In this case discussion, Dr. Summers and Dr. Cohen walk through a series of tricuspid valve repair and replacement cases that highlight how procedural success depends on imaging precision, anatomy recognition, fluoroscopy correlation, and real-time teamwork between the imager and interventionalist.
We actually have a beautiful result, you know, from this case where there was a lot of lead movement. There was at least some contribution from the leads, um, and, and we got her down to, you know, trivial, uh, tricuspid regurgitation. Hey, this is Matt Summers with Murmur MD and uh I'm privileged to be joined by my partner and colleague, Doctor Josh Cohen. Uh, Doctor Josh Cohen is uh our uh structural heart imaging director. I'm an advanced imager that trained at, at Cleveland Clinic and joined our practice in September of 2024. Um, he and I do the vast majority of, of complex AV valve disease, uh, treatments here at Uh, Centera and, and have built, um, from a tricuspid space quite a bit of, uh, experience with complex cases and common cases. And in this platform, um, the, the, uh, previous, uh, sort of focus or emphasis has been on aortic valve disease from a structural heart standpoint. Um, but one thing that we're, we're increasingly having more and more discussions about and decision points. Um, and, um, collaborative discussions about is, is the complexity of tricuspid valve, which, uh, in TR in particular, which we now have, uh, repair and replacement options for. So, it's my, uh, uh, privilege to, to introduce, uh, my incredible colleague, Doctor Cohen. Uh, Doctor Cohen, welcome. Hi everyone, uh, how are you, Matt? Thanks for having me, and um thanks to Murmur and D for, for having me. I'm uh excited to get into uh some, some tricuspid imagery. We'll get to the point now where we have some cases. Um, we, we do a decent amount of complex stuff here too, and so, we'll definitely show you that. Um, I wanted to kind of start off with, with, I stay routine. Uh, I say that, but I say it with a lot of respect to tricuspid valves, in the sense that Um, I, I will tell you, I think I learned, and I, and Matt and I say this to each other all the time, I learned something from every clip we do. I mean, really, like, the things that seem the most simple sometimes end up being the most complex, and vice versa. Um, and even some of these lead cases that we'll show you, I, you know, I would walk in. Maybe, uh, as the pessimist, and say, uh, you know, I, I'm not sure, like, should we, should we clip this? Should we not? I'm I'm worried about this lead. And we walked out with beautiful results. And so, some of that experience, kind of early in my career has, has shaped the way I approached some of this as well. Um, so, we'll start with a routine clip, uh, for one. I would just tell you too, I, I, I think what I've learned from this too that, so first looking back at the original Triuminate cases that we were doing with uh Generation 3 and, and some of the difficulties we had doing it and intent to clip views and Tricom views, um, it's remarkable that uh we got the results that we did. And so considering that if we, if we could repeat that, that trial and that, that early experience with what we're doing now and the precision that we have now, um, certainly, yeah, it, it, it's like CTOs if, you know, getting very, very good at the complex ones, uh, you know, make routine PCI, uh, all the, all the easier. Um, I, I, I do think that there's an escalation in sort of your capabilities and the kind of cases that you're willing to take on when you when you start at the standpoint of this is an imaging driven procedure. I tell every single patient that you're the eyes and I'm the hands. It's a two person operation. Because it's very much true if we don't, if you don't have a good imager that's also done the pre-imaging that's facile in all of these, your capabilities in cases that you can actually successfully embark on are a magnitude or order of magnitude different. And so what we're able to do now, what we're willing to take on now, what we're getting results on now is dramatically different than 6 months ago and 6 months before that in the trials. So I can't reiterate enough just from my position. How the routine clips would have been tough clips even a year ago, but we're getting better and better at these every single time. It's because of really the fact that this is a very collaborative procedure and is really dependent on two people working at eye levels to get a good result. Yeah, I, I, I would echo that, pun intended, but, um, I think, you know, it working with, with Matt and, and one of our other partners, uh, Parth, I, you know, I think the way we were trained, you guys are, are not heavily reliant, but, but the understanding of, of fluoroscopy angles at the same time as echo, um, and maybe we'll talk a little bit about that, you know, or, or you can, you know, shed some light on that in some of these places. I think. You