LIVE from Sentara Heart Hospital in Norfolk, VA
The Heart & Vascular Service Line Master Series
Transcatheter Aortic Valve Replacement (TAVR)
Originally Broadcast: Friday, April 22, 2022 | 12:00 PM EDT
TAVR is a minimally invasive cardiac procedure for patients with aortic valve stenosis at low, intermediate or high risk for standard valve replacement surgery. Tune in to watch the team perform this life changing procedure.
Hello. Thank you for joining at noon. My name is Deepak. Tell Rage. And I'm one of the members of the Sentara cardiology specialist structural heart team. We're excited to bring to you a live broadcast case of a trans femoral trans catheter aortic valve replacement case. That's trans femoral ta VR. We're replacing the aortic valve in a patient with severe aortic valve stenosis. And you're seeing this coming to you live from the hybrid operating room at Sentara Heart Hospital in Norfolk Virginia. Thank you again for attending during what I'm sure is a busy day for you clinically. But we're excited to bring a case like this to you. What we'd like to start with is we'd like to start with an animation of the Tavern procedure itself. This is an animation. I often show patients in the room as we're getting them worked up for this procedure and this is available on Youtube. I'll be talking as the animation plays the valve that we're using today is made by Edward's Life Sciences. It's the third generation SAPIEN valve. The SAPIEN three valve. We were actually in the pivotal trials along with many other leading centers in the country for approval of the south and we get access to the femoral artery and see you see here a balloon traveling up through the aorta over a wire across the aortic valve that separates the left ventricle from the aorta. The balloon gets inflated and then deflated and then we remove the balloon. For many patients we can do this balloon procedure either independently or right before the Tavern And then we have this large arterial sheath that's placed. It's typically about a 14 French sheath. I'm going to pause for a second here. What we have is through that sheath. We've advanced a Catheter, basically a tube that has a SAPIEN three stent and mounted inside that stent is a delicately sewn in valve. And I'll let you see we take that valve and pass it up into the circulation. And that's what you're seeing. The team due shortly and dr Mahoney dr summers dr kEMp and the team there will be explaining as they do this, we then load the balloon delivery system right into the valve in the body and that's how this has become so small as it's all loaded in the body. And then with the team there in the room using X ray fluoroscope, P and sometimes ultrasound in the time around. That that valve is advanced around the aortic arch which has been carefully mapped out with cT scans and catheterizations ahead of the procedure. During the initial work up, that valve is advanced in position very carefully inside the old aortic valve so that it's just at the right height to seal against that valve and not obstruct any structures like the coronary arteries. We can in very great detail move this up and down and advance it up and around to get it in exactly the right position while we examine this. Then we rapidly paced the heart And use a balloon to expand the valve into place and I'll pause it for a second while I mentioned that's how without putting the patient on heart bypass, we can safely put the valve in place without the valve moving during the inflation procedure. So we pace. It's something like 162, beats per minute that freezes the heart and relative motion and then the valve is inflated in place under visualization. And we actually, what's not captured in this animation is while we do that right before we inflate the valve will give an injection of contrast to see the exact level of the valves. So we can reliably predict the right height. And you can see on the bottom side of this where my pointer is that there is a ceiling skirt, a skirt of, of material that inflates against the old valve and that allows us to make sure there's no leakage around the valve. That ceiling skirt is sewed up to the mid level of the valve and then there's open frames above it so that we can access structures like the coronary arteries during a catheterization. Then, as soon as the balloon is inflated and deflated, we stopped the rapid pacing the patient resumes a normal heartbeat and the equipment is removed. Then we take another picture with the catheterization to look directly at how the valves working and we do an ultrasound to look, then the equipment is removed and the arterial me hole that was made is sealed up. There are multiple ways to do that. We often use either stitches or a device called the manta and immediately the patient goes from severe aortic valve stenosis to having a working valve that will open and close with every heartbeat and the resolution of symptoms. For example, heart failure, shortness of breath and chest pain is extremely dramatic, dramatic. It's a dynamic procedure. On average, these procedures can be done in as little as 45 minutes to an hour or so. There are some other add on procedures we sometimes do around the same time and I hope that animation gives you a feel for what will be seeing in the time to come. The patient's being prepared now and I don't know if if any of our other operators are online and want to jump in and add any commentary to what