> 02:10:23,576
PRIMARY TRIAL.

2471
02:10:23,576 --> 02:10:27,179
>> THANK YOU.

2472
02:10:27,179 --> 02:10:29,915
>> THERE'S ALSO THE PICKLE
SIGN 

2473
02:10:29,915 --> 02:10:32,251
HE MENTIONED AND JUDY HUNG 

2474
02:10:32,251 --> 02:10:32,518
MENTIONS.

2475
02:10:32,518 --> 02:10:37,189
I THINK WE HAVE A GOOD NUMBER OF

2476
02:10:37,189 --> 02:10:47,700
WAYS AS IMAGERS TO CORRELATE 

2477
02:10:49,068 --> 02:10:51,570
THOSE AND THE MODEL CAN BE 

2478
02:10:51,570 --> 02:10:55,207
CREATED FROM STARTING WITH THE 

2479
02:10:55,207 --> 02:10:58,043
NORMAL HEART TO TRY TO LOOK AT 

2480
02:10:58,043 --> 02:11:00,579
GENETIC PREDISPOSITION IN 

2481
02:11:00,579 --> 02:11:03,415
COMBINATION WITH MECHANICS WITH 

2482
02:11:03,415 --> 02:11:06,852
A POTENTIAL GENETIC 

2483
02:11:06,852 --> 02:11:09,288
PREDISPOSITION OR WHATEVER KIND 

2484
02:11:09,288 --> 02:11:12,124
OF PREDISPOSITION YOU FIND IN 

2485
02:11:12,124 --> 02:11:12,958
TERMS OF THE UNDERLYING 

2486
02:11:12,958 --> 02:11:16,462
SUBSTRATE.

2487
02:11:16,462 --> 02:11:18,864
>> YES, BECAUSE MECHANICAL

2488
02:11:18,864 --> 02:11:24,203
DISPERSION I WONDERED IS IT ONLY

2489
02:11:24,203 --> 02:11:29,441
THE MECHANICS AND YOU SEE IN THE

2490
02:11:29,441 --> 02:11:29,808
CARDIOMYOPATHY.

2491
02:11:29,808 --> 02:11:32,511
HAVING IT IN AN ANIMAL MODEL AND

2492
02:11:32,511 --> 02:11:38,918
SORTING THIS OUT IS IT MECHANICS

2493
02:11:38,918 --> 02:11:43,589
OR DIFFUSED FIBROSIS NMR.

2494
02:11:43,589 --> 02:11:47,059
>> A QUESTION FROM NHLBI,
IS 

2495
02:11:47,059 --> 02:11:53,866
THERE A ROLE FOR DIFFUSION OF ME

2496
02:11:53,866 --> 02:11:59,572
MYOCARDIAL -- I WISH I COULD SAY

2497
02:11:59,572 --> 02:12:03,876
I UNDERSTAND IT CONTINUES TO 

2498
02:12:03,876 --> 02:12:08,480
WORK AND WE'LL WORK TO CONVEY 

2499
02:12:08,480 --> 02:12:09,582
THIS IN THE PROSPECTIVE 

2500
02:12:09,582 --> 02:12:12,585
EXPERIMENTAL STUDIES THEY CAN BE

2501
02:12:12,585 --> 02:12:15,588
DOING DIFFUSION TENSER IMAGING.

2502
02:12:15,588 --> 02:12:18,023
FOLLOWING UP ON YOUR PAPER, AS 

2503
02:12:18,023 --> 02:12:19,892
WELL IN WHICH YOU DESCRIBED THE 

2504
02:12:19,892 --> 02:12:21,026
ROLE.

2505
02:12:21,026 --> 02:12:25,831
I THINK IN CARDIOMYOPATHY BUT AN

2506
02:12:25,831 --> 02:12:36,375
IMPORTANT MEASURE OF MECHANICS.

2507
02:12:37,743 --> 02:12:41,280
>> IT'S FASCINATING TO SEE
THIS 

2508
02:12:41,280 --> 02:12:42,681
AND VERY INTERESTING FINDING.

2509
02:12:42,681 --> 02:12:51,590
I JUST WANT TO KNOW IF YOU FIND 

2510
02:12:51,590 --> 02:12:58,230
SOME TYPES INSIDE THE CELLS AS 

2511
02:12:58,230 --> 02:12:59,632
DESCRIBED BY OTHERS A FEW YEARS 

2512
02:12:59,632 --> 02:13:05,170
AGO IN PATIENTS WHO EXPERIENCE 

2513
02:13:05,170 --> 02:13:08,107
THE MITRAL VALVE COLLAPSE.

2514
02:13:08,107 --> 02:13:13,279
DID YOU REMEMBER THE PAPER WITH 

2515
02:13:13,279 --> 02:13:23,822
SORT OF THE CELL AND ASSOCIATED 

2516
02:13:26,158 --> 02:13:36,335
WITH FIBROSIS 

2517
02:13:50,482 --> 02:13:52,217
>> I'LL ADDRESS THE
QUESTION TO 

2518
02:13:52,217 --> 02:13:53,986
HIM AND I CAN SAY IN THE PAPER 

2519
02:13:53,986 --> 02:13:58,824
FROM MORNING STAR FROM THREE 

2520
02:13:58,824 --> 02:14:04,463
YEARS AGO AND ACCURATE MOUSE 

2521
02:14:04,463 --> 02:14:06,865
MODEL THERE WERE MYOCARDIAL CELL

2522
02:14:06,865 --> 02:14:13,806
AB NONORMALITIES IN THE REGION  

2523
02:14:13,806 --> 02:14:15,574
LOCALIZED FIBROSIS.

2524
02:14:15,574 --> 02:14:20,879
SO YES, THERE ARE ADDITIONALLY 

2525
02:14:20,879 --> 02:14:22,848
MYOCARDIAL AND MYOCYTE 

2526
02:14:22,848 --> 02:14:24,983
ABNORMALITIES THAT CAN 

2527
02:14:24,983 --> 02:14:35,127
CONTRIBUTE TO THE ARRHYTHMIC 

2528
02:14:35,127 --> 02:14:35,361
GENESIS.

2529
02:14:35,361 --> 02:14:45,037
>> THERE WERE OXIDATIVE
STRESS I

2530
02:14:45,037 --> 02:14:48,307
THINK WE'LL SEE THE ULTRA 

2531
02:14:48,307 --> 02:14:54,913
STRUCTURAL CHANGES WITH OTHER 

2532
02:14:54,913 --> 02:14:59,151
PROTEINS IT WILL BE INTERESTING 

2533
02:14:59,151 --> 02:15:01,854
TO HAVE OUR OWN HISTOLOGY 

2534
02:15:01,854 --> 02:15:02,454
RESULTS.

2535
02:15:02,454 --> 02:15:09,928
>> AND IN THE STEDESIGN OF
THE 

2536
02:15:09,928 --> 02:15:14,333
TRIAL DR. CHIKWE TALKED ABOUT IN

2537
02:15:14,333 --> 02:15:16,135
IT FROM DIFFERENT REGIONS WILL 

2538
02:15:16,135 --> 02:15:18,337
ALSO BE VERY HELPFUL AT 

2539
02:15:18,337 --> 02:15:23,509
EXPLORING NOT ONLY THE FIBROTIC 

2540
02:15:23,509 --> 02:15:25,477
GENE EXPRESSION BUT CHANGES IN 

2541
02:15:25,477 --> 02:15:28,080
THE MYOCARDIUM AND STRUCTURAL 

2542
02:15:28,080 --> 02:15:28,447
CHANGES.

2543
02:15:28,447 --> 02:15:30,382
IT'S A GOLDEN OPPORTUNITY AND 

2544
02:15:30,382 --> 02:15:34,486
URGE PEOPLE TO AS MUCH AS 

2545
02:15:34,486 --> 02:15:35,454
POSSIBLE TO GET THOSE VERY 

2546
02:15:35,454 --> 02:15:37,122
DIFFICULT TO OBTAIN SAMPLES.

2547
02:15:37,122 --> 02:15:40,692
>> AND ON THAT NOTE, NEXT 

2548
02:15:40,692 --> 02:15:43,595
SPEAKER IN THE SESSION IS 

2549
02:15:43,595 --> 02:15:44,797
DR. BORGER.

2550
02:15:44,797 --> 02:15:46,932
>> THANKS VERY MUCH,
FRANK.

2551
02:15:46,932 --> 02:15:50,936
THANKS FOR THE INVITATION TO 

2552
02:15:50,936 --> 02:15:53,705
SPEAK AT THIS TREMENDOUSLY 

2553
02:15:53,705 --> 02:15:54,173
INTERESTING SYMPOSIUM.

2554
02:15:54,173 --> 02:15:59,545
THESE ARE MY DISCLOSURES.

2555
02:15:59,545 --> 02:16:02,648
MY HOSPITAL DOES RECEIVE 

2556
02:16:02,648 --> 02:16:04,383
CONSULTING FEES AND I DO NOT 

2557
02:16:04,383 --> 02:16:09,621
RECEIVE ANY MONIES BUT I'M A 

2558
02:16:09,621 --> 02:16:13,358
CARDIAC SURGEON AND THIS IS THE 

2559
02:16:13,358 --> 02:16:17,729
PERSPECTIVE OF THE TALK.

2560
02:16:17,729 --> 02:16:27,573
SO BOB HAS GIVEN BACKGROUND TO 

2561
02:16:27,573 --> 02:16:30,342
THE DISCUSSION WE'VE HAD AND A 

2562
02:16:30,342 --> 02:16:39,351
PAPER WE RECENTLY PUBLISHED 

2563
02:16:39,351 --> 02:16:41,920
CHANGES THAT OCCUR IN MITRAL 

2564
02:16:41,920 --> 02:16:43,455
VALVE PROLAPSE AND THE 

2565
02:16:43,455 --> 02:16:46,758
ALTERATION OF THE VALVE, 

2566
02:16:46,758 --> 02:16:48,627
VENTRICLE AND ALSO WITH THE 

2567
02:16:48,627 --> 02:16:49,795
PAPILLARY MUSCLE FIBROSIS WHICH 

2568
02:16:49,795 --> 02:16:52,698
IS NOT SO COMMONLY KNOWN WITHIN 

2569
02:16:52,698 --> 02:16:55,634
THE GENERAL CARDIOVASCULAR 

2570
02:16:55,634 --> 02:17:01,573
COMMUNITY.

2571
02:17:01,573 --> 02:17:03,208
MARK MILLER PUBLISHED THIS 

2572
02:17:03,208 --> 02:17:04,276
LOVELY PAPER AND THIS OF COURSE 

2573
02:17:04,276 --> 02:17:07,579
WHAT WE'VE BEEN TALKING ABOUT 

2574
02:17:07,579 --> 02:17:15,587
THE LAST FEW DAYS.

2575
02:17:15,587 --> 02:17:19,892
ARRHYTHMIC GENIC MITRAL VALVE 

2576
02:17:19,892 --> 02:17:21,860
PROLAPSE IS NOT COMMONLY KNOWN 

2577
02:17:21,860 --> 02:17:27,165
IN THE COMPOUND AND THANKS TO 

2578
02:17:27,165 --> 02:17:28,901
THE NIH AND CONGRESSMAN BARR AND

2579
02:17:28,901 --> 02:17:38,243
WE THOUGHT ABOUT THE HYPOTHESIS 

2580
02:17:38,243 --> 02:17:45,717
THE STRESS ON THE PAPILLARY 

2581
02:17:45,717 --> 02:17:48,954
MUSCLE.

2582
02:17:48,954 --> 02:17:55,561
THE SUBSTRATE CAN LEAD TO 

2583
02:17:55,561 --> 02:17:58,797
ARRHYTHMIAS AND SUDDEN CARDIAC 

2584
02:17:58,797 --> 02:18:03,168
DEATH AND PULLING TENSION ON THE

2585
02:18:03,168 --> 02:18:03,735
MYOCARDIUM IS AN ONGOING 

2586
02:18:03,735 --> 02:18:13,879
TRIGGER.

2587
02:18:39,338 --> 02:18:44,343
AND LOOKING AT PROLAPSE AT THE 

2588
02:18:44,343 --> 02:18:46,912
TIME WITH YOUNGER AND LOWER RISK

2589
02:18:46,912 --> 02:18:50,182
PATIENTS WITH A LONGER LIFE 

2590
02:18:50,182 --> 02:18:51,550
EXPECTANCY AND MORE POTENTIAL 

2591
02:18:51,550 --> 02:18:57,723
FOR ARRHYTHMIAS AND SUDDEN 

2592
02:18:57,723 --> 02:19:01,126
CARDIAC DEATH.

2593
02:19:01,126 --> 02:19:06,198
AND HERE BASED ON HARD WORK ONE 

2594
02:19:06,198 --> 02:19:09,735
FRANCESCA AND BOB LAVINE AND 

2595
02:19:09,735 --> 02:19:13,572
OTHERS AMONGST OTHERS 

2596
02:19:13,572 --> 02:19:17,576
IDENTIFYING THIS DEFECT IN A 

2597
02:19:17,576 --> 02:19:20,245
FAMILY THAT HAD HIGH PENETRATION

2598
02:19:20,245 --> 02:19:23,415
OF MITRAL VALVE PROLAPSE AND HE 

2599
02:19:23,415 --> 02:19:26,918
DEVELOPED THIS KNOCK IN MODEL 

2600
02:19:26,918 --> 02:19:29,321
YOU HEARD ABOUT YESTERDAY WHICH 

2601
02:19:29,321 --> 02:19:31,590
HAS TYPICAL HISTOLOGICAL CHANGES

2602
02:19:31,590 --> 02:19:32,024
IN THE MISSING.

2603
02:19:32,024 --> 02:19:35,594
WE COMPARED THE FINDINGS IN OUR 

2604
02:19:35,594 --> 02:19:40,265
PATIENTS WITH LEIPZIG WE TOOK A 

2605
02:19:40,265 --> 02:19:41,600
BIOPSY IN THE ONLY THE AREA 

2606
02:19:41,600 --> 02:19:47,272
AROUND THE PAPILLARY MUSCLES YOU

2607
02:19:47,272 --> 02:19:57,749
SEE HERE AND THE PATIENT'S 

2608
02:19:59,317 --> 02:20:02,587
MYOCARDIUM IS EXPOSED TO VOLUME 

2609
02:20:02,587 --> 02:20:04,990
OVERLOAD WHEREAS THE PAPILLARY 

2610
02:20:04,990 --> 02:20:06,858
REGION IS EXPOSED TO THESE 

2611
02:20:06,858 --> 02:20:11,563
FORCES FROM THE PROLAPSE AND WE 

2612
02:20:11,563 --> 02:20:13,965
COMPARED THIS TO CHIP'S D ZIP 1 

2613
02:20:13,965 --> 02:20:18,870
MICE AND FOUND SIMILAR FINDINGS 

2614
02:20:18,870 --> 02:20:21,740
IN THE LOCAL MECHANICALLY 

2615
02:20:21,740 --> 02:20:24,476
INDUCED AREA COMPARED TO THE 

2616
02:20:24,476 --> 02:20:26,445
APEX OF CONTROL AND IN THE WILD 

2617
02:20:26,445 --> 02:20:28,080
TYPE MOUSE THERE WAS NO OBVIOUS 

2618
02:20:28,080 --> 02:20:33,118
FIBROSIS IN EITHER THE APEX OR 

2619
02:20:33,118 --> 02:20:35,554
INTRABASAL MIEE CARDIUM AND THIS

2620
02:20:35,554 --> 02:20:43,528
IS THE -- MYOCARDIUM AND THE 

2621
02:20:43,528 --> 02:20:50,102
PAPER REFERRED TO.

2622
02:20:50,102 --> 02:20:55,340
AND LOOKING AT FIBROSIS WITHOUT 

2623
02:20:55,340 --> 02:20:57,075
ENHANCEMENT AND DEMONSTRATED 

2624
02:20:57,075 --> 02:20:58,143
HIGHER CARDIOVASCULAR EVENT 

2625
02:20:58,143 --> 02:21:03,014
RATES IN THE PATIENTS WITH THE 

2626
02:21:03,014 --> 02:21:06,017
ENHANCEMENT REGARDLESS OF THE 

2627
02:21:06,017 --> 02:21:16,561
DEGREE OF MITRAL REGURGITATION.

2628
02:21:50,729 --> 02:21:53,231
WE FOUND MORE CELLULAR VOLUME IN

2629
02:21:53,231 --> 02:21:58,637
THE PAPILLARY MUSCLE REGION AS 

2630
02:21:58,637 --> 02:22:01,206
YOU SEE HOWEVER, IT'S DIFFICULT 

2631
02:22:01,206 --> 02:22:03,341
TO IMAGE AND HE TOGETHER WITH 

2632
02:22:03,341 --> 02:22:11,583
ONE OF OUR MR SPECIALISTS USED 

2633
02:22:11,583 --> 02:22:19,591
THE PROTOCOL BUT IT'S 

2634
02:22:19,591 --> 02:22:30,135
INTERESTING AND THIS CORRELATED 

2635
02:22:40,212 --> 02:22:45,083
WITH THE BIOPSY WITH LITTLE 

2636
02:22:45,083 --> 02:22:49,754
EVIDENCE OF FIBROSIS AND THIS 

2637
02:22:49,754 --> 02:22:52,724
SHOWED POSITIVE ENHANCEMENT 

2638
02:22:52,724 --> 02:22:54,326
SHOWN ON THE THIRD IMAGE.

2639
02:22:54,326 --> 02:22:56,161
THE BLOOD IS DARK ENABLING YOU 

2640
02:22:56,161 --> 02:22:59,598
TO DETECT THIS FIBROSIS WHICH 

2641
02:22:59,598 --> 02:23:03,535
WOULDN'T NECESSARILY NORMALLY 

2642
02:23:03,535 --> 02:23:07,772
SEE AND CORRELATED WITH MODERATE

2643
02:23:07,772 --> 02:23:09,007
FIBROSIS AND THIS IS A PATIENT 

2644
02:23:09,007 --> 02:23:12,777
WITH ENHANCEMENT ON BOTH 

2645
02:23:12,777 --> 02:23:16,281
TECHNIQUES AND NOT SURPRISINGLY 

2646
02:23:16,281 --> 02:23:19,584
THE BIOPSY SHOWS FIBROSIS IN THE

2647
02:23:19,584 --> 02:23:29,728
PATIENT.

2648
02:23:33,565 --> 02:23:38,637
AND WE COMPARED AND THE HIST

2649
02:23:38,637 --> 02:23:40,205
HISTOGRAM AN ENHANCEMENT ON THE 

2650
02:23:40,205 --> 02:23:41,706
LEFT THIRD AND MIDDLE THIRD IS 

2651
02:23:41,706 --> 02:23:43,708
THE DARK BLOOD AND YOU SEE 

2652
02:23:43,708 --> 02:23:46,678
ESPECIALLY AROUND THE PAPILLARY 

2653
02:23:46,678 --> 02:23:50,348
MUSCLE REGIONS A HIGH RATE OF 

2654
02:23:50,348 --> 02:23:51,216
FIBROSIS DETECTED WITH THE DARK 

2655
02:23:51,216 --> 02:23:59,591
BLOOD AND CORAL  -- CORRELATED 

2656
02:23:59,591 --> 02:24:10,135
WITH THE HISTOLOGICAL FINDINGS.

2657
02:24:12,637 --> 02:24:21,413
AND WE SPOKE WITH JOE WU WITH 

2658
02:24:21,413 --> 02:24:31,957
HIS EXCELLENT MODEL AND YOU'LL 

2659
02:24:32,590 --> 02:24:34,693
SEE THESE VERY SENSITIVE SENSORS

2660
02:24:34,693 --> 02:24:38,296
THAT ARE ATTACHED TO THE 

2661
02:24:38,296 --> 02:24:39,798
PAPILLARY MUSCLES IN ORDER TO 

2662
02:24:39,798 --> 02:24:48,406
MEASURE FORCES.

2663
02:24:48,406 --> 02:24:53,445
ON THE LEFT IS THE SHEET MITRAL 

2664
02:24:53,445 --> 02:24:54,646
VALVE WITH LITTLE REGURGITATION.

2665
02:24:54,646 --> 02:24:58,683
ON THE MIDDLE IS WHERE THEY 

2666
02:24:58,683 --> 02:25:01,519
SIMPLY CUT ONE OF THE CHORDE AND

2667
02:25:01,519 --> 02:25:04,322
HAD MITRAL REGURGITATION AND ON 

2668
02:25:04,322 --> 02:25:07,592
THE RIGHT IS THIS INDUCED 

2669
02:25:07,592 --> 02:25:10,462
PROLAPSE THE OFF SIT OF THE 

2670
02:25:10,462 --> 02:25:11,863
TECHNIQUE MY FORMER BOSS 

2671
02:25:11,863 --> 02:25:13,331
DEVELOPED TO CORRECT PROLAPSE.

2672
02:25:13,331 --> 02:25:15,266
THE OPPOSITE OF CORRECTING 

2673
02:25:15,266 --> 02:25:15,533
PROLAPSE.

2674
02:25:15,533 --> 02:25:19,504
WE CUT THE CORDS AND PUT IN 

2675
02:25:19,504 --> 02:25:21,740
NEEDLE CHORDAE ON PURPOSE TOO 

2676
02:25:21,740 --> 02:25:25,910
LONG INDUCING MILD TO MODERATE 

2677
02:25:25,910 --> 02:25:29,814
MRI AND THE SHEET DON'T TOLERATE

2678
02:25:29,814 --> 02:25:31,916
SEVERE MR AND IT'S A FINE TUNING

2679
02:25:31,916 --> 02:25:34,919
MODEL IN ORDER TO GET THE AMOUNT

2680
02:25:34,919 --> 02:25:38,156
OF MR CORRECT AND YOU CAN SEE 

2681
02:25:38,156 --> 02:25:39,791
THE FORCED DISTRIBUTION ON THE 

2682
02:25:39,791 --> 02:25:41,359
PAPILLARY MUSCLES IS THE MOST 

2683
02:25:41,359 --> 02:25:44,629
WITH THIS MILD TO MODERATE 

2684
02:25:44,629 --> 02:25:45,997
REGURGITATION AND PROLAPSE.

2685
02:25:45,997 --> 02:25:48,700
IT'S VERY IMPORTANT THOUGH TO 

2686
02:25:48,700 --> 02:25:50,101
POINT OUT THAT THIS MITRAL VALVE

2687
02:25:50,101 --> 02:25:53,872
LOOKS NOTHING LIKE THE MITRAL 

2688
02:25:53,872 --> 02:25:55,173
VALVES DAVID ADAMS WAS SHOWING 

2689
02:25:55,173 --> 02:25:56,307
IN HIS PRESENTATIONS.

2690
02:25:56,307 --> 02:25:58,543
THESE ARE NORMAL MITRAL VALVES 

2691
02:25:58,543 --> 02:25:59,577
SLIGHTLY ALTERED.

2692
02:25:59,577 --> 02:26:02,814
THEY DON'T HAVE LARGE ANNULUS OR

2693
02:26:02,814 --> 02:26:07,852
BIG REDUNDANT TISSUE THAT ACT AS

2694
02:26:07,852 --> 02:26:08,920
SAILS IN ORDER TO INCREASE THE 

2695
02:26:08,920 --> 02:26:11,589
AMOUNT OF FORCE BEING PLACED ON 

2696
02:26:11,589 --> 02:26:21,866
THE MYOCARDIUM.

2697
02:26:36,314 --> 02:26:38,750
AND THIS UNDER SCORES HOW 

2698
02:26:38,750 --> 02:26:42,220
IMPORTANT THE PROBLEM IS AND THE

2699
02:26:42,220 --> 02:26:49,828
SHEET MODEL AND A SHOUT OUT TO 

2700
02:26:49,828 --> 02:26:51,162
THE WELL ESTABLISHED MITRAL 

2701
02:26:51,162 --> 02:26:52,464
VALVE SURGEON IN BOSTON AND 

2702
02:26:52,464 --> 02:26:55,100
SHOWED AN TONIA HOW TO TO THIS 

2703
02:26:55,100 --> 02:26:57,435
WHICH IS A TRICKY OPERATION TO 

2704
02:26:57,435 --> 02:26:57,836
DO.

2705
02:26:57,836 --> 02:27:03,141
YOU'RE BASICALLY CUTTING THE 

2706
02:27:03,141 --> 02:27:05,009
PRIMARY CHORDS AND INSERTING 

2707
02:27:05,009 --> 02:27:07,579
WHAT IS ON PURPOSE TOO LONG BUT 

2708
02:27:07,579 --> 02:27:13,084
NOT TOO TOO LONG.

2709
02:27:13,084 --> 02:27:19,290
AND THIS IS VERY SUBTLE BUT THEY

2710
02:27:19,290 --> 02:27:20,925
CAN HAVE MODERATE PULMONARY 

2711
02:27:20,925 --> 02:27:23,394
EDEMA AND WON'T SURVIVE BUT IF 

2712
02:27:23,394 --> 02:27:29,701
THE ANNULUS IS NOT ENLARGED AND 

2713
02:27:29,701 --> 02:27:33,238
MR IS NOT SEVERE AND WE SEE GOES

2714
02:27:33,238 --> 02:27:35,440
HISTOLOGIC EVERYDAY AND THE 

2715
02:27:35,440 --> 02:27:41,446
ELONGATED CHORDAE AND HERE YOU 

2716
02:27:41,446 --> 02:27:43,781
SEE EASILY THE GROSS MYOCARDIAL 

2717
02:27:43,781 --> 02:27:45,783
FIBROSIS COMPARED TO THE OTHER 

2718
02:27:45,783 --> 02:27:47,785
PAPILLARY MUSCLE WHERE THERE WAS

2719
02:27:47,785 --> 02:27:56,294
NO ELONGATED CHORDS AND PET 

2720
02:27:56,294 --> 02:27:57,328
SCANNING INDICATING SOME 

2721
02:27:57,328 --> 02:27:58,329
INFLAMMATION AS WELL.

2722
02:27:58,329 --> 02:28:03,701
THIS NEXT SLIDE I BELIEVE WE 

2723
02:28:03,701 --> 02:28:11,176
HAVE SEEN AND THE CMR WITH 

2724
02:28:11,176 --> 02:28:15,213
FIBROSIS AND IT'S A FEW MONTHS 

2725
02:28:15,213 --> 02:28:19,584
IN MILD TO MODERATE MR WITHOUT 

2726
02:28:19,584 --> 02:28:29,861
SEVERE PROLAPSE.

2727
02:29:33,958 --> 02:29:35,960
AND WE'RE TRYING TO GET A BETTER

2728
02:29:35,960 --> 02:29:37,762
VIEW IN A MOMENT.

2729
02:29:37,762 --> 02:29:39,831
THE EXTENSIVE GROSS FIBROSIS YOU

2730
02:29:39,831 --> 02:29:43,801
SEE ON THE PAPILLARY MUSCLE SO 

2731
02:29:43,801 --> 02:29:49,240
YOU SEE THESE PATCHES OF 

2732
02:29:49,240 --> 02:29:50,842
FIBROSIS AND ALSO IN THE 

2733
02:29:50,842 --> 02:29:53,311
INTRABASAL REASON IS THE AREA WE

2734
02:29:53,311 --> 02:29:55,680
DO THE BIOPSIES FROM WE DON'T 

2735
02:29:55,680 --> 02:29:58,216
WANT TO BIOPSY THE PAPILLARY 

2736
02:29:58,216 --> 02:30:02,053
MUSCLE BUT AS WE GO FURTHER DOWN

2737
02:30:02,053 --> 02:30:05,957
THE VENTRICLE YOU HAVE A 2-D 

2738
02:30:05,957 --> 02:30:08,159
VIEW OF A 3-D STRUCTURE AND THE 

2739
02:30:08,159 --> 02:30:15,466
APEX IS SIX, SEVEN CENTIMETERS 

2740
02:30:15,466 --> 02:30:17,302
AWAY AND NOT THE SAME AS YOU SEE

2741
02:30:17,302 --> 02:30:19,404
ON THE SCREEN HERE.

2742
02:30:19,404 --> 02:30:24,108
HERE IS A MITRAL REPAIR.

2743
02:30:24,108 --> 02:30:25,777
REABLATE THE MUSCLES AND LAD 

2744
02:30:25,777 --> 02:30:28,012
GOOD RESULT FROM THE SURGERY AND

2745
02:30:28,012 --> 02:30:29,547
ONE YEAR LATER HE'S COMPLETELY 

2746
02:30:29,547 --> 02:30:31,316
FINE AND HAD NO MORE DISCHARGES 

2747
02:30:31,316 --> 02:30:33,685
OF HIS ICD.

2748
02:30:33,685 --> 02:30:38,189
HIS PVC RATE DROPPED OVER 95%.

2749
02:30:38,189 --> 02:30:41,526
AND HE HAS NO MORE SYMPTOMS FROM

2750
02:30:41,526 --> 02:30:45,730
HIS MITRAL REGURGITATION EVEN A 

2751
02:30:45,730 --> 02:30:47,098
CARDIOLOGIST THEMSELVES DON'T 

2752
02:30:47,098 --> 02:30:49,267
KNOW IT'S A PROBLEM AND THERE 

2753
02:30:49,267 --> 02:30:51,302
ARE SOLUTIONS TO IT.

2754
02:30:51,302 --> 02:30:57,342
SO PRIMARY STUDY YOU HEARD MANY 

2755
02:30:57,342 --> 02:31:07,852
TIMES HERE AND WITH REGARD TO 

2756
02:31:09,854 --> 02:31:14,492
THEIR EFFECT ON PATIENT RELEVANT

2757
02:31:14,492 --> 02:31:14,759
OUTCOMES.

2758
02:31:14,759 --> 02:31:19,597
WE ALL KNOW THAT THIS IS ALREADY

2759
02:31:19,597 --> 02:31:22,166
GIVING A GROSS REPRESENTATION 

2760
02:31:22,166 --> 02:31:27,305
WITH THE ADT8 OR 10 YEARS OLD 

2761
02:31:27,305 --> 02:31:30,775
AND NOT A NORMAL LOOKING 

2762
02:31:30,775 --> 02:31:31,376
PHYSIOLOGIC MOVEMENT OF THE 

2763
02:31:31,376 --> 02:31:35,646
MITRAL VALVE COMPARED NO THE 

2764
02:31:35,646 --> 02:31:37,949
PATIENT ON THE RIGHT WHO'S HAD 

2765
02:31:37,949 --> 02:31:39,450
CHORDS IN THE LOOP TECHNIQUE TO 

2766
02:31:39,450 --> 02:31:45,490
THE POSTERIOR AND ANTERIOR 

2767
02:31:45,490 --> 02:31:49,627
LEAFLET AND YOU DON'T HAVE TO BE

2768
02:31:49,627 --> 02:31:52,864
A SPECIALIST TO SAY IT HAS TO BE

2769
02:31:52,864 --> 02:31:54,665
MORE PHYSIOLOGIC.

2770
02:31:54,665 --> 02:31:56,768
AND WE KNOW MITRAL VALVE REPAIR 

2771
02:31:56,768 --> 02:31:59,504
SURGERY AT LEAST IN GERMANY IS 

2772
02:31:59,504 --> 02:32:02,807
ON THE DECREASE PARTLY DUE TO 

2773
02:32:02,807 --> 02:32:07,845
THE INCREASE IN TIER WHICH WE 

2774
02:32:07,845 --> 02:32:18,389
ALL KNOW THERE'S DATA SHOWING AN

2775
02:32:21,159 --> 02:32:24,162
ANNUAL PROCEDURE FOR FUNCTIONAL 

2776
02:32:24,162 --> 02:32:28,399
MR LEAFLETS AND THIS IS VERY 

2777
02:32:28,399 --> 02:32:30,435
DIFFERENT ON THAT A PATIENT 

2778
02:32:30,435 --> 02:32:33,805
UNDER GOING TO TEER WHERE THERE 

2779
02:32:33,805 --> 02:32:34,439
IS NOT NEARLY THIS NORMALIZATION

2780
02:32:34,439 --> 02:32:44,615
OF FORCES.

2781
02:32:48,586 --> 02:32:51,856
THIS NORMALIZATION OF THE BIO 

2782
02:32:51,856 --> 02:32:59,564
MECHANICS MAYBE WHY WE SEE GOOD 

2783
02:32:59,564 --> 02:33:01,599
RESULTS THOUGH IT'S AN ALL 

2784
02:33:01,599 --> 02:33:02,800
COMERS PAPER WITH MORTALITY OF 

2785
02:33:02,800 --> 02:33:06,604
1.6 FOR THE ENTIRE GROUP AND 

2786
02:33:06,604 --> 02:33:13,811
MORBIDITY OR MORTALITY OF 8.7%.

2787
02:33:13,811 --> 02:33:20,384
AND LOW MORTALITY IN THE LOWER 

2788
02:33:20,384 --> 02:33:21,285
RISK PATIENTS.

2789
02:33:21,285 --> 02:33:22,386
IS THIS A CURE?

2790
02:33:22,386 --> 02:33:30,528
IF YOU LOOK AT MY ORIGINAL 

2791
02:33:30,528 --> 02:33:35,166
MENTOR YOU SEE WITH THE LARGE 

2792
02:33:35,166 --> 02:33:38,769
NUMBER OF PATIENTS EXCELLENT 

2793
02:33:38,769 --> 02:33:39,737
RESULTS REGARDING MORTALITY EVEN

2794
02:33:39,737 --> 02:33:41,172
WITH PATIENTS EARLIER IN THE 

2795
02:33:41,172 --> 02:33:44,542
DISEASE PROCESS AND IN THIS 

2796
02:33:44,542 --> 02:33:47,078
PAPER IN CIRCULATION IT WAS 

2797
02:33:47,078 --> 02:33:49,514
DEMONSTRATED NORMALIZATION OF 

2798
02:33:49,514 --> 02:33:50,715
THE SURVIVAL CURVES FOR HEART 

2799
02:33:50,715 --> 02:33:51,883
DISEASE THIS IS THE ONLY 

2800
02:33:51,883 --> 02:33:54,752
TREATMENT I KNOW OF THAT 

2801
02:33:54,752 --> 02:33:57,221
NORMALIZES ONLY SURGICAL OR 

2802
02:33:57,221 --> 02:33:58,155
INTERVENTIONAL TREATMENT THAT I 

2803
02:33:58,155 --> 02:34:00,458
KNOW OF THAT NORMALIZES THE 

2804
02:34:00,458 --> 02:34:04,529
SURVIVAL AFTER THE INTERVENTION.

2805
02:34:04,529 --> 02:34:07,064
SO MAYBE THIS IS A CURE?

2806
02:34:07,064 --> 02:34:08,833
BUT WE NEED MORE DATA AND THIS 

2807
02:34:08,833 --> 02:34:09,400
IS SOME OF THE DATA WE'RE 

2808
02:34:09,400 --> 02:34:10,768
GATHERING.

2809
02:34:10,768 --> 02:34:13,671
SO THIS IS JUST SHOWING OUR 

2810
02:34:13,671 --> 02:34:18,910
TECHNIQUE, DAVID SHOWED YOU HIS 

2811
02:34:18,910 --> 02:34:27,685
WITH THE KNIFE.

2812
02:34:27,685 --> 02:34:33,891
SO WHAT I USE IS A VERY HANDY 

2813
02:34:33,891 --> 02:34:38,896
THROUGH THE  APPROACH AND SEE 

2814
02:34:38,896 --> 02:34:41,666
WHAT YOU'RE DOING WITH THE ENDO 

2815
02:34:41,666 --> 02:34:45,269
SCOPE AND THIS IS THE AREA OF 

2816
02:34:45,269 --> 02:34:47,338
INTEREST BETWEEN THE PAPILLARY 

2817
02:34:47,338 --> 02:34:49,974
MUSCLES AND THE NEXT VIDEO -- 

2818
02:34:49,974 --> 02:34:50,274
SORRY.

2819
02:34:50,274 --> 02:34:51,576
WE'RE MISSING A VIDEO SHOWING 

2820
02:34:51,576 --> 02:34:56,314
THE CONTROL FROM THE APEX OF THE

2821
02:34:56,314 --> 02:34:57,582
LEFT VENTRICLE BUT YOU 

2822
02:34:57,582 --> 02:35:00,818
UNDERSTAND THE POINT.

2823
02:35:00,818 --> 02:35:02,753
WE'RE LOOKING AT ARRHYTHMIA'S 

2824
02:35:02,753 --> 02:35:07,959
AND CMRs AND THE SPECKLE TRACK 

2825
02:35:07,959 --> 02:35:11,596
AND DOUBLE PEAK SIGN AMONGST 

2826
02:35:11,596 --> 02:35:21,505
OTHER ON ECHO CARDIOGRAPHY AND 

2827
02:35:21,505 --> 02:35:23,975
THE PROLAPSE IS A COMMON DISEASE

2828
02:35:23,975 --> 02:35:30,114
AND ASSOCIATED WITH VENTRICULAR 

2829
02:35:30,114 --> 02:35:31,582
ARRHYTHMIAS AND MECHANICAL 

2830
02:35:31,582 --> 02:35:33,217
STRESS IS ASSOCIATED WITH THE 

2831
02:35:33,217 --> 02:35:33,684
FIBROSIS.

2832
02:35:33,684 --> 02:35:37,421
IT COULD BE THE SUBSTRATE BUT BY

2833
02:35:37,421 --> 02:35:40,558
DOING THE VENTRICULAR 

2834
02:35:40,558 --> 02:35:42,059
ARRHYTHMIAS AND BY DOING THE 

2835
02:35:42,059 --> 02:35:43,728
SURGERY YOU CAN ELIMINATE THE 

2836
02:35:43,728 --> 02:35:45,396
TRIGGER MAYBE NOT THE SUBSTRATE 

2837
02:35:45,396 --> 02:35:47,365
BUT THE TRIGGER AND MAYBE WHY 

2838
02:35:47,365 --> 02:35:51,569
THE PATIENTS HAVE A NORMAL LIFE 

2839
02:35:51,569 --> 02:35:53,471
EXPECTANCY AFTER THE OPERATION 

2840
02:35:53,471 --> 02:35:56,040
BUT ONGOING TRIALS WILL BE MORE 

2841
02:35:56,040 --> 02:35:58,376
INFORMATIVE AND WE'RE THANKFUL 

2842
02:35:58,376 --> 02:36:01,512
TO NIH FOR THE FUNDING BOB SPOKE

2843
02:36:01,512 --> 02:36:02,446
TO EARLIER WITHIN THE PRIMARY 

2844
02:36:02,446 --> 02:36:03,581
TRIAL.

2845
02:36:03,581 --> 02:36:07,351
THANK YOU FOR YOUR ATTENTION.

2846
02:36:07,351 --> 02:36:08,919
I'LL BE HAPPY TO ANSWER ANY 

2847
02:36:08,919 --> 02:36:09,186
QUESTIONS.

2848
02:36:09,186 --> 02:36:11,589
>> THANK YOU, MICHAEL.

2849
02:36:11,589 --> 02:36:13,024
DOES ANYONE HAVE BRIEF QUICKS OR

2850
02:36:13,024 --> 02:36:14,592
COMMENTS ON THE PRESENTATION?

2851
02:36:14,592 --> 02:36:19,897
>> MICHAEL, LEAPT ME ASK
YOU 

2852
02:36:19,897 --> 02:36:27,571
ABOUT THE BIO MECHANICS AND THE 

2853
02:36:27,571 --> 02:36:35,913
TRIAL YOU'RE GOING TO SEE 

2854
02:36:35,913 --> 02:36:38,582
WHETHER YOU ELIMINATE THE EMR 

2855
02:36:38,582 --> 02:36:42,053
AND THE MECHANISMS TO TO IT.

2856
02:36:42,053 --> 02:36:43,921
WHAT ABOUT THE ARRHYTHMIC 

2857
02:36:43,921 --> 02:36:45,756
PROLAPSE PART OF THIS?

2858
02:36:45,756 --> 02:36:47,591
BECAUSE IN GENERAL THE TEER 

2859
02:36:47,591 --> 02:36:50,895
CANDIDATES -- WELL, YOU CATCH US

2860
02:36:50,895 --> 02:36:51,062
UP.

2861
02:36:51,062 --> 02:36:54,665
THE TEER CANDIDATES IN GENERAL 

2862
02:36:54,665 --> 02:36:59,236
WERE SINGLE LEAFLET PROLAPSE.

2863
02:36:59,236 --> 02:37:02,473
WE BOTH HAVE SEEN MORE COMMONLY 

2864
02:37:02,473 --> 02:37:10,681
IN ARRHYTHMIC PROLAPSE.

2865
02:37:10,681 --> 02:37:16,654
AND THEY'RE CANDIDATES TO STUDY 

2866
02:37:16,654 --> 02:37:18,089
THE EFFECT ON ARRHYTHMIC 

2867
02:37:18,089 --> 02:37:21,592
PROLAPSE AND ELIMINATING 

2868
02:37:21,592 --> 02:37:23,594
REGURGITATION AND LESS ABOUT 

2869
02:37:23,594 --> 02:37:25,563
ARRHYTHMIA PRO-LAPSE.

2870
02:37:25,563 --> 02:37:27,131
>> GREAT QUESTION.

2871
02:37:27,131 --> 02:37:31,335
WE'RE NOT ENROLLING A LOT OF 

2872
02:37:31,335 --> 02:37:33,037
BARLOW'S TYPE PATIENTS.

