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I think it goes without saying that root rupture, I think, is probably the most catastrophic thing that we can see in tavern, and I shouldn't say can see in tavern, that we will see in taver, OK? Fortunately this is a relatively rare phenomenon. And it's roughly, you know, the amount of overall conversions we have to do to surgery while they're not entirely just from root rupture is about 1 in 400 to 1 in 500, so you do the math we do about 500 tapers a year we're gonna have one or two conversions, OK. Some of the conversions can be for things like valve migration can be for um an obstructed coronary that's unable to be open. It can be from an aortic dissection, but by far the most common thing that can happen is a root rupture. So thinking about the anatomy of the aortic valve, the whole reason taver works is we have calcium in the valve in the annulus and in the leaflets, and that's what we use to anchor the taver valves, right? Because without the without the calcium, essentially we can't do a taver except for specially designed valves that can attach the leaflets like the trilogy, the Yenna valve, um, that you've seen us do, and we're gonna do a lot more in the future. So the question is how do we use that calcium but not have it be. Hindrance and one of the reasons why thankfully knock on wood, everybody knock on some wood, our rate oh that's great you did it that's amazing um thankfully one of the reasons why our rates are so low really comes into the preoperative planning. So for a lot of you all in the OR you don't necessarily see this, but one of the things that we do, and I'm very thankful to have Doctor Cohen here for advanced imaging and all the APPs that go through all of the CAT scans is in the preoperative planning we look at what. Of annuus somebody has, how much calcium there is if there is, you know, if there are adverse features that make a patient at higher risk for root rupture, we're actually taking it one step further. I can't talk about all the details, but we've got some AI modeling which can even predict this even more so than any of the humans in the room that we're gonna hopefully roll out starting in 2025. So as with most things in a procedural specialty, getting good outcomes and reducing your complications starts with your preparation. So all of the valves are calcified, not all of them are calcified in the same way, um, for those that attend MDBC or those that actually look at the CAT scans, you know that the calcium for aortic stenosis isn't necessarily just confined to the annulus itself. It can creep down um onto the mitral valve, which we call candle wax or sort of calcifications. It can creep down into the LVOT along the septum and for those in the. You know, we can take out all that calcium, right? That's why we use the up biters, all the ranjours we can take all that out for the taber valves we can't, and again we need that calcium to anchor, but sometimes that calcium can be a little bit too much. So the very first step is taking a look at a patient's calcium pattern. um, we can predict reasonably well as humans and hopefully even better with AI which patients are going to be at higher risk for that calcium causing a root rupture. So how does the ta valve cause a root rupture? There's two different types of valve systems. I know you guys see us use lots of different valves, but essentially it comes down to do we expand the stent and the valve with a balloon or is it a self-expanding where the properties of the metal and the frame itself, you know, expand and conform to the annulus? There's pluses and minuses to both approach um, which one do you guys think has the higher rate for root rupture? Right, so why would that be? Right, exactly. So it's, it's pretty well known that balloon expandable valves have a higher risk for root rupture. Um, do self expanding valves have a risk for root rupture? Yeah, so where, where are the couple different places where a self expanding valve can cause root rupture? So with the balloon expanding valve we said when you, when you put it up, that's when the calcium gets cracked and it can cause a root rupture. How about for a balloon expandable valve? The self expanding. I'm sorry, yeah, yep, so it can be at the tines and the tines are up in the basket that would more cause an aortic dissection, but what, what's one thing that we do in the procedure room? Do what? so capturing and recapturing and one thing that we do, um, not infrequently for self expanding valves, but we don't have to do for balloon. Yeah, balloon before or post dilate exactly. So there's a little bit of a fallacy that the self-expanding valves have no rate of root rupture. It's really either in the pre or the post that that those things can happen, OK? So what happens when a root rupture occurs? So calcium at some point in the annulus or superannular or uh infraannular essentially breaks off from the annulus and the annulus is part of the fibrous um skeleton of the heart, but the calcium can actually rip that root apart so a couple things. You can see and I've seen all of these things you can have calcium near the membrane a septum rip a new VSD. I remember we had a case where we were all, I know you guys all remember that case, we were all happy valve implant went great and then Tanya, I think, was doing the echo afterwards as we were talking to the family and she