I've said so far. We have a spreadsheet so we're tracking any questions that are asked and if anyone has any questions while we're getting the patient ready and moving along, we'd be delighted to answer them as a team at this stage, while we're waiting on questions and waiting on the rest of the team members getting this patient almost to where they're ready. Now, I'll share with you as we know aortic valve stenosis is a clinically important condition. It affects both quality of life, severe aortic stenosis results in the three cardinal symptoms of congestive heart failure, by which I mean, shortness of breath, lower extremity, edema, fatigue, lack of energy. It can also cause chest pain and lack of output to the coronary arteries. So it causes my cardiovascular mia and it can cause sync api Passing out of those three. The worst is congestive heart failure. And when patients have severe symptomatic aortic valve stenosis, 50% of patients will no longer be alive within the next two years without intervention. In addition to trans catheter aortic valve replacement, we also offer surgical aortic valve replacement. Another excellent procedure while surgical valve replacement is more invasive, requiring an open store anatomy. It allows concurrent bypass or interventions to the aortic root. We look very carefully as a team. When we work up these patients, each patient is seen both by cardiology and cardiothoracic surgery to decide what is the best and most appropriate procedure for that individual patient to give them the right outcome. And as you'll see when we cut to our hybrid operating room in the operating room is a full cath lab team, a surgical O. R. Team cardiac anesthesiologist and a team of cardiac surgeons and cardiologists together that work together to make sure we get the best outcome possible. We're prepared to deal with complications. For example, we can initiate bypass if needed and in fact, if for any reason the patient needs an open procedure instead of the tavern procedure. If there's something that requires that the hybrid operating room at the heart hospital is fully capable of allowing an open chest and an emergent cardiac surgery or vascular surgery anytime that's appropriate. Fortunately with current generation technology that's rare. What you'll see when we enter the room is you'll see the team, you'll see. We have echo machines, cath lab machines, we have monitoring of human dynamics, blood pressure's heart rates, pacing, we can see visualization by echocardiography and by X ray Flora Skopje to see every aspect of what we're doing. Some of the questions I see already are. How has the Taber equipment involved to what we're using now, our teams were involved in the original pivotal first generations. When the catheters were much larger. They've gotten a lot smaller in that time and a lot more sophisticated to reduce the risk of leaks around the valve, to reduce the risk of need for pacemakers. And our program has been involved in a number of the trials, paul. I see your face. Can you hear what's what's going on? Listen to great job procedure. And I haven't shown any magic tricks yet. I I was wondering I was wondering if you were able to control yourself? That's a tremendously strength? Um So in addition to affecting a great operator, a good friend of ours, he's also a exponential magician magician. So you see him, please demand a magic trip. We're in the hybrid or dr Summers myself and dr related to the case the case is on the table is not quite ready. Uh She's close, we're not quite ready for us. So we're gonna keep the camera away from the patient. So we got to properly drink. We are going to do what for us has become a standard procedure. Government hospital trans capture every valve replaced. And Deepak showed you a nice animation. That's basically a way to replace the order foul cutaneous lee. There's an entirely other vascular techniques Without doing open heart surgery. So the you do anywhere from 10 to 15 hours a week at the heart hospital. And uh if you guys can see that he's talking to It's about 10-15 minutes. I know a lot of our audiences, some of the people who do a really good job taking care of our patients. I know we have a lot of the nurses are allowed to you and care units. This thing I want to thank you to every one of you guys because it really does take a team to take care of these patients. We have our Kaplan and our staff who work together in a hybrid or they do a wonderful job. And so what we want to do with this video is just let everybody know kind of what's going on up here where we started where we're going and give you guys a sense of what the procedure is, especially people who are doing such a good job taking care of the patients post op. So um this especially out here, I'll protect, I'll obscure some of the data for her anonymity. She's very she's consented to being having a case percentage. Very nice about it. She is somewhere between 75 and 85 years old, severe symptomatic areas, stenosis, um highly symptomatic who presented sent by one of our local cardiologist house to take care of her heiress synopsis. The for that for us is to be a ct scan is Deepak probably alluded you, which allows us to measure that out uh successor of access and really take aside the valve. There's three commercially available valves right now. We picked her. Anatomy is best for valve public safety. Um and I think the animation we shared was was the balloon