2873
02:37:33,037 --> 02:37:35,639
THEY'RE USUALLY SCREENED OUT AND

2874
02:37:35,639 --> 02:37:43,581
IT'S PICKING THE RUPTURED 

2875
02:37:43,581 --> 02:37:48,185
DEFICIENCY PATIENTS.

2876
02:37:48,185 --> 02:37:49,887
AND THERE MAY NOT BE A 

2877
02:37:49,887 --> 02:37:51,589
DIFFERENCE BECAUSE OF THE FACT 

2878
02:37:51,589 --> 02:37:55,526
BUT WE HAVE --  WE'RE LOOKING AT

2879
02:37:55,526 --> 02:37:58,929
SO MANY ASPECTS, REVERSE 

2880
02:37:58,929 --> 02:38:02,133
REMELDING AND CMR AND THE 

2881
02:38:02,133 --> 02:38:06,103
FIBROSIS ON CMR AND HOW IT 

2882
02:38:06,103 --> 02:38:11,575
CORRELATES WITH THE HISTOLOGIC 

2883
02:38:11,575 --> 02:38:12,643
EXAMINATION AND THE FIBROSIS 

2884
02:38:12,643 --> 02:38:14,779
WILL BE HALTED IN THE SURGICAL 

2885
02:38:14,779 --> 02:38:17,248
PATIENTS AND PROBABLY PROGRESS 

2886
02:38:17,248 --> 02:38:17,782
IN THE TEER PATIENTS.

2887
02:38:17,782 --> 02:38:21,919
>> MICHAEL, I THINK IT'S 

2888
02:38:21,919 --> 02:38:22,553
COMPLEMENTARY TO THE WORK OUR 

2889
02:38:22,553 --> 02:38:23,020
GROUP DOING.

2890
02:38:23,020 --> 02:38:24,488
I THINK THE POPULATIONS WILL BE 

2891
02:38:24,488 --> 02:38:27,291
DIFFERENT.

2892
02:38:27,291 --> 02:38:29,026
WE'RE GOING TO LEARN A LOT AT 

2893
02:38:29,026 --> 02:38:34,398
THE MICROBE SCOPIC LEVEL FROM 

2894
02:38:34,398 --> 02:38:37,768
BOTH OF THESE I'M PRETTY 

2895
02:38:37,768 --> 02:38:39,937
CONFIDENT THE VALVE MORPHOLOGY 

2896
02:38:39,937 --> 02:38:40,538
WILL BE DIFFERENT.

2897
02:38:40,538 --> 02:38:44,408
MOST THE PRIMARY CASES WILL HAVE

2898
02:38:44,408 --> 02:38:46,110
SINGLE SEGMENTS BUT THEY'RE NOT 

2899
02:38:46,110 --> 02:38:48,879
GOING TO TO BE THE SAME AS THE 

2900
02:38:48,879 --> 02:38:54,385
END STATE DEFORMITIES WE'RE 

2901
02:38:54,385 --> 02:38:54,618
SEEING.

2902
02:38:54,618 --> 02:38:59,190
>> DON'T FORGET, DAVID,
THEY'LL 

2903
02:38:59,190 --> 02:39:01,992
BE SIMILAR BY GROUP IN THE 

2904
02:39:01,992 --> 02:39:02,827
RANDOMIZED TRIALS.

2905
02:39:02,827 --> 02:39:07,598
IT HAS TO BE AGREED TO BY THE 

2906
02:39:07,598 --> 02:39:09,900
ADJUDICATION AND SUITABLE BEFORE

2907
02:39:09,900 --> 02:39:10,334
THEY'RE RANDOMIZED.

2908
02:39:10,334 --> 02:39:13,437
>> I MEANT IN TERMS OF THE

2909
02:39:13,437 --> 02:39:15,406
POPULATION WE'RE STUDYING MORE 

2910
02:39:15,406 --> 02:39:23,113
HAVE BIG DOUBOUTS AND THINK IT L

2911
02:39:23,113 --> 02:39:23,581
BE INTERESTING.

2912
02:39:23,581 --> 02:39:27,518
WE'RE GOING TO LEARN A LOT.

2913
02:39:27,518 --> 02:39:29,086
>> BRIEFLY, PLEASE.

2914
02:39:29,086 --> 02:39:30,654
>> MICHAEL, OUTSTANDING 

2915
02:39:30,654 --> 02:39:32,890
PRESENTATION AND I ENJOYED IT 

2916
02:39:32,890 --> 02:39:35,326
AND CONGRATULATIONS ON ALL THE 

2917
02:39:35,326 --> 02:39:37,261
GREAT WORK.

2918
02:39:37,261 --> 02:39:42,166
I NOTED IN AARM OF THE WORK IN 

2919
02:39:42,166 --> 02:39:44,301
THE BIOPSIES.

2920
02:39:44,301 --> 02:39:46,770
ARE YOU DOING IT IN THE BASAL 

2921
02:39:46,770 --> 02:39:47,571
ANTEARIOR WALL?

2922
02:39:47,571 --> 02:39:51,208
>> BETWEEN THE PAPILLARY
MUSCLES

2923
02:39:51,208 --> 02:40:00,784
AND AS CONTROL ON THE APEX.

2924
02:40:00,784 --> 02:40:04,989
WE FIND ON THE SEPTAL SIDE THE 

2925
02:40:04,989 --> 02:40:06,924
FIBROSIS IS MORE IMMEDIATE WHERE

2926
02:40:06,924 --> 02:40:11,495
THE A EX -- APEX IS THE LEAST 

2927
02:40:11,495 --> 02:40:12,196
AMOUNT OF FIBROSIS.

2928
02:40:12,196 --> 02:40:14,098
>> THANK YOU VERY MUCH.

2929
02:40:14,098 --> 02:40:21,972
THE NEXT PRESENTATION IS FROM 

2930
02:40:21,972 --> 02:40:23,574
CRIST

2931
02:40:23,574 --> 02:40:24,008
CRISTINA BASSO.

2932
02:40:24,008 --> 02:40:28,045
>> THE TALK IT'S NOT EASY
FOR ME

2933
02:40:28,045 --> 02:40:29,980
TO SPEAK BECAUSE WE WERE 

2934
02:40:29,980 --> 02:40:32,983
INFORMED ABOUT THE ROLE OF 

2935
02:40:32,983 --> 02:40:33,584
FIBROSIS.

2936
02:40:33,584 --> 02:40:38,122
AS YOU KNOW I'M IN PATH OL BY.

2937
02:40:38,122 --> 02:40:39,990
-- PATHOLOGY.

2938
02:40:39,990 --> 02:40:42,426
MY EXPERIENCE STARTED MANY YEARS

2939
02:40:42,426 --> 02:40:43,961
AGO STUDYING SUDDEN DEATH 

2940
02:40:43,961 --> 02:40:54,104
VICTIMS.

2941
02:40:55,806 --> 02:40:56,573
WE LOOK AT THICKENING OF THE 

2942
02:40:56,573 --> 02:41:04,949
LEAFLET.

2943
02:41:04,949 --> 02:41:07,584
MANY WOMEN WERE DYING WITHOUT 

2944
02:41:07,584 --> 02:41:12,356
OTHER REASONS NOT FROM THE 

2945
02:41:12,356 --> 02:41:20,998
DISEASE AND CONGENITAL 

2946
02:41:20,998 --> 02:41:26,737
MALFORMATION AND WE STUDIED THE 

2947
02:41:26,737 --> 02:41:28,072
ANNULUS AND PATH LOGICALLY AND 

2948
02:41:28,072 --> 02:41:29,440
CASES WITHOUT FIBROSIS.

2949
02:41:29,440 --> 02:41:34,311
SO FIBROSIS IS NOT ONLY THE 

2950
02:41:34,311 --> 02:41:37,114
SINGLE EXPLANATION FOR 

2951
02:41:37,114 --> 02:41:39,583
LIFE-THREATENING VENTRICULAR 

2952
02:41:39,583 --> 02:41:45,956
ARRHYTHMIAS.

2953
02:41:45,956 --> 02:41:48,058
WE OBSERVE THE MOVEMENT OF THE 

2954
02:41:48,058 --> 02:41:49,360
LEAFLETS AND THERE'S A CLEAR 

2955
02:41:49,360 --> 02:41:53,998
DEGENERATION WITH THE 

2956
02:41:53,998 --> 02:41:54,298
THICKENING.

2957
02:41:54,298 --> 02:41:58,102
IN THIS CASE BOTH ANTERIOR AND 

2958
02:41:58,102 --> 02:42:01,138
POSTERIOR AND SEE REDUNDANCE OF 

2959
02:42:01,138 --> 02:42:04,008
THE TISSUE AND WHEN YOU OBSERVE 

2960
02:42:04,008 --> 02:42:14,518
HISTOLOGY BOTH AT THE VALVE 

2961
02:42:14,518 --> 02:42:19,590
LEAFLET AND WE LOOK AT THE MIGHT

2962
02:42:19,590 --> 02:42:21,025
RAL VALVE.

2963
02:42:21,025 --> 02:42:26,530
--MITRAL VALVE.

2964
02:42:26,530 --> 02:42:28,832
THIS IS WHAT WE OBSERVED IN 2015

2965
02:42:28,832 --> 02:42:29,933
AFTER MONTHS AND YEARS OF 

2966
02:42:29,933 --> 02:42:31,101
OBSERVATION.

2967
02:42:31,101 --> 02:42:38,842
WE DECIDED TO OBSERVE CAREFULLY 

2968
02:42:38,842 --> 02:42:43,747
THE MYOCARDIUM AND CLOSE TO THE 

2969
02:42:43,747 --> 02:42:45,582
MITRAL VALVE AND WERE ASTONISHED

2970
02:42:45,582 --> 02:42:47,217
TO OBSERVE THE PRESENCE OF 

2971
02:42:47,217 --> 02:42:50,054
FIBROSIS IN THE REGION OF THE 

2972
02:42:50,054 --> 02:42:51,255
LEFT VENTRICLE.

2973
02:42:51,255 --> 02:42:53,090
THE BASAL PORTION AND LEFT 

2974
02:42:53,090 --> 02:42:55,626
VENTRICLE WALL AND PAPILLARY 

2975
02:42:55,626 --> 02:43:00,931
MUSCLE AND THIS FIBROSIS WAS 

2976
02:43:00,931 --> 02:43:02,766
INTERSTITIAL BUT MAINLY SCAR 

2977
02:43:02,766 --> 02:43:03,734
RELATED FIBROSIS.

2978
02:43:03,734 --> 02:43:12,376
YOU SEE THE AREA COMPLETELY BLUE

2979
02:43:12,376 --> 02:43:15,279
AND YOU SEE THE COLLAGEN FIBERS.

2980
02:43:15,279 --> 02:43:18,982
YOU SEE HERE THE ORIGINAL 

2981
02:43:18,982 --> 02:43:22,052
PUBLICATION OF THE JUNCTION 

2982
02:43:22,052 --> 02:43:24,955
COMING FROM THE SINGLE CASE 

2983
02:43:24,955 --> 02:43:25,656
REPORTER.

2984
02:43:25,656 --> 02:43:31,095
YOU SEE ON THE DIAGRAM THE EL

2985
02:43:31,095 --> 02:43:34,198
ELONGATION OF THE ANNULUS IF YOU

2986
02:43:34,198 --> 02:43:39,570
COMPARE IT WITH CONTROL NORMAL 

2987
02:43:39,570 --> 02:43:41,038
POPULATION MEASURED FREQUENTLY 

2988
02:43:41,038 --> 02:43:43,073
THERE'S AN ELONGATION OF THE 

2989
02:43:43,073 --> 02:43:43,307
ANNULUS.

2990
02:43:43,307 --> 02:43:53,717
WE PUT TOGETHER THE TWO.

2991
02:43:57,020 --> 02:44:00,958
AND THE PAPILLARY MUSCLE PORTION

2992
02:44:00,958 --> 02:44:02,926
AND THE REASON IT COULD BE AT 

2993
02:44:02,926 --> 02:44:05,996
THE MOVEMENT OF THE LEAFLET DUE 

2994
02:44:05,996 --> 02:44:13,770
TO ELONGATION AS DEMONSTRATED BY

2995
02:44:13,770 --> 02:44:14,104
RESONANCE.

2996
02:44:14,104 --> 02:44:16,907
THIS IS THE ORIGINAL PAPER 

2997
02:44:16,907 --> 02:44:21,445
COMPARING THE SUDDEN DEATH 

2998
02:44:21,445 --> 02:44:24,114
PATIENTS AND YOU SEE THE 

2999
02:44:24,114 --> 02:44:29,253
PRESENCE OF FIBROSIS IN THE 

3000
02:44:29,253 --> 02:44:31,588
INTRABASAL WALL IT'S CLEARLY 

3001
02:44:31,588 --> 02:44:33,090
STATISTICALLY SIGNIFICANT AND 

3002
02:44:33,090 --> 02:44:35,526
WHAT ABOUT THE CARDIO MYOCYTE.

3003
02:44:35,526 --> 02:44:39,429
WE OBSERVED THE MYOCYTES IN THE 

3004
02:44:39,429 --> 02:44:46,403
AREA OF FIBROSIS IS ABNORMAL AND

3005
02:44:46,403 --> 02:44:48,605
THERE'S DISEASE CLEARLY INJURY 

3006
02:44:48,605 --> 02:44:51,575
PROBABILITY DUE TO MECHANICAL 

3007
02:44:51,575 --> 02:45:01,718
STRESS.

3008
02:45:04,154 --> 02:45:07,591
SUDDEN DEATH IN PATIENTS WITH 

3009
02:45:07,591 --> 02:45:09,826
MITRAL VALVE PROLAPSE WE HAVE 

3010
02:45:09,826 --> 02:45:11,395
IMAGING AND NOT ALL THE 

3011
02:45:11,395 --> 02:45:12,896
PROTOCOLS ARE EQUAL IN THE 

3012
02:45:12,896 --> 02:45:15,265
IMAGING SETTING PARTICULARLY IN 

3013
02:45:15,265 --> 02:45:17,267
MRI AND THEN FIBROSIS.

3014
02:45:17,267 --> 02:45:19,570
IT'S THERE BUT THERE ARE MANY 

3015
02:45:19,570 --> 02:45:23,574
TYPE OF FIBROSIS AND MANY 

3016
02:45:23,574 --> 02:45:29,413
POSITION BECAUSE THEY CAN BE 

3017
02:45:29,413 --> 02:45:34,918
INTERSTITIAL OR SUB ENDOCARDIAL 

3018
02:45:34,918 --> 02:45:37,187
SO WE NEED THE TWO 

3019
02:45:37,187 --> 02:45:41,458
DISTINGUISHING TYPE AND 

3020
02:45:41,458 --> 02:45:41,825
LOCATION.

3021
02:45:41,825 --> 02:45:46,096
AND THERE ARE OTHER POSSIBLE 

3022
02:45:46,096 --> 02:45:50,667
ARRHYTHMIAS AND PROLAPSE IN THE 

3023
02:45:50,667 --> 02:45:59,243
ABSENCE OF SCARRING AND MAGNETIC

3024
02:45:59,243 --> 02:46:02,779
RESONANCE.

3025
02:46:02,779 --> 02:46:06,750
THIS IS OUR EXPERIENCE AND AS 

3026
02:46:06,750 --> 02:46:09,319
FAR AS THE PREVALENCE OF MITRAL 

3027
02:46:09,319 --> 02:46:13,323
VALVE PROLAPSE AND VICTIMS 

3028
02:46:13,323 --> 02:46:15,692
WITHOUT MITRAL REGURGITATION 8% 

3029
02:46:15,692 --> 02:46:17,961
IN THE SERIES OF SUDDEN DEATH 

3030
02:46:17,961 --> 02:46:24,434
AND UNDER THE AGE OF 40 WAS WITH

3031
02:46:24,434 --> 02:46:30,941
8%.

3032
02:46:30,941 --> 02:46:36,313
AND AND THE POPULATION AND THE 

3033
02:46:36,313 --> 02:46:38,749
AGE RANGE FROM 18 TO 90 

3034
02:46:38,749 --> 02:46:41,985
INCLUDING ELDERLY PEOPLE AND SEE

3035
02:46:41,985 --> 02:46:49,660
2% AND THE COMPARISON BETWEEN 

3036
02:46:49,660 --> 02:46:52,329
SOME PATIENTS WITH PROLAPSE YOU 

3037
02:46:52,329 --> 02:46:55,632
SEE THE FIBROSIS CHARACTERISTICS

3038
02:46:55,632 --> 02:46:58,602
IS MOSTLY INTERSTITIAL CLOSE TO 

3039
02:46:58,602 --> 02:47:01,505
100% AND REPLACEMENT OF FIBROSIS

3040
02:47:01,505 --> 02:47:03,106
IS PRESENT ONE THIRD OF THE 

3041
02:47:03,106 --> 02:47:03,307
CASES.

3042
02:47:03,307 --> 02:47:08,211
THEY DIFFERENTIATE REPLACEMENT 

3043
02:47:08,211 --> 02:47:09,179
FOR INTERSTITIAL FIBROSIS FOR 

3044
02:47:09,179 --> 02:47:14,418
MOSTLY THE MAJORITY OF PATIENTS.

3045
02:47:14,418 --> 02:47:19,623
THIS IS ANOTHER IMPORTANT PAPER 

3046
02:47:19,623 --> 02:47:29,866
PUBLISHED IN THIS PAPER FROM AN 

3047
02:47:29,866 --> 02:47:32,402
AUSTRALIAN GROUP YOU SEE BEEN 

3048
02:47:32,402 --> 02:47:34,504
THEY LOOK AT THE DISTRIBUTION 

3049
02:47:34,504 --> 02:47:37,174
AROUND THE LEFT VENTRICLE AND IN

3050
02:47:37,174 --> 02:47:40,377
A DIFFERENT LAYER EPICARDIUM AND

3051
02:47:40,377 --> 02:47:48,819
SUB ENDOCARDIAL AND THERE'S A 

3052
02:47:48,819 --> 02:47:50,687
GRADIENT AND PREVALENCE OF 

3053
02:47:50,687 --> 02:47:56,493
FIBROSIS.

3054
02:47:56,493 --> 02:48:03,333
AND YOU SEE A DEMONSTRATION OF 

3055
02:48:03,333 --> 02:48:04,935
THE MITRAL VALVE PROLAPSE AND 

3056
02:48:04,935 --> 02:48:08,238
THE FIBROSIS PARTICULARLY IN THE

3057
02:48:08,238 --> 02:48:16,546
MID MORALIAL  REGION AND LOOK AT

3058
02:48:16,546 --> 02:48:17,781
THE PROLAPSE.

3059
02:48:17,781 --> 02:48:19,583
THIS IS ANOTHER PAPER 

3060
02:48:19,583 --> 02:48:20,217
DEMONSTRATING THE PRESENCE IN 

3061
02:48:20,217 --> 02:48:24,688
THE ONLY OF REPLACEMENT FIBROSIS

3062
02:48:24,688 --> 02:48:26,323
AND IT'S VERY IMPORTANT IF YOU 

3063
02:48:26,323 --> 02:48:30,394
LOOK AT THE SERIES OF PATIENT 

3064
02:48:30,394 --> 02:48:32,929
WITHOUT MITRAL REGURGITATION YOU

3065
02:48:32,929 --> 02:48:35,565
CAN APPRECIATE THE PRESENCE OF 

3066
02:48:35,565 --> 02:48:36,867
INTERSTITIAL FIBROSIS BY 

3067
02:48:36,867 --> 02:48:39,469
TECHNIQUE AND MRI AND AGAIN CAN 

3068
02:48:39,469 --> 02:48:40,670
APPRECIATE THE DISTRIBUTION OF 

3069
02:48:40,670 --> 02:48:42,506
FIBROSIS IN DIFFERENT REGION OF 

3070
02:48:42,506 --> 02:48:46,743
THE LEFT VENTRICLE WITH THE 

3071
02:48:46,743 --> 02:48:51,348
GRADIENT FROM THE ENDOCARDIAL.

3072
02:48:51,348 --> 02:48:55,018
THIS IS A META-ANALYSIS OF 

3073
02:48:55,018 --> 02:48:58,121
CLINICAL STUDY AND SOME STUDIES 

3074
02:48:58,121 --> 02:49:02,392
INCLUDING OUR STUDY FROM 2015 

3075
02:49:02,392 --> 02:49:03,827
DEMONSTRATING THE FIBROSIS PLAYS

3076
02:49:03,827 --> 02:49:07,597
A ROLE IN THE ARRHYTHMIC 

3077
02:49:07,597 --> 02:49:08,865
STRATIFICATION BECAUSE THIS 

3078
02:49:08,865 --> 02:49:19,376
PATIENT IS AT HIGHER RISK OF 

3079
02:49:22,179 --> 02:49:22,746
ARRHYT

3080
02:49:22,746 --> 02:49:32,956
ARRHYTHMIA.

3081
02:49:36,293 --> 02:49:40,096
AND AND THE PROPORTION AND THE 

3082
02:49:40,096 --> 02:49:42,499
PAPILLARY MUSCLE AND THEN THEY 

3083
02:49:42,499 --> 02:49:45,969
INTRODUCED THE NEW MARKER THE 

3084
02:49:45,969 --> 02:49:48,672
SO-CALLED APPEARANCE OF THE 

3085
02:49:48,672 --> 02:49:50,173
PAPILLARY MUSCLE WHICH IS 

3086
02:49:50,173 --> 02:49:51,475
CORRELATING QUITE BEAUTIFUL WITH

3087
02:49:51,475 --> 02:49:55,645
THE AMOUNT OF FIBROSIS AS 

3088
02:49:55,645 --> 02:49:58,381
DEMONSTRATED BY LEFT VENTRICULAR

3089
02:49:58,381 --> 02:50:02,018
BIOPSY.

3090
02:50:02,018 --> 02:50:07,491
IF YOU SEE THE CONCLUSION OF THE

3091
02:50:07,491 --> 02:50:08,892
QUALITY OF THE SLIDE AND 

3092
02:50:08,892 --> 02:50:11,928
TRANSFORMATION AND THE IMAGING 

3093
02:50:11,928 --> 02:50:16,099
FOR THE PATIENT LOOKING AT 

3094
02:50:16,099 --> 02:50:17,100
PAPILLARY MUSCLE AND COMPARED 

3095
02:50:17,100 --> 02:50:19,736
WITH OTHER VOLUNTEERS BUT LOOK 

3096
02:50:19,736 --> 02:50:22,105
TO THE GRAPH AND COMPARE THE 

3097
02:50:22,105 --> 02:50:25,208
DARK BLOOD APPEARANCE AND VERSUS

3098
02:50:25,208 --> 02:50:26,510
THE HISTOLOGY.

3099
02:50:26,510 --> 02:50:28,778
YOU SEE THERE'S NO STATISTICAL 

3100
02:50:28,778 --> 02:50:31,414
DIFFERENCE AND IT'S QUITE 

3101
02:50:31,414 --> 02:50:33,383
OVERLAPPING THE HISTOLOGY 

3102
02:50:33,383 --> 02:50:35,585
RESULT.

3103
02:50:35,585 --> 02:50:39,155
THE NEW SIGN COMBINED WITH THE 

3104
02:50:39,155 --> 02:50:44,561
TO THE LEFT VENTRICLE FIBROSIS 

3105
02:50:44,561 --> 02:50:46,963
IN THE PATIENTS WITH THIS.

3106
02:50:46,963 --> 02:50:49,299
AND TO UNDERSTAND THE DIFFERENT 

3107
02:50:49,299 --> 02:50:51,568
IMPACT OF INTERSTITIAL FIBROSIS 

3108
02:50:51,568 --> 02:50:54,471
AND REPLACEMENT OF FIBROSIS AND 

3109
02:50:54,471 --> 02:50:55,338
PROBABLY PUTTING TOGETHER MANY 

3110
02:50:55,338 --> 02:50:58,808
DATA INCLUDING THE PRESENCE OR 

3111
02:50:58,808 --> 02:51:01,011
ABSENCE OF MITRAL REGURGITATION 

3112
02:51:01,011 --> 02:51:05,649
AND BECAUSE IT'S MY IMPRESSION 

3113
02:51:05,649 --> 02:51:10,120
THE INTERSTITIAL FIBROSIS IS 

3114
02:51:10,120 --> 02:51:14,190
INCREASING WITH LEFT VENTRICULAR

3115
02:51:14,190 --> 02:51:17,561
FIBROSIS AND I DON'T THINK IT'S 

3116
02:51:17,561 --> 02:51:21,164
SO SPECIFIC OF THE MITRAL VALVE 

3117
02:51:21,164 --> 02:51:21,798
PROLAPSE AS WELL.

3118
02:51:21,798 --> 02:51:28,104
SO THE KNOWLEDGE GAP OF COURSE 

3119
02:51:28,104 --> 02:51:32,709
BECAUSE WE HAVE PATIENT WITH 

3120
02:51:32,709 --> 02:51:35,211
ARRHYTHMIAS AND NO FIBROSIS 

3121
02:51:35,211 --> 02:51:39,215
HISTOLOGY AND THE SUBSTRATE CAN 

3122
02:51:39,215 --> 02:51:45,355
ACCOUNT FOR ELECTRIC INSTABILITY

3123
02:51:45,355 --> 02:51:47,591
AND THIS WOULD ACT AT THE LEVEL 

3124
02:51:47,591 --> 02:51:49,392
OF FIBERS IN SOME PATIENT OR 

3125
02:51:49,392 --> 02:51:51,261
FROM THE SUBSTRATE THAT SHOULD 

3126
02:51:51,261 --> 02:51:57,500
BE CAREFULLY LOOKED FOR.

3127
02:51:57,500 --> 02:52:02,439
SO THE OPPORTUNITY FOR SURE ARE 

3128
02:52:02,439 --> 02:52:05,241
ABLATION AND EXPERIMENTAL.

3129
02:52:05,241 --> 02:52:11,615
I WOULD SAY I'M PLEASED AND ONLY

3130
02:52:11,615 --> 02:52:12,515
COUR

3131
02:52:12,515 --> 02:52:14,484
 -- ENCOURAGED TO LOOK APT THE 

3132
02:52:14,484 --> 02:52:15,986
MYOCYTE AND WHAT IS GOING ON AT 

3133
02:52:15,986 --> 02:52:21,524
THE LEVEL OF THE SINGLE MYOCYTE 

3134
02:52:21,524 --> 02:52:23,593
AND THE PORTION CLOSE TO THE 

3135
02:52:23,593 --> 02:52:26,496
ANNULUS AND AT THE LEVEL OF THE 

3136
02:52:26,496 --> 02:52:29,599
APEX OF THE LEFT VENTRICLE WAS 

3137
02:52:29,599 --> 02:52:33,870
IT'S MY IMPRESSION EVERYTHING 

3138
02:52:33,870 --> 02:52:36,640
STARTED WITH THE INJURY AND HAVE

3139
02:52:36,640 --> 02:52:38,508
REPAIR PROBABLY WITH SOME 

3140
02:52:38,508 --> 02:52:39,576
INFLAMMATORY REACTION AND THE 

3141
02:52:39,576 --> 02:52:42,979
FINAL STEP IS THE REPLACEMENT OF

3142
02:52:42,979 --> 02:52:43,580
FIBROSIS.

3143
02:52:43,580 --> 02:52:45,815
I THINK THIS WAS MY LAST SLIDE.

3144
02:52:45,815 --> 02:52:46,316
AND THANK YOU FOR YOUR 

3145
02:52:46,316 --> 02:52:55,358
ATTENTION.

3146
02:52:55,358 --> 02:52:56,626
>> THANK YOU FOR THE 

3147
02:52:56,626 --> 02:52:56,960
PRESENTATION.

3148
02:52:56,960 --> 02:52:57,827
DOES ANYONE HAVE BRIEF COMMENTS 

3149
02:52:57,827 --> 02:53:00,563
OR QUESTIONS?

3150
02:53:00,563 --> 02:53:05,335
>> I DO.

3151
02:53:05,335 --> 02:53:07,737
NICE TO SEE YOU.

3152
02:53:07,737 --> 02:53:08,538
WONDERFUL PRESENTATION.

3153
02:53:08,538 --> 02:53:11,207
I THINK YOU WERE ALSO GOING 

3154
02:53:11,207 --> 02:53:15,311
AFTER THE MYOCYTE AND HAVE YOU 

3155
02:53:15,311 --> 02:53:17,180
LOOKED AT THE HISTORY LOGICAL 

3156
02:53:17,180 --> 02:53:18,048
LEVEL?

3157
02:53:18,048 --> 02:53:22,452
>> NOT REALLY BUT -- DEF
TEF 

3158
02:53:22,452 --> 02:53:22,652
HISTORY- 

3159
02:53:37,233 --> 02:53:42,806
THIS IS HAPPEN WHERE THE STRESS 

3160
02:53:42,806 --> 02:53:46,076
IS IN THE MYOCARDIUM.

3161
02:53:46,076 --> 02:53:49,612
THERE IS SOMETHING CONSTANT DUE 

3162
02:53:49,612 --> 02:53:53,149
TO THE MECHANICAL INJURY TO THE 

3163
02:53:53,149 --> 02:53:54,050
MYOCYTE.

3164
02:53:54,050 --> 02:53:55,919
PROBABLY YOU CAN HAVE SOME 

3165
02:53:55,919 --> 02:53:59,155
DISRUPTION OF THE CELL JUNCTION 

3166
02:53:59,155 --> 02:54:00,223
SO PROBABLY WE COULDN'T HAVE 

3167
02:54:00,223 --> 02:54:04,094
SOMETHING BUT I DON'T THINK IT'S

3168
02:54:04,094 --> 02:54:05,528
REALLY SOMETHING WHICH IS 

3169
02:54:05,528 --> 02:54:05,895
VISIBLE.

3170
02:54:05,895 --> 02:54:08,998
IT'S SOMETHING THAT IS ACTING IN

3171
02:54:08,998 --> 02:54:15,338
TERMS OF THE MYOCYTE AND THEN OF

3172
02:54:15,338 --> 02:54:16,606
COURSE TRIGGERING SOME SIGNAL 

3173
02:54:16,606 --> 02:54:20,610
FOR CELL DEATH.

3174
02:54:20,610 --> 02:54:23,012
>> HAVE YOU LOOKED AT THE
EP 

3175
02:54:23,012 --> 02:54:26,082
LEVEL WITH CLINICIANS ON TRYING 

3176
02:54:26,082 --> 02:54:32,255
TO UNDERSTAND HOW THE ELECTRICAL

3177
02:54:32,255 --> 02:54:35,158
CONDUCTION IS IMPACTED IN THAT 

3178
02:54:35,158 --> 02:54:35,391
REGION.

3179
02:54:35,391 --> 02:54:40,563
>> WE'RE WORKING IN THE
CLINICAL

3180
02:54:40,563 --> 02:54:41,498
SETTING AND WE'LL PROBABLY TRY 

3181
02:54:41,498 --> 02:54:43,600
TO ANSWER THE QUESTION.

3182
02:54:43,600 --> 02:54:43,933
>> WONDERFUL.

3183
02:54:43,933 --> 02:54:47,403
THANK YOU.

3184
02:54:47,403 --> 02:54:51,908
>> AND WITH THAT
INTRODUCTION 

3185
02:54:51,908 --> 02:54:58,114
OUR NEXT PRESENTATION IS FROM 

3186
02:54:58,114 --> 02:55:04,788
MARTINA PERAZZOLO-MARRA.

3187
02:55:04,788 --> 02:55:15,198
>> THANK YOU VERY MUCH.

3188
02:55:27,644 --> 02:55:30,246
IT'S IMPORTANT FOR ME TO BE HERE

3189
02:55:30,246 --> 02:55:36,019
AND MY DISCLOSURE IS I'M NOT AN 

3190
02:55:36,019 --> 02:55:36,519
ELEC

3191
02:55:36,519 --> 02:55:42,258
ELECTROPHYSIOLOGIST BUT WORK IN 

3192
02:55:42,258 --> 02:55:52,101
THE LAB AND WE KNOW FROM THE 

3193
02:55:52,101 --> 02:55:56,105
INITIAL OBSERVATION OF THE 

3194
02:55:56,105 --> 02:56:01,344
PROLAPSE OF THE MITRAL VALVE AND

3195
02:56:01,344 --> 02:56:03,580
WE KNOW THAT IT'S NOT ONLY A 

3196
02:56:03,580 --> 02:56:13,690
SPECIFIC ECG BUT ALSO YOU KNOW 

3197
02:56:13,690 --> 02:56:20,630
THE PROLONG ED AND DESCRIBED IN 

3198
02:56:20,630 --> 02:56:21,264
PATIENT WITH OR WITHOUT MITRAL 

3199
02:56:21,264 --> 02:56:29,505
REGURGITATION.

3200
02:56:29,505 --> 02:56:31,608
IT INCLUDE PATIENT WITH A 

3201
02:56:31,608 --> 02:56:36,746
SPECIFIC ECG BUT ALSO 

3202
02:56:36,746 --> 02:56:37,547
POLYMORPHIC BOTH WITH A 

3203
02:56:37,547 --> 02:56:45,722
DIFFERENT MORPH OL  GY -- 

3204
02:56:45,722 --> 02:56:48,124
MORPHOLOGY OF ARRHYTHMIA 

3205
02:56:48,124 --> 02:56:48,791
DESCRIBED IN THE RISK 

3206
02:56:48,791 --> 02:56:49,425
STRATIFICATION OF THE EUROPEAN 

3207
02:56:49,425 --> 02:56:55,598
COMMUNITY.

3208
02:56:55,598 --> 02:56:57,901
HOWEVER WE KNOW THERE'S MUCH 

3209
02:56:57,901 --> 02:56:59,569
MORE THAN MITRAL VALVE DISEASE 

3210
02:56:59,569 --> 02:57:06,142
BECAUSE WE KNOW THE ARRHYTHMIC 

3211
02:57:06,142 --> 02:57:10,113
PRODUCTS INCLUDE THE JUNCTION 

3212
02:57:10,113 --> 02:57:11,581
AND FIBROSIS IN THE SPECIFIC 

3213
02:57:11,581 --> 02:57:21,190
SITE KRICRISTINA MENTIONED AND  

3214
02:57:21,190 --> 02:57:25,094
ANTEROLATERAL WALL COMPARED TO 

3215
02:57:25,094 --> 02:57:28,665
THE PORTION AND SO THESE ARE THE

3216
02:57:28,665 --> 02:57:37,640
KEY POINTS OF THE PROLAPSE.

3217
02:57:37,640 --> 02:57:41,678
THE MORPHOLOGY HAVE BEEN 

3218
02:57:41,678 --> 02:57:43,947
DESCRIBED BUT LOOK AT THE 

3219
02:57:43,947 --> 02:57:47,784
FEATURE S

3220
02:57:47,784 --> 02:57:51,487
FEATURE DESCRIBED AND THE 

3221
02:57:51,487 --> 02:57:54,157
PATIENTS WITH FIBRILLATION ARE 

3222
02:57:54,157 --> 02:57:58,895
WITH A SPECIFIC MORPHOLOGY THAT 

3223
02:57:58,895 --> 02:58:01,030
MEANS THE SOURCE OF ARRHYTHMIAS 

3224
02:58:01,030 --> 02:58:04,267
IS THE LEFT VENTRICLE.

3225
02:58:04,267 --> 02:58:07,704
MAJOR FROM THE LEFT VENTRICLE IN

3226
02:58:07,704 --> 02:58:15,979
THE PORTION.

3227
02:58:15,979 --> 02:58:19,582
WITH KNOW WHEN WE SEE A PATIENT 

3228
02:58:19,582 --> 02:58:21,084
WITH THE MITRAL VALVE PROLAPSE 

3229
02:58:21,084 --> 02:58:24,854
AND WE HAVE A DIFFERENT TYPE AND

3230
02:58:24,854 --> 02:58:28,524
MORPHOLOGY COMING FROM DOT.

3231
02:58:28,524 --> 02:58:29,859
BUT FROM THE PREVIOUS TALK WE 

3232
02:58:29,859 --> 02:58:35,365
LEARNED THE LESSON THAT WE HAVE 

3233
02:58:35,365 --> 02:58:45,908
A DISEASE WITH ARRHYTHMIAS BUT 

3234
02:59:04,761 --> 02:59:06,195
THE LIST INCLUDES THE 

3235
02:59:06,195 --> 02:59:08,431
VISUALIZATION OF FIBROSIS.

3236
02:59:08,431 --> 02:59:10,700
WE KNOW FIBROSIS IS A SUBSTRATE 

3237
02:59:10,700 --> 02:59:19,242
FOR ARRHYTHMIAS AND SOMETIMES 

3238
02:59:19,242 --> 02:59:26,115
PECULIAR WITH THE VENTRICLE 

3239
02:59:26,115 --> 02:59:29,452
FIBRILLATION AND THE FIBROSIS IS

3240
02:59:29,452 --> 02:59:39,996
THE GOAL OF CMR AND IN THIS CASE

3241
02:59:41,431 --> 02:59:46,803
IT'S VERY IMPORTANT BUT THE 

3242
02:59:46,803 --> 02:59:55,745
AMOUNT IS 2% TO 3% AND LOOKING 

3243
02:59:55,745 --> 03:00:01,350
AT THE WALL AND THOSE ARE INSIDE

3244
03:00:01,350 --> 03:00:05,455
THE MOUSE.

3245
03:00:05,455 --> 03:00:10,093
ON THIS BASIS WE EVALUATE THE 

3246
03:00:10,093 --> 03:00:13,963
POSSIBLE MECHANISM OF THE STRESS

3247
03:00:13,963 --> 03:00:18,334
INDUCED ARRHYTHMIAS AND WE SAW 

3248
03:00:18,334 --> 03:00:20,336
THE MAPPING OF THE PAPILLARY 

3249
03:00:20,336 --> 03:00:24,974
MUSCLE IS INTRIGUING IN THE 

3250
03:00:24,974 --> 03:00:27,410
MITRAL VALVE PROLAPSE AND THE 

3251
03:00:27,410 --> 03:00:28,111
MOST IMPORTANT ACTIVATION 

3252
03:00:28,111 --> 03:00:32,982
DESCRIBED AND RECOMMENDED FOR 

3253
03:00:32,982 --> 03:00:41,157
THE ARRHYTHMIC PROLAPSE COME 

3254
03:00:41,157 --> 03:00:44,727
FROM THE INTERIOR ONE AND THE 

3255
03:00:44,727 --> 03:00:48,264
POSSIBILITY TO STRATIFY IN THE 

3256
03:00:48,264 --> 03:00:53,102
CLINICAL SETTING IS IMPORTANT.

3257
03:00:53,102 --> 03:00:54,303
CMI IS NOT ABLE TO BE PERFORMED 

3258
03:00:54,303 --> 03:01:03,212
IN ALL PATIENTS.

3259
03:01:03,212 --> 03:01:05,515
THERE'S THE POSSIBILITY OF THE 

3260
03:01:05,515 --> 03:01:07,583
GAP IN THE AND IMPORTANT TO 

3261
03:01:07,583 --> 03:01:09,285
STRATIFY THE PATIENT AND USING 

3262
03:01:09,285 --> 03:01:13,122
THE MORPHOLOGY OF THE ARRHYTHMIA

3263
03:01:13,122 --> 03:01:16,726
AND ECG WHEN WE EVALUATE THE 

3264
03:01:16,726 --> 03:01:18,227
PATIENT.

3265
03:01:18,227 --> 03:01:20,796
IN THIS ELEGANT PAPER YOU CAN 

3266
03:01:20,796 --> 03:01:24,734
APPRECIATE THE MORPHOLOGY OF THE

3267
03:01:24,734 --> 03:01:27,103
PATIENT WITH THE MITRAL VALVE 

3268
03:01:27,103 --> 03:01:32,008
PROLAPSE NOT ONLY RELATED TO THE

3269
03:01:32,008 --> 03:01:34,110
MITRAL REGURGITATION AND PLEASE 

3270
03:01:34,110 --> 03:01:37,180
LOOK AT THE MORPH OLOLOGY WITH  

3271
03:01:37,180 --> 03:01:42,385
BLOCK AND THE DIFFERENT TYPE 

3272
03:01:42,385 --> 03:01:52,929
WITH THE THIS IS A CASE OF OUR 

3273
03:01:53,329 --> 03:01:58,734
SERIES AND APPLY THE MORPHOLOGY 

3274
03:01:58,734 --> 03:02:06,676
WITH THE BLOCK AND WE LOOKED AT 

3275
03:02:06,676 --> 03:02:16,485
THE PAPILLARY MUSCLE.

3276
03:02:16,485 --> 03:02:21,791
ON THIS WE HAVE THE ALGORITHM BY

3277
03:02:21,791 --> 03:02:27,830
THE PATIENT WITH ARRHYTHMIAS 

3278
03:02:27,830 --> 03:02:29,532
COMPARED TO SIMPLIFY FOR ALL 

3279
03:02:29,532 --> 03:02:34,103
PATIENT AND FOR IMAGES THE 

3280
03:02:34,103 --> 03:02:36,205
MORPHOMOR

3281
03:02:36,205 --> 03:02:39,642
MORPHOLOGY THAT IS UNCOMMON IN 

3282
03:02:39,642 --> 03:02:42,712
ATHLETES THE POPULATION IS 

3283
03:02:42,712 --> 03:02:43,479
TYPICAL FOR THE PATIENT WITH THE

3284
03:02:43,479 --> 03:02:44,013
FWAP.

