All right. Thanks, everyone. Thanks to the organizers and Anita for putting this program together and for allowing me to be a part of it. So we know generally that MitraClip is a good therapy for higher surgical risk patients with DMR and patients with secondary mitral regurgitation, and there's been a lot of talks at this conference and at others to go over that data. So what I'd rather do is just spend a few minutes talking about the patients and anatomies that we can consider treating beyond the above categories in the contemporary era, specifically understanding what the role is of the different clips that we have and, importantly, the contemporary era of imaging. So leaflet detachment, this is a scenario that, unfortunately, all of us have probably dealt with at one time or another. So this was an 88-year-old lady. You can see here a P2 segment flail. She had a good result of a MitraClip, really trivial residual MR. We felt good about it. She felt good about it. She was doing a lot of gardening, and about eight months later, unfortunately, fell coming from her back deck into her home, hit her chest on the threshold of her house, fractured a few ribs, got short of breath, and perhaps not surprisingly, here was her echo. And so, as you see, her clip is still holding on just only to the anterior leaflet. The flail of the posterior leaflet is back. And I think this is a scenario that, whether it happens acutely or whether it happens sort of chronically, as it was for this patient, really requires a very thorough understanding of the valve anatomy to say, what can we do? What can we offer here? So we've essentially converted 100% to analyzing and procedurally guiding these kind of cases or all of our clip cases, I should say, with 3D NPR. You can see here, this is a very nice echo done by one of our imaging colleagues by placing the grasping plane in green, just lateral to the clip that's detached, a very nice sort of leaflet anterior and posterior for us to be able to grasp. And so, with that, you can see here the clip in position and a good result at the end of it all for this lady who's 88 years old. Now, where does the data tell us about these kind of procedures? This is the film registry. You can see a lot of clip procedures, 4,300, pretty low rate of SLDA or loss of leaflet insertion, about just under 4%. But if you look at the management strategies, what you see is that those patients who did best were those who had a redo mitral clip rather than those patients who are either treated medically or treated surgically. Now, certainly, there are a lot of differences here in terms of valve anatomy and what's capable or what's feasible, but I think that—and we wrote an editorial on this paper, and I think it's really important that in the current era, really understanding the anatomy with appropriate imaging can hopefully get that patient into a sort of a redo tier situation rather than considering surgery or just medical therapy. We see a lot of patients, unfortunately, who have recurrent mitral regurgitation after they have had surgery. If you look at this analysis, about a 10% recurrence of DMR due to posterior leaflet pathology surgery, almost 20% in those patients with anterior or bileaflet pathology, and we all know secondary MR patients really fare quite poorly with cardiac surgery with very, very high rates of recurrence. So what can we do for these patients who are universally, generally, at a high surgical risk? So here's a 78-year-old gentleman, a prior Duran band about two years ago, now with a recurrent flail and prolapse of his posterior leaflet. So again, understanding the anatomy in as granular detail as we can is important. So you can see here, again, the 3D NPR, and just kind of marching the imaging plane in the bottom right through the valve, we finally get to the area of flail that's pretty well localized to the P1 segment of the leaflet. You can see there's the mitral regurgitation originating right there. The mean gradient is only about 3 millimeters of mercury, so a number of favorable factors here for clipping, adequate leaflet tissue. It's close to the commissure. We're not going to do much to close the area of the valve, and a pretty low starting gradient. So here, then, the patient comes for procedure, again, guided by our imaging colleagues. There's a clip above the A1-P1 segment. Again, that's exactly where it's leaking, just to confirm. And then I just—this is all 3D NPR. I just took the grasping plane so it's easier to follow. There we are in the LV, favoring the anterior leaflet, favoring the posterior, and then where the clip is closed, no more residual mitral regurgitation. A bit of a similar but slightly more complex case. This is a patient who had functional mitral valve regurgitation, had a posterior band, and now with recurrent MR kind of in the medial aspect of A2-P2, pretty low gradient for starters at 2. What you see here, while we have the imaging plane at the level of the leaking, on 2D, it's actually kind of difficult to say whether there's truly posterior leaflet there, and it's simply shat out by the posterior ring, or that posterior leaflet is simply restricted and there isn't much leaflet there. So in these situations, again, being sort of facile with multi-modality imaging can be helpful. So this is the patient's CT scan, and if we make a plane right at the medial aspect of A2-P2, what you can see, there's actually a very nice posterior leaflet in both systole and diastole. So we know there's something to grasp, it's just that the TE imaging was a bit less than ideal in that regard because of the posterior ring. So we brought the patient to the lab. You can see here we've positioned ourselves right at the medial aspect of A2-P2. Again, we can go and pick up the anterior leaflet, still really can't see much posterior leaflet, though we kind of know that it's there, and as we start bringing the clip up and we bring that posterior leaflet away from the posterior ring, you have a much better understanding that, okay, we're in a good spot, there's something to grab onto, and go ahead, put down the gripper, close the clip, and ultimately left with a stable clip and a very nice result with trivial residual MR. So we did a meta-analysis recently, the manuscript's under review, but these aren't necessarily contemporary papers, and I say that, which is important, because this was not necessarily G4 clipping, this was not necessarily 3D MPR imaging, and in these sort of seven studies, if you take a look, about three-quarters of patients after this clip procedure were left with 1 plus or less MR, 90% left with 2 plus or less MR, and as you'd expect, substantial improvement in functional class, about 80% of patients in class 1 or 2 heart failure at the end of the case, with a relatively low in-house mortality, again, for a group of patients who's otherwise at a quite high surgical risk. So I think, again, another group of patients that we probably should consider treating. I'm going to skip over this, only because, clearly, Myra is going to cover this and some more. So to conclude, the MitraClip system, I think, is an effective tool in treating different pathologic conditions that cause MR. We can effectively treat patients beyond the typical degenerative MR or secondary MR. I would argue contemporary imaging is really imperative to successful tier, and I think it's really important that individuals and systems commit to structural imaging guidance, because in truth, I think that the number of programs that really have imagers that are dedicated to structural imaging for both diagnostics and procedural guidance, and honestly, the appreciation of how 3D MPR benefits is still kind of lacking. So thanks very much.

MitraClip therapy

mitral regurgitation

leaflet detachment

3D MPR imaging

structural imaging guidance