know, often you guys know as much as I do, right? I'm trying to get you the best picture, but, but you guys know as much as I do in terms of the imaging. And so, when you're on the same page about what we're actually doing, uh, you know, typically, you're doing things that I'm ready to tell you about before you're doing them. Um, and I think that's a, a powerful thing as part of a team, right? To, to be successful in this. Um. So, I, I, I think it really is, it is important for the interventionalist to really understand the imaging, uh, component as well. And, and even, you know, I would argue that the imager should really understand, you know, kind of all aspects of the case too. And I, I have a flora screen kind of right next to me when, when we're doing it as well, so I can kind of correlate in my mind. Um, all right, with that, let's, uh, let's start with case one. So, this is again, our, our quote unquote routine clip. So, uh, 88, uh, persistent, uh, atrial fibrillation, symptomatic bradycardia. Uh, had a leadless pacemaker, uh, a ventricular, um, a severe hef-pef, and severe, uh, symptomatic degenerative tricuspid regurgitation. You can kind of see there's maybe like a small little cord or degenerative strand on, on that valve. Um. You see a transgastric here, kind of leaks across the whole valve here, um, you know, and big, big kind of floppy looking valve. 3D NPR kind of nice images. The, the things I would point out here, um, you can, if you look closely kind of through this 3D image, you see this thing flopping around under the valve. Uh, and towards the septal leaflet, uh, or just under the septal leaflet, this is that ave that was placed. Um, I would make the comment that I think as we're placing more and more of these devices, or as our EP colleagues are placing more and more of these devices, um, again, I'm not saying all these should be driven by TE, but I do think, um, there has to be some consideration for what the future may look like, and what therapies will be able to, uh, be offered, cause this, this lead is super close to that, uh, that septal leaflet. And then, uh, your TR here. And so, again, kind of a, a wide, wide jet, uh, mostly kind of in the center. Um, and so, how do we approach this? You know, what was our procedural plan going in? I think you had asked me earlier, like, you know, what did we learn kind of from the beginning to now? I think, um, you know, starting off, I think when you talk about degenerative TR if there's something focal, often you will, will target that focal jet. It's, it's kind of a, I think, natural instinct to say there's a leak here, I should clip that, or I should target that. Um. I think with our experience, we've really kind of realized that when you start kind of near the AS cometer, or or central AS or something like that, you really do have an angioplasty effect. Um, and it really can alter the anatomy of the valve, and, and the leak significantly, even if you're not targeting that leak, uh, right at the point of it. And so, our procedural plan, I was just kind of showing this in Diastole in Sicily, to show that this really kind of was a, a mostly a, a two leaflet looking valve. Um, and so, our procedural plan, was to just kind of start near the AS and and clip back and kind of see how we uh see how we did. And so, we, we start here, we're above the valve, we're towards the anterior, uh, part of the valve again to orient you. Aortic valve here, septal, anterior, posterior, we'll say septal and lateral cause we think it's kind of a two leaflet valve. We go under uh the valve, we see the leaflets inside the clip, right? Kind of what you're looking for is in the base of the clip before you let those down. Again, as I showed you, I'm aligned reasonably well with that clip. So, I see the arms uh perfectly well, and I see where the leaflets are interacting with those arms. We come down, uh, we see both uh leaflets in the clip. Again, uh, one of the, I know this is a smaller box, but this is kind of the point I was making before, is I, I took a much smaller box here. You can see that the spatial and temporal resolution is actually much higher. Um, and you can see you got like a really nice tissue bridge there, but I am in no way imaging the entire valve, right? Um, and so I think it's just important, you know, that that's what we're doing. If you look at the next picture here, again, we just kind of go to other views to confirm. We're in the transgastric, we see the leaflets coming in, um, in our blue box down here, and we have a nice tissue bridge. So we let that one go. Uh, clip looks fine on there. There's a little bit of leak posterior. As I said, it was a reasonably wide origin in, in a degenerative pathology. Um, and so we planned for our second clip. We maneuvered that clip right over kind of where we, where our target was, right where that uh kind of second leak was. We come below the valve, again, kind of being able to understand how close are we to that