found a VSD, so that's something that can happen. Um, most of the root ruptures we notice very quickly because most of the root ruptures occur when the aorta actually tears and now all of a sudden you have blood in the pericardium, OK? And the reason why it's important to talk about these things is. Although a procedure can be as easy as 45 minutes, you know, needle out of the door, it can also be 4.5 hours if one of these things happens, and it's why it's important throughout the procedure that we're sort of always on our game and you know we're never happy until the patient's home. Well, we're never happy until we make sure that everything is OK like this. So when a root rupture occurs, it is the definition of a taver emergency. It's even more so than vascular complication in the leg, frankly, even more so than embolization because usually with embolization we've got time to snare, get another valve, figure out what's going on. So you have immediate hemodynamic compromises and most of that is from blood in the pericardium. Some of it is from the valve itself or some of the calcium can obstruct coronaries or if the valve isn't actually working you can have AS or AI in the setting of all these things um so what you'll notice when we have a root rupture is we're always thinking is this a root rupture right? Hoping it's not, but you always have to be thinking about it, uh, in order to be able to diagnose it and treat it. So for those of you in the taver room when we're concerned about a root rupture, what are some of the things that we do? And that this isn't this isn't a quiz to prove what you know or what you don't and I kinda wanna know what everybody's thinking about it. So, so Darren, I'm gonna, I'm gonna call on you. um Summers and I are doing a taver and we're worried that there's a root rupture. What are some of the things we're gonna be asking you or asking the cath lab staff? Well, we're gonna. Pull up to the field and get ready to open. Yep, that's right. And so it's gonna be your, I mean from, from a surgical tech standpoint it's gonna be getting your your perfusion tubing up and getting the right cannulas to cannulate whatever that's through the groin or if we think we have enough time we can do it centrally um. You know, get in evacuate the blood and cross as soon as possible, so we stop the bleeding. Exactly, and this is where it's really key and why I love that we've had these sessions to get everybody on board because there's things that the surgical team's gonna do and there's teams at the cath lab, uh, things that the cath lab team are gonna do as well. Um, what are some of the things for the structural and cardiologists here? What are some of the things that the cath lab team is thinking when summer says I'm worried about a root rupture. We're gonna our pigtail down, taking a flu shot. I believe that's actually what's happening. Um, we're looking at if this trans catheter fixes. It's probably not, but if there's anything we can do the salvage, um, valve and valve to fix, um, whatever's open, and then we're looking at stiff wires to change out our catheters for the. Yeah. What are the things that we can do, um, Mindy, in between what Darren said, which is the ultimate fix and what Sarah said, which is trying to troubleshoot and fix? What are some of the things that we can do? Yeah, exactly, pericardiocentesis, that's right, um, and if it is a root rupture, the pericardiocentesis isn't going to fix the problem, but it's gonna temporize it and allow us to do what Darren's talking about so. Not every time there's blood in the pericardium where we see in a fusion, is it a root rupture, but in the back of our minds it's a root rupture until proven otherwise, right? So the sequence usually goes, OK, we see an effusion um, gotta make sure it wasn't there before because a lot of these patients have heart failure but if there's a new effusion, we'll sit there and watch it for a little bit if there's any sort of hemodynamic compromise, one of these guys will put in a pericardial drain, right? And if it's a simple wire perf, sure it's gonna be blood, but it won't be re accumulating when it starts re accumulating, that's when our senses go up even more and we're more concerned about a root rupture. So what are actually I'm gonna ask the cardiology group because I know Darren knows this and the rest of the OR team does too. What, what are the ways so uh Summers and I do a Taver we're worried about a root rupture. He puts a pericardial drain in it keeps bleeding and bleeding and bleeding and the effusion keeps growing. What are the different ways that I can get on pump? You're talking about uh central versus peripheral, right? Yeah, exactly. I think from our end it's perfect. What, what time do you think that you need you need to have to mobilize your surgical team to get in the chest because that's where we have our role before and I think in the order of priorities we should already have the pericardio. on the table if we see an effusion and just as Doctor Kemp said, we're gonna notice that as hypotension after that effusion immediately expanding effusion, and then it should be intubation TEE to look at the anatomy and see what continuation this is from annular rupture. DSR, all of these things are continuing, um. And we should be actively upsizing our sheets, getting the taver out, making that an arterial cannula, getting our pacemaker out, putting in