3285
03:02:46,882 --> 03:02:49,585
DELAYED GAP.

3286
03:02:49,585 --> 03:02:54,290
THE PROBLEM IS THAT WE ARE NOT 

3287
03:02:54,290 --> 03:03:00,296
ONLY THE MUSCLE BUT THE 

3288
03:03:00,296 --> 03:03:06,102
MORPHOLOGY WITH THE JUNCTION AND

3289
03:03:06,102 --> 03:03:11,540
YOU SEE THE POPULATION AND THIS 

3290
03:03:11,540 --> 03:03:15,011
IS THE NUMBER OF OUR POPULATION 

3291
03:03:15,011 --> 03:03:17,880
NOT ONLY PATIENTS WITH 

3292
03:03:17,880 --> 03:03:20,082
ARRHYTHMIA AND PROLAPSE AND 

3293
03:03:20,082 --> 03:03:24,353
THERE'S A PROPORTION OF PATIENT 

3294
03:03:24,353 --> 03:03:31,594
WITH ARRHYTHMIA BUT WITHOUT 

3295
03:03:31,594 --> 03:03:34,630
FIBROSIS AND THIS IS THE 

3296
03:03:34,630 --> 03:03:40,102
EXPERIENCE OF OUR GROUP AND ALSO

3297
03:03:40,102 --> 03:03:43,072
IN THE PAPER DESCRIBED THE GAP 

3298
03:03:43,072 --> 03:03:46,042
IS NOT A CONSTANT IN PATIENT 

3299
03:03:46,042 --> 03:03:51,580
WITH ARRHYTHMIAS AND MITRAL 

3300
03:03:51,580 --> 03:03:55,651
VALVE PROLAPSE.

3301
03:03:55,651 --> 03:03:59,622
AND HOW DO WE JUSTIFY THE 

3302
03:03:59,622 --> 03:04:05,127
PREVALENCE IN PATIENTS WITH CMR.

3303
03:04:05,127 --> 03:04:11,467
WE EVALUATED THE PATIENTS BUT I 

3304
03:04:11,467 --> 03:04:16,639
WOULD SPECIFY A SELECTIVE 

3305
03:04:16,639 --> 03:04:21,243
PATIENT BECAUSE WITHOUT 

3306
03:04:21,243 --> 03:04:23,579
REGURGITATION AND THE PATIENTS 

3307
03:04:23,579 --> 03:04:28,584
WERE DIVIDED ON THE PRESENCE OF 

3308
03:04:28,584 --> 03:04:34,123
ARRHYTHMIAS WITH THE DEFINITION 

3309
03:04:34,123 --> 03:04:35,057
BY THE DOCUMENT OF THE EUROPEAN 

3310
03:04:35,057 --> 03:04:42,598
SOCIETY.

3311
03:04:42,598 --> 03:04:45,534
I CAN APPRECIATE THE NUMBER OF 

3312
03:04:45,534 --> 03:04:47,570
PATIENTS ENROLLED COMPARED TO 

3313
03:04:47,570 --> 03:04:48,237
OUR INITIAL PATIENT POPULATION 

3314
03:04:48,237 --> 03:04:54,243
IS NOT A CONSTANT.

3315
03:04:54,243 --> 03:04:58,147
THIS IS THE ANTEROLATERAL WALL 

3316
03:04:58,147 --> 03:05:01,650
BUT IN THE PAPILLARY MUSCLE MOST

3317
03:05:01,650 --> 03:05:04,854
IN THE POSTERIOR PAPILLARY 

3318
03:05:04,854 --> 03:05:05,087
MUSCLE.

3319
03:05:05,087 --> 03:05:14,330
ALSO DEFINIING THE PRESENCE OF 

3320
03:05:14,330 --> 03:05:15,131
ARRHYTHMIAS.

3321
03:05:15,131 --> 03:05:20,603
PATIENTS WITH ARRHYTHMIAS IN 

3322
03:05:20,603 --> 03:05:29,412
TERM OF PRESENCE OF  THIS AND 

3323
03:05:29,412 --> 03:05:31,580
THERE'S A DIFFERENT ROLE OF THE 

3324
03:05:31,580 --> 03:05:35,584
ISSUE IN THE GENESIS OF THE 

3325
03:05:35,584 --> 03:05:36,051
PROFILE.

3326
03:05:36,051 --> 03:05:40,723
WE KNOW THE LATE GAP CAN 

3327
03:05:40,723 --> 03:05:42,425
MAINTAIN ITS ROLE BUT THIS CAN 

3328
03:05:42,425 --> 03:05:45,828
DEFINE AND DETERMINE THE 

3329
03:05:45,828 --> 03:05:50,399
PRESENCE OF ARRHYTHMIAS AND THE 

3330
03:05:50,399 --> 03:05:53,836
ACTION OF THE JUNCTION THAT'S A 

3331
03:05:53,836 --> 03:05:55,971
BIG PART OF THE ARRHYTHMIC 

3332
03:05:55,971 --> 03:06:01,444
APPROACH AND WE WERE UNABLE TO 

3333
03:06:01,444 --> 03:06:05,681
PROVIDE THE PRESENCE OF THE 

3334
03:06:05,681 --> 03:06:05,981
ARRHYTHMIAS.

3335
03:06:05,981 --> 03:06:10,085
THE COMBINATION OF IT WAS 

3336
03:06:10,085 --> 03:06:15,591
TERRIBLE FOR THE PRESENCE OF 

3337
03:06:15,591 --> 03:06:22,097
MALIGNANT ARRHYTHMIAS AND THIS 

3338
03:06:22,097 --> 03:06:24,733
OBSERVES IN MY OPINION OFFERED 

3339
03:06:24,733 --> 03:06:28,003
THE POSSIBILITY TO COMPREHEND 

3340
03:06:28,003 --> 03:06:31,574
WHY MAD WAS PRESENCE AND NOT IN 

3341
03:06:31,574 --> 03:06:37,546
PATIENT WITH DIFFERENT TYPE OF 

3342
03:06:37,546 --> 03:06:40,516
ARRHYTHMIAS NOW WE CAN TALK 

3343
03:06:40,516 --> 03:06:45,154
ABOUT THE VENUE OF THE 

3344
03:06:45,154 --> 03:06:47,823
ARRHYTHMIAS AND OTHER 

3345
03:06:47,823 --> 03:06:48,190
CARDIOMYOPATHY.

3346
03:06:48,190 --> 03:06:51,627
IF THE TRIGGER IS THE MECHANICS,

3347
03:06:51,627 --> 03:06:56,565
THEY CAN BE PRESENT ALSO WITH 

3348
03:06:56,565 --> 03:07:02,304
THE PROLAPSE ON OTHER 

3349
03:07:02,304 --> 03:07:03,672
CARDIOMYOPATHY AND PATIENTS WITH

3350
03:07:03,672 --> 03:07:10,112
ARRHYTHMIC PROFILE CAN HAVE A 

3351
03:07:10,112 --> 03:07:15,718
DIFFERENT ARIDGE  -- ARRHYTHMIC 

3352
03:07:15,718 --> 03:07:16,118
EVENT.

3353
03:07:16,118 --> 03:07:20,356
THIS IS THE SEARCH PRIORITY FOR 

3354
03:07:20,356 --> 03:07:22,591
VALIDATION OF OUR ANALYSIS TO 

3355
03:07:22,591 --> 03:07:26,095
VERIFY THE DIFFERENT ROLE OF MAD

3356
03:07:26,095 --> 03:07:29,331
AND ALSO LATE GUARD AND THE 

3357
03:07:29,331 --> 03:07:34,136
SECOND IS THE PROCESSING THE 

3358
03:07:34,136 --> 03:07:39,575
EVALUATION OF LATE NOW WE ARE 

3359
03:07:39,575 --> 03:07:45,614
APPLYING THE MAPPING THE 

3360
03:07:45,614 --> 03:07:48,817
ANALYSIS AND MAPPING SOMETIMES I

3361
03:07:48,817 --> 03:07:53,422
THINK THE QUANTIFICATION OF THE 

3362
03:07:53,422 --> 03:08:00,362
PRE LAPSE ABLE TO APPLY THIS IS 

3363
03:08:00,362 --> 03:08:05,734
NOT SO EASY DUE TO THE SMALL 

3364
03:08:05,734 --> 03:08:07,036
AMOUNT OF THIS BUT IS MANDATORY 

3365
03:08:07,036 --> 03:08:12,308
AND THE IDEA IS ALSO TO EVALUATE

3366
03:08:12,308 --> 03:08:14,843
IN VIVO THE COURSE OF THE 

3367
03:08:14,843 --> 03:08:15,544
PATIENT WITH THE LATE GUARD.

3368
03:08:15,544 --> 03:08:19,048
I DON'T KNOW IF IT CAN INCREASE 

3369
03:08:19,048 --> 03:08:20,583
DURING THE TIME COURSE OF THE 

3370
03:08:20,583 --> 03:08:25,821
PATIENT AND ALSO TO EVALUATE THE

3371
03:08:25,821 --> 03:08:28,657
PATIENT WITH THE NOT LATE GUARD 

3372
03:08:28,657 --> 03:08:30,559
AND NOT SURE IF TOMORROW THE 

3373
03:08:30,559 --> 03:08:31,594
PATIENT WILL DEVELOP A LATE GAP.

3374
03:08:31,594 --> 03:08:38,267
THANK YOU VERY MUCH.

3375
03:08:38,267 --> 03:08:39,268
>> THANK YOU FOR THAT 

3376
03:08:39,268 --> 03:08:39,802
PRESENTATION.

3377
03:08:39,802 --> 03:08:40,369
ARE THERE ANY QUESTION OR 

3378
03:08:40,369 --> 03:08:50,546
COMMENTS?

3379
03:08:52,648 --> 03:08:56,452
>> THAT WAS GREAT.

3380
03:08:56,452 --> 03:08:58,020
GREAT TO SEE YOU.

3381
03:08:58,020 --> 03:09:04,793
I HAVE A QUESTION TO THE 

3382
03:09:04,793 --> 03:09:05,794
ELECTROPHYSI

3383
03:09:05,794 --> 03:09:06,195
ELECTROPHYSIOLOGY.

3384
03:09:06,195 --> 03:09:09,531
WHAT'S THE DIFFERENCE OF THE TWO

3385
03:09:09,531 --> 03:09:11,000
ARRHYTHMIA ONE IS AFTER THE 

3386
03:09:11,000 --> 03:09:13,535
POLARIZATION AND TRIGGER 

3387
03:09:13,535 --> 03:09:19,575
ACTIVITY CAN YOU GO IN MORE 

3388
03:09:19,575 --> 03:09:24,947
DETAIL TO THE ELECTROPHYSIOLOGY.

3389
03:09:24,947 --> 03:09:27,750
>> I CAN'T ANSWER MORE THE

3390
03:09:27,750 --> 03:09:29,685
QUESTION BUT TO OUR POPULATION 

3391
03:09:29,685 --> 03:09:32,388
ALL THE PATIENT WITH LATE GUARD 

3392
03:09:32,388 --> 03:09:39,561
AND ARRHYTHMIAS BUT ARE NOT ONLY

3393
03:09:39,561 --> 03:09:43,298
BECAUSE DURING THE MONITORING WE

3394
03:09:43,298 --> 03:09:47,569
LOOK AT THE RIGHT VENTRICLE TO 

3395
03:09:47,569 --> 03:09:51,173
THE DOT AND NOT SPECIFIC FOR 

3396
03:09:51,173 --> 03:09:51,840
MITRAL VALVE PROLAPSE MVP WE'RE 

3397
03:09:51,840 --> 03:09:53,442
TRYING TO EVALUATE THE ROLE OF 

3398
03:09:53,442 --> 03:09:59,581
EXERCISE IN THE GENESIS OF THE 

3399
03:09:59,581 --> 03:10:01,617
ARRHYTHMIAS BUT I THINK THE ONLY

3400
03:10:01,617 --> 03:10:04,586
STUDY WITH THE MAPPING -- I KNOW

3401
03:10:04,586 --> 03:10:06,588
THE MARKER -- SFWR YOUR 

3402
03:10:06,588 --> 03:10:10,592
DESCRIBING THE MORPHOLOGY BUT 

3403
03:10:10,592 --> 03:10:14,229
CURIOUS ABOUT IF IT'S RE-ENTRY 

3404
03:10:14,229 --> 03:10:18,834
OR THE ELECTROPHYSIOLOGICAL 

3405
03:10:18,834 --> 03:10:19,068
PROCESS.

3406
03:10:19,068 --> 03:10:20,469
>> I CAN JUMP IN.

3407
03:10:20,469 --> 03:10:22,838
WE PUT TOGETHER A DIAGRAM 

3408
03:10:22,838 --> 03:10:26,875
EXPLAINING OF THE FOUR TYPES OF 

3409
03:10:26,875 --> 03:10:28,877
ARRHYTHMIAS AND VENTRIC CLAR AND

3410
03:10:28,877 --> 03:10:30,846
TRIGGER RELATED AND TRIGGER 

3411
03:10:30,846 --> 03:10:33,048
RELATED PVCs WHAT THE MECHANISMS

3412
03:10:33,048 --> 03:10:35,284
ARE TO EACH.

3413
03:10:35,284 --> 03:10:40,122
FOUR VT YOU CAN HAVE SCAR 

3414
03:10:40,122 --> 03:10:43,592
RELATED VT AND FOR PVCs IT'S 

3415
03:10:43,592 --> 03:10:46,128
TRIGGER RELATED AND DELAYED 

3416
03:10:46,128 --> 03:10:48,597
AFTER THE POLARIZATIONS EVEN 

3417
03:10:48,597 --> 03:10:54,603
WHEN IT COMES FROM THE PAPILLARY

3418
03:10:54,603 --> 03:10:54,837
MUSCLE.

3419
03:10:54,837 --> 03:10:55,370
>> THANK YOU.

3420
03:10:55,370 --> 03:10:59,842
>> AND DID YOU SEE BUNDLE
BRANCH

3421
03:10:59,842 --> 03:11:08,784
BLOCKS LIKE MARTINA IDENTIFIED?

3422
03:11:08,784 --> 03:11:15,591
>> IT'S PRETTY CONSISTENT
AND 

3423
03:11:15,591 --> 03:11:17,526
PREDOMINANTLY PAPILLARY MUSCLE 

3424
03:11:17,526 --> 03:11:21,864
PECs AND THE SECOND MOST COMMON 

3425
03:11:21,864 --> 03:11:24,767
IS ALPHA TYPE AND WHAT I'D LOVE 

3426
03:11:24,767 --> 03:11:27,035
SOMEONE TO LOOK AT IS IS WE 

3427
03:11:27,035 --> 03:11:30,038
LOOKED AMOUNT THE TRACT AS ONE 

3428
03:11:30,038 --> 03:11:34,143
THIRD BUT IT'S NOT LVOT LOOKING 

3429
03:11:34,143 --> 03:11:37,579
BACK AT THE ABLATIONS WE'VE 

3430
03:11:37,579 --> 03:11:39,882
DONE, NEARLY 100% IS LOCALIZED 

3431
03:11:39,882 --> 03:11:43,585
TO THE RVOT.

3432
03:11:43,585 --> 03:11:45,788
IT'S PROBABLY RELATE THE 

3433
03:11:45,788 --> 03:11:46,688
MECHANICS AND THE EARLIER 

3434
03:11:46,688 --> 03:11:50,726
LITERATURE DID IT BASED ON EKG 

3435
03:11:50,726 --> 03:11:52,795
CRITERIA WHICH WAS OFTEN OUR VOT

3436
03:11:52,795 --> 03:11:54,229
BUT THEY'RE SO CLOSELY LINKED 

3437
03:11:54,229 --> 03:11:54,830
WITHOUT MAPPING YOU CAN'T BE 

3438
03:11:54,830 --> 03:11:59,334
SURE.

3439
03:11:59,334 --> 03:12:07,943
>> IT WOULD BE GOOD TO
LOOK AT 

3440
03:12:07,943 --> 03:12:11,380
CONNECTSINS VERSUS VENTRICULAR 

3441
03:12:11,380 --> 03:12:14,983
MUSCLE TO UNDERSTAND THE 

3442
03:12:14,983 --> 03:12:17,252
MOLECULAR BASIS FOR THE TYPES OF

3443
03:12:17,252 --> 03:12:20,455
ARRHYTHMIAS YOU'RE SEEING.

3444
03:12:20,455 --> 03:12:21,890
>> A QUICK QUESTION.

3445
03:12:21,890 --> 03:12:26,995
IF THE CURLING IS THE ALMOST 

3446
03:12:26,995 --> 03:12:30,065
DIVERSE OF THE MITRAL VALVE WITH

3447
03:12:30,065 --> 03:12:37,439
THE MOVEMENT OF THE ANNULUS, 

3448
03:12:37,439 --> 03:12:40,809
THEY'RE ALL CO-LINEAR AND THE 

3449
03:12:40,809 --> 03:12:43,579
HALF CURLING BECAUSE IT REMAINS 

3450
03:12:43,579 --> 03:12:46,515
ATTACHED.

3451
03:12:46,515 --> 03:12:48,817
SO CAN YOU SORT OUT THE EFFECT 

3452
03:12:48,817 --> 03:12:51,453
OF CURLING VERSUS MAD ON THE 

3453
03:12:51,453 --> 03:12:51,753
ARRHYTHMIAS?

3454
03:12:51,753 --> 03:12:54,289
IT MUST BE VERY DIFFICULT.

3455
03:12:54,289 --> 03:12:55,224
>> YEAH.

3456
03:12:55,224 --> 03:12:57,993
THANK YOU FOR THE QUESTION.

3457
03:12:57,993 --> 03:13:01,563
I THINK THAT'S VERY DIFFERENT TO

3458
03:13:01,563 --> 03:13:04,032
DEFINE THE ROLE OF MAD AND THE 

3459
03:13:04,032 --> 03:13:05,067
CURLING BUT I WOULD LIKE TO 

3460
03:13:05,067 --> 03:13:11,840
DISCUSS WITH YOU NOT ONLY THE 

3461
03:13:11,840 --> 03:13:16,645
CURLING BUT THE PORTION.

3462
03:13:16,645 --> 03:13:22,551
DO YOU SEE PATIENT WITH THE THIN

3463
03:13:22,551 --> 03:13:24,753
WALL ON THE MID PORTION ON THE 

3464
03:13:24,753 --> 03:13:26,054
CONTRARY WE HAVE MOVEMENT 

3465
03:13:26,054 --> 03:13:34,029
WITHOUT IMPRESSIVE AMOUNT AND 

3466
03:13:34,029 --> 03:13:34,763
THE PROPORTION.

3467
03:13:34,763 --> 03:13:41,904
WE LOOK AT THE MYOCYTE OF THE 

3468
03:13:41,904 --> 03:13:45,140
DIFFERENT LOCATION AND THE TYPE 

3469
03:13:45,140 --> 03:13:48,810
OF MITOCHONDRIA ARE VERY 

3470
03:13:48,810 --> 03:13:49,745
DIFFERENT.

3471
03:13:49,745 --> 03:13:54,149
I CANNOT QUANTIFY THE ASSESSMENT

3472
03:13:54,149 --> 03:13:55,984
AND THE AMOUNT ON CMR IS NOT THE

3473
03:13:55,984 --> 03:14:01,523
SAME AS THE ECHO BUT SOMETIMES 

3474
03:14:01,523 --> 03:14:09,831
WE HAVE THE MOVEMENT AND IT'S 

3475
03:14:09,831 --> 03:14:12,467
DIFFERENT AND I THINK WE HAVE 

3476
03:14:12,467 --> 03:14:14,136
ONLY FRAUM OF THE PICTURE NOT 

3477
03:14:14,136 --> 03:14:24,513
ONLY THE TIME COURSE.

3478
03:14:28,183 --> 03:14:29,151
 

3479
03:14:29,151 --> 03:14:30,185
>> IT'S PULLING EVERY BEAD

3480
03:14:30,185 --> 03:14:34,289
WITHOUT RESISTANCE SO THE MUSCLE

3481
03:14:34,289 --> 03:14:36,491
UNDER THE POSTERIOR LEAFLET AND 

3482
03:14:36,491 --> 03:14:38,493
COMES BACK LIKE YOU INTRODUCE A 

3483
03:14:38,493 --> 03:14:41,663
FINGER IN THE GLOVE AND COMES 

3484
03:14:41,663 --> 03:14:46,134
BACK TO THE NORMAL POSITION AND 

3485
03:14:46,134 --> 03:14:49,104
IN SYSTOLE YOU HAVE THE RUPTURED

3486
03:14:49,104 --> 03:14:52,040
TENDON OF THE ANNULUS AND THE 

3487
03:14:52,040 --> 03:14:54,076
MUSCLE MUST BE ABNORMAL.

3488
03:14:54,076 --> 03:14:58,113
WHEN YOU RE-ATTACH IT BY REPAIR 

3489
03:14:58,113 --> 03:15:03,585
THEN IT LOOKS NORMAL BUT LOOKS 

3490
03:15:03,585 --> 03:15:07,322
ECHO BY NORMAL DIDN'T MEAN IT IS

3491
03:15:07,322 --> 03:15:07,556
NORMAL.

3492
03:15:07,556 --> 03:15:14,963
THE MUSCLE MUST BE ABNORMAL 

3493
03:15:14,963 --> 03:15:16,198
FUNDAMENTALLY I DON'T KNOW IF 

3494
03:15:16,198 --> 03:15:22,137
YOU HAVE LOOKED AT THE WALL BUT 

3495
03:15:22,137 --> 03:15:25,707
WHAT THERE IS THE DETACHMENT AND

3496
03:15:25,707 --> 03:15:27,843
THE MOVEMENT AND WHAT IS IS IN 

3497
03:15:27,843 --> 03:15:35,317
SYSTOLE IS STRIKING.

3498
03:15:35,317 --> 03:15:44,059
SFWR 

3499
03:15:44,059 --> 03:15:48,997
>> THERE'S DIFFERENT
PATHOLOGY 

3500
03:15:48,997 --> 03:15:53,568
AND 

3501
03:15:53,568 --> 03:15:56,905
>> THEY REATTACH THEM AND
COME 

3502
03:15:56,905 --> 03:15:58,940
BACK LIKE THE REST OF THE 

3503
03:15:58,940 --> 03:15:59,207
VENTRICLE.

3504
03:15:59,207 --> 03:16:02,244
IT'S JUST A MECHANICAL EFFECT OF

3505
03:16:02,244 --> 03:16:05,213
THE DETACHMENT WHICH WE OBSERVED

3506
03:16:05,213 --> 03:16:06,081
SO IT'S VERY INTERESTING.

3507
03:16:06,081 --> 03:16:06,815
WE LOOK FORWARD TO SEEING THE 

3508
03:16:06,815 --> 03:16:10,385
PAPER.

3509
03:16:10,385 --> 03:16:15,690
>> BRIEFLY, MICHAEL.

3510
03:16:15,690 --> 03:16:21,863
>> THANKS, FRANK.

3511
03:16:21,863 --> 03:16:26,601
THE LEFT OUTFLOW TRACK LOCATION 

3512
03:16:26,601 --> 03:16:27,836
THERE IS CERTAINLY WOULD NOT BE 

3513
03:16:27,836 --> 03:16:30,405
THE PORTION I THINK IS MOST 

3514
03:16:30,405 --> 03:16:34,242
DISTRESSED BY PROLAPSING LEA

3515
03:16:34,242 --> 03:16:34,509
LEAFLETS.

3516
03:16:34,509 --> 03:16:39,581
IS THAT ADJACENT TO THE SUB 

3517
03:16:39,581 --> 03:16:44,619
AORTIC MEMBRANE OR THE BODY ON 

3518
03:16:44,619 --> 03:16:48,290
THE INSERTION INTO THE LEFT 

3519
03:16:48,290 --> 03:16:48,623
VENTRICLE.

3520
03:16:48,623 --> 03:16:51,593
I COULDN'T SEE WHERE HE WAS 

3521
03:16:51,593 --> 03:16:53,695
ABLATING.

3522
03:16:53,695 --> 03:16:55,697
>> THE SECOND MOST COMMON
SOURCE

3523
03:16:55,697 --> 03:16:56,832
IS OUTFLOW TRACK.

3524
03:16:56,832 --> 03:16:59,234
AND LVOT IS THE MOST COMMON.

3525
03:16:59,234 --> 03:17:02,370
THE PLACES WE TYPICALLY SEE IT 

3526
03:17:02,370 --> 03:17:05,407
AND SOMETIMES WE DEFINE IT ON 

3527
03:17:05,407 --> 03:17:06,641
BEING ABLATED AND THEN WENT 

3528
03:17:06,641 --> 03:17:06,875
AWAY.

3529
03:17:06,875 --> 03:17:08,610
IT'S POSSIBLE WE ABLATE IN THE 

3530
03:17:08,610 --> 03:17:12,314
CUSP BETWEEN THE LEFT AND RIGHT 

3531
03:17:12,314 --> 03:17:14,015
COMMISURE BUT IN REALITY IT'S 

3532
03:17:14,015 --> 03:17:24,459
COMING FROM BENEATH THAT.

3533
03:17:28,797 --> 03:17:31,566
 THAT WAS IN THE INTERLEUKIN 

3534
03:17:31,566 --> 03:17:34,269
LOCATION AND IN YEARS PAST WE 

3535
03:17:34,269 --> 03:17:39,641
PROBABLY ABLATED ON THE AORTA 

3536
03:17:39,641 --> 03:17:41,009
SIDE AND GAVE ENOUGH ENERGY 

3537
03:17:41,009 --> 03:17:43,378
UNDERNEATH IT AND IT'S A MEDIAL 

3538
03:17:43,378 --> 03:17:46,681
REPRESENTATION OF FOR EXAMPLE WE

3539
03:17:46,681 --> 03:17:54,322
ABLATE AND KEEP MOVING OUR WAY 

3540
03:17:54,322 --> 03:17:54,723
OVER.

3541
03:17:54,723 --> 03:17:58,059
>> THAT'S THE BETWEEN THE
NON 

3542
03:17:58,059 --> 03:18:01,329
AND LEFT CUSP BUT ISN'T IT 

3543
03:18:01,329 --> 03:18:03,565
INTERESTING ALMOST ALL THE 

3544
03:18:03,565 --> 03:18:07,135
CALCIFIED FIBROSIS IN BARLOW'S 

3545
03:18:07,135 --> 03:18:09,838
IS AROUND THE ANCILLARY MUSCLE.

3546
03:18:09,838 --> 03:18:13,775
YOU CAN GET ANYWHERE BUT MOST 

3547
03:18:13,775 --> 03:18:17,212
THE SCARRING WE SEE IN BARLOW'S 

3548
03:18:17,212 --> 03:18:19,581
IS IN THE ANTERIOR PAPILLARY 

3549
03:18:19,581 --> 03:18:23,585
MUSCLE RENAL  -- REGION.

3550
03:18:23,585 --> 03:18:24,786
I DON'T KNOW WHY THAT IS.

3551
03:18:24,786 --> 03:18:25,587
>> THANK YOU FOR THE 

3552
03:18:25,587 --> 03:18:27,522
PRESENTATION AND DISCUSSION.

3553
03:18:27,522 --> 03:18:28,256
DR. MILLER, YOU'RE THE FINAL 

3554
03:18:28,256 --> 03:18:33,361
PRESENTATION OF THIS SESSION.

3555
03:18:33,361 --> 03:18:35,263
>> THANK YOU TO THE
ORGANIZERS.

3556
03:18:35,263 --> 03:18:39,568
I'VE BEEN ASKED TO SPEAK ABOUT 

3557
03:18:39,568 --> 03:18:41,369
RISK STRATIFICATION FOR SUDDEN 

3558
03:18:41,369 --> 03:18:44,906
DEATH IN PATIENTS WITH MILD OR 

3559
03:18:44,906 --> 03:18:45,640
MODERATE MR.

3560
03:18:45,640 --> 03:18:51,446
I LOVE THE QUOTE WE REACHED THE 

3561
03:18:51,446 --> 03:18:55,951
STAGE OF IDENTIFYING CLINICAL 

3562
03:18:55,951 --> 03:18:57,986
PROBLEM.

3563
03:18:57,986 --> 03:18:59,621
AND SO WHY DOES RISK 

3564
03:18:59,621 --> 03:19:04,526
STRATIFICATION MATTER IT'S TO 

3565
03:19:04,526 --> 03:19:04,926
AVO

3566
03:19:04,926 --> 03:19:09,030
AVOID SUDDEN DEATH AND ICD.

3567
03:19:09,030 --> 03:19:15,971
PRIMARY PREVENTION WILL GO TO 

3568
03:19:15,971 --> 03:19:17,205
DEVICE COMPLICATION AND THIS IS 

3569
03:19:17,205 --> 03:19:19,608
WHERE THERE'S YOUNG PATIENTS 

3570
03:19:19,608 --> 03:19:21,509
WITH PRESERVED FUNCTION OR 

3571
03:19:21,509 --> 03:19:22,811
INCREASED RISK OF SUDDEN DEATH.

3572
03:19:22,811 --> 03:19:23,878
WHETHER PRESENT OR NOT THERE'S 

3573
03:19:23,878 --> 03:19:26,414
CLEARLY A FEAR OF THE UNKNOWN 

3574
03:19:26,414 --> 03:19:27,582
DRIVING A LOT OF CLINICAL 

3575
03:19:27,582 --> 03:19:28,717
DECISION MAKING WHEN IT COMES TO

3576
03:19:28,717 --> 03:19:34,122
RISK STRATIFICATION.

3577
03:19:34,122 --> 03:19:38,526
THIS IS HOW I VIEW THE PENDULUM 

3578
03:19:38,526 --> 03:19:40,128
OF SUDDEN DEATH OCCURRING.

3579
03:19:40,128 --> 03:19:42,998
SO 1972 THE FIRST DESCRIPTION OF

3580
03:19:42,998 --> 03:19:44,799
SUDDEN DEATH IN PATIENTS WITH 

3581
03:19:44,799 --> 03:19:52,140
PROLAPSE AND FOR MANY YEARS IT 

3582
03:19:52,140 --> 03:19:54,709
REMAINED RELATIVELY QUIET AND 

3583
03:19:54,709 --> 03:19:56,011
LOOKED AT THE PROLAPSE SYNDROME 

3584
03:19:56,011 --> 03:19:57,679
AND PEOPLE STARTED BECOMING 

3585
03:19:57,679 --> 03:19:58,013
AWARE.

3586
03:19:58,013 --> 03:19:59,914
AND DIDN'T KNOW WHAT TO DO WITH 

3587
03:19:59,914 --> 03:20:02,217
THE INFORMATION BUT THEY WERE 

3588
03:20:02,217 --> 03:20:03,418
AWARE OF THE CONDITION.

3589
03:20:03,418 --> 03:20:04,719
AND OBVIOUSLY THE GROUP CAME 

3590
03:20:04,719 --> 03:20:06,655
TOGETHER A FEW YEARS AGO AND 

3591
03:20:06,655 --> 03:20:08,790
PUBLISHED AN IMPORTANT DOCUMENT 

3592
03:20:08,790 --> 03:20:10,125
OF RESEARCH OPPORTUNITIES IN 

3593
03:20:10,125 --> 03:20:10,792
MITRAL VALVE PROLAPSE AND MORE 

3594
03:20:10,792 --> 03:20:14,195
PEOPLE BECAME.

3595
03:20:14,195 --> 03:20:15,997
OVER THE NEXT FOUR YEARS YOU 

3596
03:20:15,997 --> 03:20:17,232
HAVE FEAR OUT THERE.

3597
03:20:17,232 --> 03:20:22,537
IF YOU LOOK AT THE PUBLICATIONS 

3598
03:20:22,537 --> 03:20:25,774
OF PEOPLE WITH SUDDEN DEATH 

3599
03:20:25,774 --> 03:20:27,208
SKYROCKETED AND SO THEY'RE AWARE

3600
03:20:27,208 --> 03:20:29,144
BUT NOT SURE WHAT TO DO.

3601
03:20:29,144 --> 03:20:33,882
I WANT TO USE AN EXAMPLE FROM 

3602
03:20:33,882 --> 03:20:35,016
TWO OTHER CONDITIONS.

3603
03:20:35,016 --> 03:20:36,785
THERE'S THE FEAR OF DROPPING 

3604
03:20:36,785 --> 03:20:37,218
DEAD.

3605
03:20:37,218 --> 03:20:39,587
FROM THE PATIENT AND PHYSICIAN 

3606
03:20:39,587 --> 03:20:46,227
PERSPECTIVE.

3607
03:20:46,227 --> 03:20:48,363
AT THAT TIME THERE WAS A 

3608
03:20:48,363 --> 03:20:55,637
PETITION FROM A CITIZEN IN THE 

3609
03:20:55,637 --> 03:20:58,406
U.K. WHO SUED BECAUSE HE PASSED 

3610
03:20:58,406 --> 03:21:00,942
WITHOUT DOCUMENT AND GOT 10,000 

3611
03:21:00,942 --> 03:21:02,477
SIGNATURES WHICH BASICALLY SAID 

3612
03:21:02,477 --> 03:21:06,481
THEY WOULD APPROVE AN ICD FOR 

3613
03:21:06,481 --> 03:21:12,454
ANYONE WITH THE BRUGADA SYNDROME

3614
03:21:12,454 --> 03:21:15,323
AND IF YOU LOOK AT THE INCIDENTS

3615
03:21:15,323 --> 03:21:16,725
OF SUDDEN DEATH IN THE SYNDROME 

3616
03:21:16,725 --> 03:21:17,726
IT'S QUITE LOW.

3617
03:21:17,726 --> 03:21:19,461
THIS IS SIX MAIN STUDIES AND 

3618
03:21:19,461 --> 03:21:21,563
PATIENTS WHO DID NOT GET PRIMARY

3619
03:21:21,563 --> 03:21:25,066
PREVENTION ICDs AND FOR ALL 

3620
03:21:25,066 --> 03:21:30,672
COMERS THE RISK OF SUDDEN DEATH 

3621
03:21:30,672 --> 03:21:36,945
WAS .02%.

3622
03:21:36,945 --> 03:21:39,614
THERE'S RISK FACTORS TO DECIDE 

3623
03:21:39,614 --> 03:21:42,484
WHO WOULD BENEFIT.

3624
03:21:42,484 --> 03:21:44,586
AND RISK STRATIFICATION DOES 

3625
03:21:44,586 --> 03:21:45,520
WORK.

3626
03:21:45,520 --> 03:21:49,557
THIS IS HYPERTROPHIC 

3627
03:21:49,557 --> 03:21:50,492
CARDIOMYOPATHY BASED ON EVIDENCE

3628
03:21:50,492 --> 03:21:52,193
AND OVER THE COURSE OF THE LAST 

3629
03:21:52,193 --> 03:21:55,363
TWO DECADES THE RISK OF SUDDEN 

3630
03:21:55,363 --> 03:22:02,237
DEATH DROPPED DRAMATICALLY FOR 

3631
03:22:02,237 --> 03:22:04,939
HYPERCARDY MYOPATHY.

3632
03:22:04,939 --> 03:22:08,143
THE MAJORITY OF SUDDEN DEATH 

3633
03:22:08,143 --> 03:22:12,280
OCCURS IN PATIENTS WITH MODERATE

3634
03:22:12,280 --> 03:22:12,447
MR.

3635
03:22:12,447 --> 03:22:15,950
AND AS WE ALL KNOW THE INCIDENTS

3636
03:22:15,950 --> 03:22:17,986
OF MVP IS 4% OF THE POPULATION 

3637
03:22:17,986 --> 03:22:19,387
AND INCIDENTS OF SUDDEN DEATH 

3638
03:22:19,387 --> 03:22:23,191
COULD BE UP TO 1. 8%.

3639
03:22:23,191 --> 03:22:27,562
THE QUESTION BECOMES HOW DO WE 

3640
03:22:27,562 --> 03:22:30,899
IDENTIFY THAT PERSON AND 

3641
03:22:30,899 --> 03:22:31,900
INTERVENE BEFORE CARDIAC ARREST.

3642
03:22:31,900 --> 03:22:37,305
THIS IS HOW I TEND TO THINK 

3643
03:22:37,305 --> 03:22:41,209
ABOUT AND THERE'S A LARGE 

3644
03:22:41,209 --> 03:22:44,145
POPULATION OF MVP AND SUDDEN 

3645
03:22:44,145 --> 03:22:44,412
DEATH.

3646
03:22:44,412 --> 03:22:47,749
AS YOU START TO ADD UP ALL THE 

3647
03:22:47,749 --> 03:22:51,586
RISK FACTORS AND THE RISK GOES 

3648
03:22:51,586 --> 03:22:56,624
DOWN BUT INCIDENTS GO UP 

3649
03:22:56,624 --> 03:22:58,026
SIGNIFI

3650
03:22:58,026 --> 03:22:58,359
SIGNIFICANTLY.

3651
03:22:58,359 --> 03:23:02,397
HOW DO PREVENT THIS FROM 

3652
03:23:02,397 --> 03:23:07,368
MALIGNANT MVP AND WHO SHOULD BE 

3653
03:23:07,368 --> 03:23:10,638
RISK STRATIFIED.

3654
03:23:10,638 --> 03:23:11,573
ACCORDING TO THE CONSENSUS 

3655
03:23:11,573 --> 03:23:13,141
DOCUMENT EVERYBODY SHOULD BE 

3656
03:23:13,141 --> 03:23:14,576
RISK STRATIFIED AND THERE'S 

3657
03:23:14,576 --> 03:23:16,277
ALGORITHMS OUT THERE.

3658
03:23:16,277 --> 03:23:19,647
ALMOST EVERY JOURNAL PUBLISHED A

3659
03:23:19,647 --> 03:23:23,918
RISK STRATIFICATION ALGORITHM 

3660
03:23:23,918 --> 03:23:25,553
AND I RECOGNIZE THERE'S MULTIPLE

3661
03:23:25,553 --> 03:23:27,589
AUTHORS OF THE DOCUMENT ON THE 

3662
03:23:27,589 --> 03:23:30,191
CALL RIGHT NOW.

3663
03:23:30,191 --> 03:23:40,735
THIS IS THE EF  -- EHR CONSENSUS

3664
03:23:44,839 --> 03:23:47,475
STATEMENT AND HAVE SYMPTOMS AND 

3665
03:23:47,475 --> 03:23:50,578
HAVE SOME PVCs AND THAT'S WHEN 

3666
03:23:50,578 --> 03:23:52,547
THE ELECTROPHYSIOLOGIST TENDS TO

3667
03:23:52,547 --> 03:23:53,815
GET INVOLVED.

3668
03:23:53,815 --> 03:23:55,850
AT TWO DECISION POINTS TO THE 

3669
03:23:55,850 --> 03:24:00,255
LEFT SIDE AND THE PHENOTYPIC 

3670
03:24:00,255 --> 03:24:02,190
RISK WITH VT OR IF YOU HAVE VT 

3671
03:24:02,190 --> 03:24:06,327
THEN IT BECOMES A QUESTION OF 

3672
03:24:06,327 --> 03:24:08,663
HIGH RISK VT.

3673
03:24:08,663 --> 03:24:12,534
THOSE ARE THE TWO BRANCH POINTS.

3674
03:24:12,534 --> 03:24:16,804
SOME OF THE ISSUES I'VE HAD IS 

3675
03:24:16,804 --> 03:24:19,574
FOR EXAMPLE YOU HAVE NO 

3676
03:24:19,574 --> 03:24:28,283
VENTRICULAR TACHYCARDIA AND DO 

3677
03:24:28,283 --> 03:24:31,853
WE BELIEVE THE INVERSIONS ARE 

3678
03:24:31,853 --> 03:24:34,856
EQUAL TO PVCs ON THE EKG?

3679
03:24:34,856 --> 03:24:37,559
SO THIS HAS BEEN PRESENTED 

3680
03:24:37,559 --> 03:24:39,394
ALREADY.

3681
03:24:39,394 --> 03:24:41,563
THE EARLY DETE SUGGESTED MAD WAS

3682
03:24:41,563 --> 03:24:43,965
CORRELATED WITH MSVT AND THE 

3683
03:24:43,965 --> 03:24:46,000
AMOUNT WAS CORRELATED WITH LGE 

3684
03:24:46,000 --> 03:24:51,573
AND SEEMED TO BE A HIGH RISK OF 

3685
03:24:51,573 --> 03:24:52,740
ARRHYTHMIAS IN PATIENTS WITH 

3686
03:24:52,740 --> 03:24:53,841
MAD.

3687
03:24:53,841 --> 03:24:56,311
BUT THERE'S MORE RECENT DATA 

3688
03:24:56,311 --> 03:24:58,746
SUGGESTS THE MAD IS NOT 

3689
03:24:58,746 --> 03:25:01,015
PREDICTIVE OF ARRHYTHMIC EVENTS 

3690
03:25:01,015 --> 03:25:02,650
AND PATIENTS WITH THIS IT WAS 

3691
03:25:02,650 --> 03:25:05,853
NOT PREDICTIVE AND LGE WAS AND 

3692
03:25:05,853 --> 03:25:10,959
THIS IS A LARGE RADIOLOGY 

3693
03:25:10,959 --> 03:25:11,559
STUDIO.