clip, what's our orientation kind of all at the same time. We see our uh leaflets inside our grippers, or sorry, inside uh bouncing on the uh arms of the clip. We come down, we grasp, we're still attached here, but obviously this is a a really nice result here. Um, with, with the strategy that we planned out, you know, for. Um, and so I would argue this was a, a pretty straightforward clip. We put two clips on, uh, we went maybe a little bit more posterior on the valve than than we had planned with that second clip, um, but, you know, kind of trivial looking, uh, residual TR, um. And that that was, uh, that's the first kind of, again, quote unquote, routine case. The, the avere added a little bit of complexity in the sense that we wanted to avoid that. It was kind of right under the septal leaflet, um, but because we were able to see it, we were able to avoid it. You can kind of see, uh, in our green box here, that avere is just under that septal leaflet, but not, not totally interacting with those clips. Anything else to add to that one, Matt? No, it's, I think it's a beautiful demonstration start to finish of, of how you use 3D MPR. And again, just as an as an operator, I, I, I enjoy how iterative these procedures are. Um, you know, we go in with a plan as far as clip strategy targeting the leak, targeting the annualist. I think most of the time we're, we're starting in the AS commissure, but, but oftentimes the valve, as you mentioned, changes over the course of the procedure and so the ability to adapt and actually get as precise as saying, You know, we have enough room for an XT, don't have enough room for an XTW. You know, those kind of things are make this very, very rewarding as far as strategy and iterative sort of procedural process based on really good imaging like this. But it also, I think, highlights, I think that there's a misconception that Triclip is just a TR reducing therapy. There's very, very little TR left in the vast majority of these cases. I think in our 122, I was just looking at this, we have a 2.9 grade reduction starting from some pretty sick patients, but a pretty substantial reduction in TR. You can eliminate TR in a lot of these cases. Um, if you, if you follow a procedural, not algorithm, but approach as far as imaging intensive and then adapting your eclipse strategy much like you would at CTO when you change strategies, uh, quickly and based on what you, what you're encountering in the procedure. Awesome. Um, so case two, we're gonna, we're gonna kind of start to move into the more, uh, complex stuff. So, You know, example of of leads, what we do with these ones, we decided to move them, um, and then clip. This was a Uh, 79, uh, 79 year old with um With mitral valve disease due to functional mitral regurgitation, who um had had a prior mitral clip, uh, I think a couple of years before, um, with two XCWs. We had seen her previously where we, we fixed the mitral that had severe residual leak, um, with a clip in between, um, and had a really nice result. You can kind of just see a, a typical, uh, 3D image there, the mitral, a little bit of a gradient 4 to 5 or so at a heart rate of 80, um, but was doing well from that perspective. Um, had sick sinus syndrome, paroxysmal, uh, AF, um, left bundle lead, had CRT. Uh, more recently, and then progressive symptomatic, uh, TR. This is, this is what we're seeing in practice too, right? It's like the, the The penalty for getting a good result is that another thing crops up, you know, patients survive long enough to get something else. That's the hallmark of TA is that now patients have calcific mitral valve disease and TR and things like that that we have to address. Um, but with that last case they were referred for uh interclip MR after about a 2.5 year good result with, uh, for really tough ventricular functional MR. We, we did that left with uh with uh another clip with a grading of 4, and now 2 years later we're also approaching the tricuspid valve. Yeah. And so, you know, you can see here is there's there's severe TR mid-esophageal image quality is OK. There's a lot of kind of uh thickness around these echo densities that, you know, are leads. You can essentially see the leads kind of moving with the valves. When you go to the transgastric MPR, what you see is there's a ton of mobility to this lead. And so, uh, you know, I would point out here that In our short axis, in our green box, this is the lead, and with, with Sicily, it, it moves halfway across the, the valve. And you can see it definitely kind of restricts the motion of that septal leaflet, kind of here in our, our blue box. And this is an ICD lead, it's a thick lead. The other thing too, that you'll notice in the actual 3D image, and you'll see kind of part of in this red box, is the uh CS lead is, is very redundant as well. Um, it probably doesn't affect the TR but, but does affect how you think about, um, Getting to this valve and making sure you're not going to interact