a large Phoenix, two Lundquist wires and give them the ability to get their things ready and then get out of the way. So yeah, that's from my perspective. I honestly think you said it perfectly. I mean this is where teams have to work together in concert, right? For anesthesia, this stops being a tiva or a. That case and it's an intubation get a TEE. So while they're working on that, you know, you guys are working on the pericardiocentesis. I'm working with Darren and everybody to get the lines up and get ready to go on pump, uh, in general, if we can cannulate centrally, it's better for everybody because there's not a large bore, um, as we've seen in the in the cath lab before, even large bore cannulation and or perfusion can cause troubles, um, sometimes we don't have that luxury. So if a patient's really crashing. We have a large bore side which can easily be upsized for an arterial sheath and to Matt's 0.1 of the things that's great that you guys can be doing is already dilating for a Venus sheath where we put in our pacemaker. OK, that's the, the patients are resting and we have no time. We just have to get on pump and do it, um, and the root ruptures that I've been, I've been a part of thankfully again knock on wood we've had a little bit of time so while all these things are going on, you know, Darren's getting ready we've got the sternal saw and everything like that. And then we get in there. So what do you think we see when we do a sternotomy and there's a root rupture? like a sac. Yeah, exactly, we see hemo pericardium and you know I, I appreciate you saying that like do this and get out of the way. I actually, not that I want these to happen when they happen, you know, maybe scrub out, but, but just, just stick around and see kind of what's going on because I think you'll get an even better sense of what's happening. So essentially you have free blood that's coming from the heart, from the aorta, from the annulus, from that complex everywhere and the first step is getting on pump, right? So I remember one case. Actually I think it was the first uh root rupture I had, and this was with Mahoney, so it was probably 4 or 5 years ago um we we had blood that was in the pericardium we had put a pericardial drain and it wasn't profusely bleeding, but we would drain it and then 10 minutes later it would reaccumulate so sort of slow reaccumulation. And so we had some time, so opened up there was definitely some blood in the pericardium, had the time to Darren's Point to centrally cannulate, which is always easier for us and better for the patient if we can. And then there was just sort of bleeding coming from the aortic root and it honestly was coming down the epicardium, so didn't necessarily know what was going on but not something we could put a stitch in. So what what happens, you know, in those cases is it's a nice slow leak. Sometimes it's a very, very brisk leak and to Darren's point we just have to get in there we have to get on pump in one way, shape or form, and we have to clamp. So the important thing to remember, and for those of you guys that go to MDBC is this takes what what could have been a low risk AVR or even an intermediate risk AVR and certainly a high risk AVR and the rule is you typically multiply their risk by 3 if it's an emergent salvage, and that's part of the reason one of the things we use. For our calculus and trying to determine whether somebody is a bailout candidate. I mean, don't get me wrong, nobody wants somebody to pass away on the operating room table, but there's also realities of it, right? Somebody with an STS of 20% going in if they're gonna have a 60% with a salvage that person likely isn't going to be, um, you know, a bailout candidate, but the person who's, let's say 5%. It's intermediate risk before Taver these people would get operations every single day of the week. That takes them from 5% to 15%, even 20% for a salvage. So now you all of a sudden have a situation where somebody would have been intermediate risk and now they're really, really high risk, and that's not to say we shouldn't do it, but just to, you know, imply how emergent and how risky these cases are. From a surgical standpoint, when we do a surgical AVR, it's a pretty simple operation. We go on pump, we clamp, we stop the heart, we open up the aorta, we cut out the valve, put our sutures in, put a new valve in, close up the aorta, and we're done. With a root rupture, all the, all bets are off essentially because we don't know where the root is ruptured. We can get a good sense on TEE about what's going on, but really until you sort of deconstruct the anatomy, you don't know what you're having to deal with. So from a surgeon's perspective, first, a number one stabilize the patient to go on pump. Once you're on pump, there's a mantra at Hopkins. Uh, rule number one in cardiac surgery is the pump. Your friend, right, because when you're on pump, the patient's supported, stabilized, we can all take a deep breath and focus on what we need to do but when you're on pump, you still have to fix what's going on. So in my mind I just know this is more likely to be a major reconstruction than a minor reconstruction and that's really why it becomes sort of a triple the risk and it can take even a low risk and make them high risk because that's what we have to do. The reason why the mortality is so high for root ruptures is sometimes I'll be quite honest, you