Watch the first ever, Live Case TAVR procedure livestreamed from Georgia Heart Institute’s cath lab to the Inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia. Join Ronnie Ramadan, MD, and his team from Cath Lab 3 as they present a challenging and interesting case. Habib Samady, MD, President of Georgia Heart Institute along with Symposium panelists observe, commentate, and ask questions as the Structural Heart and Surgical team give an inside look at an Image-Guided Percutaneous Axillary TAVR.
This is an exciting moment for us at the Georgia Heart institute to do our first live cases and um we've got two phenomenal teams ready to go. So without further ado maybe before we we go into Dr Ramadan and Maya's room, maybe I can have our phenomenal panel each introduce themselves. Um so starting with, okay dan Winston, cardiac surgeon Alan Wolfe, Cardiothoracic surgeon, Angela Taylor, interventional cardiology, Mike, rinaldi interventional cardiology, structural heart Spencer king, how do I follow that? Rickshaw, interventional cardiologist, focus on structural interventions. Glenn, Henry interventional cardiologist. Fantastic. Well, um I just want to say a word. Um maybe I can say this. Um Glenn is currently at Yale but he's joining us later this year as director of interventional cardiology. So welcome and we've got an incredible, incredible lineup. Um Okay, so um Ronnie, I think we're going to lab three over to you and maybe introduce your team. Perfect. Can you guys hear us and see us? Yes, we can very well. Alright, thank you, Habib and welcome to Cath Lab Three. We're excited to share a very interesting and challenging case with you this morning and we're looking forward to any input from our esteemed panel um thomas that I can take me back some so more relaxed. We'll start by introducing our fantastic team. So to my left is Dr to DR is joining us from Beirut Lebanon as a guest operator where he serves as the director of structural heart at American University of Beirut landed late last night. So he's jet lagged. So if he's speaking in french or Arabic just ignore him. Kyle Thompson is our cardiac surgery colleague Kyle. Um Still trying to get on his good side. So you can let me go to his beach house in charleston. So hopefully after this case um Kyle maybe. Alright uh then we have our structural text specialist. We have hank and per request of everybody in the cath lab hank will remain muted for the entire duration of the case so everybody can relax. We have lori as well. Uh anesthesia. We have dr ju and then on structural imaging we have doctor Yanni method. Itis our greek freak R. M. V. P. For some of you that watch basketball and then nursing. We have amy on control. We have uh Jessica Jessica is our expert in all the updates on economy and the looming recession. So she'll take your questions afterwards and bailey is our expert in fast cars and fast driving. Uh So with that like to introduce our structural heart coordinator and a pp. The backbone of our program and really sets her and she will start by introducing the case if you can get the slides please. You can go next. Next. All right welcome everyone. So here we have a 61 year old for old lady with severe symptomatic aortic stenosis. Has a past medical history of diastolic heart failure. Concentric hypertrophic cardiomyopathy. Mechanical micro valve replacement which was a C. ST jude and 04 via port access pacemaker. I. C. D. Implanted. For primary prevention COPD and atrial fibrillation. She presented to us with new york heart association. Class three symptoms with decreased functional capacity. The initial T. T. Demonstrated mild L. V. O. T. And mid cavity gradient aortic stenosis and preserve E. F. We were unsure if that gradient was from L. V. O. T. Or aortic valve which T. E. Confirmed severe aortic stenosis with the mean gradient of 44 valve area of 440.7 with mild L. V. O. T. Gradient. She was deemed extreme surgical risks for our heart team here. Next slide please. Thank you Ansley. Uh That's her E. K. G. Um johnny told me what it shows but I forgot. Okay thank you. So we'll go to the next slide. Uh So we uh did a corny angiogram on her and her coronaries looked pretty good. Not much disease. You can see the the leads another atrium and a pacer. A defibrillator in the RV. And mechanical mitral valve can go next. So in terms of seti planning um we have an annual asse perimeter of 69.5. With an L. B. O. T. Perimeter of 66.4. So not a lot of difference between both our sinuses are measuring about 27 28 on average. I think the pertinent part here if you look at her S. T. J. Is heavily calcified with a minimum diameter of 18.6. Uh So the coronaries looked also pretty good with a height of about 15 for both the left and the right. Looking at this, she would be suitable for a 26 absolute um valve. I can tell you here that we when we looked at this case you know obviously we were going between Medtronic and SAPIEN and we just felt that her anatomy given the small S. T. J. She would have been a 23 SAPIEN with all that calcium that she would be better served with. A Medtronic valve. Here. Given concern about injury to the S. T. J. We can go next please. In terms of here you can see our co planer view and our implant review. Um We are using the cusp overlap for our medtronic valves. Like most most people these days. Uh