Chapters Transcript Video ElectroSurgery in Cardiology we're talking electro surgery techniques in interventional cardiology and what does that mean? All right. Um This is a hot topic pun intended. So we're looking tissue traversal requiring concentration of charge and tissue vaporization. But we're basically gonna do is say how can we use our ability to electrify a wire and cut tissue. Um To our advantage we want to mimic. We talked a lot this morning the structural section about mimicking some of the things that surgeons do. The surgeons get to cut stuff. So now we're trying to figure out how to do that without actually going through the skin. So tissue tissue traversal requires concentration of charge and tissue vaporization. This is cutting not coagulation. This ain't coterie. We are cutting through things and therefore to do that. We require a bunch of things. We're insulating catheters and coding to concentrate charge. You know we have to we we if we haven't exposed uninsulated wire the energy is dispersed along along access and we can't really concentrate it. So we want to insulate the catheter, insulate the wire and then concentrate the charge at a very focal point. And you can see in the yellow bucket test. Stop playing. Uh We're trying to light that up the charge concentration needs to really be at the tip. So we do it two different ways. We either use a wire which we just go right through the very tip of it, electrify the back end. Have an insulated wire using the studio 20 which is as for those of you in the cath lab corner of C. T. O. Wire or we create an elbow. Letterman robert. Letterman was kind of the mad scientist came up with most of the stuff calls it the flying V. After the famous stratocaster where they denude about 0.3 centimeters of it and create an elbow and want to denude the inside part of the elbow. And we're gonna use that when we pull up to cut stuff. All right and you can see that on the panels on the bottom. So I'll give you three concrete examples where we're using that. We touched on. I think there are at least briefly mentioned this morning. So that may be familiar but I want to show you how we've used um how we've used this particular application within structural heart and cardiology. So one of the early ones was trans cable access for Tavern. One of the guys to ever do it first Bill O'neal was Hill this morning and he told us about that. Um And we started this not not very much longer after they were doing it at Henry Ford. And the reason for that is deep. I can attest is we just started accumulating a cohort of patients for we just couldn't treat they had Badillo Federal disease. There was no subclavian access the critical areas stenosis. We just couldn't get there from here. And so we sort of hemmed and hawed and by the time we got about four or five of these patients in our practice. We realized we had to do something. So I went out and learned how to do trans cable. Um We looked at the retro the when they looked at this, the retro peritoneal human dynamics are interesting. The fear is if you make a big hole in the aorta that you'll bleed out into the retro peritoneal space, this is a realistic fear. You should fear that the reality, however, as long as you have a hole in the I. V. C. For that hole in the order to fish allies and empty into the pressure in the aorta is higher than the pressure in the retro peritoneum is higher than the pressure in the I. V. C. And that little fish allies and drain. And it turns out it's true. So then you had to figure out how to get from the I. V. C. To the aorta electrify a wire pass the wire through. So we're gonna use CT to line this up. So we sort of incorporating a lot of things we can do. We use our bony landmarks of the spine. We use R. C. T. To show a point where the I. V. C. And the order near each other we'll create two angles. One is a burning angle, one is the bullseye angle 90 degrees to make sure we're going across appropriately. And then by the way after we make this 18 french hole in the order we have to have a method to close it on the way out. So we sort of assembled all these tools but the key to doing this and here's transferable planning. So there it is and panels A. And B. Will show you the first shows of the ct showing you the area that we're aiming for. We can confirm that on B. When we do uh an angiogram to show those two C. And D. Show those two burning angles. One is the bull's eye view to make sure we're headed for the middle and D. Shows you where the wire is gonna pass E. And F. Show you the sheath going in and then the closure device coming out. So it's that simple. Um So first we localize the closing site and we do this with C. T. And we're gonna measure that in two orthogonal views. We're gonna line that up. We burn into the order. So we take the estado wire, it's inside a fine cross or piggyback catheter to further insulate it which is inside a micro catheter. So it's a telescoping system that's all inside by the way, right right facing rtC guide. And we bring it up to the exact point in the order. We want to burn at, we get it to the tip, we attach it on the back