just cannot put together what has been ripped apart, OK? And there is no worse feeling in the world as a surgeon to have to turn off a pump because you cannot fix what's going on, but going in we know where the problem is, so what are some of the ways we fix it? I've had 3 root ruptures um that I've operated on in room 5 and I've had 3 different fixes, right? One of them was that VSD and that fix was a root because the annulus was actually disrupted and I had to reconstruct it and then fix the VSD. I had one where fortunately the annulus had ruptured in a place where I could reconstruct the annulus the aorta didn't tear and I can do an AVR and then the other one had to end up doing a root just because that's how much of the tissue had been destroyed by the calcium, um. The other thing to keep in mind too is while room 5 is a full operating room, it's not room 6 it's not room 3, it's not room 2, right? It's a room that's really set up for hybrid procedures that can do surgery, not one that we ordinarily would do surgery and if we had an elective case, so. It can be a lot tougher to do it in that um and then obviously these, these patients are in for sort of a long haul, um, in terms of getting them out the mortality in in the literature, what do you guys think it is for root rupture? Just all comers, not at an experienced taver center but all comers. Yeah, it's, it's pretty close to 50%, yeah, and I will say as, as good as our teams are ours is around 50% as well. It's just, it's one of those things that we fear and it's one of those things that can be difficult. I will say I'll put our team, the OR team, and the cath lab team and the structural team and the surgical team up against anybody in the world, um, in terms of how well we do, but that's really how serious it is, um, so I. In summary, you know, root rupture is the most feared complication that we have. It absolutely has the highest mortality. The best way to prevent it is, or I'm sorry, the best way to treat it rather is to prevent it. So that's why there's so much that goes into this, and I really have to give kudos to our APP team, to our advanced imagers who do all of this work before we even decide about a valve, before we even decide. Approach to make sure that you know these patients are going to be safe for Taver and in fact we've actually had patients where although they'd be a perfect candidate for Taver otherwise size, anatomy, no other concomitant surgical needs we've actually switched to surgery so that we could take out that chunk of calcium instead of having that chunk of calcium hurt us and that's something that we've learned through time and I think you know internationally we're learning in time too. When a root rupture happens, it's all hands on deck. It's every team needs to be there. This is not something that just Darren and I can do. This is not something that just Matt and Sarah can do. This is not something that, you know, Schinderley and Ellen can do. It's absolutely everybody at once working together to get these patients through and although it's 50%, that's the patient on the table, and you gotta do what you can do to get them through. Yeah, please. Um, for us when we're doing the imaging, um, and we see porcelain aortas, are there specific areas that we should look at for like that would be prohibitive for cannulation or is it just in general? No, no, that, that's, that's very good. So to me, to me, when I look at, well, when I think about root rupture, I don't worry so much about porcelain aorta. um, porcelain aorta comes to, um, how are we going to reconstruct this if we need to do surgery. So what I do is take a look at the. and if it's truly porcelain and if for those who don't know, it means essentially circumferential calcium so it looks like bone on CT window for those patients they generally can't be centrally cannulated and oftentimes if they're really porcelain, I'll be honest, you can't really reconstruct the aorta either, um, so looking at the CAT scan, it's important to note that, um, not so much for candulation because, um, another unwritten rule at Hopkins is there's a reason God gave us groins, right? We've got access to cannulate that was not on the list, um. So we, we can almost, you know, if we can get a catheter in for Taver we can, we can get on pump that way. It may mean it'll be difficult to reconstruct, but those are the things that I look on CAT scan when I do taverse, so I know all of my options before going in. Yeah, that was a good question. One of the reasons we were looking at. size of cannula just to flag our mind if we do have an emergency of two things rupture coronary inclusion are the ones where you've got to get on the pump right away and usually peripheral, especially if there's all this uh force in things like that. So that's why we talk about it up front, um, that was, that was great, uh, I, I think like you said, the, the planning is key. Our last root rupture is January of 2023. We had a DSR and a PDA. Yeah, a little bit, but the reason that it was so long ago is because we shifted from 40%, 45% uh self-expanding valves to almost 79% when Kemp and I looked at this two years ago and we, we decided what is our most catastrophic complications and how do we avoid them. We saw coronaryclusion and annular rupture. Annual errupture, just for a frame of reference, the. Units I'm not quite sure about but relative force, acute outward