Chapters Transcript Video Aortic Stenosis: Diagnosis and Management Talreja discusses the diagnosis and management of aortic stenosis including physician exam and treatment plan. Thank you all for coming and joining again. Bright and early on a Tuesday morning, I would give, uh, Matt and Clint a, a huge amount of credit for putting together this series. You know, we do this day in and day out, but sometimes we don't have the time in the course of a busy day to, uh, to talk about what's going on, how we do this and so forth. So, uh, Amy's recording all this stuff. So it'll be alive for future generations to sort of see as we keep redoing them. What she's asked me is let's hold questions until the end because it's harder for her to, uh, edit and so forth if there's questions, but keep them in mind and write them down if you can. Because Clinton and I, and the rest of the folks online I wanna answer. I see, uh, Dave on and I think Matt's coming on too. So, again, thanks for all the hard work. You guys do. I thought last week's session was absolutely tremendous as, as we talk through this, you know, i it's, it's hard to believe. I'm one of the older guys now. Uh, it's funny. I think back when I came out of training TVER didn't exist. We did some ball and valvuloplasty and that was it. And when I first came, we did some septations, some PF OS. And then in 2011, we did our first case as part of the partner trials, which is now what sort of set this on track. And it was a time of uncertainty. We did, our first case was a cut down, everything was cut down. Vascular surgery was in the room, cardiac surgery. We were in the room. There were usually 42 cardiac surgeons, two interventionists scrubbed in the first dozen cases or so. We did trans aquis that were brutal and bloody. Uh Even the femoral cut downs were really big affairs back in those days, we got from where we did one a day in that first year to where we could do two in a day and that was considered major success. No one would have imagined we'd end up where we are now with these refined 4th and 5th generation platforms, multiple valves on the market, percutaneous approaches with, you know, cases running sometimes less than an hour and testament to all the work you guys put in. There's a lot of people in the room, as we said last time. So today, we're stepping back to some of the basics and a lot of this is stuff. Um You guys know, but if you look at aortic valve stenosis, the majority of it is degenerative calcified valve disease. In older patients, it results from lipid accumulation, inflammation, calcification that stiffens the valve leaflets. And that really is the vast majority of cases, especially in older patients. If you show us a 70 80 90 100 year old, it's almost always going to be degenerative calcific disease. More rarely we see rheumatic heart disease and usually there are other valves involved. The valve order is mitral aortic tricuspid ma T is the order of frequency. They usually have multiple valves involved. They often had an untreated strep infection as a child. Many don't remember having had that but the leaflets fuse, it's a slightly different kind of disease. But younger patients, that's what we see more often. And then a very small minority of cases are congenital where they have bic cuspid more commonly or even unic cuspid. There's one leaflet valve disease always a little bit more complicated. Those are ones that we later got experience with Tavira and still surgery remains probably in, in many of them. The first approach because of uh other disease like aortic root disease. Too many laptops up here. Uh So, aortic valve disease, we said there's calcification, fusion of commissures on the right is a BSD valve. It really has two leaflets and BSD valve disease is a spectrum. Sometimes it really is two leaflets that are equal size. A lot of times there is a fusion of one of the commissures so that you have asymmetric leaflet adjustment. And the other thing to remember is you have the coronary arteries coming off right in this region. When I think of the valves, we treat the mitral and tricuspid valves are much more complicated than the aortic and pulmonic valves because they have all these muscular attachments and otter shapes. The aortic valve is an easier valve to treat because it's in a big tube, the aorta and it, it has a structure that doesn't have any muscular attachments. But the one thing that makes the aortic valve complex is the coronary artery osteo because we have to think about are we going to impinge on those with any form of valve we put in when we look and decide if we need to treat aortic stenosis in a patient between echo ct catheterization and other imaging modalities. We look very, very specifically for hemodynamic consequences. This is a hemodynamic disease. There's a problem with flow out of the valve and these are some of the parameters we look at on the left is the valve area and less than one centimeter squared is severe aortic stenosis on echo. We look at the peak velocity of blood flow through the valve that should be less than two 0.5 if it's greater than 4 m per second, just like a water hose that's narrowed. That means there's a difficult pathway for the blood to get through. And so it's flowing harder and then mean gradient, mean gradient greater than 40. Again, this is something we do very careful of analysis of before the patient gets the ors and the calf labs. But these are the traditional criteria we use. And there are some patients, for example, if a patient has a low ef they're not going to generate as much pressure across the valve. So there are exceptions. But this is the general pattern we look at and Matt showed this slide. Matt and Clint showed this slide last week. It's one it bears repeating again. Aortic