expandable. So, um, we're getting ready. We're pretty close. We've been able to show the room in a minute. We're gonna show you the hybrid. Oh, are we? Do a lot of cases in this room. We do trans catheter aortic and mitral valve replacements. Valve repairs with capitalism here, electrophysiology colleagues use it for something. We're not really sure what they do. And then uh surgical colleagues can do endovascular repair of the aorta. So it's um it's a lot of use. It's a very important room and it has multiple teams here. So, um we're putting on the last set of drapes here and then we'll be ready to go, Let's introduce some of our team matt Summers and the junior partner, you get a lot of cases. We all did it together along with dr we have sarah Kennedy who's our nurse practitioner and uh with our reputation in the clinic and helps us with the procedure dr over here, which is our surgeon just in case and with us. And then we have our hyper team girl getting the patient ready to stand around. I think bob. Are we ready to? I think we're dreaming Man. I forgot who is now available. Dr has been working for. Uh we got our patient ready dr and I started this program in December 2011. And we'll go over 3000 speakers and and behind the uh after their way to the people of Uh we have an audience today at almost 300 people. And plus the people are gonna watch this later. We have live audio and video feeds. So as the animation showed, we're gonna get access from both groins. So kind of like cheating for the old people. Of course. All right. And we'll do red rules. This is patient. I'm gonna I'm gonna not say your name, but this is uh give her our number bob. Yes. Okay. And we are here for a trans captor. Eric replacement. Yes. Alright. So what I'm doing now is I'm taking a hollow bore needle. We're going into the controversial, growing this actually going to use that for the tavern, gonna go into the right point, which is not going to be our tavern side. And when you get arterial access, as paul mentioned, part of the thing that's already been done is we've we've looked at the CT scan and looked at the bilateral really ephemeral the vessels that we're gonna use and determined that the right side uh is best for smaller access sites that we use for imaging the valve before we deploy it. But the left side actually works better on her CT scan to place our large bore catheter, which you'll see him do here in just a second. So the patient is under what we call conscious sedation. We're not using a breathing tube. But we we have a party fantasies. Albums. That's dr roquette. And he's doing a very nice job. Making fish is very comfortable. The patients have almost no have no recall after this. So they don't uh They don't they may notice something here, but there's no post office of recall. Me too. Here you're putting arterial and venus sheets on the left and then the big sheets on the right. Is that what I heard? Yeah. She has a higher by implication on the right side and all that means is that um is that her the artery? I'm the on the left side might take a little bit lower. So it's a little bit more amenable to determine all that when the cat scan. So we're gonna put our large four enter pacemaker on the left side and just one artery on the right side. We also can see from the ultrasound the van is right under the artery over here. So we're just gonna avoid that entirely. And just use the right side on the left side for for that. All right. Just a little bit of pressure here. Good. All right. So we're still doing our preliminary work pacemaker please. So part of our basic setup is we're gonna put in a pacemaker to control the rate of the heart. When we implant the valve. We're gonna wanna taste very fast so that we know the valve won't move and your and open the air process. The fact that we can talk about how streamlined we've gotten over the years. Um We used to use general anesthesia, trans esophageal echo um central lines from the next. And we've gotten away from a lot of that. It's become more of a procedure that must have an operation. And I think one thing that the team deserves a tremendous credit for is a typical nice busy day is five cases. That's pretty remarkable. There aren't many places around the country that are getting that throughput and it's a lot of the streamlining. You talked about that the teams worked so hard to achieve getting patients to a unit that allows quick transfer in and out tremendous work by the anesthesia teams as you said. Um And that streamlining. You've worked so hard to make possible. Do you work in the heart hospital? Are aware of that case. It's pretty it's pretty fast and you got to do a great job helping us move the patients through. Alright. Pace was working itself. So as you know, Deepak we put in a pacer wire from the contra lateral side. This allows us to control the heart rate. Um When we plant the valves. When we pull out the large four sheets we want to have a uh we want to be able to slow down the, reduce the blood pressure. And if we pasted 200 or 2 20 we can get that blood pressure nice and well and and make sure the valve is not going to move our ambulance. Yeah. What you see here is that wire moving up the screen is our pig bathroom. It's going up into the ascending aorta. We're gonna use this to take pictures for the placement of our valves. So we see the pacemaker wire, we see your ultrasound in the bottom left hand and we see that pigtail