the aortic root angle is somewhat favorable uh 50 degrees. You can see how the ventricle is very hypertrophy. It uh and the cavities is quite small and we can go next for access. She has really bad femoral access. Uh The right uh um basically are are gone and the left are heavily calcified including the common femoral, all the way to the internal iliac and common iliac and very small caliber. Are we gonna go next? Um The sorry the last picture. If you go back um On the right side of the screen you can actually see the analysis that we did for the left axillary which is typically our preferred approach just because of the um ergonomics of how developed will come similar to ephemeral approach but she unfortunately also had a calcified tight spot that you can see with a diameter of 3.8 x 4.4. So that left us with a subclavian or right axillary. Her uh sorry, that left us with the transkei ver trans cable or right axillary and trans cable. Just we felt was not favorable, especially that we won't have any bailout option with emeralds. So now we can go and act so the right Axler the right accessory looked favorable. The angle ation look good. Not much tortuous city and the diameters appeared favorable. We can go next. So our plan today is general anesthesia with tea guidance. We're gonna proceed with ultrasound guided per cutaneous, right axillary access, which we will do live. We will pre dilate with 18 True if we need to. Our plan is not to pre dilate, but we'll see how it goes. Uh As I mentioned, we're gonna use a 26 Evolution Pro plus. And if we need to we'll post dilate with a 21 millimeter true balloon. Uh In terms of our access points, we have a uh left seven french sheath slender sheets in the left radio. And that's for our guiding pigtail on the right radio. We have a seven french slender um that we will put a point oh 18 steel core wire. And then at the end for closure we're gonna use a seven oh balloon for dry closure. And our bailout's gonna be an eight. Self expanding covered stent. If we run into trouble with access we can go next. I'm gonna hand it over to uh fatty to talk more about the axillary Taverner and our plan and some overview. Thanks Ronnie by the way, me and Ronnie trained together at Emory. So it's really nice having me here. Thank you so much. So for the pros of axillary tavern, it's my second preferred access for alternative. It's one the diameter is usually favorable. Not a not a lot of calcification. It's ephemeral like technique. You can have early ambulance asian and actually technically it's not challenging. The only process of it is just a set up of the room and sometimes there is some report that you might have a higher risk of stroke during these cases. Next. So usually if you look at the axillary artery, you can divide it into three zones one is medial to the pectorals minus pectoral is minor, two is below it and three is letter to it. It's very important to understand the branches. So you have the lateral touristic sub scapular and anterior sir complex human and explain it to the next slide. Next. So usually where you want to puncture is lateral to the sub scapular and sir complex human and medial to the chromium. And if you look at it usually it's usually mid humerus head. So this is the spot. The sweet spot where you want to puncture where the regal plex is is not interior. You're not gonna have nerve injury, there's low risk of pneumothorax and you actually can compress here. So we're gonna show you our setup NGO and where we're planning to stick next. So I think we can proceed if we can look, just go to our setup ngos please. So Fadi and Ronnie um first of all fatty, it's great to see you. I know you got in at one a.m. Or something from Lebanon. So pretty impressive. But maybe just while you guys set up, let's take a couple of minutes with the panel um and then we'll we'll let you show us. Um So I want to first turn to Dan Winston, who's our sort of a cardiac surgeon. Both dan and Alan are part of the structural heart team and they really focused. So um I think is there any do you want to make any comments about this patient globally? And is there any opportunity for surgical intervention here? Do you think, I think I remember this lady, I saw this lady in the office with Ainsley and I think Ronnie we this lady was super high risk for any type of open procedures. Risk were prohibited. We would never have operated on this lady. Um The interesting thing is her despite it being a high risk which went along with everything else. She ended up being an alternative access which her iliac arteries were as you saw earlier on the ct scan were heavily calcified and diffuse the disease. We we obviously prefer to go um transform early on most of these patients because they just quick easy and uh in and out um this this this is a great approach. We do these often open and we often do per Catania slee. So this is an interesting case to watch per Catania slee and hopefully will go very well. Um just just maybe one other comment either from Benny or Mike in terms of alternative access um you know do you guys like trans cable or do you what what are your go to alter and you may be a little biased because you and Ronnie have worked together for many years. But yeah there's a couple of things I'll say a couple things that have changed since I've worked with