3694
03:25:11,559 --> 03:25:19,567
AND MITRAL DYSFUNCTION MAY BE 

3695
03:25:19,567 --> 03:25:23,538
OVER  EMPHASIZED AND 

3696
03:25:23,538 --> 03:25:24,572
THREE-QUARTERS OF THE PATIENTS 

3697
03:25:24,572 --> 03:25:27,575
WOULD HAVE BEEN DIAGNOSED AND 

3698
03:25:27,575 --> 03:25:31,946
THE ONLY MAD RELEVANT IS 

3699
03:25:31,946 --> 03:25:33,314
ASSOCIATED WITH MITRAL VALVE 

3700
03:25:33,314 --> 03:25:33,681
PROLAPSE.

3701
03:25:33,681 --> 03:25:37,585
AND THIS IS AN INTERESTING 

3702
03:25:37,585 --> 03:25:38,119
MACHINE LEARNING STUDY.

3703
03:25:38,119 --> 03:25:46,127
THE CLUSTER TO THE RIGHT HAD A 

3704
03:25:46,127 --> 03:25:47,528
FO

3705
03:25:47,528 --> 03:25:47,862
FO

3706
03:25:47,862 --> 03:25:48,529
FOURFOLD DEATH AND THE PRESENCE 

3707
03:25:48,529 --> 03:25:59,073
WAS NOT PREDICTIVE IN THE MODEL.

3708
03:25:59,307 --> 03:26:01,709
MYOCARDIAL FIBROSIS IS RELATED 

3709
03:26:01,709 --> 03:26:06,781
AND SEEMS TO BE PREDICTIVE OF 

3710
03:26:06,781 --> 03:26:08,082
MAJOR ARRHYTHMIC EVENTS AND THE 

3711
03:26:08,082 --> 03:26:11,653
PRESENCE OF LGE AND IT WAS 7.7% 

3712
03:26:11,653 --> 03:26:19,293
OF THE PATIENTS OF MAJOR 

3713
03:26:19,293 --> 03:26:20,895
VENTRICULAR ARRHYTHMIAS AND AND 

3714
03:26:20,895 --> 03:26:22,664
THE OTHER MRI STUDY LAST YEAR 

3715
03:26:22,664 --> 03:26:27,568
SHOWED THE PRESENCE OF LVE WAS 

3716
03:26:27,568 --> 03:26:33,508
ASSOCIATED WAS ASSOCIATED WITH A

3717
03:26:33,508 --> 03:26:35,410
TENFOLD HIGHER RISK OF ABORTED 

3718
03:26:35,410 --> 03:26:37,845
SUDDEN DEATH AND SHOULD WE TREAT

3719
03:26:37,845 --> 03:26:48,122
IT EQUAL TO LG?

3720
03:26:49,424 --> 03:26:57,398
THEN WE MOVE TO THE RIGHT SIDE 

3721
03:26:57,398 --> 03:27:00,868
AND LOOK AT FAST NON SUSTAINED 

3722
03:27:00,868 --> 03:27:03,571
VT GREATER THAN 180 BEATS A 

3723
03:27:03,571 --> 03:27:03,805
MINUTE.

3724
03:27:03,805 --> 03:27:07,909
THIS IS A PATIENT OF MINE, 

3725
03:27:07,909 --> 03:27:10,278
56-YEAR-OLD FEMALE MINIMAL AR 

3726
03:27:10,278 --> 03:27:12,113
AND SMALL AMOUNT OF LGE IS 

3727
03:27:12,113 --> 03:27:14,182
PRESENT AND THIS IS HER EVENT 

3728
03:27:14,182 --> 03:27:17,819
MONITOR 8.8 SECONDS AT 182 BEATS

3729
03:27:17,819 --> 03:27:18,553
A MINUTE.

3730
03:27:18,553 --> 03:27:26,127
IF I WERE TO FOLLOW THAT 

3731
03:27:26,127 --> 03:27:28,396
ALGORITHM DOWN THE PATIENT WOULD

3732
03:27:28,396 --> 03:27:31,432
QUALIFY FOR AN LCD.

3733
03:27:31,432 --> 03:27:33,134
IF YOU LOOK BACK A LOT OF IT IS 

3734
03:27:33,134 --> 03:27:35,603
THE DEFINITION OF WHERE DID IT 

3735
03:27:35,603 --> 03:27:37,138
COME FROM.

3736
03:27:37,138 --> 03:27:41,075
FOR THE PATIENTS OF HIGH RISK VT

3737
03:27:41,075 --> 03:27:47,582
OF THE STUDIES MOST WOULD MEET 

3738
03:27:47,582 --> 03:27:51,486
CRITERIA BASED ON THIS OF THE VT

3739
03:27:51,486 --> 03:27:52,320
RUN GREATER THAN 180 BEATS A 

3740
03:27:52,320 --> 03:27:57,091
MINUTE.

3741
03:27:57,091 --> 03:27:57,892
THE RISK ASSOCIATED CAME FROM 

3742
03:27:57,892 --> 03:28:00,561
THE IMPORTANT PAPER ON THE 

3743
03:28:00,561 --> 03:28:03,998
OUTCOMES OF MITRAL VALVE 

3744
03:28:03,998 --> 03:28:05,566
PROLAPSE WHICH SHOWED AND 

3745
03:28:05,566 --> 03:28:07,568
OUTCOMES WERE WORSE WHEN IT WAS 

3746
03:28:07,568 --> 03:28:12,707
PRESENT.

3747
03:28:12,707 --> 03:28:15,977
AND IF YOU LOOK AT WHERE THE 

3748
03:28:15,977 --> 03:28:18,679
COMBINATION CAME FROM IT CAME 

3749
03:28:18,679 --> 03:28:22,116
FROM THE PAPER IN 2005 WHICH IS 

3750
03:28:22,116 --> 03:28:26,320
THREE PATIENTS WHO HAD RVO VT 

3751
03:28:26,320 --> 03:28:28,422
GREATER THAN 180 BEATS A MINUTE 

3752
03:28:28,422 --> 03:28:29,524
THAT'S A DIFFERENT POPULATION 

3753
03:28:29,524 --> 03:28:30,691
COMPLETELY AND I'M NOT SURE ANY 

3754
03:28:30,691 --> 03:28:34,629
OF OUR DEFINITIONS FOR COMPLEX 

3755
03:28:34,629 --> 03:28:39,033
VENTRICULAR ARRHYTHMIAS HAVE 

3756
03:28:39,033 --> 03:28:44,472
BEEN CONTEMPLATED IN PATIENTS 

3757
03:28:44,472 --> 03:28:45,206
WITH MITRAL VALVE PROLAPSE AND 

3758
03:28:45,206 --> 03:28:51,579
WILL WE END UP IMPLANTING TOO 

3759
03:28:51,579 --> 03:28:52,780
MANY AND LOOKING AT THE 

3760
03:28:52,780 --> 03:28:53,214
MISTAKES.

3761
03:28:53,214 --> 03:28:54,282
WHO LOOKED AT THIS?

3762
03:28:54,282 --> 03:28:56,918
THEY APPLIED THE CONSENSUS 

3763
03:28:56,918 --> 03:28:59,720
DOCUMENT STATEMENTS TO THEIR OWN

3764
03:28:59,720 --> 03:29:03,591
PATIENT POPULATION OF 169 

3765
03:29:03,591 --> 03:29:12,800
PATIENTS RETROSPECTIVELY.

3766
03:29:12,800 --> 03:29:16,938
IF THEY APPLIED AT THE TIME IT'S

3767
03:29:16,938 --> 03:29:21,642
YOUNG PATIENTS GET PRIMARY 

3768
03:29:21,642 --> 03:29:22,343
PREVENTION ICDs.

3769
03:29:22,343 --> 03:29:23,811
I'LL HAVE A COUPLE CASES AND SEE

3770
03:29:23,811 --> 03:29:26,948
HOW IT COULD BE MANAGED WITH OR 

3771
03:29:26,948 --> 03:29:28,683
DIFFERENT THAN THE DOCUMENT.

3772
03:29:28,683 --> 03:29:33,421
THIS IS 66-YEAR-OLD MALE WITH 

3773
03:29:33,421 --> 03:29:35,156
MITRAL VALVE PROLAPSE AND MR AND

3774
03:29:35,156 --> 03:29:45,366
RARE PVCs AND BEATS GREATER THAN

3775
03:29:45,366 --> 03:29:50,872
200 BEATS PER MINUTE AND SHOWED 

3776
03:29:50,872 --> 03:29:51,305
DISJUNCTION.

3777
03:29:51,305 --> 03:29:53,941
SO THE QUESTION IS WHAT WOULD 

3778
03:29:53,941 --> 03:29:56,310
YOU DO IN A SITUATION LIKE THIS?

3779
03:29:56,310 --> 03:30:00,548
IMPLANT AN ICD OR DO A STUDY OR 

3780
03:30:00,548 --> 03:30:02,049
BETA BLOCKERS OR ADDITIONAL 

3781
03:30:02,049 --> 03:30:02,950
IMAGING OR CONTINUING TO 

3782
03:30:02,950 --> 03:30:03,384
MONITOR?

3783
03:30:03,384 --> 03:30:07,588
WE DECIDED TO DO ADDITIONAL 

3784
03:30:07,588 --> 03:30:12,960
IMAGING TO GET MORE INFORMATION.

3785
03:30:12,960 --> 03:30:14,528
WE DID A HYBRID PET MRI AND 

3786
03:30:14,528 --> 03:30:16,197
LOOKED AT UPTAKE THAT WAS 

3787
03:30:16,197 --> 03:30:18,566
CONCORDANT IN THE TYPICAL 

3788
03:30:18,566 --> 03:30:23,571
LOCATION YOU'D EXPECT TO SEE IN 

3789
03:30:23,571 --> 03:30:33,948
MITRAL VALVE PROLAPSE.

3790
03:30:35,616 --> 03:30:37,451
ULTIMATELY THE DECISION WOULD 

3791
03:30:37,451 --> 03:30:38,719
HAVE BEEN TO PUT IN AN ICD.

3792
03:30:38,719 --> 03:30:43,524
MY PERSONAL OPINION WAS THIS 

3793
03:30:43,524 --> 03:30:44,558
FINDING IS COMMON AND THE CON 

3794
03:30:44,558 --> 03:30:49,864
STELATIONS OF FINDING AND WE 

3795
03:30:49,864 --> 03:30:51,565
RECOMMENDED BETA BLOCKERS FOR 

3796
03:30:51,565 --> 03:30:53,367
THE TIME BEING.

3797
03:30:53,367 --> 03:30:59,774
CASE 2 IS A 40-YEAR-OLD FEMALE 

3798
03:30:59,774 --> 03:31:05,046
AND THE RARE PVCs AND 142 BEATS 

3799
03:31:05,046 --> 03:31:08,349
A MINUTE AND 12 MILLIMETER OF 

3800
03:31:08,349 --> 03:31:10,117
DISJUNCTION AND NO LGE BY 

3801
03:31:10,117 --> 03:31:20,261
REPORT.

3802
03:31:24,165 --> 03:31:28,135
YOU'RE MRI SHOWED THE BEATS AND 

3803
03:31:28,135 --> 03:31:31,572
THE LEFT IS THE LGE MAP AND 

3804
03:31:31,572 --> 03:31:34,809
UPTAKE IN THE PAPILLARY MUSCLE.

3805
03:31:34,809 --> 03:31:39,580
THEY ARE HAVE SLOW SET AND 

3806
03:31:39,580 --> 03:31:47,388
SUBSTRATE.

3807
03:31:47,388 --> 03:31:50,758
IT DOESN'T TAKE INTO ACCOUNT ANY

3808
03:31:50,758 --> 03:31:53,995
OF THE POTENTIAL RISK FACTORS 

3809
03:31:53,995 --> 03:32:04,372
WHICH MAY BE RELEVANT.

3810
03:32:08,976 --> 03:32:11,278
WE DECIDED TO DO WORK UP AND IN 

3811
03:32:11,278 --> 03:32:13,581
THE PATIENT THE STRAIN IMAGING 

3812
03:32:13,581 --> 03:32:17,018
SHOWED ABNORMAL MECHANICAL 

3813
03:32:17,018 --> 03:32:19,086
DISPERSION, 86 MILLISECONDS NOW 

3814
03:32:19,086 --> 03:32:21,989
THE PATIENT HAS MULTIPLE RISK 

3815
03:32:21,989 --> 03:32:25,393
FACTORS AND SLOW NSBT AND 

3816
03:32:25,393 --> 03:32:29,397
FIBROSIS AND FDG UPTAKE AND 

3817
03:32:29,397 --> 03:32:30,164
ABNORMAL MECHANICAL DISPERSIONS 

3818
03:32:30,164 --> 03:32:32,199
AND THE QUESTION REMAINS WHAT TO

3819
03:32:32,199 --> 03:32:33,567
DO WITH THE PATIENT.

3820
03:32:33,567 --> 03:32:34,135
PERHAPS AN INTERVENTION IS 

3821
03:32:34,135 --> 03:32:44,311
NECESSARY.

3822
03:32:46,180 --> 03:32:50,384
WE KNOW STRAIN IMAGING MAY BE 

3823
03:32:50,384 --> 03:32:54,555
USEFUL FOR ADDITIVE VALUE THON 

3824
03:32:54,555 --> 03:32:59,026
 -- ON THE RISK FACTORS AND 

3825
03:32:59,026 --> 03:33:00,828
THERE'S RHYTHMIC AND 

3826
03:33:00,828 --> 03:33:05,533
NON-ARRHYTHMIC CAUSES OF SUDDEN 

3827
03:33:05,533 --> 03:33:06,367
DEATH.

3828
03:33:06,367 --> 03:33:08,702
CASE NUMBER 3 IS A FEMALE AND 

3829
03:33:08,702 --> 03:33:11,505
THIS SHOWED A PICKLE HUB AND PVV

3830
03:33:11,505 --> 03:33:12,673
BURDEN OF 6%.

3831
03:33:12,673 --> 03:33:16,844
THREE EPISODES OF NSVT AND THE 

3832
03:33:16,844 --> 03:33:19,580
LONGEST WAS 12 BEATS, 167 A 

3833
03:33:19,580 --> 03:33:25,619
MINUTE AND TECHNICALLY THE 

3834
03:33:25,619 --> 03:33:34,161
PATIENT HAD A PVC BURDENED AND 

3835
03:33:34,161 --> 03:33:34,862
UNDERWENT A HYBRID PET MRI 

3836
03:33:34,862 --> 03:33:45,039
PROTOCOL.

3837
03:33:50,611 --> 03:33:55,416
AND IN THIS PATIENT I BASICALLY 

3838
03:33:55,416 --> 03:33:56,617
FOLLOWED ALMOST INADVERTENTLY 

3839
03:33:56,617 --> 03:34:00,855
WHERE THE ARROWS WOULD HAVE LEFT

3840
03:34:00,855 --> 03:34:04,058
ME AND RECOMMENDED A LOOP 

3841
03:34:04,058 --> 03:34:06,760
RECORDER AND NO REAL VT, 

3842
03:34:06,760 --> 03:34:08,162
MULTIPLE RISK AND WE DECIDED TO 

3843
03:34:08,162 --> 03:34:14,668
IMPLANT AN IOR.

3844
03:34:14,668 --> 03:34:19,773
IT GETS IMPLANTED AND THEN AN 

3845
03:34:19,773 --> 03:34:22,610
EPISODE OF POLYMORPHIC ICT WITH 

3846
03:34:22,610 --> 03:34:33,120
A BRIEF EPISODE OF DIZZINESS.

3847
03:34:37,625 --> 03:34:40,094
TO ME IT'S ALWAYS CONCERNING AND

3848
03:34:40,094 --> 03:34:43,397
RECOMMENDED A PRIMARY ICD IN 

3849
03:34:43,397 --> 03:34:44,465
THIS PARTICULAR PATIENT.

3850
03:34:44,465 --> 03:34:45,666
THIS IS MY BASIC APPROACH AND 

3851
03:34:45,666 --> 03:34:49,303
NOT VALIDATED IN ANY WAY JUST MY

3852
03:34:49,303 --> 03:34:54,175
OPINION HOW I TYPICALLY MANAGE 

3853
03:34:54,175 --> 03:35:02,316
PATIENTS WHO HAVE MVP WITH 

3854
03:35:02,316 --> 03:35:02,616
MODERATE MR.

3855
03:35:02,616 --> 03:35:13,160
IF THEY HAVE COMPLEX VENTRICULAR

3856
03:35:16,096 --> 03:35:18,566
ECTOPY WE HAVE A RECORDER AND IF

3857
03:35:18,566 --> 03:35:24,572
THEY HAVE EPISODES OF 

3858
03:35:24,572 --> 03:35:26,073
NON-POLYMORPHIC MVP WE RECOMMEND

3859
03:35:26,073 --> 03:35:29,243
ICD AND WHAT IF THEY HAVE FOUR 

3860
03:35:29,243 --> 03:35:30,511
OR FIVE OTHER PHENOTYPIC RISK 

3861
03:35:30,511 --> 03:35:32,313
FEATURES THEN YOU NEED A 

3862
03:35:32,313 --> 03:35:33,581
DISCUSSION ABOUT THE PATIENT 

3863
03:35:33,581 --> 03:35:34,615
IT'S ESSENTIALLY A DATA FREE 

3864
03:35:34,615 --> 03:35:36,984
STONE AT THE TIME BUT WOULD BE 

3865
03:35:36,984 --> 03:35:38,352
REASONABLE TO CONSIDER AN ICD.

3866
03:35:38,352 --> 03:35:44,024
IF THE PATIENT HAS COMPLEX ECTO

3867
03:35:44,024 --> 03:35:48,562
I AND SYNCOPE YOU ARE OBLIGATED 

3868
03:35:48,562 --> 03:35:52,066
TO AN ILR OR ICD AND TRUE S

3869
03:35:52,066 --> 03:35:57,871
SYNCOPE IS A BAD PRODOME IN 

3870
03:35:57,871 --> 03:36:00,274
PATIENTS WITH THIS AND ASSUMING 

3871
03:36:00,274 --> 03:36:01,709
THEY HAVE FOR EXAMPLE THEY 

3872
03:36:01,709 --> 03:36:03,744
PASSED OUT WITH NO AWARENESS IT 

3873
03:36:03,744 --> 03:36:06,513
WAS GOING TO HAPPEN IS SOMETHING

3874
03:36:06,513 --> 03:36:08,282
TO BE CONCERNED ABOUT.

3875
03:36:08,282 --> 03:36:09,550
THE OTHER COMMON QUESTION THIS 

3876
03:36:09,550 --> 03:36:12,119
SOMETIMES TONIGHT GET ADDRESSED 

3877
03:36:12,119 --> 03:36:20,261
WHAT IF THEY HAVE A PVC BURDEN 

3878
03:36:20,261 --> 03:36:22,229
OF 12% THE PATIENT IS HIGHER 

3879
03:36:22,229 --> 03:36:22,429
RISK.

3880
03:36:22,429 --> 03:36:28,535
I LOOK AT IT DIFFERENTLY.

3881
03:36:28,535 --> 03:36:32,239
IF IT JUST COMES FROM THE 

3882
03:36:32,239 --> 03:36:33,907
PAPILLARY MUSCLE OR OUT LOW 

3883
03:36:33,907 --> 03:36:35,809
TRACK IT'S A SLIGHTLY DIFFERENT 

3884
03:36:35,809 --> 03:36:38,679
PATIENT THAN THREE OR FOUR 

3885
03:36:38,679 --> 03:36:39,013
MORPHOLOGIES.

3886
03:36:39,013 --> 03:36:41,081
WE OFTEN RECOMMEND TO TREAT THE 

3887
03:36:41,081 --> 03:36:45,653
PVCs AND THEN BEGIN THE RISK 

3888
03:36:45,653 --> 03:36:49,556
STRATIFICATION PROCESS 

3889
03:36:49,556 --> 03:36:50,324
ESSENTIALLY FROM ZERO.

3890
03:36:50,324 --> 03:36:53,093
THERE'S MORE DATA NEEDED TO 

3891
03:36:53,093 --> 03:36:55,596
CHARACTERIZE THE PHENOTYPE OF 

3892
03:36:55,596 --> 03:36:59,833
THAT TRANSITIONS TO MALIGNANT 

3893
03:36:59,833 --> 03:37:03,470
MVP AND BE ABLE TO ASSIGN A 

3894
03:37:03,470 --> 03:37:06,473
SCORE ON RISK OF SUDDEN DEATH 

3895
03:37:06,473 --> 03:37:09,977
AND DECIDE WOULD GETS AN ICD 

3896
03:37:09,977 --> 03:37:13,147
JUST LIKE FOR HYPERTROPHIC 

3897
03:37:13,147 --> 03:37:14,148
CARDIOMYOPATHY AND THAT'S THE 

3898
03:37:14,148 --> 03:37:16,917
DATA WE'LL TRY TO COLLECT FROM 

3899
03:37:16,917 --> 03:37:19,987
THIS ONGOING TO STUDY IN 

3900
03:37:19,987 --> 03:37:22,823
PATIENTS UNDER GOING TO PET MRI 

3901
03:37:22,823 --> 03:37:23,824
AND MITRAL VALVE PROLAPSE AND 

3902
03:37:23,824 --> 03:37:26,160
THE SURGICAL AND NON-SURGICAL 

3903
03:37:26,160 --> 03:37:28,595
GROUP AND THE NON-SURGICAL GROUP

3904
03:37:28,595 --> 03:37:31,565
WE'LL TRY TO LOOK AT THE 

3905
03:37:31,565 --> 03:37:33,100
CLINICAL CHARACTERISTICS WITH 

3906
03:37:33,100 --> 03:37:34,001
THE ARRHYTHMIC EVENTS.

3907
03:37:34,001 --> 03:37:36,470
AND AS SHOWN BEFORE THIS IS THE 

3908
03:37:36,470 --> 03:37:38,205
BREAK DOWN FOR MY PARTICULAR 

3909
03:37:38,205 --> 03:37:39,573
AREA IS THE NON-SURGICAL COHORT 

3910
03:37:39,573 --> 03:37:41,742
AT THE BOTTOM AND HOPEFULLY WILL

3911
03:37:41,742 --> 03:37:45,279
BE ABLE TO IDENTIFY WHICH 

3912
03:37:45,279 --> 03:37:46,213
PATIENTS ARE HAVING THESE 

3913
03:37:46,213 --> 03:37:50,884
LIFE-THREATENING ARRHYTHMIAS.

3914
03:37:50,884 --> 03:37:52,653
I WANT TO THANK EVERYONE ON THE 

3915
03:37:52,653 --> 03:37:54,588
RESEARCH TEAM WHO HELPED PUT ALL

3916
03:37:54,588 --> 03:37:57,791
THIS TOGETHER AND ALL MY 

3917
03:37:57,791 --> 03:37:58,459
CO-PRIMARY INVESTIGATORS.

3918
03:37:58,459 --> 03:38:04,531
THANK YOU.

3919
03:38:04,531 --> 03:38:05,232
>> THANK YOU VERY MUCH.

3920
03:38:05,232 --> 03:38:08,969
ANY QUESTIONS OR COMMENTS?

3921
03:38:08,969 --> 03:38:14,074
>> A BRIEF ONE.

3922
03:38:14,074 --> 03:38:15,576
PATIENTS HAVE SUDDEN DEATH AND 

3923
03:38:15,576 --> 03:38:17,244
THEY'RE RESUSCITATED.

3924
03:38:17,244 --> 03:38:20,114
I'M ALWAYS SURPRISED WHEN I SEE 

3925
03:38:20,114 --> 03:38:21,949
PATIENTS LIKE THAT AND THE ONES 

3926
03:38:21,949 --> 03:38:24,284
WE SEE, THREE AND FOUR YEARS AGO

3927
03:38:24,284 --> 03:38:30,023
THEY HAD SUDDEN DEATH AND MITRAL

3928
03:38:30,023 --> 03:38:32,292
REGURGITATION AND THEY ARE GOT 

3929
03:38:32,292 --> 03:38:33,527
AN ICD AND BECOME SYMPTOMATIC 

3930
03:38:33,527 --> 03:38:36,096
AND THEN HAVE SURGERY.

3931
03:38:36,096 --> 03:38:37,831
I'M ALWAYS SURPRISED SUDDEN 

3932
03:38:37,831 --> 03:38:39,566
DEATH IN THE FIELD DOESN'T LEAD 

3933
03:38:39,566 --> 03:38:42,536
TO LOOKING AT THE MITRAL VALVE.

3934
03:38:42,536 --> 03:38:43,537
WE WEREN'T THINKING ABOUT IT 

3935
03:38:43,537 --> 03:38:45,906
THAT WAY THREE OR FOUR YEARS AGO

3936
03:38:45,906 --> 03:38:51,578
BUT TODAY BUT IF YOU HAVE SUDDEN

3937
03:38:51,578 --> 03:38:56,650
DEATH IN THE FIELD AND YOU HAVE 

3938
03:38:56,650 --> 03:38:57,618
SIGNIFICANT PROLAPSE AREN'T YOU 

3939
03:38:57,618 --> 03:38:59,887
A CANDIDATE FOR SURGERY?

3940
03:38:59,887 --> 03:39:01,188
>> TWO COMMENTS.

3941
03:39:01,188 --> 03:39:02,556
ONE IS THERE'S A DELAY.

3942
03:39:02,556 --> 03:39:05,092
LIKE WE LOOKED AT SOME OF OUR 

3943
03:39:05,092 --> 03:39:07,561
DATA AND THERE SEEMS TO BE FROM 

3944
03:39:07,561 --> 03:39:11,598
WHEN A PATIENT GET A SECONDARY 

3945
03:39:11,598 --> 03:39:13,467
PREVENTION ICD SEEMS TO BE ON 

3946
03:39:13,467 --> 03:39:14,435
AVERAGE 7 TO 10 YEARS.

3947
03:39:14,435 --> 03:39:15,569
THERE'S TWO REASONS THEY'RE NOT 

3948
03:39:15,569 --> 03:39:16,770
GOING TO FOR SURGERY.

3949
03:39:16,770 --> 03:39:21,175
NUMBER ONE IS THEY'RE NOT 

3950
03:39:21,175 --> 03:39:23,043
RECOGNIZED AS MITRAL VALVE 

3951
03:39:23,043 --> 03:39:24,478
PROLAPSE IS A CAUSE FOR SUDDEN 

3952
03:39:24,478 --> 03:39:26,313
DEATH AND EVEN FOR MYSELF I SAW 

3953
03:39:26,313 --> 03:39:28,982
A PATIENT TWO WEEKS AGO I PUT IN

3954
03:39:28,982 --> 03:39:36,757
AN ICD IN 2015 AND NEVER DID IT 

3955
03:39:36,757 --> 03:39:38,592
DAWN ON ME THE PATIENT'S 

3956
03:39:38,592 --> 03:39:39,660
PROLAPSE WAS THE CAUSE OF SUDDEN

3957
03:39:39,660 --> 03:39:39,860
DEATH.

3958
03:39:39,860 --> 03:39:42,496
NOW LOOKING BACK ON IT NOW IT 

3959
03:39:42,496 --> 03:39:44,231
LOOKS FOOLISH BUT AT THE TIME I 

3960
03:39:44,231 --> 03:39:45,532
DID NOT RECOGNIZE IT.

3961
03:39:45,532 --> 03:39:48,302
THE SECOND ISSUE IS I'M NOT SURE

3962
03:39:48,302 --> 03:39:51,371
OUT IN THE FIELD EVENT TODAY 

3963
03:39:51,371 --> 03:39:52,739
PATIENTS HAVING MVP WITH 

3964
03:39:52,739 --> 03:39:58,579
MODERATE MR AND HAVING STUDDEN 

3965
03:39:58,579 --> 03:39:59,580
DEATH RECOGNIZED THE SUDDEN 

3966
03:39:59,580 --> 03:40:02,182
DEATH AND AWARENESS IS BETTER 

3967
03:40:02,182 --> 03:40:03,951
THAN 10 YEARS AGO BUT COULD 

3968
03:40:03,951 --> 03:40:07,287
STILL BE BETTER.

3969
03:40:07,287 --> 03:40:12,860
>> YOU LIKE TO BE
CONTROVERSIAL 

3970
03:40:12,860 --> 03:40:21,869
BECAUSE THAT'S AND AT THE TIME 

3971
03:40:21,869 --> 03:40:26,907
THERE WAS A DESIRE TO PUT ICD AS

3972
03:40:26,907 --> 03:40:37,150
IF IT WAS THE ANGEL OF DEATH.

3973
03:40:37,150 --> 03:40:40,087
AND WE SAY THE ICD IMPLANTATION 

3974
03:40:40,087 --> 03:40:41,755
IS BASED ON ARRHYTHMIA AND THE 

3975
03:40:41,755 --> 03:40:45,993
IMAGING IS THE REASON TO DO MORE

3976
03:40:45,993 --> 03:40:48,529
ARRHYTHMIA MONITORING.

3977
03:40:48,529 --> 03:40:54,167
THE GENERAL GUIDELINES ON VALVE 

3978
03:40:54,167 --> 03:41:01,708
DISEASE THE WORD HOLDER IS ONE 

3979
03:41:01,708 --> 03:41:03,143
TIME PRESENT IN VALVE DISEASE.

3980
03:41:03,143 --> 03:41:08,482
WE WANTED TO HAVE THE HOLDER AND

3981
03:41:08,482 --> 03:41:10,817
RHYTHM MONITORING AS PART OFF 

3982
03:41:10,817 --> 03:41:16,189
THE TESTING DONE IN PATIENTS 

3983
03:41:16,189 --> 03:41:23,564
WITH VALVE DISEASE.

3984
03:41:23,564 --> 03:41:30,203
EVIDENTLY THE DATA IS SMALL AND 

3985
03:41:30,203 --> 03:41:33,774
WE NEED 10,000 PATIENTS HOLDER 

3986
03:41:33,774 --> 03:41:35,008
AND LONG-TERM SURVIVAL AND HAVE 

3987
03:41:35,008 --> 03:41:36,944
THE OUTCOME IN 10 YEARS.

3988
03:41:36,944 --> 03:41:39,580
FOR NOW WE PRESENTED WHAT WAS 

3989
03:41:39,580 --> 03:41:44,151
KNOWN AT THE TIME AND MAYBE SOME

3990
03:41:44,151 --> 03:41:46,186
OTHER CRITERIA WILL APPEAR IF WE

3991
03:41:46,186 --> 03:41:49,623
HAVE THE PROPER STUDIES.

3992
03:41:49,623 --> 03:41:53,093
IT'S A NICE HYPOTHESIS WE HAVE 

3993
03:41:53,093 --> 03:41:59,366
AT LGE BUT IF YOU LOOK AT THE 

3994
03:41:59,366 --> 03:42:02,135
STUDIES THEY HAVEN'T LOOKED AT 

3995
03:42:02,135 --> 03:42:03,570
THE MAD.

3996
03:42:03,570 --> 03:42:07,574
THE BRITISH STUDY AND DATABASE 

3997
03:42:07,574 --> 03:42:10,177
AND BIO BANK IF YOU LOOK AT THAT

3998
03:42:10,177 --> 03:42:12,245
I'M NOT SURE I TRUST THE 

3999
03:42:12,245 --> 03:42:14,781
DIAGNOSIS THEY HAVE AND I'M NOT 

4000
03:42:14,781 --> 03:42:21,121
SURE I WOULD TRUST THE FIBROSIS 

4001
03:42:21,121 --> 03:42:22,189
DIAGNOSIS.

4002
03:42:22,189 --> 03:42:24,057
I REVIEWED THE PAPER.

4003
03:42:24,057 --> 03:42:26,460
TO SAY IT'S MORE FIBROSIS THAN 

4004
03:42:26,460 --> 03:42:26,693
MAD.

4005
03:42:26,693 --> 03:42:29,129
WE DON'T KNOW YET.

4006
03:42:29,129 --> 03:42:32,132
WE NEED VERY GOOD ATTENTIVE 

4007
03:42:32,132 --> 03:42:34,468
STUDIES TO SAY OKAY, WHAT IS THE

4008
03:42:34,468 --> 03:42:40,173
SPAN OF THE SCIENCE THAT ARE 

4009
03:42:40,173 --> 03:42:42,275
ASSOCIATED WITH THE ARRHYTHMIC 

4010
03:42:42,275 --> 03:42:44,211
MITRAL VALVE PROLAPSE AND WHAT 

4011
03:42:44,211 --> 03:42:46,713
IS ASSOCIATED WITH EXCESS 

4012
03:42:46,713 --> 03:42:46,980
MORTALITY.

4013
03:42:46,980 --> 03:42:48,649
WE'RE JUST AT THE BEGINNING AND 

4014
03:42:48,649 --> 03:42:51,585
HOPING TO REDO THE GRAPH WHEN WE

4015
03:42:51,585 --> 03:42:56,056
HAVE MORE OUTCOME STUDIES BUT I 

4016
03:42:56,056 --> 03:42:59,059
WANTED TO DEFEND -- 

4017
03:42:59,059 --> 03:43:01,862
>> YOU MAKE A GOOD POINT.

4018
03:43:01,862 --> 03:43:04,064
IT'S IMPORTANT THAT FINALLY 

4019
03:43:04,064 --> 03:43:12,072
MONITORING HAS COME TO SOME 

4020
03:43:12,072 --> 03:43:20,714
DOCUMENT.

4021
03:43:20,714 --> 03:43:22,015
A LOT OF PATIENTS ARE SHOWING UP

4022
03:43:22,015 --> 03:43:27,387
WITH THE DEFIBRILLATOR PUT IN 

4023
03:43:27,387 --> 03:43:28,121
ALREADY OR THEY'RE GETTING A 

4024
03:43:28,121 --> 03:43:33,126
SECOND OPINION.

4025
03:43:33,126 --> 03:43:36,763
THE DIFFERENCE IS FOR EXAMPLE 

4026
03:43:36,763 --> 03:43:38,632
YOU CAN DECIDE WHAT IT IS AND 

4027
03:43:38,632 --> 03:43:41,435
MOST OF THE PATIENTS I'VE SEEN 

4028
03:43:41,435 --> 03:43:43,236
INCLUDING PHYSICIANS SHOWING UP 

4029
03:43:43,236 --> 03:43:46,506
WITH PRIMARY PREVENTION ICDs AT 

4030
03:43:46,506 --> 03:43:49,843
THE AGE OF 35 THEY GOT AN MRI 

4031
03:43:49,843 --> 03:43:52,813
AND THE READER WROTE MITRAL 

4032
03:43:52,813 --> 03:43:58,185
ANNULAR DYSFUNCTION AND THE 

4033
03:43:58,185 --> 03:44:03,590
CARDIOLOGIST SENT THEM TO GET' 

4034
03:44:03,590 --> 03:44:05,959
DEFIBRIL

4035
03:44:05,959 --> 03:44:06,293
DEFIBRILLATOR.

4036
03:44:06,293 --> 03:44:09,596
>> WE'RE IN AGREEMENT.

4037
03:44:09,596 --> 03:44:13,433
WE SEARED IT IN A WAY WE WOULD 

4038
03:44:13,433 --> 03:44:15,569
NOT BE PUTTING ICDs RIGHT AND 

4039
03:44:15,569 --> 03:44:20,807
LEFT WITHOUT REASON.

4040
03:44:20,807 --> 03:44:24,177
AND WE HAVE TO MOVE TO 

4041
03:44:24,177 --> 03:44:25,846
DEMONSTRATE SEVERE ARRHYTHMIA 

4042
03:44:25,846 --> 03:44:29,182
AND THEN WE'LL TALK.

4043
03:44:29,182 --> 03:44:35,322
NOW, THE DEFINITION I THINK A 

4044
03:44:35,322 --> 03:44:37,691
MOVING TARGET AND WE HAVE LITTLE

4045
03:44:37,691 --> 03:44:37,891
DATA.

4046
03:44:37,891 --> 03:44:41,695
YOU ARE RIGHT.

4047
03:44:41,695 --> 03:44:46,900
THE PEOPLE WANT TO PUT ICDs LIKE

4048
03:44:46,900 --> 03:44:49,436
THEY FEEL SAFER BUT SAFER WITH 

4049
03:44:49,436 --> 03:44:51,671
THE ICD.

4050
03:44:51,671 --> 03:44:56,943
>> AND I'M AN ELECTROPH

4051
03:44:56,943 --> 03:44:58,044
ELECTROPHYSIO

4052
03:44:58,044 --> 03:44:58,478
ELECTROPHYSIOLOGIST.

4053
03:44:58,478 --> 03:44:59,513
I GET PAID TO PUT IN ICDs.

4054
03:44:59,513 --> 03:45:00,614
>> THANK YOU FOR THE 

4055
03:45:00,614 --> 03:45:02,349
PRESENTATION AND DISCUSSION AND 

4056
03:45:02,349 --> 03:45:04,518
WE'LL TAKE A BRIEF BEAK UNTIL 20

4057
03:45:04,518 --> 03:45:07,654
MINUTES AFTER THE HOUR AND BEGIN

4058
03:45:07,654 --> 03:45:08,188
THE FINAL SESSION OF THE 

4059
03:45:08,188 --> 03:45:36,805
MEETING. THANK YOU.

4060
03:45:36,805 --> 03:45:39,608
YOU SEE HERE THE CLASSIC FORM

4061
03:45:39,608 --> 03:45:48,940
OF DMR CLASSIFICATION.

4062
03:45:48,940 --> 03:45:49,974
YOU SEE THE PAPER IN THE 

4063
03:45:49,974 --> 03:45:51,909
COMMUNITY WHERE WE HAVE ALL THE 

4064
03:45:51,909 --> 03:45:57,114
PATIENTS DIAGNOSED WITH ISOLATED

4065
03:45:57,114 --> 03:45:58,816
MITRAL REGURGITATION ORGANIC EMR

4066
03:45:58,816 --> 03:46:01,485
APPROXIMATELY ONE-THIRD AND THE 

4067
03:46:01,485 --> 03:46:07,925
MAJORITY, 72% OF THE ORGANIC MR 

4068
03:46:07,925 --> 03:46:09,527
ARE CAUSED IN THE U.S. CURRENTLY

4069
03:46:09,527 --> 03:46:13,364
WITH A FEW PERCENT WITH ALL THE 

4070
03:46:13,364 --> 03:46:15,233
OTHER CAUSES THOUGH THE MOST ARE

4071
03:46:15,233 --> 03:46:21,772
DUE TO FUNCTIONAL MR.

4072
03:46:21,772 --> 03:46:26,043
AND THE FIRST THING IS MITRAL 

4073
03:46:26,043 --> 03:46:28,312
VALVE REPAIR IS CLASS I 

4074
03:46:28,312 --> 03:46:32,250
INDICATION IN THE EUROPEAN AND 

4075
03:46:32,250 --> 03:46:38,789
U.S. GUIDE LINES AND REPAIR IS A

4076
03:46:38,789 --> 03:46:49,333
SIMPLE BUT THE SURGICAL REPAIR 

4077
03:46:50,301 --> 03:46:52,203
INCLUDES SEVERAL THERAPEUTIC 

4078
03:46:52,203 --> 03:46:56,207
PARTS HERE IS RESECTION AND 

4079
03:46:56,207 --> 03:47:03,981
OFTEN RESECTION AND THREE 

4080
03:47:03,981 --> 03:47:07,818
THERAPIES TO TREAT THE PATIENTS 

4081
03:47:07,818 --> 03:47:12,056
AND YOU SEE THE SURVIVAL IS 

4082
03:47:12,056 --> 03:47:14,592
BETTER THAN MITRAL VALVE 

4083
03:47:14,592 --> 03:47:17,895
REPLACEMENT ALMOST IDENTICAL TO 

4084
03:47:17,895 --> 03:47:20,097
THE ORANGE WHICH IS THE EXPECTED

4085
03:47:20,097 --> 03:47:21,933
SURVIVAL AND RESTORING LIFE 

4086
03:47:21,933 --> 03:47:26,570
EXPECTANCY AS MANY SPEAKERS HAVE

4087
03:47:26,570 --> 03:47:26,837
INSISTED.

4088
03:47:26,837 --> 03:47:34,412
AND THE QUESTION IS DOES THAT 

4089
03:47:34,412 --> 03:47:37,181
INDICATE HIGH QUALITY VALVE 

4090
03:47:37,181 --> 03:47:40,785
REPLACEMENT AND WE LOOKED AT THE

4091
03:47:40,785 --> 03:47:42,353
REGISTRY AND SEE WITH ANY 

4092
03:47:42,353 --> 03:47:47,825
ADJUSTMENT REPAIR IS BETTER THAN

4093
03:47:47,825 --> 03:47:58,369
REPLACEMENT AND AND YOU CAN HAVE

4094
03:47:59,470 --> 03:48:04,875
BETTER OUTCOME THAN REPLACEMENT 

4095
03:48:04,875 --> 03:48:15,286
AND BECAUSE OF THAT AND 

4096
03:48:27,098 --> 03:48:28,666
PERFECTION IN THE REPAIR 

4097
03:48:28,666 --> 03:48:30,434
PERFORMED IS ESSENTIAL.