catheter. You talked about going around the aortic arch and sitting. And where do you have it positioned? Well right now we just put it in a non corner. It costs we'll adjust that to the right coronary cusp. When we're ready to do our implant. Um And right now we're just sort of parking it there, it's gonna get moved around as we bring more equipment on. Now we're getting ready to call it a large force sheet. This is we're going to deliver the valve through. We're back with the ultrasound in the leg. What is your closure plan? We're going to use what's called a man too large for access closure. It's like a giant and just feel it's a purpose built system and we'll show it to you a second. What allows us to put collagen fund right where the access site was, Get us ideally immediate into stasis. Occasionally we have to go up and do a balloon or or modify that. Um But fine well it works by blocking works pretty well. So right now we're doing a micro puncture technique and we're just going to take a little puff to make sure you have some contracts please to make sure we like where our stick is. Dr kEMp is eyeballing us behind us. Um And I will say that it's been a nice right there in the bowl. It's been a nice collaboration with cardiology and cardiac surgery. We all participate in procedure. Everybody does everything and it's been a very nice collaborative effort with an anesthesia and cardiac surgeons. We're gonna take a little puff. Make sure we like our stick, they were above the bifurcation which is good. You happy that matt? Yeah. So so all of this this the C. T. Scan the ultrasound access using a small needle to start taking a picture through that needle dilator. All that is geared around minimizing vascular complication rates which fortunately as Deepak has mentioned have gotten quite low um It's most important on the large foresight but that's why we're so focused here on making sure that we hit a very specific spot on the common femoral artery. And so it looks like we were in a nice place right here. Um Paul just took a picture of and now we're going to up size this to the large access sheet. The first thing we do with regards to that depart mentioned demand to closure device. We have to measure the art Iriondo me distance from the skin down to the artery with a dedicated measuring dilator. And that's what we're doing now. This is a stick that has little drawings on it and that tells us the distance from the skin to the access site. As matt was saying, we started doing this back in 2011 we had about 17 18% vascular complication rate. Which is fine because we're fixing a problem that people are dying of. Otherwise uh vascular complication rates are not zero but they're much much lower. Maybe 1 1.5%. Um To a lot of different variations of it improving technique, yep, improving technique, smaller catheters and and basically increased experience of the operators in the community. So we're gonna put a placeholder sheets in. This will be an eight point. So essentially we've got we've got all of our assets. We have wires on both sides. Okay? And we're getting ready to put our large four sheets in. We first started doing these in the midst of time. These were 24 french. There were eight millimeter sheets. And that was a real challenge because most human iliac, sorry, are are a little smaller than that. The sheet size now is much more favorable. Um it's 14 French and that's been a major advancement. Give us the flexibility to take a lot of patients that are on the smaller side that we couldn't have taken care of before. Can you talk about some of the alternate access approaches when someone still has problems with us getting up through the federals? Sure. So every once in a while there aren't people who have access by the federal arteries. We've got several techniques we can use here. Um One is shockwave to be able to get the usual catheter up through stenosis and several arteries. The other ones that we have are what's called trans cable. So we actually go up through the federal D. And using ct like matt had alluded to earlier, find a place in the retro peritoneum where we can cross over into the intra abdominal aorta and then still get access the same way to other techniques which we sometimes use as well would be subclavian access and provided access which both give you direct access to the aorta. So this is our large horse sheep. Um We've prepped the area, we have a toilet sniffer wiring. I'm gonna gently insert that. Sometimes the patients certainly a couple. Sometimes the patient will feel this a little bit. The moaning, you hear the papers have almost no recall. So I don't want you to think we're being cavalier. Uh we do this pretty frequently and and this is just she's aware of it but not not very bothered. And that's and that's the most uncomfortable part that we just finished there, patient standpoint. We now have our large chief in all the other capitals and we're getting ready to close to delivering about. Alright, So we'll give all the help right now. Thank you. So I love it. You've got all your sheets in place, You've got your pigtail to mark the level where you're gonna put the valve, you've got your pacer, you've moved at such a fast pace here. This is great. One of the, one of the keys to any operational procedure is, you know, you want to move efficiently and quickly that if the if you can minimize the amount of time, you're in the operating room that you minimize the amount