Ronnie one is that he's gotten a lot funnier. So I wonder if George's son, I wonder if the George's son has helped them out. Maybe it's a lesson for me. Uh And listen we we will always welcome you here and uh you know when when we work together I would say that actually was our primary secondary access point um I have to say in the last six months we've really moved more to trans cable. Um when we can do it I find it's ergonomically much easier because it's ephemeral access and then secondly um I have to say that as nice as acts where it can be. I do worry about the stroke risk and I think there's now a growing body of data that the stroke risk is higher. Um I don't know if you showed us the left axillary here but in general we try to go left axillary as much as possible so that we can have a sentinel on the right side to at least protect the cerebral vasculature. Uh So I don't know if that was a consideration here and again I didn't see your imaging of the of the left side. Yeah I think the left axillary was super disease. So we decided to go write another consideration. You have to know the angle of the insertion into the aorta and the angle is around 30. So I think we were optimistic that we were able to align the valves well from the right because in general uh if it's more than 30 I prefer going left as well. Yeah I I completely agree with me. We uh left axillary is um definitely the better option if you're gonna go per cutaneous axillary. Unfortunately this lady had really bad left axillary approach with a lot of calcium. Um You know some of the aside from the stroke risk uh the other concern is just the way the valve is gonna sit. So we typically when we go right axillary we've we've done it through um um safety and just because it's a lot easier to align the valve or actually in the in the analyst. But here just looking at the anatomy and the factor S. T. J. Is super classified. And um we we felt that medtronic would be a better option just for the valve. Um So so those were some of the considerations that we had trans cable is definitely a good a good option a good approach. And um you know we've done quite a bit of trance cable in the past and you know trained in it at Emory as well. But for her it wasn't really a good option. And her bailout was was definitely not not great either. So so that's why we ended up left with the right actually approach. So um why don't we do this just in the interest of time? Why don't you guys get started with your access and show us what you're doing and maybe uh go ahead buddy. Yeah let's move to the ultrasound just to see if you can see it if you can see our because we're going to do with NGO ultrasound guidance puncture. So we have a 18 steel core wire that's gonna help us. And if you look at the angio here we have our branches that I was talking about. So we have the sub scapular and we have the lateral Jurassic and we wanna stick in between those and this is usually the ultrasound. The ultrasound. Can we split screen ultrasound and angio please? Perfect. So here you can see um the advantage with this lady is she's uh frail and thin. Um So you can actually see very well that the vein the vein as well as the guys. I think we've got the dynamics and the ultrasound. Yeah. That's it. Okay perfect. So here you can see you can see that actually the wire that we have in the artery. So you can see that uh decadence is basically the axillary. So actually you can even see the nerves if you keep on going medial you're gonna see the nerves on top. Okay so you see it so you want to go a bit more lateral here a bit more. Yeah and I think that's a good spot and you can see the wire in the middle and Ronnie is gonna stick hopefully in mid and I'm gonna be super shallow. Okay so you're going in the middle just at this point. Sometimes I guess the axillary artery can roll a little bit right? It does and that's why sometimes it's harder actually to close with the proglide. It's a different it's a different feeling and I think that was compressive also with the ultrasound and that's another point. Uh the axillary artery at this point is actually quite compressible. Alright so actually this is exactly where we want it to be. Alright. So I'm just going to show it on with laparoscopy. This is All right. So you're in between the two branches? Exactly. And this is usually safe if we have any issues here, we still have collaterals to the arm. And then the angle if you can see uh we wanted to be shallow. So it's typically a shallow about 25 Degree angle with our stick. Typose ephemeral we kind of go 45 or hope you she can just maybe hold pressure for me. So now we're gonna put a micro puncture. We're gonna put a six french sheet. Put two pro glides upsides to an eight and then we'll Alright so our micro puncture is in and if you guys maybe can move the I I just out of the way. So that way we can just have more space. So consideration for this case we have two issues here. We have a mechanical mitral valve. So we have to make sure we don't have any interaction when we deploy and the other consideration. She has a very hypertrophic LV. So we have to be careful of suicide ventricle. So the blood pressure drop out. We have to think about suicide ventricle so the anesthesia will give us fluid new so we can give the rest of the happens so we can give maybe give 3500 