Basically, I want to talk about the goal of the Symposium, actually, is to try to help you to be more efficient in your procedures, to optimize your results, but just being quicker about how we do things. A lot of these things we can pick up to the last presentation. There are little pearls we can understand that prevent us from having issues down the road. I think when we think about leaflet grasping when we're going to do tier, successful leaflet grasping really depends on these things. If you get this right, the grasping itself is quite easy. Then you have to pick your appropriate clip, depending on your anatomy. You need to make sure your trajectory is appropriate, your alignment is appropriate for where you're going, and then you have good imaging. Without good imaging, we all know we can't do anything. We want to have adequate leaflet insertion because we don't want to see any of the complications that Paul's probably going to show us. Once we make our grasp, we want to make sure that we evaluate our MR reduction. We want to decide if the reduction is not sufficient. Is it because we don't have enough clips, or is the clip just not in the right place? We really want to reposition it if it's required, and at that point we want to decide if we need more clips and where are we going to put them. I think the essentials of tier come down to really trying to figure out what is the problem you're trying to solve, thinking through that problem, asking yourself the right questions, and then you're going to come up with the right solution. If you don't understand what's wrong, we can't fix it. I try to ask myself all these different questions when I'm going to do this. Where am I going to go with my first clip? How many clips do I think I'm going to need? What is my valve area? How big is it? If it's small, I probably only have a one clip, and I need to figure out where I'm going to put it. What is the posterior leaflet length at the grasping location, so where am I going to go? What is it going to be? That's going to decide what clip I'm going to use. Then am I perpendicular, and is my trajectory appropriate? I try to do all that before I go in the ventricle, because once you go in the ventricle, you've got to get out if it's not optimal, and that itself can be problematic. Really I think tier is five basic steps, and we're just going to talk about leaflet grasping. The questions you need to probably think about when you're going to grasp is once you've gone into the ventricle, has my clip rotated? Because if it has, I'm probably not going to grab where I think I'm going to grab, and I'm not going to get a good result. Is the shaft of the CDS in the regurgitant jet, am I where I want to be? Then once I've grabbed, do I have good leaflet insertion, and do I have MR reduction? For leaflet grasping, same sort of thing, trajectory, orientation, this is what's important to help us grab. Then imaging. We need to see well, and we need to see. In my center, we don't have a lot of NPR, we don't use that yet, but you do have to make sure your imager can show you what you need to see to grab. Sometimes that's a dedicated LVOT, but sometimes it's not, they can't find you. In those cases, you maybe want to start with a bicommissural, and then X-plate on that, and then you'll get a better view. If you see in the top, we see the posterior leaflet, but maybe not as well as we would like. If we go to a bicomm and then we X-plate on it, suddenly we see the leaflets a lot better. Play around with that, don't waste a lot of time. If you don't see what you want to see, move to another imaging plane and try to find it. In terms of leaflet grasping, all the devices that are available now have the capability to do independent grasping versus simultaneous. It'd be interesting to see what the panel thinks, but I still believe that simultaneous grasping is probably the preferred method. Then optimize if you need to. One of the things we have to think about is if we pull one leaflet and then we pull the other, we may be distorting the anatomy. What we want is we just want to get the leaflets all the way into the center of the device. One key thing to think about, if you're doing primary mRNA at a flail, you have to bring that clip all the way up to the flail level, whereas when you have restricted leaflets, if you bring your clip up too high in the ventricle, you may lose the leaflet. Depending on the anatomy you're dealing with, our techniques may be slightly different. This is much the same thing. If you have leaflet tethering, if we pull the clip up too high, we may lose everything and we may distort the anatomy. When we think about additional clips, how do we decide what are we going to put? The first thing is to make sure your first clip is where you want it and you got MR reduction. If you don't get MR reduction with your first clip, you have to ask yourself, why are you wanting to leave it there? If you want to leave it there, is it because you're trying to bring those leaflets together to put the clip where you want to put it? If that's not the reason, you probably shouldn't leave it there because it's not doing anything for you. What I think about is, what is the first clip I used? I'm not a big fan of mixing clips. I know some people do that, but I just don't really understand the concept. If I'm going to put a small arm clip, I'm probably not going to add a long arm clip beside it. I think about what's the first clip I used, what's my mitral valve gradient after my first clip? If it's two, no worries. I'm going to add more clips. If it's four, I got to ask myself, is that gradient four because I have a lot of MR or am I limited a little bit? Then what's the intended location? If you're going to go in the commissures, you may want a shorter arm clip so you don't get stuck in the cords. You may even want a skinny clip so that you don't get stuck in the cords. Those are just some things to think about when you're doing that. I will direct you to this reference, which I think is very helpful. You can download it from Sky. You can work through some of these things yourselves. You may find it helpful to get you through some of those difficult parts.

Symposium goal

efficiency in procedures

leaflet grasping

good imaging

mitral regurgitation reduction