of time making problems for farmers. Everything else is going smoothly. So they should see is a keyword up here. All right. We're getting ready to cross the valve. Alright? Marshall. So dr kEMp is gonna seven straight how to do that. Now it's a live broadcast defects. It will be nice. We won't talk about the what goes on here. But the doctor kept is uh is what he's doing is he's attempting to steer a wire through the heavily house bivalve. And that's just it's just it's just a probing. We know the valves opening and closing. We know it's very cyanotic. So it's just a simply a question of um carefully assessing it. Um probing the probably the the orifice with this. We have a variety of catheters and wires we can use. And sometimes it's quick and sometimes it's not there you are. Let's pull off the neck. Okay? And the dr Summers is removing the pigtail which was wrapped around the catheter. And this can thank you. Take a minute or two sometimes. Um Well while while dr kEMp is doing that. So what do we have on the screen? We have our blood pressure, we have our heart rate, we have an echo screen which we're not using yet, but which will use shortly. Yeah. Um uh We have our x ray image and and we have dr kEMP ladies and gentlemen nice across the valve, uh which is not always easy to do with a three ft long catheter extract. And we're gonna measure our measure over from this I think, showing them and going through that the A. S. Is gonna be instructive. All right. So um you can see on our screen. I don't know the facts. You see the human dynamic? Yes, we see them. They look great. There's two pressure tracings. The higher one is one inside the left ventricle and that shows the pressure that the heart is working at. The other one is the pressure the bodies seeing. And that delta, that gradient between the two is what the heart has to overcome. And over time this is very deleterious to the heart. So I'll take our appreciate wire now. Okay. And just to point that out to the audience, the difference between that yellow and purple in the upper right hand corner, it's worth keeping that in your mind and seeing what it's gonna look like once, once they're done here, we use all we use a lot of things to assess how we're doing procedurally, you know where we're starting to pick up where we're finishing. So human dynamics matter echo matters, blood pressure matters, and the forest copy image that we're looking at. We integrate all that stuff. There we go. Alright, we're getting close to uh delivering a valve, what's our angle? And actually while you're doing that amy I don't know if you could go over to the table and show them where the valve inside the catheter is. So they can see one, look at that before it goes up or is that in your hand now? Okay. It is yeah, that's perfect. That's perfect. You can see it right here. So in this little this little plastic housing there's a valve loaded at that tricks to reduce the size. Remember we think reducing the size is helpful. So we're gonna finish loading this valve actually inside the body, mostly assembled but not completely assembled it. I'll show you what that means. We're gonna bag down here, we're gonna make our picture bigger. We've got somebody controlling the wire as we advance the valve through the sheet. You can see at the bottom of the stream, detect the top of the sheet. Yes, exact. A little bit of force to push it through, which is always the case. So here it comes. You see, this is the valve. Now, the stent valve and the balloon are not yet assembled because we can reduce the franchise by doing that in the body. So we're gonna drag us up here. So what you're looking at the screen, the stent valve that's gonna go in and we're gonna step, that's gonna walk it back and he's gonna load that into the, into the below the balloon, into the stands and this allows us to take the french size, which is a measure of how big this tube is smaller. Yeah, one question we had is, can you explain when an active lead is needed versus a regular temporary wire? That's not active fixation? Great question. So I'm gonna separate this coming. So controlling the heart rate and pacing is critical um for the procedure and one of the risks of the procedure is we can sometimes cause conduction wide. So if someone is at high risk for right bundle and left bundle you know we're gonna just a little bit more defined. You don't have to pre existing right or left bundle. Branch block. That puts a bit higher risk for those patients. We'll start with an active fixation week usually going from the back and screw it in. That gives us a lot of advantages. We can leave that in. They can walk around and go right to the floor. All right so um if someone has a narrow complex as this nice lady does well only put an active fixation lead if we see some degree of heart block during the procedure contract. So you know again this is where we're using conscious sedation and so the patient is a little bit awake and that's fine. We saved so much risk and then trouble on the back side that we can easily take care of somebody who's just mildly away and then we go across with the valve a little bit more. That's where I got it. I got it. What's what From the C. T. Scan? We have a 24 4 model of cranial. Okay good so all right So we're close we're gonna expose our high co two across. We're getting ready to deliver the valve blood blood pressure straight straight straight the fire. Alright we're