In this provider-focused case review, cardiothoracic surgeon Dr. Clinton Kemp discusses the evaluation and treatment of an 89-year-old patient with severe aortic stenosis and multiple comorbidities. Following multidisciplinary heart team review, the patient was determined to be best suited for transcatheter aortic valve replacement (TAVR). Dr. Kemp walks through the clinical considerations, procedural strategy, and key takeaways from the case.
Hi, my name is Clint Kemp, and I'm a cardiothoracic surgeon at Centera Health here in Norfolk, Virginia. Today, we're going to show you a trans catheter aortic valve replacement or TAVR procedure. Our patient is an 89 year old female with the comorbidities outlined to the left. This slide was put together by one of our APPs, and this allows us to get through patients efficiently at our multidisciplinary valve conference meetings. She had adequate access for a femoral arterial approach, and based on her valve size, we selected a 23 navator. In the room, my partner Doctor Deepak Tel Raja is obtaining large bore access and placing a sheath in the left femoral artery. And behind him our lead APP Sarah Kennedy is helping out with the wires. As you can see, this is a team approach. Now the next step is to cross the aortic valve. We're using a catheter that directs a soft wire through the very small opening, and as you might imagine, it's difficult to get across a narrowed calcified valve. Once we're across, we have a catheter in place, and this will allow us to eventually get a wire in position to allow us to deploy the valve. While we're getting the wire in place, I will just talk about TAVR for a little bit. This has really revolutionized how we treat aortic stenosis as we're able to deliver the same kind of results as with surgical aortic valve replacement, but with a lot less morbidity and mortality than the traditional approach. We have pigtail catheters here where we're measuring pressures across the aortic valve, confirming the presence of aortic stenosis. And then the next step is going to be to check the valve and make sure that it's loaded correctly. We do this under fluoroscopy, and this was an excellent load. Following this, we do what's called a balloon aortic valvuloplasty to modify the calcium, both to give the heart some relief from the stenosis, but also to be able to optimally deploy the valve. The type of valve that we've selected is a self-expanding valve, and it relies on the properties of the metal and body temperature in order to seal to the annulus. Now we're bringing the catheter and the valve up around the aortic arch and positioning it across the native aortic valve. We're using the markers on the valve to determine how deep we're going to implant the valve so that we have an excellent result. This step takes 2 people to do, and now what you see is the valve is partially deployed, and this is a stage where we check the hemodynamics to make sure the blood pressure and everything is OK and that we're happy with the depth before we release it, which is what we're doing here. Now we have a fully functional valve. That's working and the patient's hemodynamics support this as well. This is the echocardiogram we checked to make sure that the valve was working well and there's no leaks, and the valve indeed is working well without any leaks. We now check for a gradient and we find in this case that the gradient is low and we have cured the patient's aortic stenosis.
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