Chapters Transcript Video Transcatheter Aortic Case The reason we chose this case. And Matt and Dave and Josh, and I thought this would be a good one to show is last year, we showed you a lot of straightforward tver cases. We focused on structural heart. In the last couple of years, I wanted to show you an interesting case where the interesting part is not the TVER because we've shown you that before. It's again, the concept Matt brought out, which is in this era, cardiac sur surgery, cardiology, anesthesia, ep, structural heart and, and uh the A HF teams are working together to achieve a lot. We wouldn't have done a decade ago. And so let me quickly show you this case. Whenever we bring a patient in, this is an 80 year old who had a severe aortic stenosis and needed a valve replacement. In our multidisciplinary clinic, we review all the details of each patient very carefully altogether. And this patient in fact, was touched by each of the one of us on the structural team you're seeing right now as we decided to replace his aortic valve, we go into these very thoughtful, these are often high risk patients. We ultimately decide to replace his aortic valve. And one other group to call out is our nurses and our A PPS really do all the work you see in front of you to generate the full plan, the imaging around it to pull all this and capture it. So we can have a sensible discussion. In this case, we elected to use a valve called a Navato valve. We're in some trials with this as well. It's a self expanding valve that goes in the, in the region of the annulus uneventful valve deployment just to show you uh Last year, we went through some of this for those that were there and I'm not going to belabor that point, but we very carefully deploy this new valve in the aortic position. It's a lot easier than treating the mitral valve. The aortic valve is a much simpler valve and at the end, we take some measurements, we look at what it looks like and we actually look to see if there's any obstruction or leakage. Here. We're seeing a vein graft light up because of where the catheter is. But very quickly. This is a nice result from a tver much like what we've shown you in the past. This is a patient who at baseline, I moved quickly through but he felt very poorly. He was class 3 to 4 heart failure, severe aortic valve, stenosis, a little bit of anemia as we went further and followed up this is uh six months later, he comes in with worsening anemia and now we do an echo and what we see uh uh what you're seeing in that shot that's playing right now is you're seeing the aortic valve in the center of the screen. It's a long axis view, you see color flow and if you look really carefully on the bottom of the valve, it's right in the middle of that box, you see that bright blue yellow uh area. And what that is is that's some paravalvular leakage. It's leakage around the valve. And the reason that happens, I always explain to patients when this rarely comes up is sometimes the valve. It has skirts to seal around the calcium that there is there. But that calcium can form a lump kind of like a rock in your shoe when you're trying to walk where you can't get your foot down on the ground because that rock is sitting there. And that's what's happening here. There's a rock of calcium. This patient was never a surgical candidate to begin with. And so now he's doing well, but because the blood is passing through there, we're getting a little bit of anemia because the blood cells are being broken up. We have to find some way to treat it. He's not a surgical candidate. And 11 more image there. If you look at this one on the bottom half of that circle, you see that blue and yellow curve again on the right side, that's that paravalvular leak. And so what can we do for this? This again is where it's a real union between surgery, the heart failure teams, the, um, our team and the imaging teams. And so what we decided to do is to plug that up, we have devices sort of like a little tiny marshmallow that you can jam in there and they'll seal in with endothelium. And so Dave Matt, I do this not infrequently. The reason I wanted to show this case more than anything else is I'm gonna show you two more slides and then have Josh come up and show you in an era pass before we had the level of imaging we have. Now this is what we'd be looking at to guide us. So we put catheters in. If you look carefully, you can see a jet of color when we inject a jet goes down through the valve. And that's where, where our paravalvular leak is. It's very difficult to see exactly where the hole is. You can't see it at all. Even when we're selectively near it, you can get a hint that there's flow going past. And ultimately, with catheters, we're able to put a wire through that catheter. And now you'll see, we put a little uh delivery catheter through there and through that, we can ultimately put a couple of wires and put our plugs in. But in the era when all we had was fluoroscopy and the the cat imaging systems with X rays to do this, it was very difficult and that area has really passed Josh, will you come up and show it from your perspective? What what happened next? So in this case, um we can see here there's a long access view. This is all done under te or