gonna take a little picture here without facing just to get a sense of where we are. Great. Right in the right counselor object, Okay, position looks pretty good. We're gonna make some minor adjustments. We know a lot about where we want the south to land and end and we know how it's gonna force shorten. So we're gonna we're gonna just a little bit try to move are trying to move my pigtail right now to put it into the non corner accounts, sometimes it works, sometimes it doesn't. I thought one that last picture back I thought were maybe a little ventricular Again, look how stable the blood pressure in the patient is. We can take care and take our time to measure. Is somebody out there running that one run the last picture. If you could take that all you want to mention why the position is so important relative to the height. That makes a good point. I want to put this thing right on the angles. Don't wanna be too low to increase the risk of pacemakers don't be too high and we certainly want to have it stay where we put it. So we have a fairly narrow landing zone. So I'll just tell you what we're gonna do because the next Mendoza gets into the kind of fat. We have turned on a pacer and pacer is hard at 180 beats per minute. And the idea there is we don't want any cardiac output. So that brings the blood pressure less than 60. We're not going to take a picture and if we like it, we'll move the pigtail back and we'll inflate the valve exactly what we wanted in this annuals. All right. And do you everything you add there? This looks perfect. A great job. And the position looks great. Good. Alright. Are we ready for uh ready for a pacer on. Let me come on in here. We're all friends. All right, okay. Um Everybody ready? Okay, baseline please. 1 60 to 1 80 And watching the blood pressure, make sure it gets knocked down. Enough. Go to 200. Okay. Yeah, object big back. There goes the valve that looks beautiful face off. Please watch the wire. Almost done. Heart rate looks good, Jack. Alright. Position looks very acceptable. And we're not gonna have an echo or echo tech. Uh Blue come in and you should see that picture on the screen. Yes, it looks great. We can see the aorta lighting up and it doesn't know if there's any leakage at all. Yeah. And we've taken um And we're just adjusting some of our audiovisual equipment here. And we've taken two pictures so far. The station. Got 20 CCs of contracts. We'll take one more picture of the legs and we're done. So the whole procedure can be done with a very small amount of contrast, less of the diagnostic path, which helps with our patients with renal insufficiency. Um I know you have a deep love of echoes, You can tell people what we're seeing. Did you see that around? I can so we see that in the middle of the screen, you see the mitral valve on the bottom right side and you see the aortic valve right above it, towards the center of the screen, the left ventricles to the left and it's pumping beautifully. The right side looks good. There's no para cardio fusion, there's no visible complications. And boy, that looks like a beautifully functioning valve. But I don't see any leakage from what we can see. And there's no stenosis. Left. The flow through there looks fantastic. Short actually. Thanks for the kind words feedback. We like that too. Um Well, we'll see a little bit of uh we have a wire across the valve. So we're gonna discount any little regurgitation middle. We're looking for para value leading the things Deepak talked about is the fluid around the heart. What's the function of the heart? And we're watching the uh I don't know if you guys can see the narrow complex. So we haven't alter the conduction system at all. So this patient will not get an active fixation leave because we have a narrow QRS complex and lose taking some beautiful pictures of the beating heart. Okay, thank you. So we're at this point effectively, we've done a valve replacement. Now the the goal is to get out leaving her just like she was when she came in and and try to minimize our risk of vascular. So what we're gonna do is give it to me and I'm gonna take these large sheets out. What I mean is a medication that's gonna reverse the heparin that we gave. So reduce the risk of bleeding, yep, we're gonna taste a little bit for the blood pressure. So we use this pacemaker rather than giving pharmaceutical agents that made, it's gonna be harder to control the pace finger. I can turn on and I can turn off so we'll just taste for the blood pressure a little bit. Okay? And then we'll use that. We've really measured for this already. We've already planned our closure. Are you ready? Okay so we're gonna take this large sheep out leading the wire in and over this wire. We're going to put a little plug device while you're putting in the plug hole. We've been answering many of the questions have been coming up as we've gone one that we had some answers to. But I would feel to you three again is a question of um number one, the severe vascular disease impact your ability to obtain access. Well, yeah, we mentioned that a little bit um most patients maybe 95, are good patients for transforming all access, which is what we're doing here about 2-4% orange. And we have to look for alternative access for that. We're getting ready to do our blood here. Alright, so we pre measured this, give me a second. Deepak. Why don't you talk about that while I do a little work here? Yes. And so they put