In this procedural video, Dr. Deepak Talreja presents a case of Transcatheter Aortic Valve Replacement (TAVR) using the Navitor™ valve in a high-risk patient with severe aortic stenosis. The patient has a complex medical history, including symptomatic congestive heart failure (CHF), peripheral artery disease (PAD), and multiple other comorbidities that elevated surgical risk and made TAVR the preferred intervention.
Good morning. My name is Deepak Talraja. I'm the Chief of Cardiology at Centera Health and one of our structural physicians. And on behalf of our structural team, I'd like to share with you this case of a patient with severe aortic valve stenosis. Who is undergoing implantation of an Abbott navi valve. I'll start by sharing with you the patient background, which I'll show you on this next slide. She's a 79 year old female with a body mass index of 42 and a body surface area of 2.1. As you can see in this PowerPoint slide summary, she's New York Heart Association Class 3 with symptomatic congestive heart failure. She has severe aortic valve stenosis, mixed. Mitral stenosis mitral regurgitation, which are non-severe. Recent admission for heart failure in January of 2025 adjudicated to be mostly valvular related to her aortic stenosis, and with a normal ejection fraction but associated hypertension and hyperlipidemia, diabetes mild as PAD, anemia, and elevated BMI. Her labs are notable for a creatinine of 1.5. Her platelets and CBC look otherwise normal. Her EKG shows a normal sinus rhythm with narrow complex QRSs, and she'sentulous on dental examination. She had an echocardiogram during that hospitalization in January of 2025 showing an aortic valve area of 0.5 centimeters squared with a mean gradient of 52 millimeters of mercury in the setting of an ejection fraction of 65%. She has, as noted previously, um, moderate MR and mitral stenosis. It is felt that uh the aortic stenosis is the real cause of her predominant symptoms. She's not felt to be a candidate for surgical AVR. There is obviously the concern about what will happen with her mitral valve down the road, but after a team discussion, we ultimately felt, given her STS. Salvage rate on the upper right of 24.5%, but the plan would be TAVR and follow up with subsequent interventions, especially if she can lose weight that might allow the next valves to be surgical valves. She has mild coronary disease with no symptoms of angina. She has good peripheral access, despite the reported history of PAD. And on examination, she has heavy calcification in the valve, and also in the left ventricular outflow tract. Coronary heights are 15 on the right and just over 10 on the left, and she has fairly generous sinus uh spaces. Overall, if you look at our structural considerations, we analyzed various valve platforms, and what made us excited about the navi valve in this high risk patient is that it gave us the best projected aortic orifice area. So the plan was a navi valve 25 millimeter through right femoral arterial access and subsequent follow up. You'll see the case now to follow. All right, so now we're in the cardiac cath lab, the hybrid OR at Centera Heart, and we have the patient on the table. What you can see is they have a temporary pacemaker in through the right femoral vein headed up into the right ventricular apex, so we can pace as needed. We also have our wires across. We have a pigtail catheter in the non coronary cusp, and we're gettingESI using an AL1 catheter to Pass a straight wire through the aortic valve. Now we've passed that straight wire through the aortic valve, and we have the AL catheter in there. Earlier you saw a flash up on the screen, the navi valve preloaded by our team here, and the point of looking at it is to make sure it looks aligned well, which it did. Here, we've switched over and we now have a safari wire sitting in the apex of the left ventricle. We have the pigtail marker in place and we've inserted a balloon to do a pre-BAV. We're gonna rapidly pace for a second. You can see on the pacing screen on the bottom left pacing at 160, and valve inflation. The balloon is inflating in the aortic valve, and you see it's a very tight valve there with significant constraint. We've stopped pacing as soon as we are done with the balloon inflation, and now we'll withdraw the balloon. That pre-valve inflation with the balloon is really important before trying to deploy this valve. Now you see us coming up through our large sheath axis with the inline delivery system. You can see the 3 markers, and you see the pigtail is a beautiful marker right at the bottom of the cusps. We take our original implant angle here. We're in an RAO caudal position. You see the pigtail marking where we want to be. You see the pacer wire that's actually fairly close to where we want the tip of the valve to deploy as well. And we're gently advancing from above. We're starting with the 3 markers at the mid-segment of the pigtail. And now what we're doing is we can pace, as you see, we're pacing at something like 100, 110, or 120. Here, we're at about 110. And we're starting at the top. Operator 1 is holding in position with no tension on the system, and operator 2 is unscrewing the valve, and this is pulling the delivery system back, allowing the valve to expand right into place. We're giving a little injection here and you can see the position looks quite