Okay, so I think, you know, this is a great opportunity to maybe take a pause and talk to you guys about patient selection. You know, you've seen Myra's case, and Myra showed some really nice cases of, you know, trying to attack a, you know, residual MR following mitral valve repair. What are the majority of cases you guys are seeing? Is it primary MR? Is it secondary MR? How many people are treating primarily, predominantly primary MR? And how many people are treating primarily secondary MR? So what do you guys find difficult when it comes to patient selection? Is there anything that challenges you that you have these people on the panel that might be able to help them, give you some support, but what do you find most difficult about patient selection? I'm going to pick on Paul. What do you find most difficult about patient selection? Well, I think I'm going to touch on it a little bit. Trying to identify appropriate patient anatomy, making sure there's enough posterior lethal, especially in the secondary population, that you can have an adequate grasp to anchor the clip so the clip can work as intended. And then getting outside of the A2, P2 kind of chip shots, you know, when is the clip effective and when is the clip just going to get you into trouble? You know, we saw a nice case of a clip through a ring. We could have also talked about valve and ring, so there's options out there. And I thought it was a nice demonstration of both NPR and use of CT to identify pre-procedurally anatomy that would make it, I think, amenable to clipping. I'm interested to pose this question to everyone on the panel, and I'm curious if we'll get sort of same answers, similar answers, different. So one of the things that I think is tough about treating secondary MR is, what are the factors you look at to say, I want to put an XT clip versus I want to put an NT clip? And how do you think of the anatomy in making that choice? I mean, I think secondary MR, we have to remember there's two different kinds of secondary MR. Obviously, you can think of it as sort of secondary atrial and secondary ventricular. And so when you have those, you know, atrial functional MRs, the anatomy is somewhat different. It looks like a type one where the annulus is big and the leaflets kind of come up and they don't really touch. And so you don't have what we call coaptation reserve. So those are very different from those standard functional MRs. We have bad LV function, and the leaflets are all tented down. And so depending on what you have, I think that's going to determine your clip selection. And so if I'm dealing with sort of these tented leaflets where the ventricles are very dilated and they're being pulled, I tend to prefer an NTW just to kind of gradually bring these leaflets in and sort of minimize what I think might be stress on the leaflets if I take a big clip and try to really pull it together. But I don't know what you do, Paul. Yeah, so we're about 50-50 NTW, XTW, and I'm a little bit conservative. All of our data from coapt is based on the small clips. If you can get the small clips to work, I think that the large clips aren't going to make up for inadequate…for big gaps or inadequate technique. So I tend to favor the NTW in complex and commissural anatomy and short posterior leaflet. On the other hand, if you have a huge ventricle with long leaflets and good posterior…good length of posterior leaflet, the XTW is an excellent starting point. So it's a little bit of a mix to the anatomy. So a 75-year-old, primary MR, a lot of MR, should you defer that or should you intervene? What do you guys think? Intervene, because we have data that shows that, like, the presence of moderate to severe MR or more than that actually has effects on the remodeling of leptatrium and pulmonary hypertension. And we know that, like, once we get to that realm, unfortunately, these patients may not be actually candidates for surgical repair or even transcatheter repair. And we know even if we actually do a percutaneous transcatheter repair in these patients, but if they have an intrinsic leptator disease, then the outcomes are actually not the same compared to another patient who actually don't have remodeling of leptatrium and pulmonary hypertension and RV failure. And if I could just put a little plug in, the repair MR trial is intermediate-risk patients and 75, you're going to be intermediate-risk or 75. So if you're on the fence with someone 75 to 80, consider that trial because it's going to help us answer the question on patients who are a little bit lower risk than we're currently treating. I was just going to say the age, I think, really plays a role and also the ability to take long-term anticoagulation. So if you're talking a 90-year-old or plus, you know, even in the 80s, life expectancy, you know, is not that great, then you may be okay just by improving symptoms, even though you know that you're going to leave some MR behind. We know that—we humbly learned that there's not going to be zero, right? But in a younger patient, and you know that you're not going to be able to reduce the MR, you know, significantly, and the patient can tolerate anticoagulation, then maybe, you know, considering TNVR option under a clinical trial because it's not approved yet or randomization in the only study that has the randomized option for TR versus TNVR, you know, may be an option. So I think considering age and the ability to take long-term anticoagulation are two important factors, in addition to anatomy, obviously, that we're discussing. I do think deferring care is not great, though. You should address the MR in some manner. And I think that's true whether it's primary or secondary, right, based on any of the various data we have. But, you know, I think one thing that's tough about the point you make about you have a valve, you know it's secondary, you know it's ugly, and you know that you can't put a ton of clips and close everything, and so you have some general sense, right? Sometimes we're pleasantly surprised and we think, wow, that was a better result than I planned, but that's usually not the case. It usually goes the other way, right? And so I think one thing that's an uncomfortable part of this conversation is referral patterns and how this happens for patients where they go to a center that doesn't have a TNVR program. Because unfortunately, we end up seeing a bunch of times as a referral center that someone got a couple of clips for secondary MR, the result is not good, the patient doesn't really feel much better, so then they get referred, and now we're just kind of screwed because we can't take out the clips, we can't do a TNVR. And so I think that to some degree, and I'm sure, right, everyone has had this experience, and so I think to some degree just being aware that leaving people behind with MR is not a good thing, and referring if the patient is able to go to a different place is not a bad idea. And the TNVR trials, I know M3 has it, has an arm for failed mitral clips. If you're in the room trying to do it and you just can't get a good result, take the clip off, pull everything out, and send them. So that, and that will automatically push the, you know, that's a criteria for enrollment. And I think that's a really important point because sometimes it's worth to try to put a clip on, but if you put that clip on and you realize that you're not getting much in the way of MR reduction, don't be afraid to take it off because if you leave it there, you may be causing more difficulty for the patient. We'll do one more question and then we'll... I'm Satyav Mukherjee from Phoenix, I'm an interventional cardiologist. I was wondering if you guys can share any insights into what patients would be better served with mitral clip versus Pascal with more experience. I mean, I know the trial was a small trial, no significant difference, but is there anything that you can share beyond that? I'm not sure we know yet, to be honest. I think it's a bit too early. Maybe next year. So I'm going to invite Dr. Krishna Smoothie from Mount Sinai to talk to us about clip steering, alignment, trajectory, and troubleshooting.

patient selection

mitral valve repair

mitral regurgitation

clip selection

anatomy of the heart