stenosis is an interesting disease process because for a lot of the latent period, even with significant aortic stenosis, a patient really isn't symptomatic and their survival is quite good. But as soon as they start getting one of the real symptoms, we look for angina syncope or heart failure. And the worst of those is heart failure. Then they have a steep drop off in survival. And this is one of the biggest struggles we have in clinic is you'll often ask an older patient, you know, a 90 year old, 80 year old. Um are you s are you having shortness of breath? Do you have trouble doing the things you used to do? And a lot of times they say nope, I don't have any shortness of breath, but you have to really dig in and figure out is that because they're not symptomatic or is it because they're really not doing anything anymore. A lot of people stop doing activities, figuring I'm getting older and I'm slowing down a little bit. And what they don't realize is their A S has become very symptomatic. So it's always worth repeating. Once they get symptomatic, we really have to get moving. I want to include just a couple of slides in the, uh, we're talking about the basics in the, um, offices. When we see these patients, we take careful listen to their heart. We're listening for a murmur, aortic stenosis has a very typical murmur. Uh It's a diamond shaped murmur. I'll show it to you. It tends to be loud and the later it hits its peak, the more severe the aortic stenosis. So in, in, in our current generations, we're so we're so used to using echoes and other tests to assess this that we probably aren't as good as the generation before us at physical exam. But in the old days, they used to really pick this all up by exam. The pulses tend to be diminished. They occur later and slower than you would see in a normal uh patient. And the reason is because of what we see in the Cath App, which is you have this gradient between the red and the blue curves. We look for that. We use our C systems to delineate. How much is that gradient? And that murmur is that diamond shaped yellow uh space on the bottom. It's a crescendo, decrescendo, it gets louder and then softer. And the later this peak is the more severe the aortic valve stenosis clint, anything to add to any of this. No, that, that certainly is, is everything about pathophysiology. It is interesting. By the time they come to our clinic they've had echo, they've had Cath, they've had direct measurements. So, you're right. We've kind of lost the art of physical exam, but it's not necessarily a bad thing because for every patient who, whose valve is totally fine, about half of them will say I've been told I have a murmur. So, just because you have a murmur doesn't mean you have a valvular pathology. That being said, some of the older cardiologists who have now since retired are very good at picking up these things without echo or Cath. So true. Yeah. The other thing I, I will just add is, you know, a lot of patients come to the clinic and they, they know they have something wrong with their heart, but they don't know exactly what it is. The analogy I always give them is taking it, I guess one step further than yours. It's like putting your thumb on a garden hose. You tell that to anybody and they can understand it and that's essentially what the heart is feeling just like when you put that thumb on the garden hose, you feel that pressure, that's what their heart is feeling, doing a ta or, or doing a surgical aortic valve replacement is the equivalent of taking the thumb off the garden hose. And now all of a sudden the water or in this case, blood can go where it needs to go. So, just, just, just remember that's exactly what's going on with the heart. I love that. And the other analogy I give them is if you measure your blood pressure and it's like 1 20/60 or something like that, let's say, when you have severe aortic stenosis and you have a gradient of 40 millimeters of mercury to get that blood pressure of 120 in your arm. Inside the heart, you're at rest at 120 plus another 40 or 50 or 60 or whatever we see. So inside the heart, they're continually having a blood pressure of 1 61 71 80 just to drive that blood pressure. And that's why they tend to feel so much better afterwards. One of the decisions you see us make is, are we doing if there's a blockage? Let's say there's a mid L ad lesion. Do we fix it first? Do we fix it later? Do we medically manage it a lot of times once you relieve the afterload, once you relieve that X ray aortic stenosis, a stenosis that was causing some angina earlier won't cause as much because you've relieved the work on the heart. And so that's always a sort of collaborative discussion as to, when do we fix it? Do we fix it? Do we use medicines or not? Do we do surgical revascularization? And to that point you think about it, this is the discussion every Monday morning and you guys are welcome to join in any time every Monday morning. We go through somewhere between 10 and 25 patients who are on the waiting list for a surgical A VR or TVER or medical therapy. If we don't think those are appropriate, they've been fully worked up. We've done cat scans, echoes physical exams. They've seen a cardiac surgeon, they've seen a cardiologist and their primary care teams and we go through the patients. Our A PP team does an amazing job putting together a powerpoint that has all the relevant data captured and we figure out together of this spectrum. What's the right thing for this patient? You yy, you know, in the Cath lab, you don't often get to see the, the ones that go different directions. But we have surgical aortic valve replacement plus or minus a retinue of other surgical procedures like bypass other valve interventions, root enlargement that we consider for these