<International Circulation> : So what are some of the problems that you see in the valves right now that need to be fixed?

　　《国际循环》：目前您认为瓣膜有哪些问题需要解决？

　　Prof. Hijazi: The current valve systems that we have the delivery transcatheter is large which is really where the complications come from. For example， the commercial Edward Sapian Valve is really large. To insert it in the artery you need to have a size of at least 7.5-8 ml.  When you insert the catheter there a large percentage of patients develop complications. And that is why the goal now is to miniaturize the delivery catheter. There’s a new valve called the Calibri heart valve that is being tested because it went to a 12-14 fringe and if you have a 14 fringe you can put that in basically any patient that needs a new valve. So that’s a major complication. A second major complication that we have seen is what we call stroke. Why some patients develop stroke versus we don’t exactly understand yet. This may happen after transcatheter insertion or after open-heart surgery. The occurrence of stroke after open-heart surgery is less than transcatheter but we are working to improve our techniques and maybe different devices， what we call cerebral protection devices to prevent clots from going to the brain. The third potential complication is the conduction systems， in some patients， is hard to block. This happens more with the core valve but it happens with both. If the patient develops this then they will need a pace-maker. Is the pace-maker the end of the patients’ life? No， but for the younger patients we don’t want to commit them for the rest of their life. These are the three major complications for trancatherter insertion. Let’s talk now about the mitral-valve. It is a complex structure. It’s different than the aordic valve. The progress has not been as good as the aordic valve and different companies designed different devices to repair the mitral-valve. Again， this is common in the elderly. As we get older and we sustain heart attacks and etc. the mitral-valve apparatus becomes affected and you will have a leak or degeneration. There are two types of leaks. The first kind is the functional mitral valve regurgitation which is where the left ventricle of the heart begins to dilate， giving the heart a rounder shape and the second type is structural mitral valve regurgitation because there is a leak in the mitral valve. The design of the various methods focused on either repairing the leaflets and the most common device being used for this is the MitraClip. The concept is similar to a surgical technique. Dr. Ottavi Alferi was the first in the world to describe leaflet repair. The device is attached directly to the mitral valve using a catheter. The results are good but it is not for every patient so pre-selection of the patient is essential. You need to look at the patient， the valve， the apparatus， the leak itself， and etc. so you need to look at all these criteria before deciding whether the patient is a good case for the MitraClip. New technologies are concentrated on reducing the annulus size by cinching the coronary sinus size which is the structure behind the mitra valve. If you put a rigid rod in the and you decrease it you will decrease the size of the annulus size. There is no initial result but the result can be seen after a few months and being that we are all cardiologists we want to see results right away. There are other technologies to tackle the mitra valve leaflets， the papillary muscles and etc. The best outcome in the future should be mitral valve replacement. You put a new valve and right now there are a few companies working on testing on trans-sector valve replacement. Actually， I’m currently working on a valve called the funnel valveand we hope that in five or ten years or so we will be able to apply this new technology. The progress in the area of mitra valve has been less visible simply because of the structure of the mitra valve but we are going to conquer this valve and be able to replace it in the future. The third type of valve that we are doing routine replacements of is the tricuspid valve，and the tricuspid valve is easier than the mitra valve and more difficult than the aortic valve. We have done a lot of patients who were born with congenital heart disease and the surgeon put a valve between the right ventircule and pulmonary artery and when you put these artificial materials there is a build-up of calcium so we need to replace it. So， instead of replacing it we go ahead and put the SAPIEN valve or the MELODY valve. The MELODY valve receive FDA approval in January 2010 and we are just finishing the trial and we are hoping within the next few months the FDA will give approval. But the  valve replacement is an exciting procedure. Our goal is to diminish the number of heart surgeries. If we can eliminate one or two heart surgeries that would be a phenomenal accomplishment for us.