in this plug and as they put the plug in as dr Mahoney had mentioned it's it's a like a large and a seal. There's a collagen portion that stays on the inside of the artery and there's a collagen portion on the outside that sandwiches down for a person that doesn't have severe vascular disease and that we have good access. This is a good way to close up. And then in a second the team will take a picture that will show us flow through there to make sure that there's no obstruction to flow or anything else. We have a dry groin right now, we've closed that large hole and it's either really good or really bad. So we're gonna take a quick picture to make sure it's why we like it. Digital subtraction. You can see that little metal dot shows exactly where we went into the blood vessel. Jack. Please outstanding. It doesn't even look like you were there. That's a that's a very nice result. And again, this is the advance of some of the equipment. This is purpose made for this week. Are pacers out, We're gonna remove our temporary pacemaker water. We're gonna put an end to seal on our legs and that is a trans catheter aortic valve replacement. We're gonna wake this nice lady up. We're gonna go tell our family everything went well. Um We'll spend maybe anywhere from 1 to 2 hours in our in our post anesthesia care unit but we've put together in the care unit portion of our hospital and then um so go up to a regular four where it should be emulated in four hours. Our planet would be discharged tomorrow morning around eight or 9:00 AM after breakfast. Um So any other questions or anything? We're just getting the last ivy out. There were a few questions. One thing that's impressive skin to skin that was under half an hour. You you have replaced the valve and that's great work team. One of the audience questions which it might be nice to have a couple of you answer together is with the different types of valve replacements, both trans catheter, different types and surgical. How do you determine which one to use? There's a lot that goes into that and I think it highlights the the approach that we have here, which is, you know, a team approach planning a lot of the the procedure out beforehand. One of the things we talk about is which valve we're gonna use and a lot of that's based on things like pacemaker raid access. Um You know, there's calcium around the area. We're going to implant the valves. So there's a lot of things that go into the decisions about the valve itself. We also have a lifetime management strategy to Deepak especially the younger patients who may need 12 or even three valves in their lifetime. Trying to figure out what the best approach is for the 1st 2nd and or third valve if they need it. These are important issues that we deal with a lot. We have a multidisciplinary team. The heart team discusses this. We're blessed with a lot of data from a lot of randomized trials. So we know we know for example if all of the things that are equal that a patient who is at a good candidate for either surgery or tavern can have tavern with a lower short intermediate term risk surgery however is a pretty critical component of what we do because there are some patients that are just better off with surgery because of anatomical reasons. So when people see people in the office of the clinic with valvular disease, we always look at capital based options and when that makes the most sense will offer them. We have a full complement of surgical um um procedures that we can offer as well. It's really tremendous. You've answered all the questions. You've done the full valve replacement. It looks fantastic now and now all the nice people And uh they're watching this. They're gonna do all the real work which is getting getting our patients squared away, making sure she does okay and and home safely in the morning. Um I really want to thank everybody for taking the time to join us. The hybrid O. R. Team which is awesome. And doctor Pet sarah Kennedy matt summers clint council and and it it really does take a lot of people to get this stuff done that. We have a really excellent. All right, excellent. One last question. Follow up from here for this nice patient. What's next for her? So she'll go home tomorrow. So come back and see us with an echocardiogram in the office. That's like a well baby visit. We like that one a lot because people usually are feeling much better. We can uh we can chat and sort of make sure there's no loose ends. And then we'll see him back in one year. And we generally refer them right back to the cardiologist who sent them to us so they can continue to follow them. This value should be good for 10-15 years. Okay. Outstanding. Congratulations guys. Fantastic result. Thank you and thank you for your attention deeply. Great job monitoring. Thank you very much. Yes. And just to close out thank you all for attending. We hope to do more of these presentations in october We'll have the uh annual uh center cardiology conference with information more on the structural heart realm and everything else we do throughout the century cardiology system kudos. Everyone out there and amy mike team. Thank you so much for broadcasting this, putting this together and for those of you that have colleagues that might want to see this. This will be available offline for for watching later. Have a great day. Good luck with your afternoons and clinical care. And thanks for making the time to be with us today.