Chapters Transcript Video Treating Aortic Regurgitation The Sentara Heart Valve team utilizes the JenaValve Trilogy system during a TAVR procedure to treat severe aortic regurgitation. Doctor Summers. Doctor Kemp here, Doctor T is on his way. This is a, a lovely lady that is high risk for surgery but has severe aortic insufficiency, insufficient amount of calcium to anchor a traditional TVER. And so she really doesn't have any great options besides a dedicated device, peril device for aortic insufficiency, that's minimally invasive and catheter based. And that's what we're doing today. Standard transfemoral access right now. We're getting the non large war side. So, contralateral six French in the artery to guide our vow of deployment. And it's a little bit different than a typical tower in that we do isolation shots in each cusp to make sure they capture them. So you have to capture the leaflets somewhat similarly to a MitraClip. Um but also with a, a pretty rapid deployment sequence once you're ready. So it's a lot of prep up uh prep and getting set up and, and then about five seconds of delivering the valve. Doctor Kemp. Uh We, we've done about a dozen of these. That's right. And um I know we talk about it. The, the deployment sequence is, is a little bit, it's rapid and you gotta make sure that you're perfectly lined up. And so it's a lot of getting, getting to that point, but deploys very, very nicely and it's an instant, uh, elimination of the leak. Um, what are your thoughts on, on the deployment versus regular towers? It's a little bit more onerous from the, your position. Right. Yeah. No, it certainly is. I mean, I think with these type of procedures, 95% of it is in the setup and positioning and 5% is the deployment. Um It has a very nice system to be able to deploy with and like you said, we've had results with it. Um I'm just glad that we have it at least now for high risk patients that would have no other option. But there's no reason in my mind that, that this won't be the treatment for aortic insufficiency and patients who don't need other concomitant procedures. So this is uh a two operator procedure. We, we all kind of cycle through. We have uh three G of valves today. We're very lucky to work with this company and have access to something that fills a treatment gap for us. Um But Deak's gonna take over getting large four access. We, at this point, we've got an active fixation lead in the right IJ, the pacemaker rates are lower with this because it's super annular valve design and not a whole lot goes into the LV outflow track. Um But it is a new device and the deployment sequence is so important that we have complete capture that I think we all feel much better having an active fixation lead in and we have had one late heart block with these. We've done about a dozen up to this point, maybe one or two less than that. But um bottom line he's getting uh standard large bore access. Really. The the main part here is getting these uh cusp indicators, these markers lined up equidistant between the commissures. Um You can do that through a series of cos banjo grams. Alright. So there's a kink in the mid descending. It looks like it. Uh I think you're getting through it nicely. Yeah. Where's Chris? You see this? I don't think we need a buddy or anything like that or wire. It looks pretty good. Uh The key of these procedures though and I think why we like to dial out our team is that the uh the vast majority of the work, the effective work is done in the planning phases and it makes the tower procedure itself small iterations of a general choreographed kind of dance where we're doing pretty consistent things each case to make this as safe as possible. And we have, even though it's not being spoken or said each of us, all four of us are looking at very specific things during the course of the case to make sure we're everything is perfect. Alright, so up to this point, folks, uh we have the large bore sheath in, we're henni we're confirming therapeutic anticoagulation. Um We're gonna bring our pigtail up and do a agram, Chris. What view did we have for? Co planer? I see Lao 20 called off 25. And so what we're gonna do now is confirm Deepak. Do you want to push that pigtail up to the root? Here we are. Oh yeah. It's hard to see. Can we do a high frame rate, please? And can we pull the T PRO back? A little bit more bum. Are you ready? Do you park you in c beautiful? Ok. Let's uh look at the angulation of the descending there. Once we get that sheath in it, I think we'll be alright. I do like the way the sheath passes. I'm pulling a little bit to help you around. Nice. That made it very easy. Ok. We're in the descending there, Chris, I'll take this dilator out. Ok. Ok. Ok. Yep. All right. So we're gonna come around the arch you wanted to watch in the descending for something specific, right? In the last case. Yep. Gotcha. Ok. So we're coming around now. So we drive, this is basically a long sheath that we deliver all the way to the S TJ. And we're gonna come 2 to 3 millimeters above where we think the S TJ is, right? OK. It was our last picture. It's really right where the across is or where the descending aortic branches cross. So I know that they're moving a little bit, but I would say probably right about there. Yeah. All right. You like that, Chris? All right. Now you're gonna hold some floor attention on it. I'm gonna walk this dilator back. Ok. Dilators coming back may jump out at you. But yeah, a little bit squeaky tape, blood. I feel you coming through my fingers. All right, you're out. I've got wire almost. Thank you. No. Withdrawal 50. And then they give it back through the OK. Awesome. Back. Three V I forget Chris. Do we flush that as well or just leave that for nice blood? OK. We'll flush. Yeah, good. Thank you, sir. All right. You like me to angle this up and down. You had mentioned. What do you think? OK. I think we're good there. OK. You have, tell me when you got wire back there, you got it and let's start dripping there. We're dripping. Chris, the wire position looks good. All right, coming in and I've held those down going in. OK? All right. The interface is fully in, ready to keep going. We park it in the descending so high enough we want to go higher. OK? OK. We got a little kink forming in the sheath. You see that? Yeah. Oh