happen please. Any questions from the panel about this step here. Any comments I think mike you were going to make a comment earlier. It was more just in terms of alternative access. God, it's whatever the team is comfortable with and it's best not to do like four different access is just pick one, get good at it and it doesn't really matter that much. Benny. Now I just had a question and we're done with the ultrasound. Your secondary arterial access is right. Right, right. Radio, is that correct? Yeah. Right. Radio. Yeah, yeah. We have a seven French slender uh right radio so we can able to put a via bandstand if we need to take the six French is in and out. Thank you. What were your thoughts about? Just a question about the coverage tent issue? Maybe just talked through that and just for the whole audience. Why? So now, fortunately the via bonds have now come in smaller profiles for many of the smaller sizes and I think they were thinking six. You can get it through a seven french system in the earlier days, which wasn't that long ago, you often needed sheath sizes that may have been as big as eight or nine french. So that secondary access to the risk may have been difficult. So if you really didn't have thermal access, which is often what we try to do is we'll use femoral access for our secondary access. Um you'd have to go break, you'll so I I think think the the newer self expanding stent profiles have made this a lot safer. We also have balloon expandable options that can go through seven french system as well, including the the I cast stents, but we tend to use via bonds for these situations and uh it is nice that we can now get them through smaller sheets. Uh spencer, can I ask you a question for somebody who doesn't do this? So you're talking about having the ability. Should you get a big bleed for instance, from your from your large caliber entry site that you can put in a covered stent or something to to solve it. So you put that in through your through your wrist that you've got and you've got to have a big enough catheter to get the stent in. Okay. 777 French sheath in place. That's all you need. You don't really need a guiding catheter. So just a question from logistics of access type, how much advantage do you see two doing per Catania's uh if you do a cut down they can probably go home the next day and it's like a pacemaker pocket. Um Is do you feel there's a material advantage to a per cutaneous approach or is it just cool or is there a real material advantage? That that's a great question. Um And I think as dan said, as you know, we do do cut downs for these procedures. Um uh Ronnie or body, can you guys comment about Perky Tania's versus cut down for axillary cases. Yeah. I mean in my experience if you know if if the access is is favorable for per cutaneous. Um Really complications are quite low with the procedure if it's well planned and I do still think that the patients will will do better with per catania's in terms of length of stay and risk of wood infection. I mean I've had some patients that we've done cut down on that ended up really having some wound issues. Um So um you know I I do see the point. I mean I think axillary is uh cut down is definitely a good option. Um But in selected patients I think you know like this lady she's quite thin and you can actually see that her anatomy is very favorable. I do think that Catania's might have an advantage to individualize it. So right now you're you're putting the two per closes and are there any tips and tricks with the per closes and the axillary that may be different than ephemeral or you're getting the same kind of you know 10 o'clock and two o'clock here. Yeah. So we still do that. The tenant tenant, two o'clock the arteries the characteristics of the artery is a bit different. It's less muscular. So you have this uh the sensation of the proglide when you place it is different than when you go ephemeral. Um It's a bit rubbery but otherwise it's the same same approach. Sometimes I've been using one proglide and brazil both work fine. Okay, now we have our, our eight shift is in uh, I can probably say one thing um that we probably should have done. I've had this problem in the past um which probably just didn't pay too much attention to at this point. Usually when I put my per closes, I actually like to pull my 18 wire back before I deploy my per closes. Uh and the reason is that sometimes you can actually go underneath the wire and then when uh, you know, so the closest are actually on the wire and then when you end up doing our dry closure because we need to get that balloon through the radio, you could actually uh end up cutting your sutures. Just if, if, if you end up actually catching the, the wire with the clothes. So that's actually something that we should have paid attention to. Um So I typically pulled the 018 wire back but put the per closes and then we advance our 18 safety wire afterwards. I hope that makes sense. That doesn't listen. That was a great demonstration live of, you know, perk actually access. So Ronnie and fatty, Is it okay if we let you guys get to work and maybe pop over to the coronary room where name orgasms at falcon, Patel and Bill Nicholson are gonna do a case for us. Um, Absolutely. I mean, we're gonna move forward. we're gonna basically just cross the valve and get some