Dr. Ramadan from Georgia Heart Institute presents a live case of a 92-year-old female patient receiving a percutaneous mitral valve replacement from the cath lab.
All right, ladies and gentlemen, let's take our seats. We have um three live cases, um simultaneous and as you know, patients are ready to go. So please sit down, enjoy the show. All right. Um What I'd like to do is on uh behalf of my co moderator, uh Mike, Mike, I don't think they've met you yet. So, if you want to introduce yourself, hello, Michael Haco. Uh I'm at Emory University. Happy to be here. Thank you. Yeah, Mike is uh chief of cardiac Surgery at Emory. And um, we're really, really privileged today to also have a, a live robotic mitro case done by Doctor Sloan Guy. Um, we'll have a uh structural, so Sloan's gonna do a robotic mitro, Ronnie Ramadan and his team are going to do a percutaneous mitr replacement. Um, and then Falcon Patel NMA Gaza and Glenn Henry are gonna do a complex coronary case. So over the next two hours, we're gonna be toggling back and forth across those rooms, but perhaps before we get started, we'll ask our esteemed panelists to introduce themselves and um, get the conversation going. Hi, I'm Karen Gersh. I am a currently working here at Georgia Heart Institute and these are my partners. I'm Benita Shaw. I'm an interventional cardiologist at NYU in New York. I'm Raza Boss. I'm one of the interventional cardiologists at Georgia Heart Institute. I'm Sunil around intervention cardiologist at NYU, uh uh interventional cardiologist at Brigham and women's great. So we have uh two cardiac surgeons and a few. All right. Why don't we do this? Why don't we go over to, uh, the structural room where uh Ronnie Ramadan is getting ready and I understand Ansley Setzer, our structural coordinator um who also happens to be director of all our centers of excellence are, is going to present the case that Ronnie and Kyle Thompson are doing and Janni parasitize is our expert structural imager. Um So take it away Ronnie or an um Hey, guys, I can't hear you. I can't hear my mic. OK. Can anyone in the room? Perfect. I, I can, I, I can hear you now, Habib. So um good morning and welcome to our structural heart room flat three. We're honored to um be with you again this year. Uh Before we start, I'd like to introduce the team. Uh So I'm Ronnie Ramadan. Uh to my right is uh our cardiac surgeon and uh colleague, uh Doctor Kyle Thompson. Um an update from last year, Kyle, I asked him to invite me to his um Charleston Beach house and I'm glad to report that this has not happened yet. So we're still waiting. Um And then on uh imaging, we have doctor p uh who is known as the Greek Freak. Uh But for some reason, he called me last week and he said he wants to be known as the Joker. It's a basketball thing. Um And then um we have our anesthesia colleagues in the back uh supporting us uh with our uh structural heart team, uh specialist, uh the tech we have Chance and everybody's grateful because Chance has introduced us to uh brown sugar oat milk shake and Espresso, which is really good and low calorie. Uh We have the OG Laurie uh nurses. Uh We do have uh Jess who's our wine um expert after work hours. And uh Dax, nobody messes with Dax because he drives a Harley or something in the back. We have Sarah and we have uh Ken Rick as well. Uh I wanna thank James Lee who we have from Edwards as well as David Martin that we have from Abbott. Um And finally, um we have Ansley, the backbone of our program, who's our um A PP as well as the uh coordinator for the program. And I'm gonna have Ansley start with our slides. And so if you don't forget Michael and Michael, yes. Amazing Michael uh with on, on the back with. So, uh can we get the slides guys? Thanks. All right. So we're gonna introduce our case. An All right. So, here we have a valve valve TMBR, a 92 year old female who presented us with severe dyspnea upon minimal activity. She was having nyh a class 3 to 4 symptoms at home, postural dysnea and significant functional decline over the past several weeks. Past medical history of MVR. A number 33 millimeter mosaic and a one vessel cabbage with lada L AD and 09 diastolic heart failure, permanent atrial fibrillation and G bleed transco should a preserved LV function with an abnormal functioning mit th prosthesis with a gradient of eight peak of eight millimeters of mercury. Severe Mr with a centric jet, severe tr with dilated right side of chambers, transesophageal echo uh confirmed the same with severe trans NGE education and severe tr go next, please. Here you'll see her baseline transesophageal echo with degenerative mit prosthesis and her severe eccentric Mr and severe Tr Next. So she was rapidly declining. This week. We admitted her on Tuesday with worsening symptoms. She was found to be an acute decompensated heart failure, hypertensive with narrow pulse pressures. AFI RVR and cardiogenic shock. We started Milone aggressively died. Her and she also underwent throes as well. Uh She had a right oh, go back, please. One more back, please. She had a right heart cut bole on Mione with Levi Swan R. A pressure of 20 pulmonary pressure, 60/27 with a wedge of 28 index of 1.5 and Pappy was OK at 1.6 Coronary and geography showed a, uh, Lima and her natives were. Ok. All right, we go next. Um, yeah. So, as you guys can, can see, she's, um, definitely a sick lady, uh, who's been declining rapidly. Um, her, uh, just a couple of facts about her Metronic mosaic valve. It's a porcine has Porce leaflets. That true ID is about 28. Um And then you can see the, uh, the, uh, markers that we'll see on x-ray. Um They uh delineate the ventricular post. Um And