to a bovie, go cutting it 50 and just push across. Once we clear the snare which is in the aorta, we snare it, we bring everything up and then at that point we simply leave the micro catheter up. We take a Lundquist wire through the micro catheter and you can watch in the panel on the left. Is that straightens out? Well, we know what to do with this right? We got a stiff wire going from the leg to the order. We just follow it with the sheath. We go through the side wall of the order, usually without having to pre dilate. And we place the sheath in the aorta again. Now it's just a tavern transferable tavern. Go ahead. And or complex Pc. I we've done it for that as well. We come back and we close it with an amplats. Reductive include er Alright, we did our first one in 2016 with subsequent done about 100 with a with a good safety profile. We published our date along with some other centers recently was presented at C. R. T. It's a safe effective method and it's sort of the gateway drug for electric artery electro surgery. Um The next question that came up is we talked a lot this morning about lifetime management. Doctor tell razor talked about dr yeah, kebab and one of the achilles heel is we don't want it with the second valve caused obstruction to the coronaries. We have a leaflet from the surgical valve or sometimes a native valve that sits right in front of the left main. When you put a new valve and you you put it up and you can wall off or include the coronary artery. So if we could just figure out a way to separate or or lacerate that leaflet and splay it. That would allow coronary perfusion, and that would allow access to the corner diagonal way for heart catheterization. When you include a coronary artery, by the way during Tavern carries with it a very high mortality. This is not a benign event, You can get 100 if it's unsuccessfully able to be open, The death rate of that is 100%. Um even if you're able to successfully opening up, we still have a very high mortality. So this is a dread complication of Tavern. So this cartoon will show you, we'll come down with the wire. We'll put a snare on the ventricular side. That electrified wire shows up again just like trance cable. Now we do a couple other steps, that's where the flying v. The stratocaster will come in will lacerate the leaflet. And you can see when this leaflet opens. We now have access to the coronary artery and the coronary sinus that we didn't have before when the new valve goes in. So here's one of the here's an example. Step forward traverse just like trance cable. We have a telescoping system. We got a piggyback. We got an estado wire inside a piggyback inside a guide. We have a receiving snare in the left ventricle, we have a wire to make sure that we don't fall out and we got a pigtail across there. So we maintain access and we just burn and snare. We then make that flying v on the table at the back side and we take the two catheters, we pull them together and we pull up and we just last read the leaflet. This actually tolerated pretty well by the patients. We do a lot of these that are required, a special human dynamic support. They kind of do well. We then turn and say, okay, now it's a tavern. We put a wire across and go ahead and deliver the valve. Alright, I spent some time on this. So I hope you appreciate the effort. Um, I'm gonna talk about lampoon. I had a little time sitting here. Uh, I'm old enough to remember. I used to get the national lampoon, I remember this, this cover. If you don't buy this magazine, we'll kill this dog. I thought when I was seven or eight that that was just incredibly clever. So, if you don't buy this technique, the dog gets it. All right, So what is lampoon? Um, let's go back to valve and MAC. This is one of the most challenging patient subsets that we deal with with micro calcifications. I showed this case, but didn't show all of this case this morning. So, Um, we've got a valve in Mac case that is really heavily calcified, the area is 16. The commercial distances 31 we can do a transept of Alvin Mack. However, we have a problem and the problem is that when we place a virtual valve inside this we have a neo L. V. O. T. Of zero. That means when I put a valve inside this the anti lethal will come off and completely obstruct the outflow tract and the patient will most likely knock it off the table. Not good. All right, so we have to do something to modify that. So the problem is the anterior leaflet drapes over and the problem is that there's this big septal, this big septal knob. My point at the right thing I think so, sitting right in front of the L. V. O. T. So we have two options. We can shave that down with the septal ablation with an alcohol septal ablation and we can and we can cut the leaflet and often times we do both. And in this case we talked about septal ablation is technically straightforward. You can repeat the ct to recheck it. It's challenging and thin septum is not feasible and all in all anatomy, that's pretty off label for an office procedure for an off label use. Okay, lampoon which is again I believe the technique or the dog gets it intentional