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tags: TEE Symposium
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# 19th Annual Toronto Perioperative TEE Symposium: Virtual Valve Case Review 2020 - Faculty Portal


[TOC]

## Symposium Objectives
This one-day on-line symposium consists of interactive case-based presentations focusing on intraoperative TEE assessment of MR, AI, AS and TR. The case presentations will illustrate application of the latest ASE guidelines (Nicoara 2020; Zoghbi 2017 and Baumgartner 2017) to the diagnosis of the mechanism and determination of severity of a representative spectrum of lesions in each category. Brief technical vignettes will highlight key techniques and background theory in the context of real cases.

## Presenter Instructions and Key Links
### Program
**[Symposium Program, Case and Technical Topic Lists for Faculty](https://docs.google.com/spreadsheets/d/1hQwe2G5-gUGJRgniOttjeKuluqceD-Hls_Q4jxNj6QY/edit?usp=sharing)**

**[Public Symposium Website](https://tghperioptee.ca/)** Contains the final schedule with assigned times

### Session Format and Technical Information on Video Clips
We have hired Mark Atkinson from Ardeane Consulting, a professional symposium and webinar organizer who will be handling the technical management of the symposium.

In order to ensure proper de-identification of videos and uniform formatting to avoid technical issues during the webinar **Azad will be exporting all your videos for you from PACS and removing identifying data. For UHN staff, please forward the MRNs and study dates, or acquisition numbers of the studies you need ASAP** and I will upload a de-identified set of clips and images for the whole study to the UHN One Cloud, or provide it to you on a USB key, from which you can then select the clips you need for the presentation.

For consistency **please use a recent version of Microsoft Powerpoint** if at all possible. If you need or strongly prefer to use other software please let me know.

#### Main Session Format
Each 30 minute session will include
* 2 interactive case presentations (9-10 minutes each).
* 1 technical/didactic topic (4-5 min) that is related to at least one of the cases and which can therefore be illustrated in a clinical context
* 1-2 Questions presented at any appropriate point. Answers will be reviewed at end of day.
* Additional MCQs can be presented during the presentation with participant answer distribution displayed and answers provided.

Cases have been selected to represent the spectrum of most common clinical scenarios.

Technical topics have been selected for highest practical yield. Ideally presented and illustrated in a clinical context.

#### Quiz Session (end of day)
The 1-2 questions presented at each session will be reviewed with explanations. An additional 5-10 questions will be added. Interactive session. Participants answers will be displayed. Participants can enter additional questions.

### [Presentation Template (Powerpoint)](https://tghperioptee.ca/wp-content/uploads/2020/10/20201014-Toronto-Perioperative-TEE-Symposium-2020-Template-Final.pptx)
https://tghperioptee.ca/wp-content/uploads/2020/10/20201014-Toronto-Perioperative-TEE-Symposium-2020-Template-Final.pptx

Contains a recommended flow and timeline for the case presentations and technical topic.
Please note that there is a different page format in the template for
1. Case Presentation
2. Key points slide at the end of each case
3. Technical topic

The template also contains a few key figures from the guidelines. Please include the appropriate figures into your slide deck and identify the classification of each case on the figure.
* MR Sessions:
* Figure 10 from Zoghbi (2017): MR Classification
* MR epidemiology slide. (missing from current template; will be sent out soon)

* AI Sessions:
* Figure 19 from Zoghbi (2017): AI Classification.
* AI epidemiology slide. (missing from current template; will be sent out soon)

* TR cases.
* TR epidemiology slide. (missing from current template; will be sent out soon)

## Reference Resources
### Key guidelines
1. https://www.asecho.org/wp-content/uploads/2020/06/TEE-Surgical-Decision-Making_June2020.pdf
2. https://www.asecho.org/wp-content/uploads/2017/04/2017VavularRegurgitationGuideline.pdf
3. https://www.asecho.org/wp-content/uploads/2017/04/2017ValveStenosisGuideline.pdf

### CPD Requirements for CME Accreditation
http://www.royalcollege.ca/rcsite/cpd/accreditation/toolkit/requirements-web-based-cpd-activities-e

### Objectives by Topic
Upon active participation and completion of the sessions, attendees will be able to:

#### General Objectives
1. Describe and identify the mechanical cause of valvular dysfunction in echocardiographic imaging.
2. Describe the effect of positive pressure ventilation, hemodynamic changes of anesthesia, and the opening and closure of the pericardium, on the severity of mitral, aortic and tricuspid regurgitation.
3. Discuss the relative importance of identifying mechanism and localizing lesion vs. determining lesion severity on intra-operative echo.
4. Discuss the clinical contexts in which rigorous assessment of lesion severity has significant impact on intraoperative surgical decision making
5. Describe the lesion-specific cardiac morphologic changes associated with chronic valvular heart diseases
6. Explain the underlying theory and apply guide-line-based quantification techniques to assessment of valvular heart disease.