the recommended size for this would be at 29 Edwards. We're gonna use the Resi valve. So next, uh CT planning obviously is crucial for those patients. Uh uh We simulated a 29 valve and um it's, you know, the, the, the major thing that we, we worry about is LVOT obstruction. Uh But for her, the new LVOT is quite large. So that's not gonna be an issue. Go next. Uh So our plan is going to be uh to use cerebral protection. Um It's gonna be a valve valve, TMVR uh using a 29 Edward. Um We're gonna um add two CCS to the balloon uh for the, for the valve and then decide if we're gonna post dilate, if we're gonna post dilate, we'll probably post it with a 28. True. I think a point of discussion here, the majority of those cases, Mitr procedures that we do um trans we don't close the electrogenic A SD and they do fine and they close with time uh with this lady because she has a, a really a bad RV, severe tr her shame chambers are large. We're worried that uh that's gonna be an issue um whether it's uh you know, right to left shunting uh or uh decompensated uh right sided um function uh with the flow. So we are actually planning on closing this A SD uh at the end of the procedure. If you look at the bottom, this is how we're gonna plan on implanting our valve. So we're gonna line it up with the um sort of the ventricular edge of our valve, a couple of millimeters below the um the uh the radio uh opaque markers on the by prosthetic valve. Um So that's um that's basically our presentation. Um We are uh sort of quite early in our process here. We have uh right radial access uh that we're gonna use to place our sentinel. We already uh put AJ R four in the um ascending aorta. Uh And uh she does have to tortuous anatomy. Um But hopefully, we'll be able to overcome this. Uh We do have a uh right uh Venus access for the TMVR uh left Venus access that we uh have a temp wire that we already placed and tested. We actually went ahead and did a quick right heart cath uh before, just to see what we're dealing with right now. Um I don't know if you guys can see our screen but her R A pressure is about 17 to 20. Her RV is uh 55/10. Her P A is 58/36 with a mean P A pressure of 46 and then her wedge was about 33 and her Pappy was still about 1.2. Her cardia index actually was quite, quite good. It was about three, I think. Uh we had her on 0.25 of as well as some um some uh and we um uh basically, uh that's where we're at. Great. Well, Ronnie and Ansley, um Janie and Kyle, thank you so much for that presentation. Um Obviously, obviously, obviously are a really sick patient. Um So feel free to have us come back to you earlier if you need us. Uh Sorry, Ronnie, what were you saying with some baseline images if you uh just what we're dealing with because we did run into some uh interesting findings. So I just want yanni to maybe talk about the te quickly and then you guys can go and we'll get, we'll call for you back when we're uh you know, in an interesting stage of the procedure, right? Um Hey, guys, um can you see the uh te screen? So, uh is this a joker or the Greek freak speaking? I That's right. Uh Whatever it is, uh can we make the T image? So let's let's show the T image. So we're dealing with a very sick patient here. Um So the valve is degenerated uh with AAA two immobile leaflets, maybe some uh some leaflets from bosses as well as a flail. Um There is a mild mitosis and se severe Triassic ization which is very eccentric. This is the 3D images. Um One for the time being. Um I am a little concerned about the LVOT but the CT findings and city planning was fairly reassuring. We don't really have any significant lbot gradients at baseline. Um While we're screening, um we found that we're dealing with a small which was not present in the uh previous uh te and that was the point of discussion to see how we're gonna proceed. Um I think this uh this is a small at the very tip of the appendage. Um And um after having a long discussion, we decided that we're going to proceed with the case. Um And we will be uh providing um uh cardio bolic support and we will try to stay away from the appendage as much as possible. Yeah, that, that's uh you know, definitely it's a, it's tricky, tricky situation. I mean, she's quite sick. Um You know, obviously she has a lot of things going on. Uh And her right side is definitely not uh not healthy either. Uh even though her puppy looks good. Um You know, so we, um you know, we, we, we felt that the, uh, Thrombus is, uh, which is obviously new is, uh quite distal, um, and that we hopefully will be able to kind of stay away from this and obviously, you know, use in cereal protection. I'm, I'm curious what the panel, uh, thinks of that. Maybe just quickly. I know you need to go to the room, but I think that would be a good, uh, yeah, we, we definitely will get a conversation around that. Um But I'm, I'm looking at our time as well and I wanna make sure we have enough time to show the work. Um So why don't we do this? Why, why don't we go over to uh and Glenn's room? Um, and then we'll, we'll definitely get a conversation around educations planning, et cetera while you guys get to work. So, um, we'll come back to you all. All right, let's go to uh um Ronnie and Janie and Kyle's. So once you move it back and watch the wire or so Ronnie, Ronnie, where to you? We're in your room. Can you hear us? Yeah. Yeah. Welcome back. Tell us what you've been up to. Oh, for sure. Yeah. Yeah. Yeah. So we are um got it. So basically let me just uh uh kind of take you back and tell you what we, we've done. We're actually in a good spot now to go with the valve. So when you guys came to us, we were basically just