Hi everyone, that's a, that's a very kind, uh, introduction. I appreciate that Dennis. So, um, as mentioned, I'm Josh Cohen. I'm one of the, uh, advanced imagers kind of embedded in the structural heart team as well, um, and so I'm privy to kind of everything that goes on in those discussions. Um, what I thought I'd do is maybe take us from the point of diagnosing severe AS that, um, Doctor Zivatowska beautifully talked about and then, uh, move into, so what do we actually do? How do we decide on what to do for patients, um, what happens kind of during procedures? How do we plan that, and then how do we move forward after that and what do we look for? Um, I tried to keep a, a little bit of a primary care aspect to this in the sense of, you know, what, what things are important after TAVR in case things are missed, medications, um, rhythm management type stuff, um, and what are some red flags? What are things that we, we may see that if they're, if they're missed by a cardiologist or the patient for whatever reason doesn't have follow up with a cardiologist, um, you know, what are things that should prompt, um, you know, re-referral or someone reaching out? So my disclosures, I do um some consulting um and national educational advisory boards for uh Phillips, Abbott, Medtronic, and then more recently Murmur MD which is an online platform for education. Um, so the outline here, so current day TAVR, who should get TAVR, um, how do we plan this? So the typically that's with, uh, an advanced imaging test called a cardiac CTA or a TAVR CTA. Um, how is AI coming into this conversation now, which is, it's, it's really kind of become embedded in our day to day, um, and I'll show you some of that. What are the currently available or FDA approved platforms that we use and that we choose, uh, from? And then what are post-procedural considerations? So, um, you know, pacemaker rate is a common topic that we often talk about and is different with different valve platforms and with different patients and anatomies. Uh, PVL or pervalvular leak rates, um, again, you, you saw more common with TABR than with, with surgical, uh, AVR, and then antiplatelets, anticoagulants post-procedure to keep that valve healthy. Um, and then what are red flags? So, you know, what if the gradients have jumped up? Um, what if we see new aortic regurgitation or leakiness on that valve, uh, neurologic events, anytime someone has a prosthesis in the heart, um, and they have a neurologic event, I, I, I'm a pretty strong proponent that someone should look at that valve or, or that prosthesis. Um, and then infectious symptoms and, and where does endocarditis or infection of a prosthetic, uh, valve come into play. So who should get TAVR, um, more recent guidelines, ESC or, uh, guidelines of 2025 that just came out. I'm not gonna talk so much about what the indications for TAVR are. Uh, I'll, I'll kind of start with the fact that we're at a severe point and then the big question is who gets TAVR, right? So if you have really good surgeons, it's, it's often a little bit of a fight back and forth. Um, and some of that is because we know that surgery provides really good outcomes for people. What we, what we think we, we may provide is that in patients who are elderly or very high risk, or maybe don't have a very long life expectancy, we can provide a, a very, um, reasonably low risk, uh, and life-saving procedure with, with TAVI or TAVR. Um, and so in these most recent guidelines, uh, basically, they took a, a little bit more firm approach that patients less than 70 should undergo surgical aortic valve replacement. Uh, and then patients greater than 70, uh, with suitable anatomy should have, should have TAVI. That's a, a very simplistic view, but, but I think reasonable to kind of start at a cut point of about 65 or 70. Um, I think in our practice, we tend to say if someone's 65 or less, they have to be formally turned down by a surgeon. All these patients see, um, us in the structural heart clinic, the surgeons as well, and then we have a separate meeting after Monday mornings where we discuss all these patients individually. Um, and so you see like what are we thinking about? When, um, when we're trying to decide on valves. So what you'll see here is when people are very young, we start talking about, um, either a Ross procedure that's using a pulmonary autograph, um, and putting it in the aortic position. The classic argument against that has always been that you create a two-value, uh, two valve problem upfront. So if that doesn't go well, you're now dealing with two valve issues rather than one in very good hands and single center data. That procedure provides probably the longest durability of anything. The problem is that's, that's single center data, so that's done by one or two people in the world. Um, that's done by more people than that, but the data is only validated in single centers. Um, there are other things such as not listed here, but something called an Ozaki procedure that's creating your own, uh, leaflets out of pericardium. Uh, or the sac around the heart. Mechanical valve, much more common, so younger patients will take a mechanical valve, more durability there, however, um, obligates, uh, lifelong anticoagulation, uh, which a lot of people, specifically young people, don't like. Um, and then bioprosthesis. And so these are all things going through our mind as we are trying to make these decisions