patients. We consider tver transcatheter aortic valve replacement, which is what we see in the hybrid. And again, that's after a lot of selection and careful decision making. And so what's right for that patient? Some patients we say, you know what they're so sick or we're not sure the A S is really causing their shortness of breath. They also have severe emphysema or something else. And so in those patients, we'll often do valvuloplasty. A valvuloplasty is not as good as replacing the valve, but we stretch the valve with a balloon tends to last something like six months. And if we can get a 25% reduction in the gradient, that's enough to maybe see, is it going to make a difference for the patient or can we get them through a surgery or get them to the next step? And then for some patients, we think about medical therapy or palliative therapy, I would say on, on, on the physician side, that's one of the hardest decisions for us to make because you hate to, um, not give anyone a chance. I'll mention there was a patient at beach I saw yesterday who we've kind of been watching back and forth. He has a lot of COPD. We did a balloon, he kind of felt better for three weeks but not really consistently. He's got a lot of, uh, worsening cognitive decline and so forth and we made the decision with family yesterday just to hold off and not do anything further. Those are tough because, you know, when you have a tool to make someone better, you, you really want to use it judiciously, but at the same time, try to offer it as much as you can. Well, I was gonna say it's, it's also sort of a blessing and a curse that we have everything available here. You know, you all are at a center where we can do anything from complex tavern to complex surgery to hybrid procedures in between, which is great for the patients, but sometimes it is difficult to figure out what's the best for them. Um, but we'll say one other thing we use the, the bav for is somebody who's got a myriad of issues with their heart. We think it's the A S is the most important doing a bav, see him back in clinic. They'll tell you one or two things. I felt so much better after that or, you know what, it really didn't make that much of a difference. And that certainly makes us feel better if they have a lot of things going on with their heart that if they felt better with a bav, that they're going to do better and feel better with a tab or, or a staber as well. That's a great point. All right. So a lot of different options. And then I thought the last two slides I wanted to show you. Oh, wait, three slides. So, um one thing I'm proud of our center for is you look at right now in the US, there are three commercially available Tari systems. They're the balloon expandable SAPIEN valves. We're in the third and we're in, we just finished trials for the fourth generation. So we use the S3 and a second version of that, which has a special coating on the valve, that's the Edwards valve. Um and we were in the trial, the P four partner four S four trial, that'll be the next valve coming out in that line. And then we have two self expanding valves, the Metronic core valve series um that we're currently in the fourth generation of that, we participated in every single generation and for both of these platforms and for the third platform, you know, our center participated in the pivotal trials from the very beginning in 2011 to the current time that have made these valves possible, that have tested a shared experience. And you guys have seen folks visiting from all across the US and all across the world coming in this very space and learning from us how to do this. It's super exciting. But so the self expanding valves, there's the Metronic core valve and then the Navato valve by Abbott. Originally, it was Saint Jude when we first started the trials and back then it was called the Portico valve. So those are the three commercially approved valves and then there are a number of other valves that were in trials on. For example, I think Matt alluded to the Jena valve for tic insufficiency, Clint Matta. That trial, we're in the um in a trial with Boston on a valve mentioned down here below as well. That's the accurate neo and there are other valves we've tried over the years that didn't make it to prime time. And right now it's really hard to come up with a new valve. If anyone had a great idea for a valve and wanted to market it, there's such good options on the market, it's really hard to get to that stage. But the current generation of Edwards is the S3 valve, the ultra, which has a coating called the Rosillo coating. That's a Cobalt chromium stamp frame with melted tissue inside it. As you see here delivered by typically 14 or 16 French expandable sheath. You know, a lot of this, I'm just calling out some of some of what we have evolved to now. And it's amazing. You talk about 14 and 16 French sheaths. The first tower we did in 2011 was a 28 French sheath. In fact, I I will always remember the fifth patient was a nice lady I'd known for a long time and uh each, each of us in the room took a pull at the sheath which was stuck at one point and we had vascular in the room because we knew it was high risk. And sometimes these are the decisions we have to make. We know we've got a really sick patient. We know they have no other options. We know there's kind of only one direction and that's either palliative care or going forward. And so we, we have to make that decision. And a lot of times we know as we're going in that a patient's high risk, that patient to that point, uh we each took a turn and then it was my turn again at the, and that was my patient. So I guess I was at the front and so everyone's advice was pull harder and when I pulled harder, it did come out, but it pulled the entire iliac with