good. The markers are lined up basically with the bottom of the valve. If anything, it was a bit high, and you see that Dr. Kemp, our surgeon, advanced the valve a little bit. Now you see there's some parallax. The 3 valves aren't in the 3 dots aren't in the. Same plane for that valve in the three leaflets. But as we come back, we can get to a stable spot where initially there's a stop and you would have to press the button to go further. And here we have a functioning valve. We're going to take another picture here. We take a picture and we're really focused on that non coronary cusp, and you can see the dot there is aligned perfectly. That's on the left side of the screen, right where the pig is. You can see the dot marker and you see the catheter really aligned. Now, we're very carefully analyzing, you see, the patient has stable blood pressure. Uh, every time they cut off to draw an ABG it it drops, but you see it's generally running about 110 when we have the valve in. It came down a little bit there, as we're recapturing here a little bit to try to get a better position. So now we have temporarily a non-functioning valve, but now the pressure's already rising. You see, we have time to redeploy perfectly. We wanted to get just a little bit lower because of that one high dot in our previous discussion. And so here we're a little bit lower, you can see, just between the bottom of the pig and that pacer wire, and now operator 2 is again deploying the valve in position by counterclockwise torque on the system. We counterclockwise rotate and we come up slowly. We're giving little puffs as we go to make sure we're in the position we want. You see, blood pressure is very stable. And here, if anything, we're a little bit intentionally deep, knowing that with the last deployment, we thought we were just a little bit high. I love the alignment with that dot in the non-coronary cusp, just below the pig this time. And again, we see the same parallax, the three dots that are markers of where the cusps are, and the commissures specifically are Focus one along the other along the other. Now we're going to take a picture now that we have a working valve, and that looks really good. Our whole team really appreciates that we slowly and cautiously took our time to find the perfect position. Now we're going to roll over to an LEO position and you see we're aligning the dots as we do this. So we have a sort of coaxial alignment and we'll take another picture. Now we're focused on the right side of the screen, on the left coronary cusp. That is a nice implant. It looks good. It's below the leaflets. Um, it's not very low, so this should give us our best chance of having great human dynamics and simultaneously reducing our risk of need for pacemearer. And in fact, you see the patient has a stable rhythm. Now we're rapidly pacing again at 110. We press the button, and now we're slowly, counterclockwise. Rotating the handle so that we can deploy this system. And it's a nice, slow, intentional maneuver. There's no tension on the system. Operator one really has released it and is gently holding on but exerting no pressure forward or backward. And now you see the alignment of the markers. They look absolutely beautiful as they're coming. We're gently and slowly going until we see all three of our tabs released. We're focusing down so we can see the tabs. Now we have release of all three tabs. We bring the wire back into the system and gently we'll bring back the delivery system. We want to bring the nose cone gently through and then recapture it once we're in the descending aorta. We have a functioning valve now. We leave our wire across in case we have to post dilate. The next step is we advance our pigtail catheter and we've taken a nice picture. There it is. We see no aortic insufficiency, it's good forward flow, and so at this point, we'll be ready to withdraw our safari wire from the main system. And we'll take an echo. You'll see the echo on the upper right, and here we still see the wire across the aortic valve. We're looking at a number of things. We're looking at left ventricular function, which is good. We're looking for the presence of an effusion, which there is none. And then we're going to really assess the valve, and when we look at the valve, we're looking for any unusual flow patterns. We're zooming up and seeing if there's any pervalvular leak or intravalvular leak. We don't see any here. There's nice flow acceleration through there. There's a little bit of left ventricular hypertrophy, which is not unusual in a patient with aortic valve stenosis. And then we'll take a short axis view, we can again see good left ventricular function. We see no evidence of significant effusion here, and we'll zoom right in on the valve. And what we'll see here is as we look, we'll look for any PVL. This is a replay on the left side of the screen of the final open picture of the valve. We see it looks great, and then we'll measure a final gradient by echo. That's so important to do because every subsequent measure will be by echo. And so with this picture, what we can see very nicely is we see a low gradient. Uh, this is just over 100 centimeters per second. And in a second we'll get an actual measurement of what that gradient is. I would expect it to be 3 to 4 millimeters of mercury.
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