with and for patients. Um, and then what are things that favor SAver or favor TAVR, um, and what you'll see is, you know, a lot of this actually depends on the anatomy, the patient risk, and what we think, um, kind of like their lifelong plan is. So lifetime management has become a big term in TAVR, and what that really means is, you know, if someone's 60, 65, 70 or so, the likelihood is they're probably gonna need more than one intervention in their lifetime. And so the question is how do we get them there, uh, with as little risk as possible, what, with as much benefit. Um, and that's often a very complex discussion. Do they undergo a surgery, an open heart surgery first with a plan for a valve in valve TAVR after that, um, or do they get a TAVR now, a TAVR after that, or a TAVR now and a surgery after that. And so there are a lot of discussions back and forth about what that means for patients. When you look at the ACC or AAH uh AHA guidelines, these have not been updated yet. Last was 2020. The Europeans do a bit of, uh, bit better job about updating these more frequently than we do. Um, and so you see here the cutoff is 65, anywhere 65 to 80, we think back and forth heart team discussion. Um, we've definitely taken, you know, 70s, low 80s to surgery, uh, if it's warranted. Um, and then age greater than 80 or so, uh, we think Tavi or Tver is better. And I'll show you some of the things that push us one way or the other, what the considerations are. So, what's the pre uh pre-procedural planning for this? Um, most, almost all these patients undergo a right and left heart catheterization, right heart catheterization to define the pressures in the heart, um, and understand if these patients are kind of optimized on their medicines as well. Understand the efficiency of the heart, the cardiac output, and cardiac index, and what the pulmonary pressures look like. These all go into indices of risk, um, when we are trying to figure out what to do for them. I put plus minus BAV there as well, um. You know, in patients who have kind of come in later stages of the disease, so they're already passing out, um, or they have critical AS, right? Their gradients are super, super high, um, or they come in with decompensated heart failure. A lot of those patients, we will balloon, um, upfront. And what that means is we actually just put a balloon across the aortic valve. What you can see there's, there's kind of a hinge point of calcium where that valve is really tight as it's opening up. And then you kind of see it crack and the, and the goal there is to crack the calcium, open up that valve in a temporary fashion. Usually those results last about 3 to 6 months or so, and that buys us time to do the rest of the procedural planning to then have a patient undergo a definitive fix, um, at a later time. And then, you know, other things we can do. So if you look, uh, down here at the T, so this is a 3DT you're looking at the aortic valve on FOs. What we can do if we're unsure about severity, one of the really good measures we can look at is when we go to the leaflet tips here, we can measure an aortic valve area. That's a nice way of actually looking at an, uh, an orifice area without calculating it. All the things that uh Doctor Zivotofska showed. We're, we're basically, and that, that is the gold standard, but the continuity equation, we use physics to try and understand and estimate that valve area. This is a way to actually measure that valve area. So is the valve area, you know, less than 1 or not, uh, kind of period. You can also use cardiac CT. You see those two images at the bottom here. This is CT. We can see that valve opening and closing. You can see 3 cusps of that valve, some calcium on the valve. You can see that its motion is restricted. Um, and so these are all kind of additional tests that these patients will get. What we're looking for is we're looking for, um, The, uh, vessels in the legs, what we want to understand is, are there access points to deliver the valve? Um, sometimes we'll actually do up to the carotids as well. We, we have alternate access sites where if patients are not feasible from the groins, we'll do carotid tavers, um, as well. Um, and then uh TE and Tver CTA. Great. So, uh, more procedural planning here. Um, so these are kind of the classic measurements that we do for TAVR patients. When we go over, uh, patients every Monday morning, this is all on a slide. So patients' comorbidities, their, um, you know, risk scores for surgery, uh, their EKG, their labs, all this, and then all of their CT data to understand, um, what, what are the risks of moving forward with the TAVR versus should we be proceeding with a, a SAVI. I'll try and explain. Some of that here. So, TAVR CTA we get 4D imaging of the heart, right? So this is a real-time kind of cine image, as you just saw the valve opening and closing. We get vascular imaging of the abdomen and pelvis to understand what the access sites are. That would be here, right? So you see the aorto iliac vessels coming down, we see calcifications, we measure luminal size to understand if we can deliver a device, um. We do an aortic valve calcium score here. Again, you saw that that was one of the metrics to understand severity. So that's done on all our, all of our TAVR CTAs. It also helps us understand where the calcium burden is on the valve to help understand or predict risks of, of adverse events during the procedure. So