with it when you when you go to clip it. Um And so, again, you can kind of see this this posterior movement. Again, this is our AP trajectory or AP plane here, kind of in a long axis in the stomach. It, it moves very posterior with each uh beat. And not that, you know, on flora, we can see that as well, right? So, you can see with each beat, with each systolic uh beat, that this ICD lead moves a ton. You almost see that CS lead sort of wrapping at the annulus and hitting with each contraction that the annulus, so it absolutely affects deploying the clips, but the dramatic movement of that systolic posterior movement of the ICD lead was really what stood out on that fluoro image. So, um, what we decided to do in this case, Let me go back, sorry. Doctor Summers actually took in a drillis catheter, and, and essentially kind of pulled some of the slack um out of those leads. And, uh, you know, what you'll notice is that they're not moving a ton anymore. And then kind of more dramatic, um, in my opinion, at least, is, is on echo, you can really kind of see, um, all this happening. So, I'm gonna let all these play, and now we'll kind of go through one by one. This is the original image, right? You see the, we've labeled the ICD lead and the the CS lead, and it's just a, a ton of movement, right? Posterior movement during Sicily. When he kind of got onto the leads, there's less movement, right? Just kind of having them uh corralled. And then when he actually moved them posteriorly, you, you really see in a, in a nice confirmatory way, this, this lead has now kind of been moved all the way towards the posterior aspect of the valve. Um, and no longer do we really see that CS lead kind of hovering above the valve, and in the way. Um, and what this does too, is it kind of pulls that lead away from the septal leaflet at the anterior portion of the valve, and allows us to have a target, um, to, to clip there. And so that's kind of exactly what we did. Um, we felt like our transgastric imaging was, was kind of our highest quality imaging here. And so we actually did this all from the transgastric views. And so you see us, um, Above the valve here in our, in our blue box, you see the sip clip kind of coming into view. We have our short axis view, um, and then we have our AP, um, view. And in the 3D you can see that the lead has been pulled back right here where my cursor is, and then our, you know, uh, arm orientation and our position. And so then we go under the valve, right? You now see us under the valve with the clip. We're kind of in the central AS, you know, central portion of the valve, right? But, but anterior and septal, um, Here, really nice demonstration where you see the lead. You see our uh arm orientation, you can see the the gripper line and everything here with the arms, uh, with the grippers down. Um. And leaflets inside. And then we, we start closing, and it's really kind of amazing to see this all happen. Right? So we're starting to close that clip. And we do that here, and you kind of see a really nice clip is as it's closing, it's kind of corralling everything, leads staying in place, and the valve really starts to kind of change shape and and come together. Incredible imaging in that. I mean just look at that, look at what we can see and and and the relation of the structure this this was a fun one, unbelievable. And so here again, the clip is closing more, uh, clip is closed, um. And so again, you see the lead right kind of behind that. Valve looks like it's kind of co-opting in a reasonable way. Um, and so then we're gonna assess this, you know, decide if we want to keep it, and decide if we like the result, and, and hard not to like this result. Um, obviously, the, the leaflets are in the clip there, they're nice and taut. Um, lead is, is kind of has, we've moved that kind of behind and kept it there. Um, and that this was our result. We actually had a beautiful result, you know, from this case where there was a lot of lead movement. There was at least some contribution from the leads, um, and, and we got her down to, you know, trivial, uh, tricuspid regurgitation. And then, uh, again, just showing some other views, uh, of final results here. The other thing that I want more view of what happens with the flora, yeah. There's a lot of clips there. A lot of, a lot of clips, a lot of therapies, uh, devices, um, but, but a really good result for this patient. So again, you see kind of this hinge point, lots of movement on this lead, really not, not much here when we, when we let go with the Aegilis. That's cool. That moving the leads also helps with the imaging, I think, too, right? It, it pulled out absolutely could, you could really, uh, fine tune those transgastric images. Yeah, and it kind of allowed us to have a really nice spot, both imaging wise and and on the valve wise to to understand where we could clip the valve and kind of get the most bang for our buck. Um, another case, uh, case 3, so kind of