#### Mitral Regurgitation (MR)
1. Describe a systematic approach for the intraoperative assessment of MR
2. Describe the mechanisms and classification of MR and be able to identify them on 2D and 3D echocardiographic imaging.
3. Discuss the clinical contexts in which rigorous assessment of MR severity has significant impact on intraoperative surgical decision making
4. Describe the cardiac morphologic changes associated with chronic MR
5. Explain the hemodynamic alterations associated with with chronic MR and describe their connection to Doppler flow patterns commonly observed.
6. . Explain the basic repair techniques for the mitral valve and how intra-operative characterization of the lesion can guide the selection and performance of the repair.

#### Aortic Insufficiency (AI)
1. Describe a systematic approach for the intraoperative assessment of AI
2. Describe the mechanisms and classification of AI and be able to identify them on 2D and 3D echocardiographic imaging.
3. Discuss the clinical contexts in which rigorous assessment of AI severity has significant impact on intraoperative surgical decision making
4. Describe the cardiac morphologic changes associated with chronic AI
5. Explain the hemodynamic alterations associated with with chronic AI and describe their connection to Doppler flow patterns commonly observed.
7. Explain the basic repair techniques for the aortic valve complex and how intra-operative characterization of the lesion can guide the selection and performance of the repair.

#### Tricuspid Regurgitation (TR)
1. Describe a systematic approach for the intraoperative assessment of TR
2. Describe the common mechanisms of TR, relate them to the morphology and function of the right ventricle, and identify them on echocardiographic imaging.
3. Explain the mechanisms underlying hepatic venous Doppler flow patterns and their application to the assessment of TR and hemodynamic instability.
4. Explain the basic repair techniques for the tricuspid valve and how intra-operative characterization of the valve can guide surgical decision making.

#### Aortic Stenosis (AS)
1. Explain and apply the continuity equation for calculation of aortic valve area in aortic stenosis.
2. Explain the limitations and pitfalls of continuity equation in this context.
3. Expalin and apply the dimensionless index for quantification of aortic stenosis.
4. Explain the influence of significant aortic insufficiency on aortic valve gradients.

#### Technical vignettes
The technical vignettes incorporated into the case presentations will provide focused, pragmatic and high-yield descriptions of relevant diagnostic and surgical techniques. The underlying physical and physiologic principles will be explained and the application of measurement techniques based on the latest guidelines for intra-operative echocardiography will be illustrated in the context of a relevant case.

### Case list (22)
The case list below is included as a reference to illustrate the rationale behind the case assignments for each session. The goal is to cover the main categories of pathology for each valve.

#### AI (3 sessions = 6 cases)
1. Type 1 - Normal Motion: Root+ascending enlargement; normal annulus
1. Type 1 - Annular dilation, root enlargement; STJ not effaced
1. Type 1 - Isolated root enlargement and annular dilation; STJ and ascending normal
1. Type 1 - Leaflet perforation
1. Type 2 - Prolapse - Tricuspid AV
1. Type 2 - Prolapse - Bicuspid AV

Type 3 will be covered in AS cases.

#### MR (4 sessions = 8 cases)
1. Type 1 - Normal Motion: Annular Dilation (Ischemic / DCM / NICM / AF)
1. Type 1: Leaflet Perforation (Endocarditis, congenital cleft, iatrogenic)
1. Type 2 - Excessive Motion: Prolapse (Myxomatous; isolated chordae rupture from ischemi, IE or or other)
1. Type 2: Flail (Myxomatous; isolated chordae rupture from ischemi, IE or or other)
1. Type 3 - Restricted: Calcified/thickening/fusion (Rheumatic, degenrative, IE)
1. Type 3 - Restricted: LV dilation, chordal restriction (Ischemic / DCM)
1. MR secondaty to SAM in HCM. Normal valve.
1. MR in HCM with concomittent valve abnormality (ie. atypical MR jet for pure SAM)

#### TR (2 sessions = 4 cases)
1. Primary TR
1. Secondary, with severe MR
1. Chronic PHTN, RVH
1. Dynamic TR associated with RV volume fluctuations and opening/closing of pericardium

#### AS (2 sessions = 4 cases)
1. Calcific AS (Tricuspid AV); None aneurysmal ascending Ao; No significant other valvulopathy LV dysfunction
1. Calcific AS (Tricuspid AV); Low gradient; LVEF < 40% +/- MV disease
1. AS (Tricuspid AV) + AI +/- Aortic root/ascending aorta pathology
1. AS (Bicuspid AV)

### Handout (Mashari)
* Anatomy of heart base
* Anatomy of MV and subvavluar mechanism
* Anatomy of AV complex
* Anatomy of TV
* Imaging protocol from TGH PTE Handbook for MR, AI, AS, TR
* References
* Main guidelines
* 1-2 high-yield articles for each MR, AI, AS, TR