aerodynamics and we will wait for you guys to come back to us to deplore the deployment. Let's go over to Ronnie and daddy's room and lab three and see how we're doing. Yeah, we're just going to deploy the stand in just a few moments. We'll save it. Okay. Alright. Thanks Ronnie and fatty because we want to try to see the wire, save that and you say that as a favorite and is the camera oriented the right way or should we do it the other way? Which one? You know, see how it's kind of like thin. Should we? Hey Ronnie and fatty, can you guys hear us in lap three? Alright. Yes, we can. Okay. So what have you guys been up to? All right, So let's uh you wanna just let's show them first and then we can actually start. So, so at this point we basically what we did is we um uh across the val and put a Safari extra stiff. So if you go, if you see our floral, you can see there's a wire in the ventricle. We were a bit concerned because her ventricles so small that she's gonna have a lot of activity and she's actually behaved well with this wire. So we have a stiff wire, we took our Eight French sheet and upsides that to a 14 French cook sheet that you can see in the axillary and at this point we're ready to go with the valve. We're gonna go in line so we're gonna remove this and go with our valve. We checked our valve um and it looked like it was voted properly and I just wanted to actually introduce and thank Gus and jenny from a tronic who are helping us um in the back. So we actually took a safari extra small because of the small ventricles. The question Gus, where do you want support? So not three o'clock. So typically when we go ephemeral we like the side fork to be at so you can come towards me so we're a bit more so come towards me so we're not coming at an angle so I just want to Okay. So that we could just show me that so fat if you can just bring the whole system that way. So. Yeah. Perfect. Alright. Alright. Floral. I have floral. You can see the nose of the valve coming through on the floor. You can pull your T. E. Pro back pressure is good and we're not gonna put our in line sheets too much. All right, so we're gonna stop here. All right, so now we'll just go to our co planner view. Let me just take the uh over there and I'm gonna advance the system a little bit and now we can go to our deployment angle which is let's zoom in on the valve, please Let's just go to maybe 10. Perfect. And then show us more of the ventricle. Alright, so it looks like we're coming central, which is good. I mean that's the tough part. Where are you know the the way the valve is gonna sit is a bit unpredictable here with the right axillary but it looks reasonable. So we're gonna advance, we have a pigtail in a non coronary cost, so I'm gonna advance here. Hopefully we're not gonna hit a lot of CJ calcium. I'm gonna rail you a bit. Okay, I think it's a good starting point. What do you think, fatty? Yeah, you have good control of it. I do. Maybe maybe advanced. Uh where is the line a bit? It's okay. What do you think? That's a bit So we have more control. Show me. Alright, alright. I would advance just a bit more the device. Alright, alright, perfect. So while you guys are doing this, maybe if either mike or any r him o dynamics are pretty good right now we're across the valve. We did not pre dilate. Yeah, we like to start deploying under control facing. So Jessica if we can go to 100 here, Maybe 110. Okay, zoom to eight please. So we're starting mid pigtail and usually we'll have the valve go ahead dive down and to the analyst and Ronnie is gonna control the position. We want to be one millimeter or two millimeters below the lowest point of the non coronary give us an injection there inject. Okay. Probably go a bit higher. I'm just gonna push the wire. Alright. Alright, perfect. So let's go 140 please on the pacer. All right, And go ahead. Just one injection, please. Yes. Perfect. Alright. I'm gonna push on the wire here. All right. I'm pulling back of it here, injection please. Alright, it's gonna be fine. Just push on the wire. I'm gonna advance of it here. I'm just gonna receive a bit here. You'll see there's some came a bit up so I'm gonna advance forward a bit. So don't play with your water. Too much fatty there. Alright, let's uh Yeah, let's open up an injection for us please. Yeah. Yeah. Go, keep coming injection, keep going. Let's unfolded guys. All right, stop placing here. Alright, let's Okay. We're going to actually go. Let's recapture. There's an insult. Yeah. The pressure is actually less unfolded. Yeah. So you see. Yeah, keep going, keep going, keep going, keep going, keep going, keep going, keep going. Let's give the patient a breather. Yeah. Alright. Let me pull back and then I'm gonna pull it back. Alright. And she's facing. Alright. So can you play the last image? I want to show something. Okay, pressure is fine. Okay. Did we floor save one of these images. So one of the concerns that maybe God did not agree it felt that the valve was unfolded when we open so it's better to receive and then you want to pre dilate or do you want to try to deploy a bit lower? I think we try to deploy a little bit better. So if you look at the loading of the valve, I think we were you can see that sort of line towards maybe the third um marker which you know in a 26 valve I think is probably um acceptable. Um