laminar, uh, TR and, uh, another lead. This was, uh, interesting for multiple reasons. Um, 73 year old female, um, We, we, again, we thought lead related TR this, this can be really complex in terms of understanding if the lead is the primary cause, if it's, if it's part of it. Um, and it, uh, you know, it, it tends to drive decisions sometimes, right? If you think you're not gonna be able to clip around it, um, or corral the leads, or something like that, you may have to remove them, or you may have to pick a different therapy. And so, um, upfront evaluation of this, uh, you know, it, it could be its own. Talk, but, but I think that's a really important thing that we spend a lot of time on, trying to understand the lead, uh, contribution. And so, again, really severe TR. Here, uh, you know, this is kind of a classic teaching, but you see a brief jet. This is, this is rapid equalization of, of pressures, and I'll, you know, I'll prove that to you. But there's, uh, you know, almost laminar TR you get a really dense triangular, um, Doppler profile, uh, which fits with this. Um. And so, what you notice here, in a, in a transgastric, I, I really couldn't get this to come together much better. These leaflets are very far away from each other, right? This is a massive co-optation gap, and you just kind of see this brief color, Jeff. This is, you know, torrential, um, TR, and you kind of see there's, there's maybe multiple leads here. I'll show you some other images here. And so, when I saw this transgastric, I realized it's not the, the highest quality, but if you follow me in the green box here, I thought there were 3 leads. I thought there was 1 lead here, 1 lead here. And one lead at the poster aspect. When you look at all your other views, you realize that there's one of these leads is actually coming all the way down in the right ventricle, and then curling back up. And so, at that point, I, I went back and looked at kind of our, our original testing. You know, just a, a plain film of the chest, um, obviously here again is the severe torrential TR. And, and the question at the top begs the question, right? Is it always the ventricular lead? Most of the time it is, um, but, but not in this case. And so, what you see is that the atrial lead actually swings all the way down into the right ventricle and comes back up. And that's what we were seeing. And that's kind of what you see in echo here. You see the ventricular lead here in 3D, and then you see this atrial lead come down, swing around, and back up. And, you know, at least my thought was that I think it was probably propping the, the subvalvular apparatus open. The, the sad part about this is I don't think this was recognized for many years. And so, you know, I think I think by this time, as with other lead cases too, you know, when you have a very early lead that's causing TR, oftentimes removal may fix that. Once you're, you know, past about a year or so, I, I, I think it's not often that we see people remove leads and, and just have, you know, TR be gone. Uh, and so we, we figured we would have to make a plan for this. And so, you know, we did. Again, we, we implanted a a dual chamber um leadless device. And when I say we, I mean our EP colleagues, we, it, it, you know, what's nice here is we have a really, uh, you know, really good, um, group of EP docs and, and really talented, um, Lead a a management program. And so, um, you know, We can take things out, we can have it. What's, what I really like the most is we can have their opinion on whether or not we should take things out. The last thing I wanna do when I see someone in clinic is convert a very safe tri-clip procedure to a less safe or more morbid, you know, procedure that requires cardiac surgical backup, um, or where we could tear a valve. And, and so, we've kind of gone back and forth on how aggressive we are about, you know, lead removal versus clipping around leads, or something like that. Here, that this lead, you know, came out. Um, and you can see the, the implanted device there. This is kind of post lead extraction. So again, that, that TR did not get better. That valve is still not coming together. I guess it, it, it can, you know, it could beg the question of like, were we right about it being lead associated or not. It's tough for me to know, you know, what's scarred down below the valve, but, um, you can see that, uh, leadless device kind of right down the barrel of this valve when you're looking on foss here. Super severe TR you see that uh on the ice imaging as well. So we have 3DT and then our ice images. Uh, and then, so what did we do, right? So, our procedural plan was, uh, you know, I made a little joke here. I'm, I'm kind of putting clips, like, what do we do for this? This whole thing leaks. There are big gaps, you know, should we, should we have, you know, gone the other way? Should we have done TTVR? I, I think no one would, would fault you for that. Um. But, you know, so our, our