laceration of the release of the mitral valve to reduce the risk of L bot. It's not dependent on coronary anatomy, it can be technically challenging and cannot always predict efficacy. So the first thing we did with this patient as we said, is there a good septal target? The septal thickness is 1.5. We had a nice septal perforation. You can see the degree of MAC by that picture on the left, you can see that big bulky, it's just all MAC and calcification. Um This patient was obviously turned down by surgery before we went down this path. So we wired the first septal perforation. We put a 206 balloon in there, pull the wire out and fuse alcohol. We do a bunch of things to confirm our position. We put contrast down there, we'll put optics on down there to make sure it lights up. So we put up the sign and we look at it under echo and we make sure that part of the septum that we want to burn lights up and it did we infuse alcohol and the final result. You see that septal perforation that was there before is no longer present. Okay then then we you can see a septal notch on the echo. The ultrasound people hopefully will help us. But you see this notch we did that with the septal ablation. So that makes it a little bit better. But still we have a problem when we do our images after a septal ablation. We still see that we are govt is still less. Hundreds better. But we really want it more than 200 or the risk of obstruction is bad. We can't really repeat the septal ablation because we sort of did the good septal perforations. So at this point it becomes lampoon. Let me go. No, go back with lampoon again. This isn't animating. But we cut a V shaped thing in the frame to allow blood to get to the outflow tract. Okay, there's different flavors of this. There's there's a retrograde. We did this back in the bad old days. There really hard. We don't do this anymore. And a grade is our dominant one. We burned through from the atrial sides and the ventricle pull up. You can do a modified tip to base. If someone has taken the time to show a surgical valve and ring in there. There's even a rescue lampoon in rare cases with the private micro clip you don't like. You can burn that off too. Alright. In this case we put two of those catheters in the left atrium. We burned through the leaflet and we snare it. We create this loop again, we do our flying V stratocaster. Okay, this is, there's a lot of imaging. We do three D imaging. We want to make sure we're through the base of a two and then we've snared it where we think we're gonna snare it. Okay. That red arrow conveniently located shows the site where we're looking for. So we go to the short axis won 35 out on the long axis, 1 35 outflow of you. We want to make sure that's where we perforate with our wire. And you can see there's the wire snared and we're pulling up as we go from from left to right and you can see that last little bit that pulls up. We've now lacerated unlike basilica. When you do this, when you lacerate someone's mitral valve intentionally, they get really sick. The pressure is bad. We put a balloon pump in ahead of time and we really go fast after this because a lot of human dynamic embarrassment. Um it's not made better by the fact you're now putting wires in the LV deliver valve. There's a lot of activity in the balloon pump doesn't fire. All right. So again by echo, you grasp the anterior leaflet, you burn it and then post. Sorry. Got excitable there. Okay, bear with me. All right. It's gonna go grasping in the in the there we go. In the middle we burn. And finally the last one you can see that display of the leaflet. You also know you did something because on accuracy, severe M. R. And the pressure tanks. Okay? And then quickly and expeditiously you deliver the trans catheter mitral valve and MAC. So again, we have a lot of tools at our disposal. None of them are really purpose built. This valve for example, is made to go in the order position. We're using wires that are made for coronary ct. Os to last. The proof of concept of electro surgery is here and we're developing dedicated devices that allow us to safely and more effective and more importantly, more efficiently. Make these procedures faster and safer post implant images show once the valve goes in, sort of the sky's the skies clear and the clouds part and the sun shines and the patients do really well. We take the blue and pump out and they go to the carrying it. But it's a little stressful until then. And you can see we have a nice result here with this and and there's more to come. There's sesame which is settle scoring along the midline into cardi um where we go ahead and do this instead of instead of doing an alcohol septal ablation will put a wire through the myocardial and filet it open and display that muscle open. And that's that's more to come. That's that's new out. And I think we've identified our first patient. Would like to try this procedure because we think it will help for about the Mac patient. So that is uh I think that's the final talk and I appreciate your time. Mhm Published December 7, 2022 Created by Related Presenters
BROADCASTMED