if there's heavy, heavy burden on one of the leaflets, you run the risk sometimes of pushing that calcium into a coronary, and you can run the risk of a coronary obstruction, which is a low rate event, but a very high risk event to happen in a tavern. Um, we measure the aortic annulus. OK. That's how we actually size valves. The other thing we do is we're looking for what that annulus looks like. So is this annulus hostile? Are there areas of calcium? There's a little area of calcium here. Are there big jutting out areas of calcium that actually plays into risk for what we call annular rupture, which is kind of a dreaded complication of TAVR as well, very high mortality. And those are things that, you know, when we see that, we say maybe this patient is better served by surgery, even if they're, you know, 78 or something like that. If the risk is too high, um, For, for that particular reason, it may be that doing surgery is a better option there. Um, and then just more measurements on the valve. The other thing we do here is we measure coronary heights, so height above the annulus, or the, the kind of virtual ring where that valve sits. And the reason for that is to understand when those native leaflets get pushed to the side by whatever valve we put in there, is there a risk of what we call coronary obstruction? So are those native leaflets or a chunk of calcium gonna move into the coronary and cause coronary obstruction, or is the valve platform itself, because the coronaries are not high enough, uh, going to obstruct the coronary arteries? All right. So AI based simulation, how does this come in? We, we were pretty early adopter of this, and this is still very new. So we, we partnered with a company called Dassey Simulations. Um, and what they were very smart about upfront is that they modeled valves based on CT scans. Uh, and artificial intelligence to understand, um, tissue deformation and how a valve platform will actually expand in someone's native uh anatomy. And so what that means is, if you can do that, you can actually predict all the adverse complications of TAVR that we try and predict with our typical measurements. So for example, when you expand a valve in there, what are the native leaflets and the calcium going do? And is there a risk of coronary obstruction? And then you can go back and validate that data to understand or create biomarkers or actual measurements to say, hey, you know, this is the measurement for this, there's a high risk of coronary obstruction. Um, the other thing you can do is you can understand how much it's gonna stretch the space, and is there a risk of actually rupturing that space. So, um, that's the stretch analysis here. And then, uh, apposition, so is it gonna completely cover the annulus? If it doesn't, you're at risk of PVL or pervalvular leak. Again, one of the things that is more common with TAVR than SAR. And so one of the things we're trying to reduce, it doesn't help a patient a lot if you go in and fix a tight valve and create a really leaky valve, right? Um, I, it's a different problem, but it's not a good one to have. And then lifetime management, you can see there are actually two valve platforms in there, and the, the question then is when you put in a new valve inside another valve, same thing, are you at risk of coronary obstruction and what does it actually look like? I'm gonna see if these will play. They may not, but. Any chance we can have the AV people play this on the slide? I think you just have to click on them individually. Yup. So you can see that valve expands in that space. You can see what happens to the native leaflets. That arrow there is pointing to the coronary artery and where that stent frame actually comes close to it. The next one is a stretch analysis. So you can see the heat map there, kind of the areas of red and yellow. So that's looking for annular rupture. And again, there, there are published values for what's, what's understood to be high risk, uh, based on this. And what I'll show you there is you can see as this valve turns around. Here. So right, there's a big heat map here, red is bad, and then there's a big piece of calcium. And what that's showing you is that you're deforming the calcium into the native anatomy, the aortic root, and, and there's a high risk of, of rupture there. You can play the next one. So position, you see up and down these little lines here, these red lines, those are showing where flow may come across the valve and, and where you may actually have PVL. Again, published value is 2 millimeters, 4 millimeters. How big are these gaps and what do they actually mean for predicting pervalvular leak? And then lifetime management, you see a valve within another valve platform, so that's a, uh, short frame valve and a tall frame valve trying to predict, you know, hey, 10 years from now if we have to come back and put another valve in, what are our options and what are the risks of doing that. So really cool stuff. We're, we're kind of on the bleeding edge of this. We use this in all of our conferences now. Um, they're actually coming out with an, with an app as well, um, that's not kind of live stream yet, but I think us and one other center, uh, in the country are gonna have access to that and what you can do is you can actually in real time implant different prostheses, uh, and understand what those, what those metrics do when you do that. So, uh, when we go into