thought was, let's, let's try and pull a little bit of the septal leaflet off. Let's try and get a good angioplasty effect at the AS commissure, and let's see what we're left with. Um, and so, that's exactly what we did. We kind of came down towards the anterior portion of the valve. The additional thing about anatomy that I think is helpful for this valve, which is why I think we pushed towards this, is it's also a bi-leaflet valve. And so, when you have two leaflets, I think you get much more bang for your buck. Uh, with clips kind of going stacking, uh, you know, anterior to posterior, then, then having to understand what the anatomy does when you have a true, you know, AP commissure or AP Canyon. Um. So, we get under the valve, uh, again, imaging is a little grainy here, but you can see the leaflets in the base of the clip. We closed that clip. Leaflets are nice and taut. We're right kind of adjacent, right in the AS commissure. We look in transgastric, we kind of confirm that. Do we like the way it came in? Um, and what I would say here is we've converted, you know, Laminar torrential TR to severe TR. There, there's definitely still a lot of TR. There's definitely big coaptation gaps. They're not quite as big, but this was, I think, promising, um. For us. And so, we then decided to come in with a second clip, just behind that first one, lined it up the same way we always do, came below the valve. Again, I'm aligned with uh with our arms here, and so I can see really nicely in our green box, green line through the arms, green box. I can see the leaflets really nicely. We pull that together again, kind of really nice result. Everything comes in. You see how this actually looks like a valve now, right? Um, and there is Almost no leaf left. So we, we, we laugh and we say washing jets. Um, this is, uh, this is a really nice result, especially given what we started with. Um. And so, um, this is a case we were really proud of, right? This, this lady went through a lot. She, you know, had to have, uh, a lead extraction, um, had really torrential TR, was, was suffering with symptoms quite a bit, um, and then we were able to get her a really nice result, um, with this. She's a lady that this is the other thing that's traumatic to me in clinic is how many patients come in with cardiac achexia from undiagnosed degenerative TR. It just hasn't had therapeutic options in the past. Um, this obviously was a combination and it was by leaflet valve and so. You know, we were pretty worried about her frailty going in with all of this, but it was, it was absolutely necessary given the severity of her symptoms, um, and like you, you said earlier, it's a safe procedure, um, in the vast majority of scenarios we're able to, to reconstruct this valve. Agreed. And then, just, just kind of showing, you know, we use dice in this, we Do we need it? I, I think we could argue maybe, maybe we didn't, right? We had really good TD imaging, we were able to see. Images were a little grainy, right? But again, use, use your tools if you have them. And so, um, able to see kind of leaflet insertion here, we reconstruct in 3D. You see it well. This is after that first clip. There's TR, but it's not anything like it was before. Again, we were encouraged by that, especially cause it's kind of in this one place. Uh, we go back with uh a second clip, get a really good, uh, grasp, and have, again, trivial, uh, TR even even by ice there. So use, use all your tools. You saw that we went and confirmed in the transgastric, right? We're, we're up and back. The last thing we wanna do is, is not be sure, and sometimes that happens, but when that happens, we've exhausted all of our other tools, um, you know, and then we know we're, we're not gonna see it better in any way. Um, and then just showing kind of what the floral images look like. First clip, second clip, and our, uh, our result there. I know most people have adopted this practice, but I think swinging over to, uh, take the parallax out of your AV groove for both mitrals and tricuspids, but particularly the tricuspids, it is extremely helpful, especially if you're, uh, doing multiple clips. Um, you can really assess, uh, subtle changes in your orientation. Um, with advancement of the clip as you get more knobs, uh, uh, on to, to change your trajectory position, um, it also, you know, the clip wants to transmit that torque, uh, later, and so you tend to get a lot of spins and you don't wanna make a ton of movements under the valve, of course. And so lining things up in this way is really key from an operator's standpoint too and making sure you understand the 3D NPR, the 3D anatomy in the context of a two dimensional fluoro image. Agreed. Um, and our last case here, so, again, there's maybe a little bit of a, a lead theme or something. I don't think that was the purpose, um, but just to kind of demonstrate the imaging and, and the complexity, um, this was an acute, uh, flail during an extraction. So, again, it