4098
03:48:30,434 --> 03:48:35,306
THE GUIDELINES BASED ON THE 

4099
03:48:35,306 --> 03:48:36,974
REPAIR, RESTORE LIFE EXPECTANCY 

4100
03:48:36,974 --> 03:48:39,677
INDICATE ON THE LEFT SIDE THE 

4101
03:48:39,677 --> 03:48:40,978
PEOPLE WITH EITHER SYMPTOMS OR 

4102
03:48:40,978 --> 03:48:44,648
LV DYSFUNCTION NEED TO HAVE 

4103
03:48:44,648 --> 03:48:46,684
MITRAL SURGERY FOR FURTHER 

4104
03:48:46,684 --> 03:48:50,488
REPAIR BUT THE PATIENT ON THE 

4105
03:48:50,488 --> 03:48:56,193
RIGHT SIDE ASYMPTOMATIC THINK 

4106
03:48:56,193 --> 03:48:58,162
ABOUT REPAIR IF YOU THINK YOU 

4107
03:48:58,162 --> 03:49:00,031
CAN REPAIR THIS VALVE AND MAYBE 

4108
03:49:00,031 --> 03:49:02,767
THAT ATTITUDE OF DON'T LOOK AT 

4109
03:49:02,767 --> 03:49:07,304
ANYTHING ELSE HAS NOT BEEN A 

4110
03:49:07,304 --> 03:49:17,848
POSITIVE THING OF THE GUIDELINE.

4111
03:49:21,952 --> 03:49:30,461
YOU SEE THE RISK ASSOCIATED WITH

4112
03:49:30,461 --> 03:49:31,862
SEVERE MR AND PROLAPSE THE 

4113
03:49:31,862 --> 03:49:36,067
BOTTOM CURVE IS FOR MODERATE OR 

4114
03:49:36,067 --> 03:49:38,602
SEVERE NRM OR REJECTION FRACTION

4115
03:49:38,602 --> 03:49:41,005
AND HAVE EXCESS MORTALITY AND IN

4116
03:49:41,005 --> 03:49:44,041
THE SYMPTOMATIC MR WITH NORMAL 

4117
03:49:44,041 --> 03:49:45,843
EF AT THE BEGINNING THERE'S 

4118
03:49:45,843 --> 03:49:47,378
EXCESS MORTALITY IN THE PATIENTS

4119
03:49:47,378 --> 03:49:51,449
WHO HAVE A VERY LARGE DEGREE OF 

4120
03:49:51,449 --> 03:49:52,516
MR.

4121
03:49:52,516 --> 03:50:02,993
SO MR SEVERE IS BAD OUTCOME.

4122
03:50:03,194 --> 03:50:06,530
SHOULD WE WAY FOR THE CLASS 1 

4123
03:50:06,530 --> 03:50:08,232
SYMPTOMS AND LOW EF AND THERE'S 

4124
03:50:08,232 --> 03:50:10,401
TWO TYPES OF WORK THAT SAY NO, 

4125
03:50:10,401 --> 03:50:11,335
DO NOT WAIT.

4126
03:50:11,335 --> 03:50:14,872
ON THE LEFT SIDE IS THE MAYO 

4127
03:50:14,872 --> 03:50:17,374
STUDY WE DID ON ALL PATIENTS 

4128
03:50:17,374 --> 03:50:18,642
OPERATING THOSE WITH CLASS 1 ON 

4129
03:50:18,642 --> 03:50:21,545
THE LEFT AT THE BOTTOM HAVE IS 

4130
03:50:21,545 --> 03:50:23,681
THE WORSE SURVIVAL AS COMPARED 

4131
03:50:23,681 --> 03:50:24,682
TO EARLY SURGERY EVEN ADJUSTING 

4132
03:50:24,682 --> 03:50:30,321
FOR ALL DIFFERENCES.

4133
03:50:30,321 --> 03:50:34,125
AND RECENTLY IN THE EUROPEAN 

4134
03:50:34,125 --> 03:50:36,193
JOURNAL OF IMAGING A PAPER 

4135
03:50:36,193 --> 03:50:38,863
SHOWING MORE TRIGGERS ARE 

4136
03:50:38,863 --> 03:50:42,633
ASSOCIATED WITH MORE MORTALITY 

4137
03:50:42,633 --> 03:50:44,201
AND IN PARTICULAR CLASS I 

4138
03:50:44,201 --> 03:50:50,407
TRIGGERS THE MORE YOU HAVE THE 

4139
03:50:50,407 --> 03:50:57,548
MORE SURVIVAL IS.

4140
03:50:57,548 --> 03:51:01,218
THE BEST TIME IS EARLY SURGERY.

4141
03:51:01,218 --> 03:51:02,419
IT'S PREFERRED.

4142
03:51:02,419 --> 03:51:07,324
WHEN THEY DID THAT IN THE 

4143
03:51:07,324 --> 03:51:09,393
REGISTRY WE OBSERVED THAT IN THE

4144
03:51:09,393 --> 03:51:10,394
OVER ALL POPULATION AND IN 

4145
03:51:10,394 --> 03:51:13,998
PROPENSITY SCORE MATCHED EARLY 

4146
03:51:13,998 --> 03:51:16,967
SURGERY HAD A BETTER SURVIVAL 

4147
03:51:16,967 --> 03:51:20,204
AND LOWER HEART FAILURE RATE 

4148
03:51:20,204 --> 03:51:23,974
THAN PATIENTS WHO AFTER THE 

4149
03:51:23,974 --> 03:51:26,877
FIRST THREE MONTHS WERE 

4150
03:51:26,877 --> 03:51:27,711
MEDICALLY UNTIL THEY REQUIRED 

4151
03:51:27,711 --> 03:51:27,945
SURGERY.

4152
03:51:27,945 --> 03:51:29,613
SO THE OUTCOME WAS BETTER WITH 

4153
03:51:29,613 --> 03:51:39,857
EARLY SURGERY.

4154
03:51:43,127 --> 03:51:45,496
HAVING REPAIR AND THE BEST 

4155
03:51:45,496 --> 03:51:46,997
TREATMENT AND IN THE COMMUNITY 

4156
03:51:46,997 --> 03:51:50,367
ONLY 37% OF PATIENTS WITH 

4157
03:51:50,367 --> 03:51:54,238
MODERATE OR SEVERE MR ARE EVER 

4158
03:51:54,238 --> 03:51:54,672
OPERATED.

4159
03:51:54,672 --> 03:51:57,508
37% ONLY AND BECAUSE OF THAT 

4160
03:51:57,508 --> 03:52:00,878
THESE PATIENTS WITH MODERATE OR 

4161
03:52:00,878 --> 03:52:02,012
SEVERE MR IN THE COMMUNITY HAVE 

4162
03:52:02,012 --> 03:52:02,947
AN EXCESS MORTALITY RATE 

4163
03:52:02,947 --> 03:52:05,883
COMPARED TO THEIR EXPECTED 

4164
03:52:05,883 --> 03:52:08,219
MORTALITY IN THE SAME COMMUNITY.

4165
03:52:08,219 --> 03:52:12,189
SO WE ARE NOT SUCCESSFUL IN 

4166
03:52:12,189 --> 03:52:13,357
INDICATING SURGERY IN THE 

4167
03:52:13,357 --> 03:52:16,961
PATIENTS AND THE GUIDELINES HAVE

4168
03:52:16,961 --> 03:52:21,131
NOT ACHIEVED AN ACCOMPLISHMENT 

4169
03:52:21,131 --> 03:52:23,534
OF TREATMENT BY MITRAL VALVE 

4170
03:52:23,534 --> 03:52:27,204
REPAIR IN AND OF PATIENTS.

4171
03:52:27,204 --> 03:52:31,742
AND THIS LACK OF TREATMENT IS 

4172
03:52:31,742 --> 03:52:35,846
RELATED TO IMPRESSION OF 

4173
03:52:35,846 --> 03:52:36,213
MORTALITY.

4174
03:52:36,213 --> 03:52:40,184
AND OVERTIME IN THE '90s WE 

4175
03:52:40,184 --> 03:52:45,689
OBSERVED THAT THE REPAIR FOR 

4176
03:52:45,689 --> 03:52:46,991
GENERATIVE MR INCREASED MARKEDLY

4177
03:52:46,991 --> 03:52:48,926
AND THE MORTALITY DECREASED 

4178
03:52:48,926 --> 03:52:50,561
MARKEDLY BUT SEE IN THE OLDER 

4179
03:52:50,561 --> 03:52:56,066
PATIENTS THE RISK IS STILL 

4180
03:52:56,066 --> 03:52:57,668
SIGNIFICANT AND MORE RECENT WORK

4181
03:52:57,668 --> 03:53:02,906
SHOWS THE EXPERIENCE WITH SES 

4182
03:53:02,906 --> 03:53:05,542
WHERE THE MEDIAN MORTALITY IS 

4183
03:53:05,542 --> 03:53:08,212
0.43% WHICH IS VERY LOW BUT IF 

4184
03:53:08,212 --> 03:53:13,183
YOU LOOK AT THE NUMBER OF MITRAL

4185
03:53:13,183 --> 03:53:14,685
OPERATIONS DONE BY HOSPITAL, THE

4186
03:53:14,685 --> 03:53:17,488
HOSPITALS WITH LESS THAN 10 IS 

4187
03:53:17,488 --> 03:53:22,726
REPRESENT ALMOST A QUARTER OF 

4188
03:53:22,726 --> 03:53:26,897
THE PATIENTS OPERATING FOR 

4189
03:53:26,897 --> 03:53:28,832
MITRAL VALVE DISEASE AND 

4190
03:53:28,832 --> 03:53:31,468
MORTALITY WHICH IS HIGHER, 2% 

4191
03:53:31,468 --> 03:53:32,269
AND CONVERSE TO VALVE 

4192
03:53:32,269 --> 03:53:34,238
REPLACEMENT THE HIGHEST AND WITH

4193
03:53:34,238 --> 03:53:35,639
THE HIGHER OPERATING MORTALITY.

4194
03:53:35,639 --> 03:53:38,742
SO FOR THE CARDIOLOGIST 

4195
03:53:38,742 --> 03:53:40,644
REFERRING THE PATIENTS IF YOU 

4196
03:53:40,644 --> 03:53:43,047
HAVE ACCESS TO A BIG CENTER WITH

4197
03:53:43,047 --> 03:53:47,451
LOW MORTALITY IT'S OKAY BUT IN 

4198
03:53:47,451 --> 03:53:49,787
PATIENTS WITH DMR IN GENERAL IN 

4199
03:53:49,787 --> 03:53:51,155
THE POPULATION THE RISK INCURRED

4200
03:53:51,155 --> 03:53:54,058
AT INTERVENTIONS ARE DETERRENT 

4201
03:53:54,058 --> 03:53:57,127
TO EARLY SURGERY BECAUSE WE ARE 

4202
03:53:57,127 --> 03:53:59,697
AS PHYSICIAN RISK AVERSE.

4203
03:53:59,697 --> 03:54:07,204
SO WE HAVE TO DO A COMPARISON TO

4204
03:54:07,204 --> 03:54:09,173
SOMETHING THAT WE CAN DO FOR THE

4205
03:54:09,173 --> 03:54:10,974
PATIENT AND TO THE NATURE 

4206
03:54:10,974 --> 03:54:11,208
HISTORY.

4207
03:54:11,208 --> 03:54:15,879
SO IN THE PATIENTS WITH THE VERY

4208
03:54:15,879 --> 03:54:22,986
HIGH RISK THERE IS THE REPAIR 

4209
03:54:22,986 --> 03:54:33,530
AND THE EVEREST TRIAL HERE YOU 

4210
03:54:42,706 --> 03:54:44,575
QUAN SEE SURGERY DID BETTER THAN

4211
03:54:44,575 --> 03:54:52,916
PERCUTANEOUS TREATMENT.

4212
03:54:52,916 --> 03:54:55,018
BECAUSE OF THE IMPROVEMENT IN 

4213
03:54:55,018 --> 03:54:56,186
FUNCTIONAL CLASS WITH THE 

4214
03:54:56,186 --> 03:54:58,989
DEVICE, THE DEVICE WAS APPROVED 

4215
03:54:58,989 --> 03:55:04,228
EVEN THOUGH THE RESULTS IN THE 

4216
03:55:04,228 --> 03:55:07,798
DEGENERATIVE MR THE PINK ON THE 

4217
03:55:07,798 --> 03:55:12,569
SECOND LINE OF NOT AS GOOD AS 

4218
03:55:12,569 --> 03:55:13,537
SURGERY BUT WAS NEVERTHELESS 

4219
03:55:13,537 --> 03:55:13,837
APPROVED.

4220
03:55:13,837 --> 03:55:16,206
WE DON'T KNOW BASED ON THAT 

4221
03:55:16,206 --> 03:55:18,308
BECAUSE IT WILL NOT BE AN 

4222
03:55:18,308 --> 03:55:19,777
ADDITIONAL TRIAL VERSUS MEDICAL 

4223
03:55:19,777 --> 03:55:21,445
TREATMENT WITH THE DEVICE THAT 

4224
03:55:21,445 --> 03:55:27,584
WE DON'T KNOW THE OUTCOMES OF 

4225
03:55:27,584 --> 03:55:28,018
THE PATIENTS.

4226
03:55:28,018 --> 03:55:31,622
AND SO IT'S BEEN IN THE 

4227
03:55:31,622 --> 03:55:32,790
GUIDELINES IF THE PATIENT HAS 

4228
03:55:32,790 --> 03:55:35,759
SURGICAL RISK AND MORE THAN ONE 

4229
03:55:35,759 --> 03:55:41,598
YEAR OF EXPECTED LIFE THAT THEY 

4230
03:55:41,598 --> 03:55:44,301
SHOULD HAVE TRANS CAN TER EDGE 

4231
03:55:44,301 --> 03:55:50,774
TO EDGE TREATMENT.

4232
03:55:50,774 --> 03:55:54,878
AND COMPARED THE REGISTRY OF 

4233
03:55:54,878 --> 03:55:56,146
MULTIPLE CENTERS FOR TER AND FOR

4234
03:55:56,146 --> 03:55:58,515
THE UNOPERATED PATIENTS.

4235
03:55:58,515 --> 03:56:02,052
YOU CAN SEE COMPARING THE TWO 

4236
03:56:02,052 --> 03:56:07,825
GROUPS EVEN WITH MATCHING OF THE

4237
03:56:07,825 --> 03:56:09,159
BASELINE CHARACTERISTICS WITH 

4238
03:56:09,159 --> 03:56:11,495
TREATMENT OF THE MR PROVIDED A 

4239
03:56:11,495 --> 03:56:13,063
BETTER RESULT THAN THE 

4240
03:56:13,063 --> 03:56:15,966
UNOPERATION OF THE PATIENTS AT 

4241
03:56:15,966 --> 03:56:20,571
HIGH RISK.

4242
03:56:20,571 --> 03:56:25,776
THE PROBLEM IS RESIDUAL MR.

4243
03:56:25,776 --> 03:56:28,712
THERE'S OFTEN RESIDUAL MR AND 

4244
03:56:28,712 --> 03:56:30,681
THAT'S THE GREEN CURVE MODERATE 

4245
03:56:30,681 --> 03:56:33,817
OR SEVERE RESIDUAL MR THE 

4246
03:56:33,817 --> 03:56:35,719
SURVIVAL AFTER THE INTERVENTION 

4247
03:56:35,719 --> 03:56:40,557
IS AS BAD AS THE UNOPERATED 

4248
03:56:40,557 --> 03:56:40,858
PATIENTS.

4249
03:56:40,858 --> 03:56:46,463
SO IT IS CLEAR THAT FOR THE 

4250
03:56:46,463 --> 03:56:48,398
PATIENT TREATED THERE'S A NEED 

4251
03:56:48,398 --> 03:56:51,401
FOR PERFECTION IN TREATMENT.

4252
03:56:51,401 --> 03:56:54,371
IF WE LOOK AT THE EUROPEAN 

4253
03:56:54,371 --> 03:56:55,806
GUIDELINES THEY ARE ARE 

4254
03:56:55,806 --> 03:56:57,941
DIFFERENT FROM THE AMERICAN 

4255
03:56:57,941 --> 03:56:59,042
GUIDELINES BECAUSE THERE ARE 

4256
03:56:59,042 --> 03:57:02,980
ADDITIONAL TRIGGERS FOR SURGERY 

4257
03:57:02,980 --> 03:57:07,284
HERE, ATRIAL FIBRILLATION AND 

4258
03:57:07,284 --> 03:57:10,053
SYSTOLIC PULMONARY ARTERY 

4259
03:57:10,053 --> 03:57:16,026
PRESSURE AND WITH THE ADDITIONAL

4260
03:57:16,026 --> 03:57:16,426
TRI

4261
03:57:16,426 --> 03:57:17,961
TRIGGERS CAN WE DEFINE OTHER 

4262
03:57:17,961 --> 03:57:20,097
TRIGGERS AND CAN WE HELP IN 

4263
03:57:20,097 --> 03:57:23,000
INCREASING OR DECREASING THE 

4264
03:57:23,000 --> 03:57:26,203
UNDER TREATMENT OF MITRAL 

4265
03:57:26,203 --> 03:57:26,537
REGURGITATION.

4266
03:57:26,537 --> 03:57:29,406
SO ATRIAL FIBRILLATION AND 

4267
03:57:29,406 --> 03:57:30,374
TENSION NOT PRESENT IN THE 

4268
03:57:30,374 --> 03:57:32,409
U.S. GUIDELINES IN THE FRAMEWORK

4269
03:57:32,409 --> 03:57:38,682
OF TREATMENT.

4270
03:57:38,682 --> 03:57:49,159
AND ATRIAL FIBRILLATION IS 

4271
03:57:55,232 --> 03:57:56,633
CORRELATED WITH LONG-TERM 

4272
03:57:56,633 --> 03:57:58,035
RECOVERY AND BENEFIT FROM MITRAL

4273
03:57:58,035 --> 03:58:01,305
VALVE REPAIR WHEN THERE'S A 

4274
03:58:01,305 --> 03:58:02,873
SMALL ATRIAL FIBRILLATION AND 

4275
03:58:02,873 --> 03:58:08,211
BELIEVE IT SHOULD BE A CLASS I 

4276
03:58:08,211 --> 03:58:08,779
INDICATION FOR MITRAL VALVE 

4277
03:58:08,779 --> 03:58:17,020
REPAIR.

4278
03:58:17,020 --> 03:58:23,026
THE OLD STUDY SHOWED PATIENTS 

4279
03:58:23,026 --> 03:58:26,530
WITH PULMONARY HYPERTENSION HAD 

4280
03:58:26,530 --> 03:58:32,169
IT IMPROVED AFTER SURGICAL TR

4281
03:58:32,169 --> 03:58:34,738
TREATMENT BUT THERE'S RISK 

4282
03:58:34,738 --> 03:58:37,874
ASSOCIATED WITH PATIENTS WITH 

4283
03:58:37,874 --> 03:58:39,176
PULMONARY HYPERTENSION POST 

4284
03:58:39,176 --> 03:58:39,776
SURGERY.

4285
03:58:39,776 --> 03:58:42,112
THIS SHOULD BE A CLASS I NOT 

4286
03:58:42,112 --> 03:58:47,618
CLASS II INDICATION FOR SURGERY.

4287
03:58:47,618 --> 03:58:58,128
AND NOW THERE'S THIS PAPER ON 

4288
03:58:58,662 --> 03:59:05,936
OUR APPRAISAL OF THE 

4289
03:59:05,936 --> 03:59:07,738
HYPERTENSION AND YOU SEE THE 

4290
03:59:07,738 --> 03:59:10,140
CURVE OF RISK ASSOCIATED WITH 

4291
03:59:10,140 --> 03:59:15,112
THE DOPPLER PRESSURE AND AROUND 

4292
03:59:15,112 --> 03:59:19,483
35 MILLIMETERS OF MERCURY 

4293
03:59:19,483 --> 03:59:24,087
THERE'S A STEP UP IN RISK AND 

4294
03:59:24,087 --> 03:59:26,823
THE MODERATE PULMONARY 

4295
03:59:26,823 --> 03:59:28,792
HYPERTENSION IS ASSOCIATED WITH 

4296
03:59:28,792 --> 03:59:30,694
MARKEDLY INCREASED RISK AS 

4297
03:59:30,694 --> 03:59:32,295
COMPARED TO THE PATIENT WITHOUT 

4298
03:59:32,295 --> 03:59:37,167
PULMONARY HYPERTENSION AND YOU 

4299
03:59:37,167 --> 03:59:43,607
SEE EARLY SURGERY PERFORMED 

4300
03:59:43,607 --> 03:59:45,342
ASSOCIATED WITH BENEFIT.

4301
03:59:45,342 --> 03:59:49,146
THE MAGNITUDE IS NOT AS BIG AS 

4302
03:59:49,146 --> 03:59:56,219
THE MODERATE AND SEVERE 

4303
03:59:56,219 --> 03:59:58,522
PULMONARY HYPERTENSION BUT 

4304
03:59:58,522 --> 03:59:59,723
THERE'S BENEFIT AT ALL LEVELS 

4305
03:59:59,723 --> 04:00:03,093
YOU HAVE AN ENORMOUS BENEFIT 

4306
04:00:03,093 --> 04:00:04,961
BYING TO EARLY SURGERY.

4307
04:00:04,961 --> 04:00:06,396
-- BY DOING EARLY SURGERY.

4308
04:00:06,396 --> 04:00:16,940
WE BELIEVE WE NEED TO TRANSFORM 

4309
04:00:23,113 --> 04:00:24,214
IF YOU 

4310
04:00:24,214 --> 04:00:28,218
IF YOU 

4311
04:00:28,218 --> 04:00:30,754
IF YOU HAVE ATRIAL FIBRILLATION 

4312
04:00:30,754 --> 04:00:32,989
ORE OTHERS YOU HAVE SHOULD HAVE 

4313
04:00:32,989 --> 04:00:34,391
SURGE I HAVE AND THE PEOPLE WITH

4314
04:00:34,391 --> 04:00:36,993
THOSE MARKERS ARE HIGH RISK AND 

4315
04:00:36,993 --> 04:00:41,531
FOR THESE PEOPLE WE NEED TO DO A

4316
04:00:41,531 --> 04:00:45,669
RESCUE SURGERY WHICH RELIEVES 

4317
04:00:45,669 --> 04:00:50,741
THE PATIENT BUT WE HAVE A 

4318
04:00:50,741 --> 04:00:53,210
MEDIOCRE POSTDOC OUTCOME AND YOU

4319
04:00:53,210 --> 04:00:56,646
HAVE PATIENTS WITH NONE OF THESE

4320
04:00:56,646 --> 04:00:59,049
AND MAY BE CONSIDERED FOR EARLY 

4321
04:00:59,049 --> 04:01:02,786
SURGERY.

4322
04:01:02,786 --> 04:01:13,330
AND EARLY SURGERY IS  RESTORES 

4323
04:01:15,065 --> 04:01:16,099
LIFE EXPECTANCY AND FOR THAT 

4324
04:01:16,099 --> 04:01:18,869
PURPOSE THE CARDIOLOGISTS, THE 

4325
04:01:18,869 --> 04:01:20,003
PHYSICIAN NEED TO BALANCE THE 

4326
04:01:20,003 --> 04:01:25,242
RISK OF THE INTERVENTION WITH 

4327
04:01:25,242 --> 04:01:35,452
THE RISK  UNDER MEDICAL 

4328
04:01:35,452 --> 04:01:37,154
MANAGEMENT AND YOU SEE POINTS AT

4329
04:01:37,154 --> 04:01:43,860
THE BOTTOM USED IN THE FACTORS 

4330
04:01:43,860 --> 04:01:48,198
OF THE SCORE AND THE SURVIVAL 

4331
04:01:48,198 --> 04:01:51,635
AFTER DIAGNOSIS ARE HIGHLY 

4332
04:01:51,635 --> 04:01:53,203
ASSOCIATED WITH SURVIVAL AND 

4333
04:01:53,203 --> 04:01:56,206
IT'S BETTER THAN SURVIVAL AND 

4334
04:01:56,206 --> 04:01:58,375
MEDICAL MANAGEMENT BUT YOU SEE 

4335
04:01:58,375 --> 04:02:00,177
YOU DISTRIBUTE ALREADY THE 

4336
04:02:00,177 --> 04:02:02,879
PATIENTS WITH THE COMBINATION OF

4337
04:02:02,879 --> 04:02:05,649
THESE SEVEN FACTORS.

4338
04:02:05,649 --> 04:02:10,954
BUT NEXT WE HAVE NOW MODIFIED 

4339
04:02:10,954 --> 04:02:12,956
THAT IN THE MORTALITY THAT 

4340
04:02:12,956 --> 04:02:20,197
INCLUDES FOR ALL THE SEVERITY 

4341
04:02:20,197 --> 04:02:22,933
WITH THE POINTS WHEN IT'S LESS 

4342
04:02:22,933 --> 04:02:26,536
THAN 20 AND FOUR GRADES MODERATE

4343
04:02:26,536 --> 04:02:31,775
SEVERE AND VERY SEVERE WHICH AT 

4344
04:02:31,775 --> 04:02:33,109
POINTS AND SEPARATES PEOPLE WITH

4345
04:02:33,109 --> 04:02:35,912
3% MORTALITY AT THE TOP AND 

4346
04:02:35,912 --> 04:02:38,782
PATIENTS WITH 95% PROBABILITY OF

4347
04:02:38,782 --> 04:02:40,217
MORTALITY AT FIVE YEARS.

4348
04:02:40,217 --> 04:02:43,153
WE BELIEVE THE SCORE SHOULD BE 

4349
04:02:43,153 --> 04:02:47,190
LIKE ALL SCORE A LIVING SCORE 

4350
04:02:47,190 --> 04:02:52,429
MODIFIABLE TO ADDRESS NEW 

4351
04:02:52,429 --> 04:02:54,898
MARKERS OF OUTCOME BUT WE HAD 

4352
04:02:54,898 --> 04:02:56,032
THE DISCUSSION YESTERDAY AND 

4353
04:02:56,032 --> 04:02:57,500
NEED TO USE THE SCORE AND NEED 

4354
04:02:57,500 --> 04:02:59,469
TO COMPLETE THE STORE WITH NEW 

4355
04:02:59,469 --> 04:03:04,341
FACTORS THAT WILL COUNT AND WILL

4356
04:03:04,341 --> 04:03:14,885
REVIEW SOME OF THOSE RIGHT NOW.

4357
04:03:16,253 --> 04:03:26,429
AND LOOK AT NORMALIZE AND YOU 

4358
04:03:26,429 --> 04:03:31,735
SEE THE ORANGE CURVE IS FOR 

4359
04:03:31,735 --> 04:03:38,408
INDEX OF MORE AN 60 MILLIMETER 

4360
04:03:38,408 --> 04:03:40,977
SQUARE.

4361
04:03:40,977 --> 04:03:47,050
AND THE VOLUME IS A VERY 

4362
04:03:47,050 --> 04:03:49,052
IMPORTANT MEASURE IN PATIENTS 

4363
04:03:49,052 --> 04:03:56,092
WITH MR TO ASSESS THE RISK NOW 

4364
04:03:56,092 --> 04:03:58,328
WE HAVE THE FUNCTION THAT 

4365
04:03:58,328 --> 04:04:01,364
APPLIES ONLY IN PATIENTS WITH 

4366
04:04:01,364 --> 04:04:06,703
SINUS RHYTHM OTHER WISE WE DON'T

4367
04:04:06,703 --> 04:04:10,240
KNOW THE INTRINSIC CONTRACTION 

4368
04:04:10,240 --> 04:04:13,043
OF THE THE ATRIUM AND ON THE 

4369
04:04:13,043 --> 04:04:14,477
RIGHT ARE THE TISSUE AND THE 

4370
04:04:14,477 --> 04:04:17,547
RATIO IS HIGHLY PREDICTIVE EVEN 

4371
04:04:17,547 --> 04:04:19,816
BETTER THAN THE LEFT ATRIAL 

4372
04:04:19,816 --> 04:04:21,718
VOLUME INDEX AND HAS A BIG 

4373
04:04:21,718 --> 04:04:25,355
EFFECT ON SURVIVAL OF THE 

4374
04:04:25,355 --> 04:04:30,760
PATIENT AND IS INCREMENTAL.

4375
04:04:30,760 --> 04:04:32,028
THIS MEASURE SHOULD BE IN THE 

4376
04:04:32,028 --> 04:04:34,698
NEXT VERSION OF THE RISK SCORE 

4377
04:04:34,698 --> 04:04:42,038
FOR PATIENT WITH MITRAL 

4378
04:04:42,038 --> 04:04:42,906
REGURGITATION.

4379
04:04:42,906 --> 04:04:48,778
THE SCORE HAS THIS PAPER AND 

4380
04:04:48,778 --> 04:04:49,679
DYSFUNCTION JUST MEASURED BY THE

4381
04:04:49,679 --> 04:04:52,215
VISUAL ESTIMATE BY THE PHYSICIAN

4382
04:04:52,215 --> 04:04:56,219
AND OBSERVED THE PATIENTS WITH 

4383
04:04:56,219 --> 04:04:57,520
RIGHT VENTRICULAR DYSFUNCTION 

4384
04:04:57,520 --> 04:05:00,023
HAVE EXCESS MORTALITY AND 

4385
04:05:00,023 --> 04:05:02,258
BENEFIT MARKEDLY FROM AN EARLY 

4386
04:05:02,258 --> 04:05:02,592
INTERVENTION.

4387
04:05:02,592 --> 04:05:05,161
SO WE SHOULD NOT ONLY USE THAT 

4388
04:05:05,161 --> 04:05:08,565
BUT ALSO DEVELOP BETTER MEASURE 

4389
04:05:08,565 --> 04:05:11,067
FOR ASSESSING RIGHT VENTRICULAR 

4390
04:05:11,067 --> 04:05:20,510
FUNCTION IN THOSE PATIENTS.

4391
04:05:20,510 --> 04:05:24,214
THE STANDARD BNP SO WITHIN THE 

4392
04:05:24,214 --> 04:05:25,515
NORMAL BLACK CURVE YOU HAVE A 

4393
04:05:25,515 --> 04:05:27,183
GOOD SURVIVAL.

4394
04:05:27,183 --> 04:05:31,154
IF YOU'RE BNP RATIO TO THE UPPER

4395
04:05:31,154 --> 04:05:32,455
LIMIT NORMAL IS COMPARED TO FOUR

4396
04:05:32,455 --> 04:05:36,192
TIMES THE NORMAL THEN YOU HAVE 

4397
04:05:36,192 --> 04:05:37,060
CONSIDERABLE MORTALITY AND THIS 

4398
04:05:37,060 --> 04:05:40,530
FORM OF BNP SHOULD BE INCLUDED 

4399
04:05:40,530 --> 04:05:49,806
IN THE MARKER OF OUTCOME.

4400
04:05:49,806 --> 04:05:53,109
THE FIBROSIS IS ALSO A CANDIDATE

4401
04:05:53,109 --> 04:05:59,215
AND YOU SEE THIS AND IT'S 

4402
04:05:59,215 --> 04:06:03,920
IMPORTANT.

4403
04:06:03,920 --> 04:06:08,024
THE MARKER WE'RE NOT SUPPOSED TO

4404
04:06:08,024 --> 04:06:11,027
DO ANYTHING FOR PROGRESSIVE 

4405
04:06:11,027 --> 04:06:15,565
TREATMENT MR NEXT AND I DO 

4406
04:06:15,565 --> 04:06:20,937
BELIEVE THIS IS THE 

4407
04:06:20,937 --> 04:06:31,648
CLASSIFICATION WE PUBLISHED THE 

4408
04:06:31,648 --> 04:06:35,051
OUTCOME ACCORDING TO THIS 

4409
04:06:35,051 --> 04:06:36,753
QUANTIFICATION AND YOU SEE 

4410
04:06:36,753 --> 04:06:42,592
SEVERE MR BY QUANTIFICATION IS 

4411
04:06:42,592 --> 04:06:44,894
ASSOCIATED WITH EXCESS MORTALITY

4412
04:06:44,894 --> 04:06:46,796
THIS HAS BEEN CONFIRMED IN THE 

4413
04:06:46,796 --> 04:06:49,399
STUDY OF THE WORK OF THE ECHO 

4414
04:06:49,399 --> 04:06:51,835
LAB NOT JUST THE PILOT DATA FROM

4415
04:06:51,835 --> 04:06:55,138
THE INVESTIGATORS AND THE 

4416
04:06:55,138 --> 04:07:00,243
MORTALITY'S EXACTLY THE SAME.

4417
04:07:00,243 --> 04:07:02,812
EVEN IN ROUTINE PRACTICE 

4418
04:07:02,812 --> 04:07:03,379
QUANTIFICATION OF MR IS AN 

4419
04:07:03,379 --> 04:07:08,885
IMPORTANT PREDICTOR OF OUTCOME.

4420
04:07:08,885 --> 04:07:19,429
SO MITRAL REGURGITATION AND IF 

4421
04:07:29,239 --> 04:07:32,108
YOU HAVE THE MARKERS MORE 

4422
04:07:32,108 --> 04:07:33,843
YELLOWS WELL ESTABLISHED THE 

4423
04:07:33,843 --> 04:07:34,911
GREEN ARE LESS ESTABLISHED, 

4424
04:07:34,911 --> 04:07:38,615
CONSIDER EARLY SURGERY IN USING 

4425
04:07:38,615 --> 04:07:43,486
THAT MULTIPLICITY OF FACTOR TO 

4426
04:07:43,486 --> 04:07:47,023
INDICATE AND PUSH THE PHYSICIAN 

4427
04:07:47,023 --> 04:07:57,467
TO CALL FOR EARLY SURGERY.

4428
04:07:59,169 --> 04:08:04,207
AND IN PROLAPSE THERE'S 20% OF 

4429
04:08:04,207 --> 04:08:14,684
THE PATIENTS WITH PROLAPSE.

4430
04:08:25,995 --> 04:08:27,864
THERE'S A RISK SHOWING EXCESSIVE

4431
04:08:27,864 --> 04:08:29,065
MORTALITY COMPARED TO THE 

4432
04:08:29,065 --> 04:08:30,967
POPULATION.

4433
04:08:30,967 --> 04:08:35,038
THEY NEED OUR ATTENTION AND 

4434
04:08:35,038 --> 04:08:37,540
DESERVE TREATMENT.

4435
04:08:37,540 --> 04:08:40,143
AND YOU SEE HERE IN THE PATIENTS

4436
04:08:40,143 --> 04:08:43,446
WITH MODERATE MR ON THE LEFT, 

4437
04:08:43,446 --> 04:08:48,251
THE PRESENCE OF MODERATE OR 

4438
04:08:48,251 --> 04:08:50,753
SEVERE HYPERTENSION HAS A ROLE 

4439
04:08:50,753 --> 04:08:54,057
ALMOST AS BIG AS WITH PATIENTS 

4440
04:08:54,057 --> 04:08:56,192
WITH SEVERE MR AND THE FORCES 

4441
04:08:56,192 --> 04:08:59,796
ALSO WORK FOR MODERATE MR.

4442
04:08:59,796 --> 04:09:04,200
AND THIS IS AN UNPUBLISHED DATA 

4443
04:09:04,200 --> 04:09:07,870
OR PATIENTS WITH MODERATE MR 

4444
04:09:07,870 --> 04:09:08,771
EXCLUSIVELY EARLY SURGERY IN THE

4445
04:09:08,771 --> 04:09:12,308
PATIENTS WITH MODERATE MR AND 

4446
04:09:12,308 --> 04:09:13,376
SOME HYPERTENSION IS ASSOCIATED 

4447
04:09:13,376 --> 04:09:21,818
WITH IMPROVED OUTCOME.

4448
04:09:21,818 --> 04:09:23,953
SO MODERATE DMR NEEDS OUR 

4449
04:09:23,953 --> 04:09:28,391
ATTENTION.

4450
04:09:28,391 --> 04:09:37,667
THE DMR TREATMENT AND VALVE 

4451
04:09:37,667 --> 04:09:41,037
REPAIR AND TEER FOR HIGH RISK S 

4452
04:09:41,037 --> 04:09:48,311
AND ALL REPAIRS TEER OR SURGICAL

4453
04:09:48,311 --> 04:09:51,014
AIM AT PERFECTION AND IN THE 

4454
04:09:51,014 --> 04:09:55,184
RESEARCH PRIORITY TO MY MIND THE

4455
04:09:55,184 --> 04:09:56,586
FIRST RESEARCH PRIORITY TO 

4456
04:09:56,586 --> 04:09:57,954
CONSIDER COMMUNITY STUDIES TO 

4457
04:09:57,954 --> 04:10:06,195
REDUCE DMR AND TREATMENT TOE 

4458
04:10:06,195 --> 04:10:12,101
CONSIDER REGISTRIES FOCUSSED ON 

4459
04:10:12,101 --> 04:10:14,103
MITRAL VALVE DISEASE AND SEE ALL

4460
04:10:14,103 --> 04:10:21,210
THE MARKERS THAT SHOULD BE 

4461
04:10:21,210 --> 04:10:27,216
INCLUDED IN THE TO CONSIDER 

4462
04:10:27,216 --> 04:10:29,952
CLINICAL TRIAL IN MODERATE DMR.

4463
04:10:29,952 --> 04:10:32,221
THANK YOU SO MUCH FOR YOUR 

4464
04:10:32,221 --> 04:10:42,398
ATTENTION.

4465
04:10:44,767 --> 04:10:45,468
>> THANK YOU.

4466
04:10:45,468 --> 04:10:46,135
WE HAVE A LITTLE TIME FOR 

4467
04:10:46,135 --> 04:10:51,674
QUESTIONS OR COMMENTS.

4468
04:10:51,674 --> 04:10:58,281
>> I'LL ASK YOU ABOUT THE 

4469
04:10:58,281 --> 04:11:02,452
HYPERTENSION WHICH I THOUGHT WAS

4470
04:11:02,452 --> 04:11:03,319
REALLY INTERESTING.

4471
04:11:03,319 --> 04:11:06,889
AND YOU CANNOT THINK AND THE 

4472
04:11:06,889 --> 04:11:10,560
PROBLEM I WANT TO ASK WAS I GET 

4473
04:11:10,560 --> 04:11:12,128
ECHO REPORTS EVERY WEEK, 

4474
04:11:12,128 --> 04:11:13,429
MODERATE TO SEVERE.

4475
04:11:13,429 --> 04:11:16,165
AND SOMETIMES I JUST CHUCKLE 

4476
04:11:16,165 --> 04:11:17,166
BECAUSE THERE'S LIKE FIVE JETS 

4477
04:11:17,166 --> 04:11:23,940
IN A VALVE AND THEY CALL IT MED 

4478
04:11:23,940 --> 04:11:25,608
RAT -- MODERATE AND THIS IS 

4479
04:11:25,608 --> 04:11:30,947
ANOTHER CHALLENGE FOR US TO MOVE

4480
04:11:30,947 --> 04:11:34,584
THE FIELD FORWARD HOW DO WE 

4481
04:11:34,584 --> 04:11:36,452
TRUST WITH MODERATE AND THE 

4482
04:11:36,452 --> 04:11:39,021
PATIENT WILL GET A TE AND NOW 

4483
04:11:39,021 --> 04:11:41,758
THEY CALL IT MODERATE BECAUSE 

4484
04:11:41,758 --> 04:11:43,292
THEY PUT THE PATIENT TO SLEEP 

4485
04:11:43,292 --> 04:11:45,661
AND DON'T HAVE RUPTURED CHORDS 

4486
04:11:45,661 --> 04:11:47,697
AND THIS IS ANOTHER REAL ISSUE.

4487
04:11:47,697 --> 04:11:54,070
SO THE SIGNS LIKE AFIB, REALLY 

4488
04:11:54,070 --> 04:11:58,174
LARGE LEFT ATRIUM AND PULMONARY 

4489
04:11:58,174 --> 04:12:03,980
HYPERTENSION AND ATRIAL 

4490
04:12:03,980 --> 04:12:05,915
ARRHYTHMIAS AND ALL THESE BIG 

4491
04:12:05,915 --> 04:12:07,750
THINGS THAT HAPPEN PROBABLY ALL 

4492
04:12:07,750 --> 04:12:11,154
GO BACK TO YOUR UNDERESTIMATING 

4493
04:12:11,154 --> 04:12:12,355
THE REGURGITATION.

4494
04:12:12,355 --> 04:12:22,765
WHAT ARE YOUR THOUGHTS?

4495
04:12:26,803 --> 04:12:31,507
THE PHYSICIAN MAY OVER ESTIMATE 

4496
04:12:31,507 --> 04:12:37,747
WHEN I THE JET LOOKS LARGE OR 

4497
04:12:37,747 --> 04:12:39,982
UNDERESTIMATE WHEN IT TONIGHT 

4498
04:12:39,982 --> 04:12:41,851
LOOK BIG AND THE PRESSURE IS LOW

4499
04:12:41,851 --> 04:12:43,386
AND THE NUMBERS WORK BETTER THAN

4500
04:12:43,386 --> 04:12:48,024
THE ESTIMATION BY THE DOCTOR.

4501
04:12:48,024 --> 04:12:56,199
WE SHOULD PUSH MORE AND MORE 

4502
04:12:56,199 --> 04:12:57,133
LABS TO BE QUANTITATIVE AND WE 

4503
04:12:57,133 --> 04:12:59,669
HAVE TO BE CAREFUL IN OUR 

4504
04:12:59,669 --> 04:13:01,103
INTERPRETATION OF MODERATE 

4505
04:13:01,103 --> 04:13:02,438
BECAUSE IT TELLS THE PHYSICIAN 

4506
04:13:02,438 --> 04:13:02,839
DON'T TO ANYTHING.

4507
04:13:02,839 --> 04:13:07,276
YOU DON'T NEED TO WORRY.