it off of the aorta. And Vaser was for in the room, we were anticipating that. So we cut down. Um, she got through it and, and uh lived for, I think another year after that. But um we call that iliac on a stick and we have a fire drill on vascular emergencies in a couple of weeks. Um One other thing I'll add to this too is you may ask yourself when we do some of these cases, why do we have so many people in the room? Right. I don't mean interventional cardiologist, Cath lab surgeon. I mean, why are there so many people from industry? So many people from research? The reason why is in order to get these valves approved, we have to take very careful measurement. And you may notice behind the control desk, we're taking lots of pressures and lots of things that we don't normally do. The reason why is to be able to get good data, to be able to see whether these valves work, whether they don't the flip side of that is although it may be busy, there's extra people in the room. We at this center then get access to all of the valve platforms. We we get not only the ones in research, but when they are finally approved, we were one of the first centers in America to get the latest version of the evolut FX plus um which is a whole lot better than the one before. So these are some of the things that although it may be a little bit more difficult for those cases, give us access, give your parents access if they need it, give a friend, give everybody in the community. And so I really appreciate you guys being willing to have that many people in the room to go through it, to do the extra steps to take a little bit longer so that we can have access to these platforms for our patients. And so to Clint's Point, the, the eu we have that FX platform, this is a Porcine valve inside a night off frame that expands in place. Navato is also uh now it's Bovine, but it's inside a night no frame and expands into place and then accurate Neo two. We were in the trial that's closed. Now, we'll see what evolves from there. If the data looks good, that's one that may be added to the spectrum as well. And we also mentioned uh Geno valve. So we've got a number of different valve technologies. And I thought it worth seeing because not everyone, some of you have done this day in day out. Some of you really haven't been a part of getting to see some of what we do. So I thought I'd show these two quick videos just showing the sequence and we'll talk through it as we go and then we'll open the floor to any questions, comments or thoughts, but reiterating what, what Clint said, you know, again, thank you to you guys for being willing, being patient as we do all this stuff. We have incredible support. Vascular surgery has done a great job supporting us in those cases. We see them in the room a lot of time for those of you that sit in the room. But a lot of their work actually is beforehand. This Monday, we had two cases where we were debating between peripheral access, carotid access. Um You know, in the scope of my career when we first started, we had two access points, femoral or trans, uh trans, uh apical. I forget it because we don't even use it anymore. It's been decades since we did it. The last couple of those we did were, were really brutal and had limited uh good outcomes. Then we moved, we did direct Aortic. We've done trans cable, we've done Trans Kate Trans, we've tried almost every different access out there. And you've seen those of you that have been around for a while in evolution. As we've gone forward, we tend to try to stick to the things that are safest. And in my career, it's been neat to see us move from trans April to direct aortic, which was still kind of a cut down to trans, uh trans um uh where we're going from the aorta into the aorta from the Venus system, uh trans cava, we call that it's from the Vena cava system to the AORTA and that worked well for us, but that's pretty dangerous when you think about sticking into the side of the aorta at the level of the abdomen. Now to where we've, we've gotten carotid access and I give the surgeons huge credit for making that look incredibly easy and appealing. Now there are times. So we looked at one case yesterday and I was saying, gosh, there's so much metal in the aorta we could probably get through there, but it might just be simple to have a cut down into the, into the neck and there's stuff that seems crazy at first like trans cable and trans cared to me for a while. But once you do it, you, you see how slick it is and how much we can do. So let's let's look at these two quick videos. These are produced by the companies. This is the SAPIEN Three Valve and this is by Edwards. I'm gonna mute this. So uh it doesn't talk and we can hear only us. So this is the trans thermal procedure. They have animations for all the different versions. But you think about how we do standard access and ultimately get in our sheath. And then this system is designed to make it smaller and smaller by separating the balloon, which is on the top from the valve stent frame, which is on the bottom. So we actually pull the balloon back into the stamp frame And that lets us make the sheath a little smaller. And once it's perfectly aligned, then we can put rotation on the catheter which allows it to swing one way or the other. And then we go over our stiff wire and across and position ourselves within the aortic valve. So we've got left ventricle aortic valve aorta and we bring the catheter around on our wires. We're careful as we navigate around. And one of the things I'll just quickly mention is in the talks to come, there'll be talks on valve selection on alternate access and all these things to come. We're alluding a lot of what's to come later, but we position ourselves and this has a tremendous amount of flexibility