our, uh, our cases, our multidisciplinary valve conference every morning, what we're doing is we get kind of a readout like this. And the readout shows you with different platforms, a balloon expandable valve at a 29 millimeter size, self-expanding valve, and I'll show you the difference between these 34 millimeter size. And then it tells you how is this over or under sized for the anatomy. The coronary analysis, again, these are published values that I won't go into, but what you're, these are predictive of coronary obstruction. Your gaps here, these are predictive of pervalvular leak, and then your stretch analysis, um, anything greater than about 1.6 or so, we worry about root rupture. And so it tells you kind of with each platform, what are the risks of those, and then you get like really nice visuals as well to understand what does that valve look like as it's expanding in the space. This one's having a seizure, um. But it, it does that once, not multiple times, and then, uh, different valve here and two different platforms, and I'll show you what, what those look like. The other thing you can do is based on CTs, you can predict where the electrical system of the heart is. Um, based on what we call the membranous septum, and, and the electrical system runs in there and so you can try and plant, uh, or, or try and plan an implant depth, how low or how high can you be to understand where you may actually interact with the conduction system, and that can help predict, uh, the need for, you know, pacer having high degree conduction abnormalities post TAVR. So again, this is just kind of summarizing what we talked about. AI based simulation is now kind of being used in addition to our, our typical ways of doing things for risk of coronary obstruction, coronary reaccess, uh, hemodynamics. They have some things coming out of where we can actually try and predict what the gradients are going to be before ever putting the valve in, uh, annular rupture risk, pacemaker risk, and per valvular leak risk. So the current FDA approved platforms, uh, are Edward Sapien, uh, S3 Ultra Resilient. This is a short frame valve balloon expandable. So it's loaded onto a balloon, you, uh, balloon it open, it cannot be, um, retracted. So you implant, and what you implant is what you get. Um, Medtronic Evolut Pro Plus, this is a self-expanding valve, so you actually just unsheathe the valve and the metal itself, uh, will expand. Um, that is retrievable. Or redeployable, uh, I should say, and is what's called a supra annular valve. So this first one, balloon is an intra-annular valve, goes right at that virtual ring where the, the valve is. Uh, this valve sits the, uh, sits actually above the native annulus, we call that a sup annular valve. And then the Abbott Navator, which is kind of the newer kid on the block, is an intra-annular self-expanding valve if, if we didn't make it confusing enough. So, Um, really what this is, is they all have different strengths and weaknesses, um, and so shorter frame, lower profile, the thought is maybe, you know, accessing the coronaries after that, a lot of these patients have concomitant coronary disease is not so hard, right? Usually it sits below the coronaries. You access them the same way you would if someone has a STEMI or some or ACS after that. Um, larger platform here. The big thought with these is that the valve actually sits above the native annulus, and there's some data to suggest that you get better hemodynamics, and so people will do better and the valve will last longer because you have better hemo hemodynamics through that valve. And then this is Abbott's attempt to kind of, uh, combine the two essentially. And so the post-procedural assessment, so, you know, rhythm monitoring, a lot of these patients will have new conduction abnormalities. The conduction system sits right next to where the aortic valve, uh, is deployed. Um, sometimes there's a pacemaker requirement. A lot of them will go home with a, a month of rhythm monitoring that we will know about, um, you know, if something happens, that's kind of our way of making sure we don't lose people. A lot of times we will get EP or Doctor Patel's assessment to understand is this patient someone who's gonna progress and need a pacemaker or not. Um, echocardiographic assessment, we look at the gradients postoperatively. We look to make sure there's not a lot of pervalvular leak. Um, EOAs, what that means is an effective orifice area. You're using the same continuity equation to calculate a valve area. These are heavily error prone, so I would, I would give a word of caution to kind of using and reporting those routinely in the absence of other things going on, um, post procedural medical management. So I think this is an important point. Um, single antiplatelet therapy has been proven to be better than dual antiplatelet therapy in this setting. Reason is just that you decrease the rate of, of major bleeding and then you don't give up anything in terms of, uh, hard cardiovascular outcomes. Um, our group tends to do Plavix 75 daily for 6 months and then transition to aspirin. There's some retrospective data that maybe that's better, um, as long as they're on a single antiplatelet agent, so 70, uh, aspirin, uh, or Plavix is fine. Um, if they have an indication for oral anticoagulation, they have concomitant atrial fibrillation or something like that, we'll just keep them on their monotherapy with