We what we notice is you can see this kind of dark line that we saw on the side of the valve which made us think that it's unfolded. And then when we looked at the Chemo dynamics at 80% expansion, the blood blood pressure was not was not good. Right? We should have normal blood pressure at that point. So that makes us uh more convinced that it was unfolded and that's why the valve was not functioning normally. So I think what we'll do um is try to um do another deployment. Maybe we'll try to be a bit more deeper I think maybe part of the problem that we're so shallow Which is our plan because we we wanted to land very shallow on the non to avoid any interaction with the mitral. So we'll give it one more try we still have the same problem then we'll have to actually relate or change the valve completely go the wire. Okay? So let me find you maybe do adjustments without the wire. Let me just do it with. Okay. Alright, so let's space at 100 here. Yes, gus can I ask a V team to remove the time from this monitor because it's in a there. Thank you so much. All right, so we're ready to go. So let's face that 100. You want to dance a bit more. Alright, go ahead, fatty. Alright. You are just running. All right, give me an injection. All right, Okay, perfect. So let's go um 160 here. Okay. They're you know, they're pacing to really essentially stop the heart so that they can accurately going all the way. Go, go, go, go fast, fast, fast, fast, fast, fast. The ultimate 80. Alright. And now stop pacing. Come come a bit more to us so mike and Vinny any comments while they're working? Yeah, it um it appears to me we still have the unfolding. I have to rotate the gantry to see. Can you describe This is where you see where the tail is. There's a line that gives the impression that the valve is not fully open, it's actually unfolded and usually an N fold can be solved two ways. Either you remove the valve for another one or with the post dilation. But if you want to post dilate and unfold, you have to make sure your not too shallow with your deployment. So you don't am belies the valve. Yeah. So, I think at this point if you look, our thermodynamics are good. Right? So this is really the key point. So we have time to think is the patient is stable, aerodynamically stable. So we can maybe assess the valve here with um an angio and the T. IV. So in fact if you can just put us in a good L. A. Angle that we are, we don't have any no parallax parallax. So this basically the elio angle, we ignore the non coronary cusp here. We basically focus on the left coronary cost uh to allow us to understand what our depth is on the left. We expect to be deep on the left just because of the way the orientation is from the from the right axillary. And if you can notice here we're hugging the inner curvature right? So you can see our catheter is in the inner curvature. Typically we like to be midline or outer curvature. What that means is we want to be as shallow on the none. And that's what we expected. A shallow on a non as possible. And that way when we release the valve will tilt towards the outer curvature. And then with that movement uh the expectation is the left cusp uh end of the valve is actually gonna come up because it's gonna tilt that way and then none will come down. So that's typically how we deploy it when when we're hugging the inner curvature. So that's why we really wanted to be as high as possible on the nun to allow us to do that. Maybe we can take uh how much do we have on contrast there? Now we got a okay, let's take a 15 1. Now we just show show 15 15 will show the nun. We'll show you how the left looks like the nun here. We don't really again care about how the non looks. Uh the nun is going to be based on our picture in the customer overlap. We'll just give you a picture here and see how we look on the left and then we'll have the greek freak, show us uh D. T. Images. And if he likes it or not, any comments from the panel, just can I ask our structural, it looks like it's just a little more about the non coronary and maybe expand a little bit on that. So everyone's on the same page. I mean the important thing here is to focus on whether it looks like it opened up, but you have to spend the gantry around and see it in the 480 degrees play. Yeah, you can get fooled. And certainly at this point before you release that, you do want to rotate the gantry and see everything because if that's a live shot, it looks like it's still unfolded there by the pigtails, back to your other comment um uh about the non coronary cusp. So when we're doing self expanding valves and we're thinking about this whole cusp overlap concept, we typically put the pigtail catheter in the non coronary cusp. With the idea of deploying our valve in relation to that customers want to be as high as possible there because just underneath the non coronary cusp is where the conduction system really lies. So if you can be as high as possible in relationship to the non coronary cusp, you're less likely to have interaction with interaction with the conduction system and hopefully reduce your likelihood of pacemaker. Um It does look like they're the that it's still unfolded. Right. Do you agree? Mike can you guys described to us when you say it's unfolded? What aspect of that is showing the unfolding? I think it's over. It looks