4508
04:13:07,276 --> 04:13:09,278
I WOULD LIKE TO SUGGEST MODERATE

4509
04:13:09,278 --> 04:13:16,185
IS NOT BENIGN AND WE NEED TO 

4510
04:13:16,185 --> 04:13:18,855
REALLY OPERATE THE PATIENTS AND 

4511
04:13:18,855 --> 04:13:22,725
NEED TO DO SOMETHING FOR THOSE 

4512
04:13:22,725 --> 04:13:27,196
AT LOW RISK AND NEED MANAGEMENT.

4513
04:13:27,196 --> 04:13:29,565
>> YOU'RE COMMUNITY STUDY
AND 

4514
04:13:29,565 --> 04:13:32,068
THE PAPER BOTH SHOW MORTALITY 

4515
04:13:32,068 --> 04:13:32,535
IMMEDIATELY.

4516
04:13:32,535 --> 04:13:33,736
SO THERE'S SOMETHING GOING ON 

4517
04:13:33,736 --> 04:13:35,638
ABOUT THE ENROLLMENT WHEN SOME 

4518
04:13:35,638 --> 04:13:40,743
OF THESE PATIENTS GOT IN BECAUSE

4519
04:13:40,743 --> 04:13:42,712
THERE IS NO IMMEDIATE MORTALITY 

4520
04:13:42,712 --> 04:13:44,213
THEY MUST HAVE BEEN MORE END 

4521
04:13:44,213 --> 04:13:46,182
STAGE AND SHOWED UP IN THE LAST 

4522
04:13:46,182 --> 04:13:47,783
STAGE OF HEART FAILURE AND HOW 

4523
04:13:47,783 --> 04:13:52,855
WE GOT TO THREE LINES.

4524
04:13:52,855 --> 04:13:58,361
HOW DO WE UNDERSTAND THAT?

4525
04:13:58,361 --> 04:13:59,962
>> YOU HAVE TO WORK WITH
THE 

4526
04:13:59,962 --> 04:14:01,330
PATIENTS YOU SEE.

4527
04:14:01,330 --> 04:14:06,702
THE MEAN AGE OF MR IS 73.

4528
04:14:06,702 --> 04:14:09,772
73 THERE IS COMORBIDITY AND THE 

4529
04:14:09,772 --> 04:14:12,308
PATIENTS ARE NOT 25 YEARS OLD 

4530
04:14:12,308 --> 04:14:13,376
WITH NOTHING ELSE.

4531
04:14:13,376 --> 04:14:14,677
HOW MANY PATIENTS DIE?

4532
04:14:14,677 --> 04:14:16,212
THEY SAY THEY DON'T HAVE 

4533
04:14:16,212 --> 04:14:20,216
SYMPTOMS BUT THEY HAVE HEART 

4534
04:14:20,216 --> 04:14:22,151
FAILURE AND MAY DIE OR MAYBE 

4535
04:14:22,151 --> 04:14:23,986
SOMETHING ELSE.

4536
04:14:23,986 --> 04:14:30,526
SO EACH CURB HAS TO BE TAKEN IN 

4537
04:14:30,526 --> 04:14:31,661
THAT PHASE AND THE THREE MONTHS 

4538
04:14:31,661 --> 04:14:32,929
IS A REASONABLE TIME FOR PEOPLE 

4539
04:14:32,929 --> 04:14:34,397
TO MAKE THEIR DECISION.

4540
04:14:34,397 --> 04:14:36,265
BUT THERE IS NOTHING SPECIAL 

4541
04:14:36,265 --> 04:14:37,400
WITH THREE MONTHS.

4542
04:14:37,400 --> 04:14:39,035
YOU TAKE SIX MONTHS IT'S THE 

4543
04:14:39,035 --> 04:14:40,002
SAME THING.

4544
04:14:40,002 --> 04:14:40,536
THE SAME OUTCOME THAT YOU 

4545
04:14:40,536 --> 04:14:46,943
DESCRIBED.

4546
04:14:46,943 --> 04:14:52,848
IT'S NOT LIKE IT'S WRITTEN BY 

4547
04:14:52,848 --> 04:14:56,419
GOD ON A STONE.

4548
04:14:56,419 --> 04:14:59,221
WE HAVE TO NOT LET THE PATIENT 

4549
04:14:59,221 --> 04:15:00,923
TWO AND COME BACK AND THEY 

4550
04:15:00,923 --> 04:15:03,960
DISAPPEAR AND THEY'RE AFRAID OF 

4551
04:15:03,960 --> 04:15:05,227
COMING BECOME AND HAVE TO GIVE 

4552
04:15:05,227 --> 04:15:07,530
THEM TIME TO GET SOMETHING DONE 

4553
04:15:07,530 --> 04:15:07,797
PROMPTLY.

4554
04:15:07,797 --> 04:15:11,200
AND I THINK WE CAN ACHIEVE 

4555
04:15:11,200 --> 04:15:12,435
SOMETHING IF WE'RE MORE 

4556
04:15:12,435 --> 04:15:13,769
CONVINCED THAT WE NEED TO REPAIR

4557
04:15:13,769 --> 04:15:18,341
MORE OF THESE PATIENTS.

4558
04:15:18,341 --> 04:15:20,309
>> THANK YOU.

4559
04:15:20,309 --> 04:15:21,711
FRANCESCA, BRIEFLY, PLEASE.

4560
04:15:21,711 --> 04:15:23,879
>> VERY BRIEF.

4561
04:15:23,879 --> 04:15:25,047
WONDERING WHAT YOU THINK ABOUT 

4562
04:15:25,047 --> 04:15:32,221
THE BIKE STRESS TESTING THAT 

4563
04:15:32,221 --> 04:15:34,357
DON'T HAVE HYPERTENSION AT REST 

4564
04:15:34,357 --> 04:15:36,959
BUT MAYBE WE SHOULD STRESS THEM 

4565
04:15:36,959 --> 04:15:42,798
MORE OFTEN TO SEE IF THEY ARE 

4566
04:15:42,798 --> 04:15:43,499
HAVE THAT WITH EXERCISE.

4567
04:15:43,499 --> 04:15:47,336
>> IN PATIENTS WHO SAY
THEY'RE 

4568
04:15:47,336 --> 04:15:49,238
SYMPTOMATIC AND HAVE A GREAT 

4569
04:15:49,238 --> 04:15:49,772
NUMBER.

4570
04:15:49,772 --> 04:15:55,044
20% OF PEOPLE WHO SAY THEY'RE 

4571
04:15:55,044 --> 04:15:57,947
ASYMPTOMATIC HAVE FUNCTIONAL 

4572
04:15:57,947 --> 04:15:58,347
REDUCED CAPACITY.

4573
04:15:58,347 --> 04:16:01,150
WE'VE NOT BEEN SUCCESS IN DOING 

4574
04:16:01,150 --> 04:16:11,661
RECOME -- RECUMBENT BIKE AND 

4575
04:16:12,261 --> 04:16:13,863
EXERCISE TESTING ON THE 

4576
04:16:13,863 --> 04:16:15,498
TREADMILL AND YOU MEASURE 

4577
04:16:15,498 --> 04:16:16,932
SOMETHING OF THE PHYSICAL 

4578
04:16:16,932 --> 04:16:22,138
ABILITIES OF THE PATIENT THAT IS

4579
04:16:22,138 --> 04:16:23,072
OBJECTIVE.

4580
04:16:23,072 --> 04:16:27,343
AND SO OF THE EXERCISE TESTING, 

4581
04:16:27,343 --> 04:16:28,511
THE TESTING ON THE TREADMILL IS 

4582
04:16:28,511 --> 04:16:31,714
THE ONE I PREFER.

4583
04:16:31,714 --> 04:16:35,651
>> THAT COULD BE AN
ALTERNATIVE 

4584
04:16:35,651 --> 04:16:37,186
WITH SEDATION.

4585
04:16:37,186 --> 04:16:40,022
>> ABSOLUTELY.

4586
04:16:40,022 --> 04:16:43,025
IT'S A MUCH EASIER -- THE 

4587
04:16:43,025 --> 04:16:45,294
PROBLEM IS OUR COLLEAGUE AND YOU

4588
04:16:45,294 --> 04:16:48,130
SEE A PATIENT WITH MR AND DON'T 

4589
04:16:48,130 --> 04:16:49,465
HAVE AN APPOINTMENT FOR THE 

4590
04:16:49,465 --> 04:16:50,533
EXERCISE TEST HOW ARE YOU GOING 

4591
04:16:50,533 --> 04:16:51,701
TO SCHEDULE THAT?

4592
04:16:51,701 --> 04:16:53,202
YOU START BEGGING PEOPLE TO TAKE

4593
04:16:53,202 --> 04:16:54,704
THE PATIENT AND IT WORKS 

4594
04:16:54,704 --> 04:16:55,938
SOMETIMES AND SOMETIMES IT 

4595
04:16:55,938 --> 04:16:57,139
DOESN'T WORK.

4596
04:16:57,139 --> 04:16:59,208
MY BEGGING IS NOT VERY 

4597
04:16:59,208 --> 04:16:59,742
EFFECTIVE.

4598
04:16:59,742 --> 04:17:02,545
>> THANK YOU FOR THAT.

4599
04:17:02,545 --> 04:17:04,213
AND JORDAN SEEMS TO BE NODDING 

4600
04:17:04,213 --> 04:17:07,116
IN AGREEMENT AND HE IS OUR NEXT 

4601
04:17:07,116 --> 04:17:08,117
PRESENTER.

4602
04:17:08,117 --> 04:17:09,685
>> THANK YOU VERY MUCH.

4603
04:17:09,685 --> 04:17:14,623
IT'S A PLEASURE AND HONOR TO BE 

4604
04:17:14,623 --> 04:17:21,597
HERE AND SURROUNDED BY SUCH LUME

4605
04:17:21,597 --> 04:17:22,198
NAR

4606
04:17:22,198 --> 04:17:24,800
 -- LUMINARIES IN THE FIELD AND 

4607
04:17:24,800 --> 04:17:28,204
THINGS THAT DETERMINE THE 

4608
04:17:28,204 --> 04:17:29,438
PERIOPERATIVE RISK AND THE 

4609
04:17:29,438 --> 04:17:30,639
CLINICAL COMORBIDITIES THAT GO 

4610
04:17:30,639 --> 04:17:33,042
WITH THIS AND ONE COMMON ONE WE 

4611
04:17:33,042 --> 04:17:40,182
ARE SEEING INCREASINGLY IN OLD 

4612
04:17:40,182 --> 04:17:43,119
ER ADULTS IS FRAILTY.

4613
04:17:43,119 --> 04:17:44,220
I WANTED TO SPEAK A BIT ABOUT 

4614
04:17:44,220 --> 04:17:54,330
THAT.

4615
04:17:58,434 --> 04:18:04,206
I WANTED TO THANK NIH IN 

4616
04:18:04,206 --> 04:18:08,210
PARTICULAR TO SUPPORT THE 

4617
04:18:08,210 --> 04:18:12,214
INITIATI

4618
04:18:12,214 --> 04:18:16,185
INITIATIVES.

4619
04:18:16,185 --> 04:18:20,923
AND I PRESENTED A MOTIVATING 

4620
04:18:20,923 --> 04:18:25,861
CASE EXAMPLE YOU KNOW A FRAIL 

4621
04:18:25,861 --> 04:18:27,563
INDIVIDUAL WHEN YOU LOOK AT THEM

4622
04:18:27,563 --> 04:18:29,265
BUT QUANTIFYING IS CHALLENGING 

4623
04:18:29,265 --> 04:18:39,809
AND OFTEN MISSED OR NOT CAPTURED

4624
04:18:41,076 --> 04:18:50,085
AND WE KNOW AND OFTEN DON'T 

4625
04:18:50,085 --> 04:18:52,254
INCLUDE FRAIL PATIENTS AND WE'RE

4626
04:18:52,254 --> 04:19:00,196
LEFT WITH CLINICAL PRACTICE AND 

4627
04:19:00,196 --> 04:19:02,464
GUIDANCE AND THE MORE 

4628
04:19:02,464 --> 04:19:05,234
CHALLENGING DECISIONS ARE REALLY

4629
04:19:05,234 --> 04:19:07,403
EYE FUNCTION OF OUR 

4630
04:19:07,403 --> 04:19:08,137
UNDERSTANDING OF BOTH TATE AND 

4631
04:19:08,137 --> 04:19:12,308
ALSO THE PATIENT IN FRONT OF US.

4632
04:19:12,308 --> 04:19:13,742
I THINK THIS JUST GOES TO SHOW 

4633
04:19:13,742 --> 04:19:17,246
YOU IF YOU DON'T HAVE THE 

4634
04:19:17,246 --> 04:19:22,718
PICTURE HERE YOU HAVE AN 

4635
04:19:22,718 --> 04:19:27,122
83-YEAR-OLD AND BOTH LOW SOCIO 

4636
04:19:27,122 --> 04:19:28,257
ECONOMIC STAT AND PRESENTED WITH

4637
04:19:28,257 --> 04:19:33,195
THE PERSON ON THE LEFT VERSUS 

4638
04:19:33,195 --> 04:19:36,765
RIGHT MOST PEOPLE WOULD SAY THE 

4639
04:19:36,765 --> 04:19:38,267
ONE WITH THE CANE.

4640
04:19:38,267 --> 04:19:40,069
I THINK THERE'S A CERTAIN AMOUNT

4641
04:19:40,069 --> 04:19:42,471
OF THIS THAT ULTIMATELY GETS 

4642
04:19:42,471 --> 04:19:44,106
CAPTURED IN THE SURGICAL 

4643
04:19:44,106 --> 04:19:46,609
DECISION MAKING AND THAT'S 

4644
04:19:46,609 --> 04:19:46,976
VALUABLE.

4645
04:19:46,976 --> 04:19:49,378
MY RESEARCH HAS DATA IN THE 

4646
04:19:49,378 --> 04:19:50,846
CORNER SUGGESTING ONE OF THE 

4647
04:19:50,846 --> 04:19:55,885
HIGHEST RISK FACTORS YOU CAN 

4648
04:19:55,885 --> 04:19:59,989
HAVE FOR UNDERGOING MULTI-VESSEL

4649
04:19:59,989 --> 04:20:01,523
ECI IS THE SURGICAL TURN DOWN 

4650
04:20:01,523 --> 04:20:04,193
AND THE DECISION TO OPERATOR NOT

4651
04:20:04,193 --> 04:20:07,062
OPERATE IS A HIGHLY SELECTIVELY 

4652
04:20:07,062 --> 04:20:08,264
DECISION AND BASED ON THE BASIS 

4653
04:20:08,264 --> 04:20:12,801
OF A LOT OF DIFFERENT FACTORS.

4654
04:20:12,801 --> 04:20:21,844
I WANTED TO TALK MORE ABOUT HOW 

4655
04:20:21,844 --> 04:20:27,049
FRAILTY AND LOOKS AT VETERANS 

4656
04:20:27,049 --> 04:20:29,852
ACROSS THE U.S. WITHIN AGE 

4657
04:20:29,852 --> 04:20:32,821
GROUPS AND STRATIFIED BY SEX AND

4658
04:20:32,821 --> 04:20:39,261
LOOKS AT QUANTITATE WILL THE 

4659
04:20:39,261 --> 04:20:40,996
FRAILTY AND WITHIN THE AGE GROUP

4660
04:20:40,996 --> 04:20:43,165
FRAILTY STRATIFIES RISK OF 

4661
04:20:43,165 --> 04:20:45,601
MORTALITY THAN DIFFERENCES 

4662
04:20:45,601 --> 04:20:48,270
BETWEEN AGE GROUPS.

4663
04:20:48,270 --> 04:20:51,140
SO THIS A POWERFUL RISK MARKER 

4664
04:20:51,140 --> 04:20:53,242
AND THERE ARE YOUNGER 

4665
04:20:53,242 --> 04:20:55,544
INDIVIDUALS PARTICULARLY IN THE 

4666
04:20:55,544 --> 04:20:58,480
65 TO 74 AGE GROUP THAT MAY HAVE

4667
04:20:58,480 --> 04:21:00,282
SUBSTANTIAL FRAILTY AND MODIFIED

4668
04:21:00,282 --> 04:21:04,186
THEIR PERIOPERATIVE RISK 

4669
04:21:04,186 --> 04:21:11,827
TREMENDOUSLY.

4670
04:21:11,827 --> 04:21:19,301
WHAT IS FRAILTY AND THERE'S 

4671
04:21:19,301 --> 04:21:22,972
DEFINITIONS OF FRAILTY AND OVER 

4672
04:21:22,972 --> 04:21:28,210
ALL ONE IS THE PHENOTYPIC 

4673
04:21:28,210 --> 04:21:32,214
DEFINITION OF FRAILTY WHICH 

4674
04:21:32,214 --> 04:21:35,250
OTHERS VIEWED FRAILTY AS A 

4675
04:21:35,250 --> 04:21:38,854
PHENOTYPE ASSOCIATED WITH WEIGHT

4676
04:21:38,854 --> 04:21:43,425
LOSS AND REDUCED GAIT SPEED AND 

4677
04:21:43,425 --> 04:21:52,201
ENERGY AND FRAILTY IS THE  SUM 

4678
04:21:52,201 --> 04:21:56,205
OF THE PARTS AND THE MORE THE 

4679
04:21:56,205 --> 04:22:00,042
HIGHER DEGREE OF FRAILTY.

4680
04:22:00,042 --> 04:22:03,746
THERE'S THE BIOLOGIC 

4681
04:22:03,746 --> 04:22:07,016
DETERMINATION AND IT'S VERY 

4682
04:22:07,016 --> 04:22:09,985
CHALLENGING TO DISAGGREGATE THE 

4683
04:22:09,985 --> 04:22:11,120
TWO.

4684
04:22:11,120 --> 04:22:20,195
THE GERONTOLOGY AND LOOKING AT 

4685
04:22:20,195 --> 04:22:27,169
HOMO STASIS -- HOMEOSTASIS AND 

4686
04:22:27,169 --> 04:22:29,271
WE'RE TALKING ABOUT LOW ENERGY, 

4687
04:22:29,271 --> 04:22:30,773
WEIGHT LOSS, EXHAUSTION AND TO 

4688
04:22:30,773 --> 04:22:36,812
THE EXTENT THOSE CHANGES ARE 

4689
04:22:36,812 --> 04:22:47,122
BIOLOGIC CHANGES AND WHAT'S 

4690
04:22:47,122 --> 04:22:47,790
DRIVING THE FACTOR AND HOW THEY 

4691
04:22:47,790 --> 04:22:48,357
INTERACT WITH THE OUTCOMES 

4692
04:22:48,357 --> 04:22:58,467
RISKS.

4693
04:23:01,437 --> 04:23:04,540
THIS IS FROM 2001 AND LOOKING AT

4694
04:23:04,540 --> 04:23:08,210
THE STATE OF UNDER CHRONIC, 

4695
04:23:08,210 --> 04:23:15,217
UNDER NUTRITION AND NIGHT  -- 

4696
04:23:15,217 --> 04:23:18,253
NITROGEN BALANCE AND THE 

4697
04:23:18,253 --> 04:23:19,421
ASSOCIATION WITH DISEASES THAT 

4698
04:23:19,421 --> 04:23:23,125
SET PEOPLE BACK FURTHER AND YOU 

4699
04:23:23,125 --> 04:23:28,163
GET LOSS OF MUSCLE, SARCOPENIA 

4700
04:23:28,163 --> 04:23:30,833
TRANSLATING TO LOWER VO2 MAX AND

4701
04:23:30,833 --> 04:23:34,670
STRENGTH AND POWER AND LOWER 

4702
04:23:34,670 --> 04:23:39,141
RESTING METABOLIC RATE AND THE 

4703
04:23:39,141 --> 04:23:41,076
VALUE OF DOING THE CARDIO 

4704
04:23:41,076 --> 04:23:45,681
PULMONARY TEST AND THE V O2 MAX 

4705
04:23:45,681 --> 04:23:47,683
AND THE REASON IT'S IMPORTANT IS

4706
04:23:47,683 --> 04:23:51,386
PART OF WHAT IT'S DETECTING THE 

4707
04:23:51,386 --> 04:23:58,927
COMBINATION OF THE VENTRICULAR 

4708
04:23:58,927 --> 04:24:03,532
AND DISEASES THE SARCOPENIA AND 

4709
04:24:03,532 --> 04:24:04,199
THE CONDITIONS THAT MAY 

4710
04:24:04,199 --> 04:24:14,409
CONTRIBUTE.

4711
04:24:15,711 --> 04:24:17,880
WE LOOK AT RESTING METABOLIC 

4712
04:24:17,880 --> 04:24:21,150
RATE AND DECREASED ACTIVITY AND 

4713
04:24:21,150 --> 04:24:24,720
MORE CHRONIC MAL OR UNDER 

4714
04:24:24,720 --> 04:24:25,387
NUTRITION AND BECOMES MORE OF A 

4715
04:24:25,387 --> 04:24:35,497
CYCLE.

4716
04:24:40,802 --> 04:24:44,106
AND THERE'S INFLAMMATORY MARKERS

4717
04:24:44,106 --> 04:24:46,208
AND THEY'RE NON SPECIFIC AND CAN

4718
04:24:46,208 --> 04:24:49,611
HAPPEN IN MULTIPLE DISEASES SO 

4719
04:24:49,611 --> 04:24:50,445
WHAT IS ASSOCIATED WITH THE 

4720
04:24:50,445 --> 04:25:00,989
SYNDROME REMAINS TO BE UNCLEAR.

4721
04:25:29,885 --> 04:25:32,621
AND THEY'RE ALL ASSOCIATED WITH 

4722
04:25:32,621 --> 04:25:36,525
INCREASED RISK OF ADVERSE 

4723
04:25:36,525 --> 04:25:36,792
OUTCOMES.

4724
04:25:36,792 --> 04:25:37,893
AND NOW THE COMMON WAY TO 

4725
04:25:37,893 --> 04:25:43,165
MEASURE THIS HAS BEEN THROUGH 

4726
04:25:43,165 --> 04:25:45,534
LOOKING AT YOU SAY LOOK AT THE 

4727
04:25:45,534 --> 04:25:55,077
NUMBER OF HOSPITALIZATIONS AS AN

4728
04:25:55,077 --> 04:25:57,813
ACCUMULATION OF THE FRAILTY AND 

4729
04:25:57,813 --> 04:26:02,317
THIS IS UTILIZATION OF FRAILTY.

4730
04:26:02,317 --> 04:26:04,853
THE CHALLENGE IS THERE'S NOT A 

4731
04:26:04,853 --> 04:26:06,722
OVERLAP BETWEEN THOSE WITH HIGH 

4732
04:26:06,722 --> 04:26:10,092
UTILIZERS OF HEALTH CARE AND 

4733
04:26:10,092 --> 04:26:11,326
THOSE WHO HAVE PHENOTYPIC 

4734
04:26:11,326 --> 04:26:11,660
FRAILTY.

4735
04:26:11,660 --> 04:26:16,498
THIS PAPER WAS PUBLISHED IN THE 

4736
04:26:16,498 --> 04:26:19,935
LANCET ON FRAILTY RISK SCORE AND

4737
04:26:19,935 --> 04:26:22,304
LOOKING AT CLUSTERS OF HIGH 

4738
04:26:22,304 --> 04:26:26,441
UTILIZATION WITHIN HOSPITALS AND

4739
04:26:26,441 --> 04:26:29,077
SEE THE CORRELATION OR THE 

4740
04:26:29,077 --> 04:26:32,414
STATISTIC FOR ASSOCIATION AGREED

4741
04:26:32,414 --> 04:26:35,250
WITH THE FRAILTY INDEXES WERE 

4742
04:26:35,250 --> 04:26:37,686
BOTH FAIRLY WEAK.

4743
04:26:37,686 --> 04:26:39,788
THEY DON'T NECESSARILY OVERLAP 

4744
04:26:39,788 --> 04:26:42,591
WITH AN EXISTING DEFINITION OF 

4745
04:26:42,591 --> 04:26:45,327
FRAILTY AND WHAT'S MORE THERE'S 

4746
04:26:45,327 --> 04:26:46,261
NOT REVERSAL OF DIRECTION.

4747
04:26:46,261 --> 04:26:52,000
ONCE YOU HAVE A COMORBIDITY YOU 

4748
04:26:52,000 --> 04:26:55,103
HAVE IT AND SO THE IDEA OF 

4749
04:26:55,103 --> 04:26:59,808
FRAILTY AS A DYNAMIC PHENOTYPE 

4750
04:26:59,808 --> 04:27:01,043
WHERE FOR EXAMPLE SOMETHING LIKE

4751
04:27:01,043 --> 04:27:03,779
REHABILITATION MAY HAVE AN 

4752
04:27:03,779 --> 04:27:06,214
EFFECT ON IMPROVING SARCOPENIA 

4753
04:27:06,214 --> 04:27:09,618
AND MUSCLE PASS AND ULTIMATELY 

4754
04:27:09,618 --> 04:27:10,819
POSTSURGICAL OUTCOME.

4755
04:27:10,819 --> 04:27:12,187
THE CHALLENGING THINGS WITH A 

4756
04:27:12,187 --> 04:27:15,424
NUMBER OF SCALES AND THIS IS 

4757
04:27:15,424 --> 04:27:17,259
WITH EVEN WITH THE FREE FRAILTY 

4758
04:27:17,259 --> 04:27:19,561
PHENOTYPE IT ASSIGNS SIMILAR 

4759
04:27:19,561 --> 04:27:20,862
WEIGHT AND MAY NOT BE THE CASE.

4760
04:27:20,862 --> 04:27:24,466
IT MAY BE FOR ONE TREATMENT 

4761
04:27:24,466 --> 04:27:25,934
OUTCOME RELATIONSHIP THERE'S 

4762
04:27:25,934 --> 04:27:27,636
MORE IMPORTANCE FOR ONE PART OF 

4763
04:27:27,636 --> 04:27:30,272
FRAILTY OR DISEASE ASSOCIATED 

4764
04:27:30,272 --> 04:27:32,841
WITH FRAILTY THAN ANOTHER.

4765
04:27:32,841 --> 04:27:38,480
AND AN EXAMPLE AND IN THE 

4766
04:27:38,480 --> 04:27:41,249
TREATMENT RELATIONSHIP THAT IT 

4767
04:27:41,249 --> 04:27:43,585
MAY MORE IMPORTANT TO OUTCOME 

4768
04:27:43,585 --> 04:27:44,753
THAN SOMETHING LIKE USE OF 

4769
04:27:44,753 --> 04:27:45,053
WHEELCHAIRS.

4770
04:27:45,053 --> 04:27:48,690
THE INDIVIDUAL WEIGHS WE ASSIGN 

4771
04:27:48,690 --> 04:27:49,324
THE VARIABLES OFTEN ASSUMED TO 

4772
04:27:49,324 --> 04:27:59,868
BE THE SAME BUT IN FACT ARE NOT.

4773
04:28:04,873 --> 04:28:06,308
AND IT'S CHALLENGING ON A CASE 

4774
04:28:06,308 --> 04:28:07,642
BY CASE BASIS.

4775
04:28:07,642 --> 04:28:11,546
WE SEE THIS DISCREPANCY BETWEEN 

4776
04:28:11,546 --> 04:28:13,248
THE LITERATURE OF FRAILTY 

4777
04:28:13,248 --> 04:28:15,851
SUGGESTING IT'S UTILITY OF RISK 

4778
04:28:15,851 --> 04:28:16,385
MARKER AND ACTUAL USE IN 

4779
04:28:16,385 --> 04:28:25,060
CLINICAL PRACTICE.

4780
04:28:25,060 --> 04:28:27,729
SO THIS IS WORK DONE ON BEHALF 

4781
04:28:27,729 --> 04:28:34,069
OF MY K AWARD LOOKING AT THE 

4782
04:28:34,069 --> 04:28:38,073
EFFECT OF FRAILTY AND THIS IS 

4783
04:28:38,073 --> 04:28:44,212
LOOKING AT 1,442 INDIVIDUALS IN 

4784
04:28:44,212 --> 04:28:45,981
HIGH RISK TRIALS WHICH EXAMINE 

4785
04:28:45,981 --> 04:28:48,517
VALVE REPLACEMENT AND THOSE WERE

4786
04:28:48,517 --> 04:28:50,385
LINKED TO CMS CLAIMS AS PART OF 

4787
04:28:50,385 --> 04:28:54,356
THE STUDY AND WE LOOKED AT THE 

4788
04:28:54,356 --> 04:28:55,624
JOHNS HOPKINS CLAIMS BASED 

4789
04:28:55,624 --> 04:28:56,792
FRAILTY INDEX AND THE REASON WE 

4790
04:28:56,792 --> 04:28:58,760
FOCUSSED ON THE INDEX WAS IT WAS

4791
04:28:58,760 --> 04:29:02,297
VALIDATE AND BASED ON THE 

4792
04:29:02,297 --> 04:29:04,399
PHENOTYPE BASED FRAILTY INDEX 

4793
04:29:04,399 --> 04:29:08,203
AND LOOKED AT THE SCALE AND YOU 

4794
04:29:08,203 --> 04:29:12,774
CAN TAKE ANY DATA SET AND PULL 

4795
04:29:12,774 --> 04:29:13,642
MULTIDIMENSIONAL ELEMENTS OUT 

4796
04:29:13,642 --> 04:29:16,211
AND CREATE THE SCALE WHICH IS 

4797
04:29:16,211 --> 04:29:20,782
WHAT WE DID AS WELL.

4798
04:29:20,782 --> 04:29:24,152
WE SHOWED THE INDEX HAS 

4799
04:29:24,152 --> 04:29:26,021
SIGNIFICANT OR LEADS TO 

4800
04:29:26,021 --> 04:29:31,026
SIGNIFICANT OR ASSOCIATED WITH 

4801
04:29:31,026 --> 04:29:31,693
SIGNIFICANT IMPAIRMENTS MEASURED

4802
04:29:31,693 --> 04:29:33,495
LIKE SIX MINUTE WALK TIME, 

4803
04:29:33,495 --> 04:29:36,198
QUALITY OF LIFE, ETCETERA AS 

4804
04:29:36,198 --> 04:29:37,432
WELL AS DISABILITY.

4805
04:29:37,432 --> 04:29:39,501
WHEN YOU LOOK AT WHETHER OR NOT 

4806
04:29:39,501 --> 04:29:40,902
IT STRATIFIES THE BENEFIT YOU 

4807
04:29:40,902 --> 04:29:42,037
FIND SOMETHING DIFFERENT.

4808
04:29:42,037 --> 04:29:47,275
SO HERE ON THE LEFT IS THE INDEX

4809
04:29:47,275 --> 04:29:50,245
ON THE RIGHT IS THE FRIED INDEX 

4810
04:29:50,245 --> 04:29:53,815
AND WE LOOKED AT A RELATIVE RISK

4811
04:29:53,815 --> 04:29:56,885
DIFFERENCE BASICALLY THE SAME.

4812
04:29:56,885 --> 04:29:59,988
YOU CAN SEE IN GENERAL A 

4813
04:29:59,988 --> 04:30:02,624
PREFERENCE WITH A SURVEY WITH 

4814
04:30:02,624 --> 04:30:04,893
INJURY AND THAT WAS UNIFORM 

4815
04:30:04,893 --> 04:30:07,095
ACROSS THE BOARD REGARDLESS IF 

4816
04:30:07,095 --> 04:30:09,931
YOU LOOK AT THE ROCKWOOD AND 

4817
04:30:09,931 --> 04:30:15,036
ACROSS QUARTILES OF FRAILTY 

4818
04:30:15,036 --> 04:30:17,572
THERE WAS NOT A CLEAR OUTCOME 

4819
04:30:17,572 --> 04:30:22,711
AND THERE WAS A HYPOTHESIS FROM 

4820
04:30:22,711 --> 04:30:24,212
THE START OF THE TRIAL AND THE 

4821
04:30:24,212 --> 04:30:28,183
PEOPLE WITH INCREASED FRAILTY 

4822
04:30:28,183 --> 04:30:33,255
WOULD HAVE A GREATER BENEFIT AND

4823
04:30:33,255 --> 04:30:36,758
MAY REFLECT MORE OF A 

4824
04:30:36,758 --> 04:30:38,393
SELF-SELECTED HEALTHIER 

4825
04:30:38,393 --> 04:30:40,529
POPULATION THAN THOSE SEEN IN 

4826
04:30:40,529 --> 04:30:42,063
CLINICAL PRACTICE AND MAY 

4827
04:30:42,063 --> 04:30:43,999
REFLECT THE FACT THAT IN FACT 

4828
04:30:43,999 --> 04:30:45,767
FRAILTY INCREASES YOUR RISK FOR 

4829
04:30:45,767 --> 04:30:47,302
BOTH TREATMENTS AND BOTH 

4830
04:30:47,302 --> 04:30:49,237
TREATMENTS EQUAL.

4831
04:30:49,237 --> 04:30:52,941
IT MAY BE IN FACT YOU'RE RISK OF

4832
04:30:52,941 --> 04:30:58,046
HOSPITAL IZATION IS HIGHER AND 

4833
04:30:58,046 --> 04:30:59,247
THE TREATMENT BENEFIT IS NOT 

4834
04:30:59,247 --> 04:31:01,917
CLEAR AND THIS IS LOOKING AT 

4835
04:31:01,917 --> 04:31:04,185
DIFFERENT DISEASES WITH 

4836
04:31:04,185 --> 04:31:05,754
DIFFERENT AFFECTS.

4837
04:31:05,754 --> 04:31:09,991
FRAILTY TURNS OUT TO STRATIFY 

4838
04:31:09,991 --> 04:31:12,260
THE TREATMENT BENEFIT AND PEOPLE

4839
04:31:12,260 --> 04:31:18,133
SEEM TO BENEFIT THE MOST FROM 

4840
04:31:18,133 --> 04:31:21,202
ANTI-COAGULATION AND HIP 

4841
04:31:21,202 --> 04:31:23,939
FRACTURES SEEMS TO IN GENERAL 

4842
04:31:23,939 --> 04:31:27,876
THOSE AT HIGHEST RISK OF THE 

4843
04:31:27,876 --> 04:31:32,914
IDEA IF THEY FALL AND THOSE WITH

4844
04:31:32,914 --> 04:31:33,682
HIGHEST DEGREE OF FRAILTY THERE 

4845
04:31:33,682 --> 04:31:44,225
IS A SIGNIFICANT ACTION BETWEEN 

4846
04:31:46,661 --> 04:31:46,995
BEN

4847
04:31:46,995 --> 04:31:47,395
BEN

4848
04:31:47,395 --> 04:31:51,366
BENZODIAZMINE USE AND HOW DOES 

4849
04:31:51,366 --> 04:31:52,200
THIS WORK FOR MITRAL VALVE 

4850
04:31:52,200 --> 04:31:57,072
DISEASE.

4851
04:31:57,072 --> 04:31:59,040
THIS IS WHAT WE WERE LOOKING AT 

4852
04:31:59,040 --> 04:32:00,942
EARLIER AS PART OF THE K AND 

4853
04:32:00,942 --> 04:32:02,944
LOOKED AT 2300 INDIVIDUALS AT 

4854
04:32:02,944 --> 04:32:04,212
HIGH RISK AND CONTINUED ACCESS 

4855
04:32:04,212 --> 04:32:06,848
STUDIES THAT ARE LINKED TO 

4856
04:32:06,848 --> 04:32:07,515
MEDICARE CLAIMS.

4857
04:32:07,515 --> 04:32:13,288
WE VALIDATED THE HOPKINS FRAILTY

4858
04:32:13,288 --> 04:32:15,790
INDEX MEASURED IN THE TRIAL.

4859
04:32:15,790 --> 04:32:18,360
IN GENERAL THIS WAS A HIGH 

4860
04:32:18,360 --> 04:32:18,793
FRAILTY POPULATION.

4861
04:32:18,793 --> 04:32:22,063
WE ESTIMATE 20% OF THE GENERAL 

4862
04:32:22,063 --> 04:32:23,298
POPULATION IS FRAIL AND THE 

4863
04:32:23,298 --> 04:32:26,001
TRIAL POPULATION IS 65% OF THE 

4864
04:32:26,001 --> 04:32:27,535
POPULATION.

4865
04:32:27,535 --> 04:32:30,405
HIGHER FRAILTY WAS ASSOCIATED 

4866
04:32:30,405 --> 04:32:32,340
WITH GREATER NUTRITION AND 

4867
04:32:32,340 --> 04:32:33,708
DISABILITY AND COGNITION AND 

4868
04:32:33,708 --> 04:32:35,944
RATE OF HEALTH.

4869
04:32:35,944 --> 04:32:39,681
AND IN THE RISKS OF ONE 

4870
04:32:39,681 --> 04:32:41,049
MORTALITY WERE INCREDIBLY 

4871
04:32:41,049 --> 04:32:42,584
GREATER WITH INCREASED FRAILTY 

4872
04:32:42,584 --> 04:32:44,853
AND THAT WAS PROVED DESPITE 

4873
04:32:44,853 --> 04:32:52,193
ADJUSTING FOR ABLE, SEX, CLASS 

4874
04:32:52,193 --> 04:32:57,432
AND RISK SCORE.

4875
04:32:57,432 --> 04:33:01,236
THERE'S SOMETHING FRAILTY ADDS 

4876
04:33:01,236 --> 04:33:04,205
BUT WHETHER IT HAS BENEFIT 

4877
04:33:04,205 --> 04:33:05,740
REMAINS UNCLEAR AND DEPENDENT ON

4878
04:33:05,740 --> 04:33:16,284
EACH INDIVIDUAL CASE SITUATION.

4879
04:33:34,269 --> 04:33:40,208
AND SOME DIMENSIONS OF FRAILTY 

4880
04:33:40,208 --> 04:33:42,077
HAVE A LARGE EFFECT ON OUTCOMES 

4881
04:33:42,077 --> 04:33:45,346
AND THOSE ASSOCIATED WITH THE 

4882
04:33:45,346 --> 04:33:46,981
FRAILTY PHENOTYPE AND CAUSE A 

4883
04:33:46,981 --> 04:33:49,517
CORRELATION BETWEEN AGE AND 

4884
04:33:49,517 --> 04:33:49,851
FRAILTY.

4885
04:33:49,851 --> 04:33:53,788
WE LOOKED AT THE HEALTH STUDY 

4886
04:33:53,788 --> 04:33:57,459
PARTICIPANTS THOSE WITH THE 

4887
04:33:57,459 --> 04:33:59,294
ECHOCARDIOGRAM AND LOOKED AT 

4888
04:33:59,294 --> 04:34:02,263
DATA AND STRATIFIED SOME FRAILTY

4889
04:34:02,263 --> 04:34:02,597
RISKS.

4890
04:34:02,597 --> 04:34:06,167
AND SAMPLE VALIDATION LOOKS AT 

4891
04:34:06,167 --> 04:34:08,803
DEMOGRAPHIC MARKERS AND 

4892
04:34:08,803 --> 04:34:10,338
ULTIMATELY IDENTIFIED VARIABLES 

4893
04:34:10,338 --> 04:34:11,906
WITH THE GREATEST DIFFERENCE IN 

4894
04:34:11,906 --> 04:34:15,577
CORRELATION BETWEEN AGE AND 

4895
04:34:15,577 --> 04:34:18,246
FRAILTY AND IDENTIFIED THOSE 

4896
04:34:18,246 --> 04:34:20,181
RELATED TO FRAILTY AND NOT 

4897
04:34:20,181 --> 04:34:24,385
ASSOCIATED WITH ABLE AND WHAT 

4898
04:34:24,385 --> 04:34:25,286
CORRELATES WITH THAT AND THE 

4899
04:34:25,286 --> 04:34:28,656
SPECIFIC OUTCOME AND WITHIN EACH

4900
04:34:28,656 --> 04:34:30,692
QUARTILE THE INDEX HAD A BETTER 

4901
04:34:30,692 --> 04:34:33,361
PREDICTIVE FIT THAN THE FREED 

4902
04:34:33,361 --> 04:34:35,764
INDEX FOR ALL CAUSE OF 

4903
04:34:35,764 --> 04:34:38,199
CARDIOVASCULAR DEATH.

4904
04:34:38,199 --> 04:34:41,169
IT WAS DEVELOPED ON HEALTH AND 

4905
04:34:41,169 --> 04:34:41,536
DATA.

4906
04:34:41,536 --> 04:34:43,004
WE THOUGHT THIS WAS DATA THAT IS

4907
04:34:43,004 --> 04:34:44,639
NOW IMPRESSED.

4908
04:34:44,639 --> 04:34:48,409
AND IT SEEMS THAT THOSE RELATED 

4909
04:34:48,409 --> 04:34:52,747
TO FRAILTY INCLUDED THINGS LIKE 

4910
04:34:52,747 --> 04:34:56,184
DEPRESSION, INCOME, ALL THE 

4911
04:34:56,184 --> 04:35:00,021
SUPPORTIVE LITERATURE BEHIND 

4912
04:35:00,021 --> 04:35:10,498
THEM AS WELL AND EDUCATION.

4913
04:35:51,105 --> 04:35:53,308
AND FRAILTY IMPACT ON OUTCOMES 

4914
04:35:53,308 --> 04:35:55,944
REMAINS UNCLEAR AND WHAT 

4915
04:35:55,944 --> 04:35:56,978
PROPONENTS ARE MOST ASSOCIATED 

4916
04:35:56,978 --> 04:35:58,379
WITH RISK.