anticoagulation. And then antibiotic prophylaxis, this is really important as well. Um, they need to have this prior to dental procedures, uh, to, you know, thwart off the, the risk of infective endocarditis. Um, and then we tell them to avoid dental procedures for 6 months after their, um, their index operation. Um, and the typical dose there is amoxicillin, uh, 2 g, about an hour before their procedure. So red flags Uh, when the gradients are elevated, so, you know, someone will do a post-op exam, let's say the gradient, you know, a mean gradient through the valve is 5 or so, a brand new valve, there shouldn't be much of a gradient. Um, they come back and see us at 1 month or a year or something like that, and instead of 5, it's now 20. That's a red flag, right? That's something that we should look into. A lot of times it becomes really hard to see the leaflets on a surface echo and so then you start moving towards advanced testing, CT or TE or something like that. That the common reasons for elevated gradients are one, maybe we picked the wrong valve. So patient prosthesis mismatch, is the valve too small for uh the patient's body requirements. That's rare because we have a big eye on that going into the procedure, but it happens. Um, normally, what that is, is the valve is totally normal, opening, closing normally, there's just not uh enough area to support the patient's, uh, needs. Prosthetic valve stenosis as the valve kind of worn out. In the early stages, 1 month, 1 year, 2 years, that really shouldn't happen. Um, so, High, high, uh, bar to, to hit that. High flow state is the patient anemic, newly anemic, bleeding, those kind of things that will increase your gradients through any valve. It doesn't have to be prosthetic. Um, Halt, uh, what you see here, I've included an example on this CT. So HALT is a CT diagnosis, hypoattenuated leaflet thickening, thickening. What it means is basically that you see darkness on these leaflets. All three leaflets here are dark. You can actually see they're very thick. This is one of the more impressive cases of HALT that I've seen. Um, you can imagine that will increase the gradients through the valve because they're not moving because they're what we would call subclinically thrombosis. This one is, is probably nearing clinical thrombosis, but, um, this can often be treated with anticoagulation when it's this severe, sometimes this actually requires, uh, an eggplant and, and a surgical AVR. So we, we try and avoid this, um, obviously. And then, uh, aortic regurgitation. So, then you have to define it. Is it pervalvular, is it around the valve, or is it through the valve? If it's through the valve and the valve is older, that's a, a big red flag. A lot of times, uh, you know, at 78, 1012 years or so, um, you can have a leaflet tear, you can have all those things. And so if you're leaking through a prosthetic valve, uh, that's almost always never normal. So, you know, sometimes there are trivial leaks, kind of where the leaflets come together, that's OK. Um, and then pervalvular leak, uh, those tend to, you know, identify themselves a year, within a year or so, but sometimes they do get worse, um, and what you'll see here, so this is a TEE. The taver valve is in the middle. This is not a bad leak, but if you see here, there's an origin around the valve, so paravalvular leak. This is a mild pervalvular leak. Uh, kind of at the anterior aspect of the valve. OK, just to understand what that looks like. And the reason is we're, again, when, when a surgeon goes in there, they cut out a valve, they sew in a new valve. There's not a lot of place for that to leak when you're sewing it in directly into the annulus. When we put in a valve, we're kind of opening it into that space where their native valve was. There are chunks of calcium, rocks, calcium, and so it doesn't often perfectly sit in that space. And so that's why you get leak, OK. Uh, CVA and then, uh, infectious symptoms. Again, if someone has prosthetic material in the heart, this kind of goes for, you know, in my mind, pacemakers, microclips, Watchman device, all those kind of things. Someone's had a, a, a stroke or is having kind of persistent fevers, night sweats, chills, those kind of things, those, uh, prosthetic devices need to be evaluated and there needs to be a concern for, for some sort of prosthetic endocarditis, um, in that setting. So, um, I think we'll probably open to questions. I've included my email there. If anyone ever has any questions on this stuff gets me jazzed. I'm happy to talk about it to, to anyone. Um, this is our team. This is, uh, I'm gonna place a caveat here. This is just a small portion of our team. Um, this is with a, a recent technology. There's now TAVR valves to treat aortic regurgitation, dedicated devices to treat that. We were one of the first centers, uh, in the country, uh, to actually deploy this technology. It's a really cool technology. It's called the Yenna valve. Um, I'm sure you'll hear about that at a different time. Um, but we, we cannot function at the level that we do without everyone involved. That's echo techs, that's our CT department, that's MRI, that's our imagers, that's our EP colleagues, everyone. So this is just a, a small part of, um, our team, our research team, um, but we, uh, we love what we do and we're happy to see your patients if you guys need us to. So, thank you.
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