like it's pleaded and pleaded. Yeah. And and again that can be resolved by post dilation or by more aggressively. I guess the concept here is that the native leaflet or a native analyst isn't allowing the valve. So it's kind of under expansion but it's controlled under expansion. And I know there was some discussion earlier about whether it's the pre dilate the valve to begin with or whether at some point you go with it and then you just focus on post delimitation. Yeah, I think in this case every balloon dilatation. You think about, you have to think about carefully only because I think they said at the beginning of the case there, you can see this S. T. J. Was circumstantially calcified. And I think they said it was around 18 millimeters. So there is a risk for S. T. J. Injury with every balloon dilatation. So I'm sure that's what they're thinking about here. But certainly if the valve is not functioning right with unfolding then I think you have to think about post dilating carefully. So this is the S. T. J. Is a signer to tubular junction and there's concern that post dilating that could injure that. Exactly. I think I would have chosen a self expanding valve for that very same reason here too because if you put in a 23 millimeter balloon expandable valve which has a 23 millimeter balloon in a sign a tubular junction that is circumstantially calcified at 18 millimeters. You worry that that would either cause the valve to m belies into the ventricle or worse you actually rupture the S. D. J. In which case you have a problem. Yeah I know I could we completely agree with you Vinnie. Um You know obviously that was the main reason. We also did not want to go with the balloon expandable platform. Her S. T. J. You know we got it measured different different measurements. We got you know somewhere maybe I would say everybody agrees about 2020 21 2021. We got generous, yeah if you wanna if we tried to kind of look from calcium to calcium. The narrowest spot. We got about 18. uh we completely agree with you. We think the valve is unfolded we'll give you a shot now in the non coronary cusp. Um view the customer overlap. You know the the question here is you know our options are basically two options. We either say you know this is unfolded, we don't want to deal with it and then we'll just take the whole valve out and then just get a new valve. Um And uh and then just you know that that would be basically the solution um which I would say would be definitely my way to go if we have bad Hema dynamics once the valve is at 80% right? So often if the unfold is really terrible which you know had at least one case like that. You see a lot of ai on tv you see the pressure is not good and in those situations it's not worth it. So we just take the valve out and then just get a new valve in this situation. I'm just wondering and I definitely we value your input on this. We have good Hema dynamics. The patient is stable and then I'm gonna have Yani actually just go over the T. E. Uh and show us how the valve looks in terms of depth depth and um P. VL I think if the depth looks okay and the P. V. L. Is not significant. Um we might just decide to go ahead and take this one understanding that we do have an unfold. Um and I try to post dilate it um instead of pulling up. So I think that would be sort of my thought process and fatty's thought process. I don't know Ronnie, let's you guys let's start interrupt. Let's go ahead and see that maybe Yanni can make some comments on the T. E. Because we probably need to go to the other room bot of you. Do you can you hear you can you can you please describe to us what you see? And so the valve is actually um based on the images. The depth of the valve is uh is adequate, it's not too deep. I don't see any interference with the mitral valve. Um It's slightly under expanded and there is mild para popular league, can you show us color through the, can you show us the Tv L. Yani just to see where where it's coming from and you may see PBL right there at the bottom, are you able to get us maybe a gastric trans gastric or maybe a three uh short access and you can appreciate you can put the arrow, please appreciate that there's a mild PPL which is fine. This is not the fully deployed that's para valvular leak. Right? And it's right there and then it's really not that bad. And then if you can just show us a quick short access and trans gastric and then we'll make a decision please. It's interesting because if if the valves under expanded and you have a valve your league, that's just gonna want you to dilate that. I mean that wouldn't that solve both problems assuming it gives or yields? One would hope again, I think you just have to be careful about the size of balloon that you choose here because of the S. T. J. Issues. But you know also this is a super high risk patient. I don't know what the human dynamics were, what you got before in terms of the gradient was it, was it really high mean of 50? And presumably now it's it's pretty small. So I'm also a proponent of perfection being the enemy of good enough in a very complex patient like this. And uh and I think at least based on what I've seen right now, if the gradients are okay, I probably get out of dodge now. If you have a high gradient, you might need to think about doing something here. Yeah, completely. Yeah, I