to this system it can deliver and we can position it and move it around until we're perfectly aligned. And again, great collaboration with industry. Industry colleagues are often in the room with us and helping sort of think about think through decisions, we can get it to the exact right level. And then with each generation, there's markers we use here, you see, we use that fat marker sort of at the bottom and then we expand it into place with rapid pacing, rapid pacing was a brilliant idea to effectively achieve what the surgeons do with bypass in the or with, uh you know, getting us stability where it's not moving. And then we remove the system and typically perclose or Manta or Angio steel on our way out. And that's the way the safety and system, it's a balloon expandable system. Um, it's one shot. You get it in place. Um, the valve four shortens as you saw and that's what we look for there. Anything to add. Yeah, I know we're going to talk about it in another session, but it probably seems like some days it's a flip of a coin, whether we're using a SAPIEN or an avatar or an evolut or some days, it may be all volutes or all Sapiens. But to reiterate Deepak's point though, the amount of work that goes into planning and picking the exact valve. That's right for the patient is a lot. Um, the majority of it's done by our A PP as I see Marianna out there and Joe, um, and Sarah and Mindy and Danielle as well. And then there's a lot of thought, um, amongst the cardiologists and the surgeons as to which valve is gonna be best for the patient. Sometimes there are ones that are better. Sometimes it truly is, you know, either could be used, but there is a lot of thought that goes into it. So that's why we pick the valves we do and you bring up an important point that, uh, that I was gonna make later, but we'll make it. Now. Uh, our A PTP team is really amazing. You wouldn't, you, you, you don't get to see the behind the scenes work that gets into getting these patients ready and you guys do see that a lot of times they'll be pulling up power points and things like that. A lot of centers uh you know, rely on industry to supply us with all the pre op assessments here. It's, it's our team that really does a great job. And traditionally, we've not had our own advanced images. You know, we've relied on imaging from our A PP team only now, we're going to have advanced images as well that will work with our teams as well. But really it kudos to the A PP team and to all our teams. Frankly, I can't call out enough of the credit that goes to everyone. All right. Now, let's look at how the Metronic evolut valve and Navato is a lot like this. So I figured I'd just show this one video to capture how both of these work. The difference is, it doesn't require as much pacing. It's a self expanding platform, it's a taller frame, you know. And so there's pros and cons as Clint said to everything and we'll leave a long discussion on that to later here you see from above the valve, the two coronary ostia, and you see this valve aging in front of you as it becomes sort of calcific and denote, you see the beating heart. And this emphasizes that we have multiple access points, direct aortic secan carotid and femoral here, we're advancing the system transfemoral here. This is designed again to sweep around and we position it. Some differences are, this is expands into position and it's recapture for a lot of its length. So we can get it into the right spot deployed if we don't like it, uh recapture if we haven't deployed fully and then we can get it into that spot where it's expanded fully and now it's no longer recapturing at this stage, it's been released in the system. Um And we can, we can sort of analyze the human dynamics oftentimes, even before we release it, we can take pictures of the corna and make sure we're not obstructing them. Um The latest generation as Doctor Kemp alluded to has larger openings. So it's easier to get in from a calf. And that's kind of the system of the evolut. We'll go into this more. But for a basic approach today, we wanted to show you what is a s how do we diagnose it, what's taking, you know, what takes place in the work up and you've seen before, the uh powerpoints we generate that have all the testing CTS echoes catheterizations and then preoperative assessment. And you've seen now the two valve deployments, both the Edward SAPIEN valve Metronic core valve, which is very much like the Navato Valve. And many of you have seen this live. But I think the animations uh add something because in, in the cath up, you can't see the structures around it. You can only see the metallic frames. And when we give to, we'd love to open up and, and I see uh David and I think Matt and Danielle and Sarah and others on the phone and Amy. So if anyone wants to add stuff again, one thing to me, if I, if I had one comment, I'd end my comments with this. This approach is amazing to see what what's happened in the last almost 15 years now, between administrative teams, between our valve coordinators, between Amy and the office upstairs, the surgical teams, the S CS teams between the Cath lab teams, the or teams and all those I haven't mentioned. This really is a team sport and thank you, we know this is hard work. We know, you know, a lot of times we're getting stuck late in cases, we're moving fast to get cases on and so forth. Um One of the challenges of having the best center in the region is all every other center sends folks to us and so we get the toughest cases for better or for worse and the volume of this and all of cardiology right now is just through the roof. Published September 6, 2024 Created by Related Presenters Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile
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