force for these valves just for a frame of reference, a BAB, how we do it conservatively is in the 200 range. A Sapient is 400. A self-expanding valve like a evolute is a 75 range. When we post dilate, we're post dilating into a men number and so it's still a conservative post dilation. So just with an eye towards balancing annular ruptures we make a valve selection, and we're usually balancing that against pacemaker rate and then PDL risk by an intentional focus on us saying look. We want durability. We want safety on the front end, and we want the ability to treat people on the back end. We adopted a way of picking these valves where. We're comfortable doing coronary protection and leaflet modification for the coronary issues. We are more comfortable with our valve selections as far as avoiding any rupture, and now that we've we've had a decent volume of experience of expandables and self-expandings, we know we can treat them in 15 years. And so all of that, like Kemp said, is a pre-procedural avoidance of these kind of catastrophic things, and it works if you do it in a sophisticated way like we. And it's also important, I mean, you know, when you go when so all patients go to Doctor Google, right? You guys know that you see it, I see it, and they know that they're candidates for tavern. They haven't seen their CT scan yet and it's a difficult conversation to have with somebody where I know you want a taver, but let us talk to you about all these things that are going on why we don't think there's a taver. I will say, you know, there's. Some disappointment for sure, but then once the patients see how much thought and planning has gone into it and what can happen if we don't do it the way that we think we should do it, I, I haven't had a patient yet that's excited for surgery, but they at least understand, you know, OK, I get it, you know, and the next time could be a tab, so yeah, Joe on the um. Conversion. Do you guys typically like having the A and the B line on the same leg? Good question. Um, in, in an emergency, I don't care. I just need an A and a V, and we go on. And the sheets are, um, part of the er kit, right? They're not, we're not pulling out like 12 sheets that are just normal I mean there's. No, OK. So you know, actually I'll I'll go into that because it'll be good for the cath lab team as well. Here, um, so in an emergency, any A and any V in the groin is gonna work, um, if we have time, I'd like to have them separate because if you have the arterial and the venous on the same side, you can get congestion and these can be long cases, um, to answer your other question, so, um, we've started taking to naming what peripheral cannules we want and having them in the room so we're right ready um almost everybody for a taver can get. By with a 1416 or 18 arterial cannula. Conveniently we've got 1214, and usually 14 and 16 sheets so that's an easy conversion on the arterial side for the venous side it depends on how big the patient is, but it's usually a 25, 27, or 29 French. So that's where to Matt's point the arterial we have already, right? That's either the inline sheet. Or it's either thee sheet or an inline valve delivery system that can be easily exchanged for the other side, it takes about 30 seconds to dilate up. So if while we're getting the lines up, you guys can go ahead and put in, you know, whatever size sheet that we can hold as a placeholder or even just put a dilator in there to hold, then we can go right on. That's that's the one when we see it, we say annual rupture and cancer organizing scene. We get the taver system out if you if it's an evolute you put back in the sheet. And we upsize our our 8 beats on the other side. That's the reason we get the contralateral 8. We don't need an 8 there anesthesia you can put in line. Um, the only, the only reason we put those in is for pacemaker, which we could obviously get from a neckline too, but, but to have it as a backup for conversion that's a good point because there has been times where I mean maybe it's rare but we haven't gotten a Venus line because we've got an active fixation up front. Every one of those cases we have to think about what the risk is we've had to in conversion switch over and get a venous line. It's not terrible, but it's also not something you want as an extra step in the middle of all of this with CPR ongoing or things like that. So by and large every patient going through, this is the minimness approach, but it's it's approaching our setup. Um, should have a contralateral 8, that we're giving to anesthesia that we have for a pacemaker and that we can convert very quickly, putting a stiff wire up to it and then dilating up, just get a big sheet and then. We leave those two Lundy's in the A and B and let Doctor Kemp put them on. That would be. So if we do a place holder 5, that's fine as well. Yeah, yeah, yeah, because all, all we need is a stiff wire and we can dilate. Um, I don't know if there's a way to ask anybody who's watching upstairs from the surgical team if they have any questions. I can see you, Risa, and I'm assuming there's some other folks there too. Does anybody have any questions or comments from up there? All right. Well, thank you guys. Appreciate it. Published January 7, 2025 Created by Related Presenters Clinton Kemp, M.D. Sentara Mid-Atlantic Cardiothoracic Surgeons View full profile
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