think we have enough depth to release this if we want to post dilate. So guys, why don't we um Ronnie and fatty, if you don't mind. Um I know we're in a critical part here but with that discussion, let's go ahead to lab five and then we'll come back to you to see what you did. Yes, we're going to record the deployment for you and then you can just take maybe a picture here to show our depth on the none in this OK, Neema and Calgon and Bill. We're back to you in lab five um and we are running a little behind um so Ronnie and fatty. Yeah, I'm letting you call it. Okay, pull it out. Hey, hey, maybe just about two or three minutes and if we don't get completely done, you can give us the feedback after words. But actually, yeah, actually deployed the valve is gonna show you do you want to play the fantastic Yeah. So we deployed the valve here. Um can you hold on here. Yeah. So this was a really interesting why is this stuck here? I think we're good here. I'm just gonna pull you wanna pull it? Sorry? All right. Just we're gonna do it. So Ronnie can play, just go to the release of the valve. So we promised that we were gonna keep the flesh. Yeah, Yes. So go there. So basically this is our release here. So what we did is we basically um paste at 1 60 we went super slow and you can see here that we release the valve and the valve was really remained stable. Uh So the key issue here is because of that unfolding and the annual ation. We can go next to hank uh the key is really to make sure because we don't even have enough space because we become an axillary is if you actually see that nose cone, we want to make sure that nose cone does not interact with the base of the valve because that basically would would symbolize the valve. And given the fact that we have some unfolding and it's a bit narrowed at least that's what we think. We just wanted to be extra cautious. So here what we're doing is we're manipulating the wire. Maybe push and pull, try to make sure that we centralize that nose cone that you see in the L. V. O. T. To go next here again. See that. So we're pulling, pushing the wire, pulling the wire, making sure that we're not caught. So we took really our time, we took a lot of time. This is very important. It's probably the most important step of this whole procedure and then we're able to go inside the valve and go next. The next step here is the recapture again, we do not have a lot of space. Typical recapture we do in the descending uh here what we actually did is we just recaptured develop the same way by turning the knob instead of connecting them. And we took our time. I'm pushing on the wire here and that he was actually turning the wheel and now we make sure that we clear the valve. So now the valve is deployed. We pulled the system out and put a 14 French back in in case we need to post dilate and then you can you just show us the images now and just tell us what you, I have one preloaded over there. If you want to just go ahead and just describe it to the uh so the valve is basically well expanded. The position is good. I don't see any interference with the Mitel valve. And uh the mean gradient is three. There is trace for a bubble organization and the left ventricle is happy so far. Sorry, what was the gradient? three of Mercury. Yeah. And really trace P VL So maybe we can take and maybe you can just do us like go from zero to R E O. So we'll just look at the valve on floral guys. So we'll just kind of sometimes when you go oreo you'll see if there's any constraints and you'll appreciate it. So we're just gonna go R E O to L A. Oh here, you can see there's some constraints and maybe there's some under expansion on the non here that we're that we saw that line of potential unfolding there so you can see there's some under expansion at the base of the valve which we expected. Um but I think we should be fine. There's no leaflet there. Um I think we should take him a dynamic gradient other than the echo taken angiogram but from a PPL standpoint and from the height we're perfect. What do you what do you guys think? Yeah, no, I I mean let me turn to Benny and mike. I mean to me, given that this patient is on dialysis is on homo too And you've dropped the gradient from almost 40 for 50 down to three, you don't have parabolic a leak. And really it was a very small ventricle with, you know, a concern for suicide ventricle in this case. So, any closing comments, let's take about two minutes to close out. We're a good bit behind. I mean, I would just say this is a wonderful case, a fantastic result in a very complex patient. And I think it just shows you that even though Tavern has become almost routine and you just think you're gonna get great results every time, attention to detail really matters. Every case is a little bit different. And and they think illustrated very nicely how you have to really match technology to patients anatomy and really think through every little detail and when you do that, you get great results, but but it is not routine. Fantastic. Well, listen, let's give a hand for Lab three and the team. That was fantastic results. Um and and I do apologize that we're running a little behind but that was definitely worth it. And I want to congratulate um both labs and staff and team for pulling that off
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