yeah, we straightened out. OK. So we're gonna come lal you like everything you see there as far as the valve prep, right? OK. All right. Deepak. All ready to hang on. Yep. All right, it's coming. I'm just going nice and slow. So those dots will come down to just above the S TJ 2 to 3 millimeters above and you'll leave your sheath parked. And so the sheath isn't advancing much, but we're slowly peaking out here until you get those dots just above the marker like there like that. We want to bring this down and do a root shot again. Oh It's hard to see. There you go. Alright, Chris, I'm gonna take a picture here. We were right at the S TJ with that distal marker. So we had a little bit high. So we're gonna go in with a unit to advance the whole system in. Yep, I got wire, you're advancing them in block together. Perfect like that. Let's take another picture one second. Let me come down just a little bit closer. Deak floor there. Ok. Alright. Or more too. Huh. So we gotta get that more proximal marker and the dots down to the S TJ. Advance the whole unit in. Yeah, I like that a lot. Alright. Take tails back. I did. Ok. Now we're gonna want to do this. So. Yep. So your sheath is gonna come back to the descending depo you fix your right hand. There you go one second. Let me just fix that your valves coming up a little bit guys. Yeah, I see it. Thank you. Good job, Kim. Ok. All right. That's good. Let's bring that back another centimeter deepak just in the descending. There we go. Alright. Let's uh bring this down a bit so we're gonna isolate the cup. C OK. I see it spinning so we're just trying to line these markers up with the base of each cusp. Ok. Ok. You got about 80%. Ok. That's max. Oh no I'm sorry. No. Yeah that's what I was. Ok. So our deflection is at 60 50% and now we're rotating this. Yeah, and clocking, right? Ok. That's 90 degrees. That's why it wasn't moving 90 degrees. You have 90 degrees. Oh yeah, there it is. Ok. Ok. To 20 degrees back towards me a counter. Ok. A little bit more counter. Ok. Just a little bit so that to us. Ok. Yeah, I see. Yeah, I did it there a little bit. Ok. Ok. C arm sweep Deepak middle dot Should come to the anterior and it does good. Alright, so we've isolated. Oh, very nice, Bob. You're showing us the spines in there. That looks good. It's 2025. I think we see our two non coronary and left looked. Ok. On that last shot. Could you do a short access again, right through the tip of the uh spines that are sitting right above the leaflets down more towards the uh tip of the valve? That's nice. Even a little further. We can see those two splines separating out and pretty good if you go even more towards the. Yeah, that's that's it, that's it. That's great, Bob. No, that's good. Those look nice. You see those two spines, one in each cusp. 180. The third is shadowed but it should be right between them in a triangular fashion so it should be good and that fits with what we're seeing on Floo. Alright, so the sequence is gonna be Pacer 180 We're gonna be on I'm gonna pull the safety, you hold it up here to pull the safety off. Rotate away from me I let go and then push it forward and then I will tell you when Pacer is off, ok? Alright. It's floral. Yeah you wanna test the pacemaker real quick. There's a lot of movement on that good job Sarah. Yeah you got it. We're gonna use this as an opportunity to do the pacing and do a shot with the pacing, ok? It's a good idea, Chris. All right. So Pacer on 180. Alright, sunny. Ok. Off pacing good. Oh look at that. That's beautiful. You see the leaflets coming up and under. That's really nice by script. Ok. Ready Pacer on 180. Got it off Pacer, ok. And there are six points of contact. Mhm. Fleur De they all look free and clear. I agree you want to swing, we're free and clear all the way across, ok. This is our co planner. I'll just go back and see what we look like in that. Ok. You'll start drinking right hand. Cere Pusher. Cold water with. Bye. I like it. Ok, that's fine. What do you want? The salt? Yeah, but water. Ok. Arts to pro back. Just a touch. Josh, we're at 50% deflection right now. Ok. 40% deflection. Yep. Yeah, I'm pulling out in block. Right. Uh huh. Yeah, it's coming nicely. That looks good. So, thanks. But yeah, we I think we need to bring the whole system back lower into a straight part of the aorta. Ok. So let's walk all this out in block. I've got them together so nice and slow. Ok. It's just because she's got a terribly tortuous aorta here. We still have 40% or 20%. Let's get that pig tail all the way back below so it doesn't keep us from. Uh there you go. Alright. I'm gonna try to overs sheath it again. Nice, beautiful. Get so used to working in one position. It's very important that we do stuff like this so that we're all comfortable with it. But doctor Kemp has been the pro and deployment. Yes. Yeah. Yeah. While kidding aside, it's nice to have a person who doesn't have their hands on because they can be watching everything at once. I guess one of the things that makes our team so good is we've got multiple people here. Not only that can do each position but looking out when they don't have a physical responsibility. That's the merit, you know, behind double scrubbing, any or triple scrubbing, any complex procedure. We do it in CTO S. You guys do it in complex mills and any of that kind of stuff. New devices. Always best team sport. Ok. Yeah, let's take a picture. You down there deep. Ok. Let me zoom in once and let me get, uh, the vow centered there. That's nice there. Almost perfect. There we go. All right ready when you are beautiful. Love it and the right looks nice. Coroners are filling. We're good and the right to look. Alright Josh, you're up to get as much as you can. I don't see any leak from the quick snapshots I saw make sure we're down here ready when you are. Hold great. All right we'll do manual on the left and we'll keep the pacer in nice. Ok? You got the can and all the stuff. Yeah, I'll do that. Good job. Good job Chris. Sweet. Published September 19, 2024 Created by Related Presenters Matthew Summers, M.D. Sentara Cardiology Specialists View full profile Deepak Talreja, M.D. Sentara Cardiology Specialists View full profile Clinton Kemp, M.D. Sentara Mid-Atlantic Cardiothoracic Surgeons View full profile
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