kind of goes back to that. Do you send someone, right? Do you send someone, and, and this, this was an extraction for lead related issues that were not valve related. Um, this, these were, uh, a failed lead. Um. But able to deal with this on the other side, um, you know, when our EP colleagues call us, uh, especially to support, you know, a, a really good extraction program, cause this is bound to happen. Um, and so this was a 67 year old male, uh, diabetes, hyperlipidemia, a reasonably healthy guy, um, had a pacemaker, um, placed many years ago due to syncope and carotid hypersensitivity. He had lead failure, and so he had a lead extraction. Unfortunately, this was complicated by a, a torn Uh, tricuspid leaflet or flail flail leaflet. Um, there's some question of like, did we, did we, did, did the, uh, AS commissure, you know, get avulsed? Is it a mostly anterior flail, um. And then, um, you know, what were we gonna do for this gentleman? And so, you know, I think the plan here, um, you know, given normal RV function and, and the fact that we were worried about getting a really durable result with, with a, a flail, and, you know, maybe, um, some sort of version of the AS AS commissure, uh, we decided to pursue, uh, pursue TTVR and so, you know, we screened him. Um This image kind of shows this was, uh, I think during the extraction, you see this flail leaflet. There may be very well may be part of a, a pat muscle on there. Um. There's a significant TR network uh here as well, and I, I don't think we totally appreciate the extent of that TR. You go into NPR, you see it's really kind of involving, you know, maybe the AS commiser, certainly, uh, this kind of anterior portion of the anterior leaflet. Um, and then you see it's that that jet is fairly broad in origin, um, and really kind of originates exactly, uh, where that pathology is. And so, um, you know, this was a multidisciplinary effort where what we did was we screened, uh, with CT. And then we actually brought this patient back for a leadless implantation under TE guidance, um, with a subsequent uh TTVR. You know, the, the, uh, with Evoke. The, the issue here is you, you do have to have room between the device, uh, the, the leadless device. And the valve you're gonna place the annulus. Um, and so, this, this was actually one of the harder parts of the case is, you know, we, we placed this in multiple different areas. And then what we're doing with, with NPR is measuring, you know, are we, uh, you know, I think what companies will tell you is you have to be like above 1/8 or so. They'd like you above 2 as for margin of error, but, um, You know, so we were about to, after multiple uh attempts. Sometimes we, we try and go up towards the RVOT, you know, I think, and I, I wouldn't speak as an EP, but I think sometimes that's a less, um, Uh, a less good place for them to place it, but maybe more, uh, maybe more fitting for us, uh, in the valve, uh, on the valve side. But we, we ended up, you know, getting about 2 centimeters from the annulus. Um, and so we felt good about that. Um, here was just some kind of basic CT measures. He sized for a 44. You know, the things that we were concerned about, um, were appropriately looked at. You know, the, the big question was, is it less than a third of the annulus that's involved with this flail? Um, and then the things we also were concerned about is this guy really hadn't remodeled, right? This was an acute issue. And so, um, RA height was, was a question. We ended up going, uh, from the left, um, and we're able to get this done. Showing here just in, in 3D some of the pre-measurements we make. Uh, you know, um, Uh, AS, uh, measurements, and then, um, Uh, septolateral measurements as well, uh, AP dimensions, sorry, and septolateral dimensions, and then a, uh, a perimeter. And again, just, just kind of demonstrating some of the complexity here. The Avir is here, uh, or the lead list is here, the flail is here, maybe with some some pat muscle there, and then a big uh QR network, which, again, isn't too much of an issue, but like, when you're bringing big things into the right side of the heart, you could certainly get tangled in that. And then that with the flail is is maybe not a great combination. So, um, just, you know, quick points of this. So wire position is a big issue here. You wanna make sure that you're behind the, the anterior pap muscle. We also wanna make sure we were out of the way of the leadless device. You see that nicely here. This is, again, a long axis in the stomach. You see that flail kind of at the anterior portion of the valve, you see a little bit of that Chiari network coming in, you see the wire, and you see the vere. Um, then you want to look for the capsule gap. What you want to make sure is that you're not interacting with the pat muscles, but you're also below the valve. You see that capsule gap, nicely pointed out with the yellow, that correlates to this fluoro image. Um, and then