4917
04:35:58,379 --> 04:36:04,752
THE CHALLENGE IS IN FRAILTY IS 

4918
04:36:04,752 --> 04:36:06,154
IN FEW DATA SETS.

4919
04:36:06,154 --> 04:36:08,823
THESE ARE SOME STUDIES PUBLISHED

4920
04:36:08,823 --> 04:36:11,759
TO MY KNOWLEDGE AND LOOKED 

4921
04:36:11,759 --> 04:36:14,162
SPECIFICALLY AT FRAILTY IN THE 

4922
04:36:14,162 --> 04:36:14,896
POPULATION.

4923
04:36:14,896 --> 04:36:22,937
THE FIRST IS A POPULATION PEOPLE

4924
04:36:22,937 --> 04:36:23,538
UNDER GOING TO MITRAL VALVE 

4925
04:36:23,538 --> 04:36:29,110
REPLACEMENT AND HIGH RISK AND 

4926
04:36:29,110 --> 04:36:32,413
THE PRE-FRAILTY PHENOTYPE AND IT

4927
04:36:32,413 --> 04:36:35,283
WAS ASSOCIATED WITH INDEPENDENT 

4928
04:36:35,283 --> 04:36:38,720
RISK OF MORTALITY.

4929
04:36:38,720 --> 04:36:42,223
AND THE STUDY LOOKING AT PEOPLE 

4930
04:36:42,223 --> 04:36:47,295
WHO HAVE FRAILTY BASED ON THE 

4931
04:36:47,295 --> 04:36:52,700
CFI AND LOOKED AT MORTALITY AND 

4932
04:36:52,700 --> 04:36:54,669
LOOKING AT CARDIAC AND 

4933
04:36:54,669 --> 04:36:58,172
NON-CARDIAC REHOSPITALIZATION 

4934
04:36:58,172 --> 04:37:01,843
AND THOSE WHO HAD THE HOPKINS 

4935
04:37:01,843 --> 04:37:04,545
CFI MEASURE ASSOCIATED WITH 

4936
04:37:04,545 --> 04:37:07,315
HIGHER RISK OF IN HOSPITAL 

4937
04:37:07,315 --> 04:37:09,417
MORTALITY AND DISCHARGE AND 

4938
04:37:09,417 --> 04:37:14,088
THERE WAS NO DIFFERENCE IN 

4939
04:37:14,088 --> 04:37:19,527
LENGTH OF STAY AND LOOKING AT 

4940
04:37:19,527 --> 04:37:23,331
INDIVIDUALS WHO AND ASSOCIATED 

4941
04:37:23,331 --> 04:37:28,202
WITH HIGHER TOTAL COST 

4942
04:37:28,202 --> 04:37:29,137
ATTRIBUTABLE FROM HIGHER RATES 

4943
04:37:29,137 --> 04:37:30,004
OF LEADING INFECTION.

4944
04:37:30,004 --> 04:37:31,606
PEOPLE DON'T DIE OF FRAILTY.

4945
04:37:31,606 --> 04:37:34,042
THEY DIE OF OTHER COMPLICATIONS 

4946
04:37:34,042 --> 04:37:38,146
AND IDENTIFYING WHAT CAUSES THAT

4947
04:37:38,146 --> 04:37:48,489
IT WILL HELP INFORM.

4948
04:37:50,925 --> 04:37:53,027
AND THIS IS DATA FROM REPORTS 

4949
04:37:53,027 --> 04:37:58,800
AND 319,000 ECHO REPORTS AND 

4950
04:37:58,800 --> 04:38:02,804
CAPTURE INFORMATION ON PRESENCE,

4951
04:38:02,804 --> 04:38:07,108
SEVERITY AND PRESENTATION MR 

4952
04:38:07,108 --> 04:38:09,877
SEVERITY AND MITRAL VALVE 

4953
04:38:09,877 --> 04:38:13,081
DYSFUNCTION TO THE HOPKINS CFI 

4954
04:38:13,081 --> 04:38:15,917
THROUGH CLAIMS USING LINKAGE 

4955
04:38:15,917 --> 04:38:26,427
THROUGH ALL PAYER CLAIMS AND 

4956
04:38:27,261 --> 04:38:28,429
WE'LL LOOK TO SEE WHETHER THOSE 

4957
04:38:28,429 --> 04:38:30,999
WITH FRAILTY HAVE AN INCREASED 

4958
04:38:30,999 --> 04:38:34,268
RISK OF MORTALITY AND HOW THAT 

4959
04:38:34,268 --> 04:38:37,772
IS ATTENUATED REGARDLESS OF THE 

4960
04:38:37,772 --> 04:38:39,173
AGE AND FRAILTY STATUS BY THE 

4961
04:38:39,173 --> 04:38:47,281
MITRAL VALVE REPLACEMENT.

4962
04:38:47,281 --> 04:38:50,752
I SENT IDENTIFIERS OUT AND 

4963
04:38:50,752 --> 04:38:53,554
RECEIVED OUT PATIENT AND IN 

4964
04:38:53,554 --> 04:38:59,394
PATIENT DATA FROM 2004 TO 2011 

4965
04:38:59,394 --> 04:39:00,361
AND THEY HAVE CLAIMS INFORMATION

4966
04:39:00,361 --> 04:39:03,965
ACROSS THE DATA SETS AND WE HAVE

4967
04:39:03,965 --> 04:39:04,866
DONE EXPLORATORY ANALYSIS WITHIN

4968
04:39:04,866 --> 04:39:10,071
THE CMR SUBSET AT 2018 TO 2024.

4969
04:39:10,071 --> 04:39:13,708
THIS FROM AI SUBSET OF DATA AND 

4970
04:39:13,708 --> 04:39:16,177
THOSE WITH MVP AND NO MVP.

4971
04:39:16,177 --> 04:39:20,214
THOSE WITH MVP IN THE DATA SETS 

4972
04:39:20,214 --> 04:39:26,754
RELATIVELY OLDER THERE'S A SPLIT

4973
04:39:26,754 --> 04:39:31,692
AND A POSTERIOR MVP AND RATES OF

4974
04:39:31,692 --> 04:39:33,928
MR WERE MUCH GREATER SEVERITY 

4975
04:39:33,928 --> 04:39:39,067
ABOUT 10% OF THE MVP COHORT HAD 

4976
04:39:39,067 --> 04:39:41,302
IT VERSUS 21% OF THE NO MVP 

4977
04:39:41,302 --> 04:39:46,140
COHORT AND LOOKING AT LOVE GE 

4978
04:39:46,140 --> 04:39:48,609
AND PEOPLE WERE REFERRED ON THE 

4979
04:39:48,609 --> 04:39:50,745
BASIS OF SUSPICION OF SYSTEM NO 

4980
04:39:50,745 --> 04:39:52,413
CORE HAD A FAIR AMOUNT OF LGE 

4981
04:39:52,413 --> 04:39:54,549
BUT THERE'S A DIFFERENCE IN 

4982
04:39:54,549 --> 04:39:54,782
PATTERN.

4983
04:39:54,782 --> 04:39:58,052
YOU SEE THE MUSCLE LG IN 

4984
04:39:58,052 --> 04:40:04,192
PARTICULAR WAS MOST COMMON 

4985
04:40:04,192 --> 04:40:07,161
AMONGST THOSE COMPARED TO THOSE 

4986
04:40:07,161 --> 04:40:10,198
WHO DON'T HAVE MVP.

4987
04:40:10,198 --> 04:40:16,204
THOSE WHO HAD A HIGHER RATE OF 

4988
04:40:16,204 --> 04:40:17,171
SUGGESTIVE OF INTERSTITIAL 

4989
04:40:17,171 --> 04:40:17,438
FIBROSIS.

4990
04:40:17,438 --> 04:40:20,475
I REALIZE I'M RUNNING OUT OF 

4991
04:40:20,475 --> 04:40:23,311
TIME.

4992
04:40:23,311 --> 04:40:24,345
THIS IS PRELIMINARY LOOK AT 

4993
04:40:24,345 --> 04:40:25,880
ACROSS THE ABLE GROUPS AND YOU 

4994
04:40:25,880 --> 04:40:30,351
CAN SEE THE PREVALENCE OF MVP IN

4995
04:40:30,351 --> 04:40:33,221
THE CMR DATA WAS INCREASED WITH 

4996
04:40:33,221 --> 04:40:33,821
AGE GROUPS.

4997
04:40:33,821 --> 04:40:37,825
AND THE YOUNGER POPULATION 

4998
04:40:37,825 --> 04:40:39,660
TENDED TO PRESENT MORE WITH 

4999
04:40:39,660 --> 04:40:44,432
BILEAFLET PRO PROLAPSE AND THE 

5000
04:40:44,432 --> 04:40:48,369
OLDER POPULATION WITH PROLAPSE 

5001
04:40:48,369 --> 04:40:49,770
THREE OR FOUR PLUS MR WAS 

5002
04:40:49,770 --> 04:40:51,372
GREATER ACROSS THE BOARD AND 

5003
04:40:51,372 --> 04:40:53,207
IT'S A SMALLER GROUP BUT THE 

5004
04:40:53,207 --> 04:40:56,911
PEAK INCIDENTS FOR PREVALENCE OF

5005
04:40:56,911 --> 04:40:59,147
THE DISJUNCTION ARE AGE 50 TO 65

5006
04:40:59,147 --> 04:41:01,115
AGE GROUP AND THEN SEEMED TO 

5007
04:41:01,115 --> 04:41:02,116
DROP OFF AND IT WILL BE 

5008
04:41:02,116 --> 04:41:03,551
INTERESTING TO SEE WHETHER OR 

5009
04:41:03,551 --> 04:41:08,189
NOT THE FINDING CONTINUES AS WE 

5010
04:41:08,189 --> 04:41:08,756
CONTINUE THE DATA ANALYSIS.

5011
04:41:08,756 --> 04:41:10,091
AND THEN AGAIN SIMILARLY THESE 

5012
04:41:10,091 --> 04:41:14,328
ARE SMALL NUMBERS LOOKING AT 

5013
04:41:14,328 --> 04:41:20,134
PATHWAY MUSCLE LGE AND THE RATES

5014
04:41:20,134 --> 04:41:24,572
WERE COMPARING MVP WERE GREATEST

5015
04:41:24,572 --> 04:41:26,807
IN THOSE MIDDLE AGED GROUP.

5016
04:41:26,807 --> 04:41:34,115
ALL AGE GROUPS SEEM TO HAVE AN 

5017
04:41:34,115 --> 04:41:35,183
INCREASED RATE OF INTERSTITIAL 

5018
04:41:35,183 --> 04:41:37,251
FIBROSIS AND WE JUST GOT THE 

5019
04:41:37,251 --> 04:41:40,188
CLAIMS TWO WEEKS AGO AND ARE 

5020
04:41:40,188 --> 04:41:43,024
SORTING THROUGH THIS SO 

5021
04:41:43,024 --> 04:41:44,825
HOPEFULLY WE'LL BE ABLE TO GET 

5022
04:41:44,825 --> 04:41:47,295
INTO THE ROLE OF FRAILTY IN 

5023
04:41:47,295 --> 04:41:57,705
MANAGEMENT AND OUTCOMES.

5024
04:42:02,310 --> 04:42:06,847
WITH THAT THEY ENROLLED A YOUNG 

5025
04:42:06,847 --> 04:42:11,752
POPULATION AND LOOK AT LOOK AT 

5026
04:42:11,752 --> 04:42:13,921
THE MORE COMMON COHORT IN THOSE 

5027
04:42:13,921 --> 04:42:17,792
OF 50 TO 65 AND THE AGING AND 

5028
04:42:17,792 --> 04:42:18,826
FRAILTY OUTCOME INDICATE REMAINS

5029
04:42:18,826 --> 04:42:19,227
TO BE DETERMINED.

5030
04:42:19,227 --> 04:42:25,266
THANK YOU VERY MUCH.

5031
04:42:25,266 --> 04:42:27,935
>> THANK YOU VERY MUCH,
JORDAN.

5032
04:42:27,935 --> 04:42:29,303
ONE OF YOUR ASSISTANTS I TAKE 

5033
04:42:29,303 --> 04:42:34,875
IT.

5034
04:42:34,875 --> 04:42:37,245
WE ARE RUNNING SHORT ON TIME SO 

5035
04:42:37,245 --> 04:42:44,218
I'D LIKE TO MOVE AHEAD DIRECTLY 

5036
04:42:44,218 --> 04:42:47,154
TO ALEXANDER IRIBARNE.

5037
04:42:47,154 --> 04:42:48,623
>> GOOD AFTERNOON,
EVERYONE AND 

5038
04:42:48,623 --> 04:42:49,290
THANK YOU FOR THE OPPORTUNITY TO

5039
04:42:49,290 --> 04:42:58,366
PRESENT THIS AFTERNOON.

5040
04:42:58,366 --> 04:43:00,201
SO I'M GOING TO DISCUSS A 

5041
04:43:00,201 --> 04:43:04,205
PATIENT CENTERED APPROACH FOR 

5042
04:43:04,205 --> 04:43:08,209
TREATMENT DECISIONS IN MITRAL 

5043
04:43:08,209 --> 04:43:17,084
VALVE PROLAPSE.

5044
04:43:17,084 --> 04:43:19,887
SOME SLIDES WE TALK ABOUT 

5045
04:43:19,887 --> 04:43:20,388
ALREADY.

5046
04:43:20,388 --> 04:43:28,195
WE KNOW TEER VOLUME CONTINUES TO

5047
04:43:28,195 --> 04:43:32,266
FWROE AT  -- GROW AT A RAPID 

5048
04:43:32,266 --> 04:43:37,271
PACE AND VOLUMES OUTPACE MVP 

5049
04:43:37,271 --> 04:43:38,472
REPAIR VOLUMES AMONG MEDICARE 

5050
04:43:38,472 --> 04:43:41,042
PATIENTS AROUND 2019 WAS THE 

5051
04:43:41,042 --> 04:43:42,843
INFLEXION POINT BASED ON THE 

5052
04:43:42,843 --> 04:43:45,212
STUDY ON MEDICARE CLAIMS DATA AT

5053
04:43:45,212 --> 04:43:48,482
DARTMOUTH BUT YOU CAN SEE THE 

5054
04:43:48,482 --> 04:43:50,484
INFLEXION POINT AROUND 2019 AND 

5055
04:43:50,484 --> 04:43:55,990
ON THE RIGHT HOW THE ANNUALIZED 

5056
04:43:55,990 --> 04:43:57,358
RATIO OF TEER COMPARED TO MITRAL

5057
04:43:57,358 --> 04:44:05,299
VALVE REPAIR CONTINUES TO GROW.

5058
04:44:05,299 --> 04:44:11,305
I THINK WE TALKED ABOUT IN MORE 

5059
04:44:11,305 --> 04:44:19,146
DETAILS PREVIOUSLY OUTCOMES TEER

5060
04:44:19,146 --> 04:44:21,215
ARE IMPROVING WITH TIME AND YOU 

5061
04:44:21,215 --> 04:44:23,818
HAVE TO BE CAREFUL HOW YOU READ 

5062
04:44:23,818 --> 04:44:24,185
PAPERS.

5063
04:44:24,185 --> 04:44:27,955
HERE IT SAYS SUCCESS DEFINED AS 

5064
04:44:27,955 --> 04:44:29,657
MODERATE AND RATING OF 10 CAN BE

5065
04:44:29,657 --> 04:44:33,894
ACHIEVED IN 90% OF PATIENTS WITH

5066
04:44:33,894 --> 04:44:34,362
MITRAL VALVE PROLAPSE.

5067
04:44:34,362 --> 04:44:37,832
AS WE TALKED ABOUT EARLIER THIS 

5068
04:44:37,832 --> 04:44:48,376
DEFINITION OF SUCCESS INCLUDES 

5069
04:44:49,710 --> 04:44:55,082
PATIENTS AND IT'S NOT SUCCESS 

5070
04:44:55,082 --> 04:44:56,417
CLINICALLY TO HAVE MODERATE MR 

5071
04:44:56,417 --> 04:45:00,354
AND THE NEXT STUDY THAT WAS 

5072
04:45:00,354 --> 04:45:02,556
PUBLISHED BY DR. CHIKWE RECENTLY

5073
04:45:02,556 --> 04:45:03,858
AND AGAIN LOOKING AT SURGERY AND

5074
04:45:03,858 --> 04:45:11,432
TRANS CATHETER INTERVENTIONS FOR

5075
04:45:11,432 --> 04:45:11,866
DEGENERATIVE MITRAL 

5076
04:45:11,866 --> 04:45:14,235
REGURGITATION AMONG MEDICARE 

5077
04:45:14,235 --> 04:45:17,104
CLAIMS BENEFICIARIES.

5078
04:45:17,104 --> 04:45:21,275
THE CONCLUSION WAS THE EARLY 

5079
04:45:21,275 --> 04:45:22,810
COMPARISON AMONG BENEFICIARIES 

5080
04:45:22,810 --> 04:45:25,279
SHOWED AN INCREASE WAS 

5081
04:45:25,279 --> 04:45:28,215
ASSOCIATED WITH WORSE SURVIVAL, 

5082
04:45:28,215 --> 04:45:32,520
INCREASED READMISSIONS AND MORE 

5083
04:45:32,520 --> 04:45:33,621
MITRAL INTERVENTIONS.

5084
04:45:33,621 --> 04:45:36,190
THERE'S REALLY A NEED FOR 

5085
04:45:36,190 --> 04:45:38,459
COMPARATIVE EFFECTIVENESS DATA 

5086
04:45:38,459 --> 04:45:40,761
AND AS A RESULT OF THAT WE HAVE 

5087
04:45:40,761 --> 04:45:42,396
ONGOING RANDOMIZED TRIALS SUCH 

5088
04:45:42,396 --> 04:45:49,003
AS PRIMARY AND REPAIR MR THAT 

5089
04:45:49,003 --> 04:45:51,472
WILL PROVIDE DATA ON THE 

5090
04:45:51,472 --> 04:45:52,106
COMPARATIVE EFFECTIVENESS OF 

5091
04:45:52,106 --> 04:45:53,941
TEER VERSUS SURGERY.

5092
04:45:53,941 --> 04:45:57,278
WE ALSO KNOW AND AS AN 

5093
04:45:57,278 --> 04:45:59,914
INVESTIGATOR A LOCAL ADVOCATOR 

5094
04:45:59,914 --> 04:46:01,482
ENROLLING PATIENTS IN THE 

5095
04:46:01,482 --> 04:46:03,150
PRIMARY TRIAL WE KNOW THAT 

5096
04:46:03,150 --> 04:46:07,488
ENROLLMENT IN COMPARATIVE 

5097
04:46:07,488 --> 04:46:09,623
EFFECTIVENESS TRIALS GOES TO 

5098
04:46:09,623 --> 04:46:15,329
PATIENT AND PHYSICIAN 

5099
04:46:15,329 --> 04:46:16,197
PREFERENCES ON TREATMENT 

5100
04:46:16,197 --> 04:46:17,364
APPROACH AND WE HAVE PATIENTS 

5101
04:46:17,364 --> 04:46:20,434
TRYING TO CONSENT FOR THE 

5102
04:46:20,434 --> 04:46:22,236
PRIMARY TRIAL AND HAVE STRONG 

5103
04:46:22,236 --> 04:46:22,903
PREFERENCES INTERESTINGLY ENOUGH

5104
04:46:22,903 --> 04:46:25,005
THEY WANT SURGERY AND SOMETIMES 

5105
04:46:25,005 --> 04:46:29,310
THAT'S INFLUENCED BY THE 

5106
04:46:29,310 --> 04:46:31,946
CONVERSATIONS THAT HAVE WITH 

5107
04:46:31,946 --> 04:46:33,914
THEIR REFERRING CARDIOLOGISTS 

5108
04:46:33,914 --> 04:46:36,050
AND BASED ON THE CURRENT 

5109
04:46:36,050 --> 04:46:41,622
EVIDENCE BASE THE PATIENTS LOW 

5110
04:46:41,622 --> 04:46:45,693
OR INTERMEDIATE RISK SHOULD BE 

5111
04:46:45,693 --> 04:46:46,360
GETTING MITRAL VALVE REPAIR AND 

5112
04:46:46,360 --> 04:46:47,962
SOMETIMES THIS HAS BEEN THE 

5113
04:46:47,962 --> 04:46:48,562
DISCUSSION THAT TAKES PLACE 

5114
04:46:48,562 --> 04:46:51,432
BETWEEN THE SURGICAL TEAM AND 

5115
04:46:51,432 --> 04:46:55,903
THE STRUCTURAL CARDIOLOGIST AND 

5116
04:46:55,903 --> 04:46:56,637
REFERRING CARDIOLOGIST ABOUT 

5117
04:46:56,637 --> 04:46:57,371
CONSIDERING PATIENTS FOR 

5118
04:46:57,371 --> 04:46:58,506
ENROMMENT IN THE TRIAL.

5119
04:46:58,506 --> 04:47:00,207
THIS IS THE KIND OF PREFERENCES 

5120
04:47:00,207 --> 04:47:03,611
THAT WILL BROADLY IMPACT THE 

5121
04:47:03,611 --> 04:47:05,045
IMPLEMENTATION AND DISSEMINATION

5122
04:47:05,045 --> 04:47:06,380
OF TRIAL FINDINGS UPON 

5123
04:47:06,380 --> 04:47:12,786
PUBLICATION.

5124
04:47:12,786 --> 04:47:15,256
SO WE KNOW THAT BASED OFTEN THE 

5125
04:47:15,256 --> 04:47:18,859
PAPER FROM JAMA THE FRACTION OF 

5126
04:47:18,859 --> 04:47:20,160
DISCOVERY SCIENCES REACHING 

5127
04:47:20,160 --> 04:47:21,629
PATIENTS IN CLINICAL PRACTICE IS

5128
04:47:21,629 --> 04:47:22,630
VERY LOW.

5129
04:47:22,630 --> 04:47:26,133
IT TAKES AN AVERAGE OF 17 YEARS 

5130
04:47:26,133 --> 04:47:29,003
FOR ONLY 14% OF NEW DISCOVERIES 

5131
04:47:29,003 --> 04:47:36,210
TO ENTER DAY TO DAY CLINICAL 

5132
04:47:36,210 --> 04:47:44,184
PRACTICED AND ON AVERAGE 

5133
04:47:44,184 --> 04:47:50,391
AMERICANS RECEIVE HALF.

5134
04:47:50,391 --> 04:47:53,627
THE NIH HAS A STRONG INTEREST IN

5135
04:47:53,627 --> 04:47:54,995
UNDERSTANDING IMPLEMENTATION AND

5136
04:47:54,995 --> 04:47:55,696
DISSEMINATION SCIENCE AND IN THE

5137
04:47:55,696 --> 04:47:58,198
CHART FROM A PUBLICATION BY 

5138
04:47:58,198 --> 04:48:04,004
DR. MENSA FROM THE NIH, YOU CAN 

5139
04:48:04,004 --> 04:48:07,007
SEE THE PATHWAY OF PARALLELS AND

5140
04:48:07,007 --> 04:48:09,043
THE PROGRESSION OF THOUGHTS IN 

5141
04:48:09,043 --> 04:48:10,945
THE TWO-DAY SYMPOSIUM GOING FROM

5142
04:48:10,945 --> 04:48:12,246
BENCH RESEARCH TO BEDSIDE FIRST 

5143
04:48:12,246 --> 04:48:20,020
IN HUMAN STUDIES AND PHASE II 

5144
04:48:20,020 --> 04:48:24,158
AND III CLINICAL TRIALS TO 

5145
04:48:24,158 --> 04:48:25,092
TRIALS TO EFFECTIVENESS RESEARCH

5146
04:48:25,092 --> 04:48:35,502
LIKE THE PRIMARY TRIAL.

5147
04:48:41,542 --> 04:48:43,243
HOW DO YOU TALK THE 

5148
04:48:43,243 --> 04:48:44,211
EFFECTIVENESS RESEARCH AND HOW 

5149
04:48:44,211 --> 04:48:46,814
THE FINDINGS ARE APPLIED IN 

5150
04:48:46,814 --> 04:48:48,015
BROADER PATIENT POPULATIONS.

5151
04:48:48,015 --> 04:48:52,953
I'M A MEMBER OF THE CT SURGERY 

5152
04:48:52,953 --> 04:48:56,256
NETWORK AND IN THE CT SURGERY 

5153
04:48:56,256 --> 04:48:58,425
NETWORK YOU HAVE ONE GRANT THAT 

5154
04:48:58,425 --> 04:48:58,759
I HAVE.

5155
04:48:58,759 --> 04:49:03,430
WE BROADLY WITHIN THE NETWORK IN

5156
04:49:03,430 --> 04:49:05,299
THE CYCLE PLACED A STRONG 

5157
04:49:05,299 --> 04:49:07,134
EMPHASIS ON RESEARCH AND 

5158
04:49:07,134 --> 04:49:07,701
TRAINING AND IMPLEMENTATION 

5159
04:49:07,701 --> 04:49:11,372
SCIENCE WITHIN A RANDOMIZED 

5160
04:49:11,372 --> 04:49:15,309
CLINICAL TRIALS.

5161
04:49:15,309 --> 04:49:19,680
AND SO THE REASON WHY I FEEL THE

5162
04:49:19,680 --> 04:49:22,850
NIH HAD A STRONG INTEREST IN 

5163
04:49:22,850 --> 04:49:23,517
IMPLEMENTATION SCIENCE RESEARCH 

5164
04:49:23,517 --> 04:49:25,886
IS THE CRITICAL NEED TO BRIDGE 

5165
04:49:25,886 --> 04:49:28,188
THE GAP BETWEEN T3 AND T 

5166
04:49:28,188 --> 04:49:30,524
RESEARCH AND REALLY CLOSE THE 

5167
04:49:30,524 --> 04:49:32,359
GAP HOW WE TAKE FINDINGS FROM 

5168
04:49:32,359 --> 04:49:35,129
THIS BENCH TO THE BEDSIDE TO 

5169
04:49:35,129 --> 04:49:36,563
CLINICAL TRIALS AND REALLY 

5170
04:49:36,563 --> 04:49:38,232
INCREASE THE AMOUNT OF OR REDUCE

5171
04:49:38,232 --> 04:49:40,067
THE TIME IT TAKES TO APPLY THE 

5172
04:49:40,067 --> 04:49:41,168
SETTINGS MORE BROADLY AND MAKE 

5173
04:49:41,168 --> 04:49:44,071
SURE THE FINDINGS ARE REALLY 

5174
04:49:44,071 --> 04:49:46,507
BEING DISSEMINATED CORRECTLY.

5175
04:49:46,507 --> 04:49:48,642
AND THERE ARE A LOT OF 

5176
04:49:48,642 --> 04:49:51,111
CHALLENGES TO THIS.

5177
04:49:51,111 --> 04:49:52,046
PRIMARILY THE IMPLEMENTATION 

5178
04:49:52,046 --> 04:49:54,314
SCIENCE RESEARCH OFTEN LAGS 

5179
04:49:54,314 --> 04:49:55,649
BEHIND PUBLICATION OF PIVOTAL 

5180
04:49:55,649 --> 04:49:57,384
TRIALS AND THAT'S WHAT REALLY 

5181
04:49:57,384 --> 04:49:58,852
LIMITS ITS UTILITY.

5182
04:49:58,852 --> 04:50:00,220
AND IF YOU LOOK AT THE SLIDE 

5183
04:50:00,220 --> 04:50:02,322
WHICH TALKS ABOUT BARRIERS TO 

5184
04:50:02,322 --> 04:50:03,590
CLINICAL ADOPTION OF RESEARCH 

5185
04:50:03,590 --> 04:50:06,593
FINDINGS, ONE OF THE BIGGEST 

5186
04:50:06,593 --> 04:50:11,799
ONES RELATES TO THE TIME LINE 

5187
04:50:11,799 --> 04:50:14,001
BETWEEN PRACTICE AND DECISION 

5188
04:50:14,001 --> 04:50:14,835
SUPPORTS.

5189
04:50:14,835 --> 04:50:18,272
THE PERFECT EXAMPLE IS WHAT 

5190
04:50:18,272 --> 04:50:19,840
HAPPENS WHERE YOU'RE SUPPOSED TO

5191
04:50:19,840 --> 04:50:21,608
DO SHARED DECISION MAKING WITH 

5192
04:50:21,608 --> 04:50:24,578
OF IN PATIENTS WITH TAVR THOSE 

5193
04:50:24,578 --> 04:50:26,413
DECISION AIDS WERE PUBLISHED 

5194
04:50:26,413 --> 04:50:29,349
AFTER THE PUBLICATION OF THE 

5195
04:50:29,349 --> 04:50:31,919
PIVOTAL TRIALS AND THE DECISION 

5196
04:50:31,919 --> 04:50:37,491
BETWEEN THE IN SURGE I HAVE WAS 

5197
04:50:37,491 --> 04:50:40,127
ALREADY HAPPENING BEFORE THEY 

5198
04:50:40,127 --> 04:50:41,228
WERE PUBLISHED AND THAT REALLY 

5199
04:50:41,228 --> 04:50:42,930
LIMITED THE UTILITY AND 

5200
04:50:42,930 --> 04:50:44,498
PRACTICALITY OF INTEGRATING THEM

5201
04:50:44,498 --> 04:50:46,800
BECAUSE THERE WAS A LAG BETWEEN 

5202
04:50:46,800 --> 04:50:48,202
THE TIME THE DECISION AIDS 

5203
04:50:48,202 --> 04:50:50,337
BECAME PUBLIC AND THE TIME THEY 

5204
04:50:50,337 --> 04:50:57,311
COULD BE UTILIZED IN PRACTICE.

5205
04:50:57,311 --> 04:50:58,812
SO IMPLEMENTATION SCIENCE IS 

5206
04:50:58,812 --> 04:50:59,947
TRYING TO UNDERSTAND 

5207
04:50:59,947 --> 04:51:02,783
SPECIFICALLY HOW TO TAKE THE 

5208
04:51:02,783 --> 04:51:03,917
FINDINGS FROM TRIALS AND 

5209
04:51:03,917 --> 04:51:05,319
RESEARCH STUDIES AND UNDERSTAND 

5210
04:51:05,319 --> 04:51:08,655
HOW THEY CAN BE APPLIED IN 

5211
04:51:08,655 --> 04:51:11,258
LARGER POPULATIONS AND CLOSE 

5212
04:51:11,258 --> 04:51:18,332
THAT GAP IN THE TIME AT WHICH 

5213
04:51:18,332 --> 04:51:19,233
SCIENTIFIC DISCOVERIES ENTER 

5214
04:51:19,233 --> 04:51:21,235
CLINICAL PRACTICE AND MAKE SURE 

5215
04:51:21,235 --> 04:51:23,370
IT'S HAPPENING IN AN APPROPRIATE

5216
04:51:23,370 --> 04:51:24,538
WAY.

5217
04:51:24,538 --> 04:51:26,173
SO, WITH REGARD TO SHARED 

5218
04:51:26,173 --> 04:51:29,643
DECISION MAKING, IT'S REALLY NOT

5219
04:51:29,643 --> 04:51:34,314
SOME SORT OF CONSTRUCT THAT HAS 

5220
04:51:34,314 --> 04:51:35,749
NO SCIENTIFIC BASIS.

5221
04:51:35,749 --> 04:51:37,818
THERE'S BEEN A LOT OF WORK 

5222
04:51:37,818 --> 04:51:38,886
PARTICULARLY WITH THE GROWTH OF 

5223
04:51:38,886 --> 04:51:42,523
STRUCTURAL INTERVENTIONS ON THIS

5224
04:51:42,523 --> 04:51:43,590
IN CARDIOVASCULAR HEALTH.

5225
04:51:43,590 --> 04:51:45,192
THIS SCIENTIFIC STATEMENT FROM 

5226
04:51:45,192 --> 04:51:47,027
THE AMERICAN HEART ASSOCIATION 

5227
04:51:47,027 --> 04:51:48,629
WHICH WAS PUBLISHED LAST YEAR 

5228
04:51:48,629 --> 04:51:50,097
REALLY GOES INTO A LOT OF 

5229
04:51:50,097 --> 04:51:52,933
DETAILS ABOUT THE IMPORTANCE OF 

5230
04:51:52,933 --> 04:51:56,203
INTEGRATING SHARED DECISION 

5231
04:51:56,203 --> 04:51:59,740
MAKING WITHIN MULTI-DISCIPLINARY

5232
04:51:59,740 --> 04:52:02,342
HEART TEAM AND THEIR CLOSING 

5233
04:52:02,342 --> 04:52:03,677
STATEMENT SUMMARIZES IT 

5234
04:52:03,677 --> 04:52:05,946
PERFECTLY WHICH SAYS JUST AS OUR

5235
04:52:05,946 --> 04:52:07,581
THERAPEUTIC ADVANCES HAVE 

5236
04:52:07,581 --> 04:52:09,283
MARKEDLY IMPROVED CARDIOVASCULAR

5237
04:52:09,283 --> 04:52:13,554
OUTCOMES WE NEED TO ENSHURP SURE

5238
04:52:13,554 --> 04:52:15,923
THE WAYS OF COMMUNICATING WITH 

5239
04:52:15,923 --> 04:52:16,990
PATIENTS ARE EVIDENCE BASED AND 

5240
04:52:16,990 --> 04:52:18,892
ALIGN WITH PATIENTS GOALS AND 

5241
04:52:18,892 --> 04:52:20,627
NEEDS ARE OPTIMIZED.

5242
04:52:20,627 --> 04:52:31,171
YOU SEE ONE EXAMPLE IN THE  2003

5243
04:52:34,842 --> 04:52:39,213
GUIDANCE THERE'S SHARED DECISION

5244
04:52:39,213 --> 04:52:40,814
MAKING AND SOCIAL DETERMINATES 

5245
04:52:40,814 --> 04:52:43,817
OF HEALTH TO HELP PATIENTS MAKE 

5246
04:52:43,817 --> 04:52:45,586
INFORMED DECISIONS IT MEANS 

5247
04:52:45,586 --> 04:52:48,088
YOU'RE HAVING A FORMAL 

5248
04:52:48,088 --> 04:52:50,257
DISCUSSION WITH PATIENTS 

5249
04:52:50,257 --> 04:52:51,625
DISCUSSING WHAT IS THE EVIDENT 

5250
04:52:51,625 --> 04:52:53,527
BASE AND HELPING THEM MAKE AN 

5251
04:52:53,527 --> 04:53:01,935
INFORMED DECISION.

5252
04:53:01,935 --> 04:53:08,208
AGAIN LIKE THERE'S ISSUES WITH 

5253
04:53:08,208 --> 04:53:09,009
IMPLEMENTATION SCIENCE AND HOW 

5254
04:53:09,009 --> 04:53:11,078
DO YOU LOOK AT POLICIES AND 

5255
04:53:11,078 --> 04:53:11,912
REIMBURSEMENT FOR DOING THIS?

5256
04:53:11,912 --> 04:53:16,116
EVERYONE HAS LIMITED TIME BUT 

5257
04:53:16,116 --> 04:53:20,854
FOR TRANS CATHETER AORTIC VALVE 

5258
04:53:20,854 --> 04:53:21,521
REPLACEMENT THIS IS SOMETHING 

5259
04:53:21,521 --> 04:53:27,494
CMS MANDATED TO DO.

5260
04:53:27,494 --> 04:53:35,969
YOU NEED IT VALIDATED AND 

5261
04:53:35,969 --> 04:53:37,871
SUFFICIENT WORK FLOWS WHETHER 

5262
04:53:37,871 --> 04:53:44,211
INTO AN E.H.R. OR MULTI-DES  

5263
04:53:44,211 --> 04:53:47,314
DISCIPLINARY MAKING AND ACCESS 

5264
04:53:47,314 --> 04:53:50,017
TO DECISION AIDS AND PATIENT 

5265
04:53:50,017 --> 04:53:50,350
ENGAGEMENT.

5266
04:53:50,350 --> 04:53:52,185
ONE OF THE MOST IMPORTANT THING 

5267
04:53:52,185 --> 04:53:54,021
IS EVACUATE 

5268
04:53:56,356 --> 04:54:00,294
 HAVING ACCESS TO DECISION AIDS 

5269
04:54:00,294 --> 04:54:01,228
BECAUSE WITHOUT THESE 

5270
04:54:01,228 --> 04:54:02,729
INSTRUMENTS YOU CAN'T EVEN HAVE 

5271
04:54:02,729 --> 04:54:04,831
A DISCUSSION ABOUT THE UTILITY 

5272
04:54:04,831 --> 04:54:05,365
OF INTEGRATING THEM INTO 

5273
04:54:05,365 --> 04:54:11,371
PRACTICE.

5274
04:54:11,371 --> 04:54:16,209
AS I MENTIONED EARLIER ONE OF 

5275
04:54:16,209 --> 04:54:17,177
THE MAJOR CHALLENGES WITH 

5276
04:54:17,177 --> 04:54:20,213
IMPLEMENTATION SCIENCE AND 

5277
04:54:20,213 --> 04:54:22,482
DECISION AIDS IS IT HAPPENS AT 

5278
04:54:22,482 --> 04:54:24,084
THE CONCLUSION OF THE RANDOMIZED

5279
04:54:24,084 --> 04:54:26,987
TRIAL AND IT CAN BE DELAYED ONE 

5280
04:54:26,987 --> 04:54:29,356
YEAR, TWO YEARS AND THAT LIMITS 

5281
04:54:29,356 --> 04:54:31,291
THE UTILITY OF THE PRACTICE.

5282
04:54:31,291 --> 04:54:36,396
SO WHAT WE THINK ABOUT IS THIS 

5283
04:54:36,396 --> 04:54:40,200
HYBRID EFFECTIVENESS 

5284
04:54:40,200 --> 04:54:40,968
INFLAMMATION   

5285
04:54:44,438 --> 04:54:48,909
IMPLEMENTATION MODEL AND TAKES 

5286
04:54:48,909 --> 04:54:50,844
EFFECTIVENESS AND IMPLEMENTATION

5287
04:54:50,844 --> 04:54:53,613
AND THE PATHWAY IS THE 

5288
04:54:53,613 --> 04:54:54,848
PROVINCIAL MODEL GOING FROM ONE 

5289
04:54:54,848 --> 04:54:57,584
TO THE OTHER AND DO EACH 

5290
04:54:57,584 --> 04:54:58,618
INDIVIDUALLY IN SUCCESSION.

5291
04:54:58,618 --> 04:55:00,487
WHEN WE THINK OF HYBRID DESIGN 

5292
04:55:00,487 --> 04:55:02,322
IT'S REALLY PEOPLE SAYING OKAY, 

5293
04:55:02,322 --> 04:55:04,024
WHY DON'T WE CHANGE THE MODEL?

5294
04:55:04,024 --> 04:55:07,027
WHY ARE WE WAITING UNTIL THE END

5295
04:55:07,027 --> 04:55:12,966
OF THE TRIAL TO TRY TO FIGURE 

5296
04:55:12,966 --> 04:55:15,469
OUT HOW TO GET PATIENT AND 

5297
04:55:15,469 --> 04:55:16,837
PHYSICIAN PREFERENCES WHY DON'T 

5298
04:55:16,837 --> 04:55:19,239
WE GET IT AS THE TRIAL IS GOING 

5299
04:55:19,239 --> 04:55:19,439
ALONG?

5300
04:55:19,439 --> 04:55:21,174
THAT'S WHAT I'M GOING TO TALK 

5301
04:55:21,174 --> 04:55:24,111
ABOUT AND WHAT THE CAROL ACT WAS

5302
04:55:24,111 --> 04:55:26,079
FOR WAS THIS HYBRID TYPE I 

5303
04:55:26,079 --> 04:55:29,349
DESIGN TESTING A CLINICAL 

5304
04:55:29,349 --> 04:55:32,219
INTERVENTION WHILE GATHERING 

5305
04:55:32,219 --> 04:55:39,860
INFORMATION ON IMPLEMENTATION.

5306
04:55:39,860 --> 04:55:44,197
IT'S ACTIVELY ENROLLING IN THE 

5307
04:55:44,197 --> 04:55:46,033
TRIAL COMPARING TEER TO MITRAL 

5308
04:55:46,033 --> 04:55:48,101
VALVE THERAPY AND OBSERVED 

5309
04:55:48,101 --> 04:55:49,736
STRONG PREFERENCES EXIST AMONG 

5310
04:55:49,736 --> 04:55:52,105
PATIENTS AND PHYSICIANS DESPITE 

5311
04:55:52,105 --> 04:55:54,041
THAT THE TRIAL IS ENROLLING VERY

5312
04:55:54,041 --> 04:55:55,242
WELL BUT THERE'S PATIENTS WE 

5313
04:55:55,242 --> 04:55:56,843
WANT TO ENROLL IN THE TRIAL AND 

5314
04:55:56,843 --> 04:55:57,611
WE DON'T.

5315
04:55:57,611 --> 04:55:59,346
THESE ARE TE DISCUSSIONS THAT 

5316
04:55:59,346 --> 04:56:01,982
COME UP.

5317
04:56:01,982 --> 04:56:11,358
WE ANTICIPATE OR I ANTICIPATE 

5318
04:56:11,358 --> 04:56:15,929
UPON COMPLETION A FORMAL SHARED 

5319
04:56:15,929 --> 04:56:17,297
DECISION MAKING TOOL WILL BE 

5320
04:56:17,297 --> 04:56:17,597
BENEFICIAL.