　　Hijazi教授：我们目前使用的瓣膜问题首先是输送导管体积大，造成血管并发症问题。Sapien瓣膜体积大，为了将其插入动脉，需至少17.5-18 F导管。而插入导管时很多患者会发生并发症。因此目前目标是将输送导管小型化。目前有一种叫Calibri的新型心脏瓣膜，只需12-14 F输送导管。如果使用14 F导管，就可用于所有需新瓣膜患者。第二个主要并发症是卒中。我们目前尚不清楚为什么一些患者会发生卒中。卒中在导管手术和心脏直视手术后都有可能发生。外科手术后卒中发生率低于导管术后，但目前我们正努力改进技术。新装置，我们叫做脑保护装置，可以预防血栓进入大脑。第三个潜在并发症是传导系统。如果患者发生传导阻滞，就需要植入起搏器。起搏器是患者生命的终结吗？并不是，但是较年轻的患者并不想余生都依赖起搏器。导管手术有这三个主要并发症。接下来我们讨论二尖瓣。二尖瓣结构复杂，与主动脉瓣不同。二尖瓣方面进展不如主动脉瓣。不同公司也设计了不同装置修复二尖瓣。同样，二尖瓣在老年人中也较常见。当年龄变老，发生心肌梗死等疾病后，二尖瓣会受到影响，发生反流或退变。二尖瓣反流有两种，第一种是功能性二尖瓣反流，是由于左心室和心脏扩张，导致心脏呈球形。第二种是结构性二尖瓣反流，是由于二尖瓣存在漏。不同设计方法都集中于修复瓣叶。最常见的装置是MitraClip。导管手术概念和外科手术相似。使用导管将装置连接至二尖瓣。总体疗效很好，但并非每个患者都能达到。因此对患者选择非常重要。在决定患者是否适合MitraClip治疗前，需关注瓣膜、装置和反流等。新技术聚焦于减小瓣环尺寸。如果减小其中轴杆尺寸，就减小了瓣环尺寸。目前还没有初步结果，但几个月后就可以看到，所有心内科医生都在期待这个研究结果。还有其他一些处理二尖瓣叶的技术，如乳头肌等。将来能够取得最好结果的应当是瓣膜置换，植入新瓣膜。目前有几个公司在进行经导管瓣膜置换方面研究。目前我也在进行一项新瓣膜研究，希望5~10年内我们能使用这项新技术。由于二尖瓣结构问题，我们在二尖瓣方面进展不那么明显。但将来我们能取得胜利，对瓣膜进行置换。第三种我们进行常规置换的瓣膜是三尖瓣。三尖瓣置换比二尖瓣简单，但比主动脉瓣难度高。我们治疗了许多出生时就有先天性心脏病的患者，外科医生在房室瓣和主动脉瓣之间植入瓣膜，而植入人工材料时，会有钙化累积，因此我们需要进行置换，植入SAPIEN瓣膜或MELODY瓣膜。MELODY瓣膜于2010年1月被FDA批准。而我们刚刚结束试验，希望新瓣膜能在几个月内得到FDA批准。瓣膜置换术是令人激动的手术。我们的目标是降低心脏外科手术数量，这对于我们来说是非常大的成就。

　　<International Circulation>: OK， thank you very much. My last question is what are some of the main advances in multimodality imaging methods for catheter based intervention in structural heart disease?

　　《国际循环》：非常感谢。我的最后一个问题是关于结构性心脏病导管介入术中多模影像方法的主要进展。

　　Prof. Hijazi: Congenital and structural heart disease joined and if you want to repair something you need to see it so the role of imaging is critical because if you don’t see something well you can’t fix it. So we start with echo-cardiography which is non-invasive and it gives you the data you want. Initially it started with 2-D and now we have 3-D. You can see the structure and the format so that’s been a great advancement over the last ten years. Then we have CT， we have MRI and we have thermography. We have all of these. So， imaging is critical for both structural and congenital heart disease and the collaboration between the imaging and the cardiologist is essential to the success of the procedure so we are working very close with our colleagues in the ECHO lab and really everybody to gather information that will enable us to fix the defect without any problem.

　　Hijazi教授：对于先天性和结构性心脏病，如果你希望对疾病进行治疗，首先需要看到它。因此影像学地位非常重要，因为不进行观察就没法进行治疗。我们最开始使用超声心动图，这是无创检查，并且能够得到我们希望得到的数据。最开始是2D，目前我们有了3D技术。我们能够看到心脏结构。这是过去10年的重要进展。目前我们有了CT、MRI和热成像技术。因此，影像学对于结构性和先天性心脏病非常重要。影像学医师和心血管医师之间的合作对于手术成功非常重要。我们和超声及影像的同事密切合作，搜集相关信息来保证我们安全的完成治疗。

　　<International Circulation>: Fantastic. Thank you. That is it for my questions.

　　《国际循环》：您的介绍非常精彩。谢谢。