transesophageal echocardiography, which uh should probably be standard for all these procedures Uh moving forward. I don't think 3D imaging was utilized in this case, but I'm gonna show you examples where it is. Um And so you see a long axis image there, you see um a posteriorly uh originating jet of paravalvular uh aortic regurgitation around this valve and then you see in the short axis kind of the same thing uh the equivalent but probably a higher resolution um that jet uh in a posterior origin as well. So we can then uh under real time guidance uh help locate that leak and, and make sure we're not near a coronary or something like that um and guide some catheters while we do that. Um So what I've placed here and I'll let these all maybe start playing. Um So I, the image on the left here is the image of the um actual their, their catheter in the area of PV L and that's where they're gonna deploy. Um plugs. I've shown some um examples with 3D imaging or 3D multiplanar reconstruction during echo um on the other side of the screen where you can actually see the origin, you can locate the origin. Um You can be completely on foss with the aortic valve and the stent frame of the tver valve um and guide catheters in real time. Um And I think that's really important. There are certain complications. We don't want to be near a left main when we're doing this. Uh We don't want to be near an RC A when we're doing this. And with uh 3D multiplane reconstruction, we can very precisely locate the jet uh with on FOSS imaging. And also at the same time, see catheters and make sure we're not causing any complications or we're not gonna deploy a plug that will either interfere, interfere with the valve itself um or interfere with the coronary. And so here, this is some post procedural imaging just to sh show resolution of the paravalvular leak. Um You can see um some of those echo densities that weren't there before. Th those are the plugs that are actually placed. Um And you see that there's really no um residual leak there. Um So this is a nice example of how we can guide um certain procedures in the uh in the or the hybrid or Cath lab. Um For a really good result for this patient, I'll make just a plug for um 3D guidance of, of structural heart procedures here as well. Um These are a couple of cases we've done uh at least on the left side screen within the last couple of days. Um This was a degenerative Mr case, you see a nice um P three prolapse and flail there, you see a huge jet of mi regurgitation that takes kind of a anterolaterally directed jet. Um And then you see the bottom images here where there's actually a clip in place, we've clipped that pathology directly. Um And we have, you know, maybe mild uh residual mi regurgitation. So it's a really nice example of what we can do. Um The alternatives for this, this patient was high risk for surgery. Um You know, the alternative is an open heart surgery and a and a high risk gentleman. Um We've provided a really uh nice durable outcome there. The other thing I'll show you um next to that are images of guiding um catheters and, and Tricuspid clips. And so you can actually see the catheter coming in from the IVC there um directly over the Tricuspid valve. Um And then another image there that is kind of a Floro equivalent. Um I remember showing this case to doctor Summers where we were looking at flora at the same time and, and this kind of perfectly mirrors that image as well. Um That shows the catheter again coming in from the IVC directly hovering above the Tricuspid valve. And this is how we um look for, you know, appropriate orientation as we go to uh clip these valves and, and try and repair them. The last slide there um is left atrial appendage, uh anatomy. Um And this is, you know, specifically relevant in wa uh watchman cases or uh occlusion cases. Um The point being that uh with really high fidelity, you can um guide people with these procedures uh or guide your interventionists with these procedures and really assist um in having uh better outcomes In my opinion. Um I will skip this slide for the sake of time, but I will just say that, you know, it's inter we are, are now kind of equipped to do just about anything in the structural lands uh landscape. So we do left atrial appendage uh occlusion. We do per device closures if there happens to be leaks after those. Um We do everything on the mitral side from balloon valvuloplasty to uh edge to edge repair to TMVR. As Doctor Summers just spoke about um uh percutaneous annual plasty uh as well. And then PV L closures if they're needed for, for uh surgical cases. Um on the Tricuspid side, same thing, we're waiting on some therapies there, however, uh able to do repairs uh with TT or um and then aortic as well. Now getting into the aortic space where we can treat aortic regurgitation with uh catheters as well with the, with the uh new Yena valve. Um and then a couple of uh transcatheter pulmonic cases. So really we, we run the gamut, we're able to take care of really complex cases uh as you guys have seen. Um And it's an exciting time to be instruct. So. Published November 14, 2024 Created by Related Presenters Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile
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