similarly a fluoro image of where that wire is placed in relation to the device. So then, you know, really, and sorry, these are a little out of order, but really what what this ends up being is you start to slowly deploy the arms of this device, um, and then they start to curl up, and, and basically about halfway through that, what you're doing is you're making sure that you're in position to capture all these leaflets. And so, this is a pretty imaging, uh, intense procedure, and, and what you do is, you know, kind of in this area here, um, where you see all these arms, what you want to make sure is that Uh, you know, you'll kind of call out in the room, hey, we're looking at green box, left side of the screen, or something like that. It, it doesn't really matter which side, right? You just have to all be on the same page. Um, and you wanna make sure that when you put this green line over each one of these dots here, which is essentially these, these arms, um, you wanna make sure that the leaflet is up and over and capture. Um, and, and we're kind of calling that out as a procedure, uh, or, or during the procedure. And then each stage of the way, we're kind of coming up closer to the annulus. Making sure that we have capture, and then really just working on trajectory to make sure that we're gonna abut the annulus both septillaterally, uh, and AP and, and then you essentially deploy the device, and you kind of see the, the fluoro correlates here of what those arms are doing, and kind of the, the relation as well to the Avir, and it's, it's really kind of nicely positioned to not interact with that. Um, and so this is really kind of high fidelity imaging to, to guide really, in my opinion, about as complex as it gets. Um. Then you'll see we start to uh deploy the ventricular portion of the valve, or expand the ventricular portion of the valve, similar here, more expansion, um, and then, uh, you know, full expansion here. Look, look at the, look at the flow of the proximity, how, how close we are to that ear and, uh, and how precise it had to be placed, uh, by, by Doctor Keel. Uh, it's pretty, pretty incredible that we can guide. I think that's an important highlight of this too is that you can guide their reimplantation, uh, very precisely with TE to make this feasible. Absolutely. Um, and so then, you know, we have a nice, you know, working tricuspid valve. There's a trivial amount of, you know, valvular leak, um, There You can see, I think some of that Chiari left uh near that valve. Really nice ice images here as well. And then just showing uh 3D images on ice as well. No paravalve. Early leak, valves functioning well. Um, and that gentleman did, did really well. Um, this is, uh, me and Doctor Summers, we had the privilege to go to Sao Paulo in Rio and, and proctor their first Triclips, and, uh, we've been involved in, in some of the tricuspid, uh, Triclip 101 training, as well as some of the advanced imaging training. Um, and it's, it's absolutely a privilege to be part of the, you know, educational rollout and, and, um, sitting next to, you know, some of my mentors, uh, with very much imposter syndrome, uh, to be involved in some of these conversations. But Um, I really appreciate the, uh, The offer to come here and, and speak about the stuff that, uh, that we're really passionate about here. Yeah, well, I really appreciate you doing this as well. I think, um, from a standpoint of uh these therapies getting rolled out, the way that the results are safeguarded with all tricuspid therapies, um, is really an attention to detail that you, you garner from advanced imaging. And as, as a, a place that does, uh, the common and the complex and, and both, uh, therapies. And uh be involved in, in, in most of the trials. I think one of the things that I've taken away, not as an imager, but as someone that is heavily reliant on imaging is that the feasibility of these cases is highly dependent on understanding the fundamental things that you went through, which is, is that you have to understand anatomy. You have to understand to get to the level where you can, uh, fill in the gap, no pun intended, the gaps as far as what you're seeing and what you're not seeing. Using ice, using a lot of different modes, a lot of different understanding of views and how to uh optimize those views. Uh, I don't think anyone does it, does it better when when we're at these courses. Um, and, uh, your counterparts are, are, are there. I, I do think that there's a different level of, uh, precision with, with a lot of this imaging, and, uh, kudos to you and really appreciate you going through all the details. Hopefully, of course, other image images on this platform, even interventionalists like myself, uh, who learn a lot from, uh, the descriptions of this anatomy by imagers that are looking at it day in and day out, uh, benefits, uh, other folks at other programs. Awesome. Awesome. Thank you.
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