5321
04:56:17,597 --> 04:56:19,332
THEREFORE WE HAVE THIS UNIQUE 

5322
04:56:19,332 --> 04:56:21,568
OPPORTUNITY TO ACTIVELY STUDY 

5323
04:56:21,568 --> 04:56:23,737
PATIENT AND PROVIDER PREFERENCES

5324
04:56:23,737 --> 04:56:25,772
WITHIN THE CONTEXT OF AN 

5325
04:56:25,772 --> 04:56:28,208
ACTIVELY ENROLLING RANDOMIZED 

5326
04:56:28,208 --> 04:56:29,876
CONTROL TRIAL WHICH WE'VE NOT 

5327
04:56:29,876 --> 04:56:31,044
DONE BEFORE AND THE CT SURGERY 

5328
04:56:31,044 --> 04:56:36,083
SURGERY NETWORK.

5329
04:56:36,083 --> 04:56:39,219
SO THE TITLE OF MY CAROL ACT 

5330
04:56:39,219 --> 04:56:41,288
WORK WHICH I THANK THE NIH FOR 

5331
04:56:41,288 --> 04:56:43,423
AWARDING ME WAS PATIENT CENTERED

5332
04:56:43,423 --> 04:56:46,026
APPROACH FOR TREATMENT DECISIONS

5333
04:56:46,026 --> 04:56:51,598
IN MITRAL VALVE PROLAPSE AND I'M

5334
04:56:51,598 --> 04:56:55,001
THE P.I. WITH JOHN PURTUS AND 

5335
04:56:55,001 --> 04:57:00,040
DR. CHIKWE AT CEDAR SINAI AND 

5336
04:57:00,040 --> 04:57:04,211
OTHERS AND WE'VE BEEN ABLE TO 

5337
04:57:04,211 --> 04:57:06,413
RECRUIT SOME HIGH VOLUME SITES 

5338
04:57:06,413 --> 04:57:07,948
ENROLLING IN THE PRIMARY TRIAL 

5339
04:57:07,948 --> 04:57:08,548
LOCATE WILL ACROSS THE 

5340
04:57:08,548 --> 04:57:10,550
U.S. WHICH WILL ALLOW US TO HAVE

5341
04:57:10,550 --> 04:57:11,351
A GEOGRAPHICALLY DIVERSE PATIENT

5342
04:57:11,351 --> 04:57:17,457
POPULATION.

5343
04:57:17,457 --> 04:57:24,598
THE FIRST AIM WAS TOE  -- TO 

5344
04:57:24,598 --> 04:57:26,099
IDENTIFY PATIENTS CONSIDERING 

5345
04:57:26,099 --> 04:57:27,601
TEER VERSUS MITRAL VALVE REPAIR 

5346
04:57:27,601 --> 04:57:33,006
AND WE'VE DONE A QUALITATIVE 

5347
04:57:33,006 --> 04:57:34,241
FOCUS GROUP ACROSS ALL SITES TO 

5348
04:57:34,241 --> 04:57:39,713
DEVELOP A CONSOLIDATED FRAMEWORK

5349
04:57:39,713 --> 04:57:41,448
OF OUTCOMES PATIENTS VALUE.

5350
04:57:41,448 --> 04:57:43,216
YOU SEE SOME OF THE TYPES OF 

5351
04:57:43,216 --> 04:57:44,217
QUESTIONS WE'VE SATURDAY FOR 

5352
04:57:44,217 --> 04:57:47,020
THIS AND UNDERSTANDING THE -- 

5353
04:57:47,020 --> 04:57:49,055
WE'VE ASKED ABOUT THIS AND WHAT 

5354
04:57:49,055 --> 04:57:50,023
THEY ARE UNDERSTAND AND TELL ME 

5355
04:57:50,023 --> 04:57:52,893
ABOUT WHY YOU ARE DIAGNOSIS AND 

5356
04:57:52,893 --> 04:57:55,395
THE EXPERIENCE WITH THE HEART 

5357
04:57:55,395 --> 04:57:58,331
TEAM AND DOCKERS TO TREATING YOU

5358
04:57:58,331 --> 04:57:59,332
AND OUTCOMES IMPORTANT TO 

5359
04:57:59,332 --> 04:58:01,101
PATIENTS AND WHEN YOU THINK 

5360
04:58:01,101 --> 04:58:04,638
ABOUT THE DIFFERENT OPTIONS FOR 

5361
04:58:04,638 --> 04:58:09,476
FIXES YOUR HEART VALVE COMIMPORT

5362
04:58:09,476 --> 04:58:10,777
TO YOU AND WHAT IS THE DECISION 

5363
04:58:10,777 --> 04:58:14,114
FOR TREATING YOUR LATER VALVE.

5364
04:58:14,114 --> 04:58:16,016
THESE HAVE BEEN DIRECT PATIENT 

5365
04:58:16,016 --> 04:58:17,817
ENGAGEMENTS THROUGH ZOOM CALLS, 

5366
04:58:17,817 --> 04:58:21,988
FIVE TO 10 PATIENTS EACH OF THE 

5367
04:58:21,988 --> 04:58:23,223
SITES AND WITH PATIENTS 

5368
04:58:23,223 --> 04:58:24,724
SOMETIMES THEY BRING THEIR 

5369
04:58:24,724 --> 04:58:28,929
RELATIVES ON THE CALL OR FAMILY 

5370
04:58:28,929 --> 04:58:29,429
MEMB

5371
04:58:29,429 --> 04:58:32,332
MEMBERS ON THE CALL AND HAVE HAD

5372
04:58:32,332 --> 04:58:34,534
IMPLEMENTATION SCIENTISTS AT MID

5373
04:58:34,534 --> 04:58:35,702
AMERICA HEART ANALYZE THE 

5374
04:58:35,702 --> 04:58:46,112
TRANSCRIPTS FROM THOSE.

5375
04:58:47,214 --> 04:58:48,682
WE TOOK THE DATA FROM THE FOCUS 

5376
04:58:48,682 --> 04:58:51,551
GROUP AND REVIEWED THE 

5377
04:58:51,551 --> 04:58:53,753
TRANSCRIPTS TO DEVELOP A 

5378
04:58:53,753 --> 04:58:54,421
QUANTITATIVE SURVEY BECAUSE THAT

5379
04:58:54,421 --> 04:58:58,058
WAS QUALITATIVE AND NOW WE 

5380
04:58:58,058 --> 04:59:00,060
DEVELOPED THE QUANTITATIVE 

5381
04:59:00,060 --> 04:59:02,429
SURVEY TO SEE HOW PATIENTS 

5382
04:59:02,429 --> 04:59:05,799
PRIORITIZE OUTCOMES UTILIZING 

5383
04:59:05,799 --> 04:59:06,800
ALLOCATION TEST FRAMEWORK BASED 

5384
04:59:06,800 --> 04:59:08,902
ON DATA FROM OUR QUALITATIVE 

5385
04:59:08,902 --> 04:59:10,537
FOCUS GROUPS.

5386
04:59:10,537 --> 04:59:14,608
THIS IS A LONG SURVEY TAKES 15, 

5387
04:59:14,608 --> 04:59:18,411
MAYBE 20 MINUTES TO DO BUT ARE 

5388
04:59:18,411 --> 04:59:19,913
REIMBURSED WITH A SMALL GIFT 

5389
04:59:19,913 --> 04:59:22,215
CARD FOR DOING IT AND THIS IS 

5390
04:59:22,215 --> 04:59:24,184
ONE SCREEN OF THE SURVEY.

5391
04:59:24,184 --> 04:59:26,019
THEY ARE TOLD IMAGINE YOU HAVE 

5392
04:59:26,019 --> 04:59:27,520
100 SPENDING COINS AND HAVE TO 

5393
04:59:27,520 --> 04:59:30,023
MOVE THESE SLIDERS TO GET TO 100

5394
04:59:30,023 --> 04:59:31,524
AND ASKED INVASIVENESS AND TIME 

5395
04:59:31,524 --> 04:59:34,494
TO RECOVER AND RISK OF DEATH, 

5396
04:59:34,494 --> 04:59:35,762
PROCEDURAL COMPLICATIONS, HEALTH

5397
04:59:35,762 --> 04:59:38,965
STATUS AND QUALITY OF LIFE, 

5398
04:59:38,965 --> 04:59:40,834
REPEAT HOSPITALIZATION OR VALVE 

5399
04:59:40,834 --> 04:59:42,502
PROCEDURE AND CONTINUED VALVE 

5400
04:59:42,502 --> 04:59:43,603
LEAKINESS THAT DIDN'T EFFECT ANY

5401
04:59:43,603 --> 04:59:45,972
OTHER OUTCOMES LISTED AND THE 

5402
04:59:45,972 --> 04:59:48,208
PATIENTS CAN ADJUST THOSE TO 

5403
04:59:48,208 --> 04:59:49,042
ALLOCATE HOW THEY PRIORITIZE 

5404
04:59:49,042 --> 04:59:50,677
EACH OF THESE OUTCOMES AND THEN 

5405
04:59:50,677 --> 04:59:53,346
WE GO INTO MORE DETAIL ABOUT 

5406
04:59:53,346 --> 04:59:54,447
EACH OF THESE AND GET 

5407
04:59:54,447 --> 04:59:56,182
DEMOGRAPHIC DATA FROM THE 

5408
04:59:56,182 --> 05:00:06,526
PATIENTS AT THE END.

5409
05:00:07,227 --> 05:00:11,264
WE SPOKE TO PHYSICIANS AND BASIC

5410
05:00:11,264 --> 05:00:15,735
CARDIOLOGISTS AND THOSE TREATING

5411
05:00:15,735 --> 05:00:19,039
PATIENTS WITH DEGENERATIVE MR 

5412
05:00:19,039 --> 05:00:20,940
AND FIVE TO 10 PHYSICIANS PER 

5413
05:00:20,940 --> 05:00:23,376
GROUP AND LOOKED AT OUTCOMES 

5414
05:00:23,376 --> 05:00:24,444
IMPORTANT TO THE TEAM WHEN 

5415
05:00:24,444 --> 05:00:28,114
YOU'RE DECIDING OR REFERRING A 

5416
05:00:28,114 --> 05:00:30,650
PATIENT FOR TEER VERSUS SURGERY 

5417
05:00:30,650 --> 05:00:33,386
AND WHAT ARE PATIENT PREFERENCES

5418
05:00:33,386 --> 05:00:34,587
AND ABOUT WHAT IS IMPORTANT AND 

5419
05:00:34,587 --> 05:00:38,992
BA IS YOUR APPROACH TO 

5420
05:00:38,992 --> 05:00:39,559
INTEGRATING SHARED DECISION 

5421
05:00:39,559 --> 05:00:40,660
MAKING?

5422
05:00:40,660 --> 05:00:51,204
AND LIKE WE DID IN THE FIRST ONE

5423
05:00:52,372 --> 05:00:55,175
AND PRIORITIZED OUTCOME AND THE 

5424
05:00:55,175 --> 05:00:56,209
ALLOCATION TEST FRAMEWORK AND 

5425
05:00:56,209 --> 05:00:59,045
YOU CAN SEE NOW WE'RE ASKING THE

5426
05:00:59,045 --> 05:01:01,181
PHYSICIANS TO RANK THESE ON 

5427
05:01:01,181 --> 05:01:07,354
SCALE FROM 1 TO 7, PATIENT AGE 

5428
05:01:07,354 --> 05:01:08,188
AND ANATOMY OF THE MITRAL VALVE 

5429
05:01:08,188 --> 05:01:18,365
AND SO ON.

5430
05:01:20,266 --> 05:01:23,370
WE LOOKED AT SHARED DECISION 

5431
05:01:23,370 --> 05:01:30,410
MAKING AND WE ASKED QUESTIONS 

5432
05:01:30,410 --> 05:01:32,278
LOOKED AT THE DECISION IN THE 

5433
05:01:32,278 --> 05:01:37,050
HEART TEAM.

5434
05:01:37,050 --> 05:01:43,089
AND IN THE FINAL TWO SLIDES AND 

5435
05:01:43,089 --> 05:01:51,064
WE'VE LOOK EDAL  -- LOOKED AT TE

5436
05:01:51,064 --> 05:01:52,532
GROUPS AND ANALYZED THE 

5437
05:01:52,532 --> 05:01:57,270
TRANSCRIPTS AND TOOK THE DATA 

5438
05:01:57,270 --> 05:01:59,038
FROM THE QUALITATIVE SURVEYS AND

5439
05:01:59,038 --> 05:02:00,473
THIS IS ENROLLMENT OVER TIME.

5440
05:02:00,473 --> 05:02:11,017
WE'VE BEEN ABLE TO ENROLL AND WE

5441
05:02:17,190 --> 05:02:18,691
HAVE 80 TO 100 PHYSICIANS THAT 

5442
05:02:18,691 --> 05:02:21,327
HAVE DONE THE SURVEY AND IT'S A 

5443
05:02:21,327 --> 05:02:23,396
SIGNIFICANT ACHIEVEMENT WAS IT'S

5444
05:02:23,396 --> 05:02:26,699
CHALLENGING TO GET APATIENT TO 

5445
05:02:26,699 --> 05:02:30,036
SIT DOWN TO DO THIS AND ALL 

5446
05:02:30,036 --> 05:02:38,411
ACTIVELY SEEN AND A COHORT OF 

5447
05:02:38,411 --> 05:02:38,678
PATIENTS.

5448
05:02:38,678 --> 05:02:49,189
SO IN TERMS OF FUTURE DIRECT 

5449
05:02:52,725 --> 05:02:56,196
INTERVIEWING OF PATIENTS 

5450
05:02:56,196 --> 05:02:57,997
CONCURRENT WITH TRIAL ENROLLMENT

5451
05:02:57,997 --> 05:02:59,365
AND GETTING THE DATA AS WE DO 

5452
05:02:59,365 --> 05:03:00,967
THE TRIAL AND NOT ONLY TALKING 

5453
05:03:00,967 --> 05:03:06,306
DIRECTLY TO PATIENTS BUT 

5454
05:03:06,306 --> 05:03:13,513
DIRECTLY TO NOT ONLY THE BUT THE

5455
05:03:13,513 --> 05:03:15,648
EMPHASIS ON SHARED DECISION 

5456
05:03:15,648 --> 05:03:17,250
MAKING AND DATA FROM THE STUDY 

5457
05:03:17,250 --> 05:03:19,586
WILL BE INTEGRAL FOR DEVELOPING 

5458
05:03:19,586 --> 05:03:21,788
A FORMAL DECISION AID IN 

5459
05:03:21,788 --> 05:03:23,823
PARALLEL WITH PUBLICATION AT THE

5460
05:03:23,823 --> 05:03:24,891
PRIMARY TRIAL AND THINK THAT 

5461
05:03:24,891 --> 05:03:28,194
WILL BE ABLE TO INCREASE THE 

5462
05:03:28,194 --> 05:03:29,362
UTILIZATION OF THIS BECAUSE IT 

5463
05:03:29,362 --> 05:03:31,731
WILL HAPPEN WHEN THE TRIAL IS 

5464
05:03:31,731 --> 05:03:32,999
PUBLISHED NOT GOING TO HAPPEN A 

5465
05:03:32,999 --> 05:03:35,001
YEAR OR TWO YEARS AFTERWARDS.

5466
05:03:35,001 --> 05:03:37,937
SO BY PROVIDING DATA ON PATIENT 

5467
05:03:37,937 --> 05:03:40,206
PROVIDER PREFERENCES AND 

5468
05:03:40,206 --> 05:03:44,978
DECISION MAKING OUR STUDY WILL 

5469
05:03:44,978 --> 05:03:46,145
ALLOW FOR IMPLEMENTATION AND 

5470
05:03:46,145 --> 05:03:49,148
DISSEMINATION OF FINDINGS IN THE

5471
05:03:49,148 --> 05:03:50,617
BROADER U.S. POPULATION 

5472
05:03:50,617 --> 05:03:51,518
ULTIMATELY IMPROVING HEALTH.

5473
05:03:51,518 --> 05:03:54,254
I THINK THIS IS A GREATER 

5474
05:03:54,254 --> 05:03:56,189
EXAMPLE OF HOW WE CAN RUN THE 

5475
05:03:56,189 --> 05:03:59,359
FULL SPECTRUM OF GOING THROUGH 

5476
05:03:59,359 --> 05:04:04,197
BASIC SCIENCE ALL THE WAY UP TO 

5477
05:04:04,197 --> 05:04:07,800
PIVOTAL RANDOMIZED TRIAL AS 

5478
05:04:07,800 --> 05:04:09,402
THERE'S BEEN A PREFERENCE WITHIN

5479
05:04:09,402 --> 05:04:12,372
THE NIH LOOKING AT PATIENT ED 

5480
05:04:12,372 --> 05:04:14,440
OUTCOME RESEARCH WITH AGE EYE TO

5481
05:04:14,440 --> 05:04:15,108
UNDERSTANDING THE IMPLEMENTATION

5482
05:04:15,108 --> 05:04:16,976
AND DISSEMINATION FROM A 

5483
05:04:16,976 --> 05:04:17,677
PATIENT-CENTERED APPROACH.

5484
05:04:17,677 --> 05:04:20,213
AND I'D LIKE TO CONCLUDE AGAIN 

5485
05:04:20,213 --> 05:04:27,420
BY THANKING THE NIH AND NHLBI 

5486
05:04:27,420 --> 05:04:28,821
AND THE CAROL ACT TO CONDUCT THE

5487
05:04:28,821 --> 05:04:32,258
RESEARCH AND BENEFIT PATIENTS SO

5488
05:04:32,258 --> 05:04:42,435
THANK YOU.

5489
05:04:42,869 --> 05:04:44,637
>> THANK YOU.

5490
05:04:44,637 --> 05:04:45,538
DOES ANYONE HAVE LAST BRIEF 

5491
05:04:45,538 --> 05:04:47,941
COMMENTS OR QUESTIONS ON THE 

5492
05:04:47,941 --> 05:04:50,176
LAST PRESENTATION?

5493
05:04:50,176 --> 05:04:55,682
>> I CAN ASK QUICKLY ON
THE LAST

5494
05:04:55,682 --> 05:05:01,087
PRESENTATION, ALEX, STHCHL  -- 

5495
05:05:01,087 --> 05:05:05,792
THANKS FOR DOING THIS BUT HOW DO

5496
05:05:05,792 --> 05:05:08,995
YOU DO THE EDUCATION OF THE 

5497
05:05:08,995 --> 05:05:14,934
PATIENT AND IF I LOOKED AT JOE'S

5498
05:05:14,934 --> 05:05:18,605
LAST PAPER IN JTCBS AND THAT A 

5499
05:05:18,605 --> 05:05:21,641
CANCER PAPER ADJUVANT THERAPY 

5500
05:05:21,641 --> 05:05:24,877
AND THIS IS IF WE JUST DO 

5501
05:05:24,877 --> 05:05:25,812
RESECTION, HERE'S YOUR SURVIVAL 

5502
05:05:25,812 --> 05:05:27,380
AT THREE YEARS.

5503
05:05:27,380 --> 05:05:28,348
THERE WOULDN'T BE SURVEYS.

5504
05:05:28,348 --> 05:05:31,618
EVERY DOCTOR WOULD SAY THESE ARE

5505
05:05:31,618 --> 05:05:35,989
YOUR SURVIVAL CURRENTS AND WHY 

5506
05:05:35,989 --> 05:05:37,624
WE MAKE THE RECOMMENDATION SO 

5507
05:05:37,624 --> 05:05:39,826
WHAT DATA IS BEING SHARED WITH A

5508
05:05:39,826 --> 05:05:41,861
60-YEAR-OLD THAT COMES TO SEE 

5509
05:05:41,861 --> 05:05:43,997
YOU TODAY AND SAYS I HAVE A 

5510
05:05:43,997 --> 05:05:46,265
SIMPLE PROLAPSE CAN I BE 

5511
05:05:46,265 --> 05:05:51,304
RANDOMIZED AND YOU'VE SEEN THE 

5512
05:05:51,304 --> 05:05:54,207
PAPER.

5513
05:05:54,207 --> 05:05:56,142
HOW DO WE INFORM THE PATIENT 

5514
05:05:56,142 --> 05:05:57,777
WHAT THE DATA POTENTIALLY MEANS 

5515
05:05:57,777 --> 05:05:58,811
FOR THEM?

5516
05:05:58,811 --> 05:06:00,613
>> THAT'S WHY I WANTED TO
DO THE

5517
05:06:00,613 --> 05:06:01,247
STUDY.

5518
05:06:01,247 --> 05:06:02,649
WHEN WE DO THE FOCUS GROUPS WITH

5519
05:06:02,649 --> 05:06:05,018
THE PATIENTS AND THE RED CAP 

5520
05:06:05,018 --> 05:06:07,420
SURVEY I SHOWED, WE'RE ASKING 

5521
05:06:07,420 --> 05:06:08,187
THEM WHAT'S IMPORTANT TO THEM 

5522
05:06:08,187 --> 05:06:15,662
AND ONE OF THOSE THINGS IS 

5523
05:06:15,662 --> 05:06:15,995
MORTALITY.

5524
05:06:15,995 --> 05:06:17,430
>> IS THAT THREE YEARS
LATER AND

5525
05:06:17,430 --> 05:06:24,037
YOU'RE 60 YEARS OLD?

5526
05:06:24,037 --> 05:06:25,838
>> WE DON'T SPECIFY THE
TIMING 

5527
05:06:25,838 --> 05:06:28,041
BUT THE IMPORTANT THING IS WHEN 

5528
05:06:28,041 --> 05:06:29,976
WE ULTIMATELY FINISH AND PUBLISH

5529
05:06:29,976 --> 05:06:31,911
IT, I THINK THE GOAL IS TO 

5530
05:06:31,911 --> 05:06:37,450
GATHER WHAT'S IMPORTANT TO 

5531
05:06:37,450 --> 05:06:41,187
PATIENTS AND THEN SUPPLEMENT 

5532
05:06:41,187 --> 05:06:42,789
THAT AND HAVE DATA JOE PRESENTED

5533
05:06:42,789 --> 05:06:43,990
AND WE'LL HAVE MORE FROM PRIMARY

5534
05:06:43,990 --> 05:06:46,993
TRIAL AND FROM 42 REPAIR MR, WE 

5535
05:06:46,993 --> 05:06:49,762
CAN THEN FEED THAT DATA INTO THE

5536
05:06:49,762 --> 05:06:52,465
DECISION AID TO SAY TO MAKE LIKE

5537
05:06:52,465 --> 05:06:55,334
A CALCULATOR OR MAKE A DIAGRAM 

5538
05:06:55,334 --> 05:06:57,870
TO SHOW PATIENTS AND SAY LOOK, 

5539
05:06:57,870 --> 05:06:59,639
IF YOU CHOOSE THIS, THIS IS YOUR

5540
05:06:59,639 --> 05:07:01,274
RISK OF DEATH.

5541
05:07:01,274 --> 05:07:04,210
IF YOU CHOOSE THIS, THIS IS YOUR

5542
05:07:04,210 --> 05:07:04,410
RISK.

5543
05:07:04,410 --> 05:07:05,978
NOW KNOWING WHAT THE FACTORS 

5544
05:07:05,978 --> 05:07:08,014
THAT ARE IMPORTANT TO THEM IS 

5545
05:07:08,014 --> 05:07:13,052
YEAH, MAYBE FOR SOME PATIENTS 

5546
05:07:13,052 --> 05:07:15,688
LOW BASE IS IMPORTANT AND WHAT 

5547
05:07:15,688 --> 05:07:17,690
THEY PLAY THINK BUT IF YOU 

5548
05:07:17,690 --> 05:07:18,925
CREATE A DECISION AID AND PLAY 

5549
05:07:18,925 --> 05:07:21,561
BE ONE THING YOU CLICK AS 

5550
05:07:21,561 --> 05:07:24,063
IMPORTANT BUT IF YOU CLICK 

5551
05:07:24,063 --> 05:07:25,131
SURVIVAL IS IMPORTANT HERE'S THE

5552
05:07:25,131 --> 05:07:27,500
RISK OF MORTALITY WITH TIER 

5553
05:07:27,500 --> 05:07:29,902
VERSUS MORTALITY AND THAT WILL 

5554
05:07:29,902 --> 05:07:31,003
THEN THEM UNDERSTAND THIS IS 

5555
05:07:31,003 --> 05:07:31,337
SURGERY.

5556
05:07:31,337 --> 05:07:33,072
WE KNOW FROM THE RANDOMIZED 

5557
05:07:33,072 --> 05:07:35,074
TRIAL DATA THIS IS GOING TO BE 

5558
05:07:35,074 --> 05:07:39,412
THE PENALTY IF I CHOOSE TEER.

5559
05:07:39,412 --> 05:07:47,854
THAT'S WHAT I WANT TO DO.

5560
05:07:47,854 --> 05:07:58,297
I WANT PATIENT TO MAKE DECISIONS

5561
05:07:58,297 --> 05:08:01,234
ON REAL TIME AND SOME MAY HAVE 

5562
05:08:01,234 --> 05:08:05,505
SIGNIFICANT AND RECURRENT MR 

5563
05:08:05,505 --> 05:08:08,207
WHICH MAY DRIVE THE TRIAL AND 

5564
05:08:08,207 --> 05:08:12,812
WANT THE SURGERY AND THAT'S OKAY

5565
05:08:12,812 --> 05:08:16,716
BECAUSE WE HELPED CREATE THE AID

5566
05:08:16,716 --> 05:08:18,451
TO HELP WITH THE DECISION.

5567
05:08:18,451 --> 05:08:20,186
>> IT WILL BE INTERESTING
TO SEE

5568
05:08:20,186 --> 05:08:22,255
WHO ELECTS TO DO THAT AND MY 

5569
05:08:22,255 --> 05:08:24,857
PREDICTION IS OLDER PATIENTS 

5570
05:08:24,857 --> 05:08:27,160
WILL BE HAPPY TO BE RANDOMIZED 

5571
05:08:27,160 --> 05:08:32,431
AND YOUNGER PATIENTS PROBABLY 

5572
05:08:32,431 --> 05:08:42,608
WON'T BE.

5573
05:08:45,611 --> 05:08:47,346
RECOVERY RATES ARE BETTER WITH 

5574
05:08:47,346 --> 05:08:50,917
THE MINIMALLY INVASIVE TRICKS WE

5575
05:08:50,917 --> 05:08:53,586
PRACTICE AND MORTALITY IS A 

5576
05:08:53,586 --> 05:08:55,621
FAIRLY BIG ONE FOR A CURABLE 

5577
05:08:55,621 --> 05:08:56,556
DISEASE.

5578
05:08:56,556 --> 05:08:56,856
>> YES.

5579
05:08:56,856 --> 05:08:58,191
>> OKAY, THANK YOU.

5580
05:08:58,191 --> 05:09:06,599
>> THANK YOU FOR YOUR
COMMENTS.

5581
05:09:06,599 --> 05:09:07,900
>> WE HAVE ONE MORE
QUESTION 

5582
05:09:07,900 --> 05:09:08,935
FROM THE VIDEOCAST.

5583
05:09:08,935 --> 05:09:10,203
DAVID, THIS MAY BE FOR YOU.

5584
05:09:10,203 --> 05:09:12,205
I HAVE A QUESTION FOR ALL THE 

5585
05:09:12,205 --> 05:09:15,174
CLINICIANS AND SURGEONS.

5586
05:09:15,174 --> 05:09:17,643
I'M GUESSING VALVE SURGERY IS 

5587
05:09:17,643 --> 05:09:18,211
HIGHLY TECHNICAL.

5588
05:09:18,211 --> 05:09:20,847
WHAT ROLE DOES THE SKULL OF THE 

5589
05:09:20,847 --> 05:09:24,517
SURGEON PLAY IN THE OUTCOME OF 

5590
05:09:24,517 --> 05:09:24,750
SURGERY?

5591
05:09:24,750 --> 05:09:29,121
ARE THERE MECHANISMS IN PLACE 

5592
05:09:29,121 --> 05:09:33,793
FOR CENTERS AND SURGEONS?

5593
05:09:33,793 --> 05:09:37,964
>> IF YOU LOOK AT OUR DATA
THAT 

5594
05:09:37,964 --> 05:09:40,299
WERE PUSH ESTABLISHED AND THE 

5595
05:09:40,299 --> 05:09:45,204
PAPER WE PUBLISHED IN NEW YORK 

5596
05:09:45,204 --> 05:09:46,405
STATE CLEARLY THERE'S A 

5597
05:09:46,405 --> 05:09:47,039
RELATIONSHIP BETWEEN VOLUME AND 

5598
05:09:47,039 --> 05:09:56,182
EXPERIENCE AND OUTCOMES.

5599
05:09:56,182 --> 05:09:59,952
IF YOU HAD A SURGEON IN WERE 

5600
05:09:59,952 --> 05:10:03,623
HOSPITAL WITH MORE THAN 25 THEN 

5601
05:10:03,623 --> 05:10:05,358
THE PERFORMANCE WENT UP AMONG 

5602
05:10:05,358 --> 05:10:07,393
ALL SURGEONS.

5603
05:10:07,393 --> 05:10:08,494
THAT'S RELATED TO THE SKILL OF 

5604
05:10:08,494 --> 05:10:11,364
PE AND PATTERN RECOGNITION AND 

5605
05:10:11,364 --> 05:10:14,233
INVOLVEMENT AND IMAGINE THAT 

5606
05:10:14,233 --> 05:10:16,602
AGAINST COMPLEXITY.

5607
05:10:16,602 --> 05:10:18,571
I WILL ALSO TELL YOU THE IDEA 

5608
05:10:18,571 --> 05:10:24,744
YOU ONLY CAN TWO TO CEDARS OR 

5609
05:10:24,744 --> 05:10:27,580
MOUNT SINAI OR CLEVELAND TO GET 

5610
05:10:27,580 --> 05:10:29,348
A VALVE REPAIR ISN'T TRUE.

5611
05:10:29,348 --> 05:10:31,751
WITH A PROJECT WITH THE MITRAL 

5612
05:10:31,751 --> 05:10:33,252
FOUNDATION AND AMERICAN HEART 

5613
05:10:33,252 --> 05:10:34,120
ASSOCIATION WE IDENTIFIED OVER 

5614
05:10:34,120 --> 05:10:35,588
40 SITES THAT APPLIED AND WENT 

5615
05:10:35,588 --> 05:10:38,057
THROUGH A RIGOROUS PROFESSION TO

5616
05:10:38,057 --> 05:10:41,360
BE IDENTIFIED AS A REFERENCE 

5617
05:10:41,360 --> 05:10:42,728
CENTER OUR GOAL IS TO FIND 

5618
05:10:42,728 --> 05:10:44,030
REGIONAL CENTERS ACROSS THE 

5619
05:10:44,030 --> 05:10:45,164
COUNTRY IF YOU WERE INTERESTED 

5620
05:10:45,164 --> 05:10:47,366
IN TRYING TO GET A VALVE REPAIR 

5621
05:10:47,366 --> 05:10:49,001
AND HAD A MORE COMPLEX 

5622
05:10:49,001 --> 05:10:52,872
MORPHOLOGY YOU COULD GO TO.

5623
05:10:52,872 --> 05:10:54,807
BUT IN THE PAPER THE MORTALITY 

5624
05:10:54,807 --> 05:10:59,345
RATES WERE LOW ACROSS THE BOARD 

5625
05:10:59,345 --> 05:11:02,014
AND I THINK THE RATES HAVE 

5626
05:11:02,014 --> 05:11:04,183
STEADILY INCREASED IN THE UNITED

5627
05:11:04,183 --> 05:11:04,417
STATES.

5628
05:11:04,417 --> 05:11:06,552
FOR MOST SIMPLE PROLAPSE, THE 

5629
05:11:06,552 --> 05:11:15,628
KIND YOU COULD TREAT WITH TEER 

5630
05:11:15,628 --> 05:11:19,098
MOST CAN DO A VALVE REPAIR AND 

5631
05:11:19,098 --> 05:11:20,066
THERE'S SCENARIOS WHERE IT'S 

5632
05:11:20,066 --> 05:11:26,272
GOING TO MATTER EVEN MORE BUT 

5633
05:11:26,272 --> 05:11:29,075
CLEARLY THIS IS A TOPIC THAT'S 

5634
05:11:29,075 --> 05:11:33,279
IMPORTANT AND SOMETHING TO KEEP 

5635
05:11:33,279 --> 05:11:34,413
EMPHASIZING IS MITRAL VALVE 

5636
05:11:34,413 --> 05:11:36,215
REPAIR YOU HAVE TO DO ENOUGH OF 

5637
05:11:36,215 --> 05:11:39,251
IT TO GET THERE AND CUMULATIVELY

5638
05:11:39,251 --> 05:11:44,056
IT'S NOT A REASON TO DO ANY 

5639
05:11:44,056 --> 05:11:45,024
OTHER PROCEDURES INCLUDING VALVE

5640
05:11:45,024 --> 05:11:47,360
REPLACEMENT OR REPAIR OR 

5641
05:11:47,360 --> 05:11:57,370
ANYTHING.

5642
05:11:57,370 --> 05:12:02,641
THE VALVE REPAIR SPACE IS MORE 

5643
05:12:02,641 --> 05:12:07,713
THAN YEARS AGO AND I WAS A 

5644
05:12:07,713 --> 05:12:09,081
NATIONAL CO-P.I. OF A TRIAL AND 

5645
05:12:09,081 --> 05:12:14,687
I'LL SAY THIS TO EVERYONE FROM 

5646
05:12:14,687 --> 05:12:19,692
THAT PERSPECTIVE IS THE MEAN AGE

5647
05:12:19,692 --> 05:12:22,862
WERE 78 OR 80 AND YOU'RE RISK 

5648
05:12:22,862 --> 05:12:23,129
INCREASES.

5649
05:12:23,129 --> 05:12:25,664
WHEN YOU GET YOUNGER THEN YOUR 

5650
05:12:25,664 --> 05:12:28,067
RISK DON'T INCREASE THEN IT'S 

5651
05:12:28,067 --> 05:12:29,335
JUST ABOUT AVOIDING THREE WEEKS 

5652
05:12:29,335 --> 05:12:32,271
TO RECOVER FROM SURGERY.

5653
05:12:32,271 --> 05:12:34,407
THAT'S WHERE LONG-TERM OUTCOMES 

5654
05:12:34,407 --> 05:12:36,375
HAVE TO BE OUR PRIMARY FOCUS.

5655
05:12:36,375 --> 05:12:40,079
IT'S VERY DIFFERENT AND YOUNG 

5656
05:12:40,079 --> 05:12:40,579
PEOPLE.

5657
05:12:40,579 --> 05:12:41,714
OLDER PEOPLE IT WILL BE 

5658
05:12:41,714 --> 05:12:45,985
INTERESTING TO SEE WHAT DATA WE 

5659
05:12:45,985 --> 05:12:46,719
LEARNED.

5660
05:12:46,719 --> 05:12:48,854
I IMAGINE IF YOU'RE 80 YOU'RE 

5661
05:12:48,854 --> 05:12:50,056
THINKING BETTER ABOUT LIVING 

5662
05:12:50,056 --> 05:12:52,191
BETTER THAN LONGER AND THAT'S 

5663
05:12:52,191 --> 05:12:59,365
NOT TRUE AT 65 OR 70.

5664
05:12:59,365 --> 05:13:01,167
MORTALITY SHOULD BE THE 

5665
05:13:01,167 --> 05:13:07,606
OVERRIDING THING AND QUALITY OF 

5666
05:13:07,606 --> 05:13:07,840
REPAIR.

5667
05:13:07,840 --> 05:13:10,142
>> JORDAN, YOU MAY HAVE
THE LAST

5668
05:13:10,142 --> 05:13:10,376
COMMENT.

5669
05:13:10,376 --> 05:13:12,411
>> THIS IS RELATED AND
BEGS THE 

5670
05:13:12,411 --> 05:13:16,949
QUESTION SOMETHING LIKE A SYNTAX

5671
05:13:16,949 --> 05:13:18,651
SCORE EQUIVALENT FOR MITRAL 

5672
05:13:18,651 --> 05:13:20,886
VALVE OPERATIONS OF VALUE THAT 

5673
05:13:20,886 --> 05:13:22,822
CAPTURES THE COMPLEXITY OF THE 

5674
05:13:22,822 --> 05:13:24,190
PROCEDURE ITSELF BUT NOT 

5675
05:13:24,190 --> 05:13:30,362
NECESSARILY THE COMORBIDITIES OR

5676
05:13:30,362 --> 05:13:38,270
ETCETERA OR AGE OF THE PATIENT 

5677
05:13:38,270 --> 05:13:43,509
REPAIR DONE AT MANY SITES VERSUS

5678
05:13:43,509 --> 05:13:44,643
GUIDANCE TO REPAIR.

5679
05:13:44,643 --> 05:13:45,578
IS THAT SOMETHING YOU THINK 

5680
05:13:45,578 --> 05:13:46,679
WOULD BE OF VALUE?

5681
05:13:46,679 --> 05:13:48,514
>> I THINK IT WOULD BE AND
I 

5682
05:13:48,514 --> 05:13:59,058
HOPE OVER THE NEXT SEVERAL YEARS

5683
05:14:04,263 --> 05:14:07,299
WE'LL LOOK INTO THE 

5684
05:14:07,299 --> 05:14:10,536
INDENTATIONS, FREE COMMISSURES 

5685
05:14:10,536 --> 05:14:12,605
SEGMENTS AND UNDERSTAND THE 

5686
05:14:12,605 --> 05:14:13,305
COMPLEXITY AND DIRECTIONS 

5687
05:14:13,305 --> 05:14:15,174
BECAUSE IF WE CAN DO THAT WE'LL 

5688
05:14:15,174 --> 05:14:17,610
BE IN A BETTER PLACE TO GIVE 

5689
05:14:17,610 --> 05:14:18,644
PATIENT THE IDEA WHETHER THEY 

5690
05:14:18,644 --> 05:14:23,082
NEED TO GO TO A MORE ADVANCE D 

5691
05:14:23,082 --> 05:14:26,185
CENTER TO KEEP THEIR VALVE OR 

5692
05:14:26,185 --> 05:14:31,323
LET'S PRETEND YOUR 80, AM I A 

5693
05:14:31,323 --> 05:14:33,425
GOOD TEER CANDIDATE AND I THINK 

5694
05:14:33,425 --> 05:14:35,060
YOU'RE HITTING AN IMPORTANT 

5695
05:14:35,060 --> 05:14:35,261
TOPIC.

5696
05:14:35,261 --> 05:14:36,962
ONE OF OUR RESPONSIBILITIES THE 

5697
05:14:36,962 --> 05:14:39,265
NEXT SEVERAL YEARS IS TO 

5698
05:14:39,265 --> 05:14:43,369
ABSOLUTELY GET THERE.

5699
05:14:43,369 --> 05:14:45,337
REALLY DEFINE THE MORPHOLOGY AND

5700
05:14:45,337 --> 05:14:49,508
COUNT ON IMAGING TO MAKE IT MORE

5701
05:14:49,508 --> 05:14:52,811
REDUCIBLE AND SAY THEY NEED 

5702
05:14:52,811 --> 05:14:54,346
CONSULTATION AND GIVE US BETTER 

5703
05:14:54,346 --> 05:14:56,982
TOOLS TO DECIDE WHETHER THEY CAN

5704
05:14:56,982 --> 05:14:59,385
STAY HERE OR WHETHER WE SHOULD 

5705
05:14:59,385 --> 05:15:01,053
REFER THEM AND WHICH PROCEDURE 

5706
05:15:01,053 --> 05:15:01,453
TO DO.

5707
05:15:01,453 --> 05:15:04,190
IT'S AN EXCELLENT POINT TO END 

5708
05:15:04,190 --> 05:15:06,959
ON.

5709
05:15:06,959 --> 05:15:07,927
>> THANK YOU.

5710
05:15:07,927 --> 05:15:09,461
ON BEHALF OF THE NHLBI I'D LIKE 

5711
05:15:09,461 --> 05:15:11,363
TO THANK THE PARTICIPANTS FOR 

5712
05:15:11,363 --> 05:15:12,932
YOUR ADVICE AND WISDOM OVER THE 

5713
05:15:12,932 --> 05:15:14,900
LAST TWO DAYS AND WE APPRECIATE 

5714
05:15:14,900 --> 05:15:16,068
ALL THE TIME AND EFFORT YOU PUT 

5715
05:15:16,068 --> 05:15:22,374
INTO THE PRESENTATIONS.

5716
05:15:22,374 --> 05:15:24,109
IN THE COMING MONTHS YOU'LL BE 

5717
05:15:24,109 --> 05:15:25,377
HEARING FROM ME AGAIN AS WE 

5718
05:15:25,377 --> 05:15:26,912
START WORKING ON A PUBLICATION 

5719
05:15:26,912 --> 05:15:32,918
TO FOLLOW FROM THIS UPDATE.

5720
05:15:32,918 --> 05:15:35,354
AGAIN I'D LIKE TO THANK ALL OF 

5721
05:15:35,354 --> 05:15:36,722
YOU AND THANK THE SUPPORT STAFF 

5722
05:15:36,722 --> 05:15:40,492
FOR THEIR WORK OVER THE LAST TWO

5723
05:15:40,492 --> 05:15:41,727
DAYS AND THIS WORKSHOP IS 

5724
05:15:41,727 --> 05:15:41,994
ADJOURNED.

5725
05:15:41,994 --> 05:15:42,361
THANK YOU AGAIN.

5726
05:15:42,361 --> 05:15:44,129