had our access, um uh our access um in place and our temp wire. So we ended up uh doing our trans puncture uh and can actually show us a little bit about, you know, our, our angles. But you know, the key for these um as you guys all know, you wanna be uh as inferior and posterior as you can just to help with the trajectory of the valve um across the septum. You know, for micro clip, we like to stick um sort of mid, mid and posterior uh to have a lot of height uh to allow you to, to navigate here. You want to be kind of close to the valve. So you're not kind of tenting in the, in the left atrium. Uh Her anatomy is definitely challenging because her R A as you can see is huge. Um She's post surgical and her RV uh chambers are really bad. So, you know, we were expecting some difficulties there. Um We were able to actually get a uh a good puncture. We used um an sl one and a VRK needle that actually ended up being better than us using uh a to do our puncture. Um And then um you know that we're getting access to the left atrium, our left at pressure. Uh I don't know if you guys can see that, but uh it was um 32 with a V wave of about 50. Um And then we um so Danny. I don't know if you want to talk maybe a little bit show the, the trans puncture part. Sure. Let me go back. So, um it was not an intra particularly because the right ventricle, right tumor are huge, but we made it, but we made it, we did a, a relatively uh inferior and posterior stick. Uh we punctured about four centimeters above the Mittal valve. Um And um so, um and then uh under 3D te guidance, we're able to cross the valve. And uh here is basically how we're crossing the valve. And this is where we are right now. Yeah. So basically, we uh we crossed the, we crossed the septum uh with our sl one, we um went to the left upper permanent vein just to make sure that uh you know, we made sure that we're away from that um from uh from that uh uh appendage with a clot. And then basically got our ali sheath. Um We have our uh 14 or 16 French E sheath in place. Um And we crossed the valve using the Agius with a pigtail and see if I can just show you this. Um So here you can see we have our ali directed above the valve. And then we, we basically, it was easy to cross the valve with a pigtail. And it's always challenging when you actually try to put your Safari wire because uh you have to be careful because everything can prolapse. So we just kind of took our time and flexed a list to make sure we have enough support. Um The um implantation angle, as you can see, uh is reo nine Cranie 26 where you can see the three markers lined up uh distant from each other. Uh Before uh we did, after we did our trans uh just to make sure uh that we can, you know, we want to put our Sentinel obviously. Uh but we didn't want to give Heparin until we did our trans. So we did our trans. Uh once we get access, we gave Heparin and then we ended up going up and doing our Sentinel device here, especially with what I mentioned earlier with our concern for a tiny thrombus in the left atrial appendage, Ronnie, Ronnie. Ronnie, let me just Wayne, I just want to make sure all the room knows what a Sentinel is and the fact that you took right, you got right radial access. Um Maybe while you're working Benny, can you just describe to the audience just briefly what the and what the thought is in this case? All right guys, let's go with our um Yeah. So a Sentinel device is uh basically two baskets that can be deployed from the right wrist. So one basket will end up in the uh left carotid artery and the other one will end up in the anonymous artery, thereby protecting the right crot artery in the right vertebral, the left vertebra remains unprotected with the sentinel device. Um for most patients, it's pretty quick to deploy. And the idea is that if any debris gets liberated during this case, that it would hopefully be caught up in those baskets before it ends up in the cerebral vascular. Um I I think he was considering using us for this case. One is that they did see some thrombus in the left atrial appendage. So if that got liberated during the procedure, perhaps it would be caught. Uh The other thing is that these fairly degenerated um uh bioprosthetic valves, you worry about potential fracture of valves or material that could go up north. Uh I don't uh use sentinel in, in many of these cases. I mean, I'll use it if I'm worried about left atrial thrombus or, or, you know, a valve that just looks heavily calcified, degenerated if I'm doing this for mit regurgitation, II, I may not necessarily put it in. Um but uh but uh and it's really, you know, it was really designed for the space. So uh the, the thought was that we would be able to reduce uh strokes with using this device. It's interesting that, you know, the recent uh sentinel study was essentially a negative study for the or it depends on what end point you. Right. Right. I, I've heard that right. There we go. It for disabling strokes. It still has a lot of potential but for, you know, 72 hours for strokes, but we can't cast it aside for truly disabling strokes. There is probably an advantage advantage. Yes. But here in the MITR space, I think you explained really well, what the thought is here, both the left atrial appendix, thrombus, and then potentially fracturing of the, the old surgical valve. It is, it is remarkable to me though how infrequently we see neurological events with MIT procedures, even though we're mucking around the left atrial, uh left atrium. Uh uh you know, much less than the aortic suggesting that just the pathology of the aortic itself is a major issue. All right. Uh Ronnie and team back to you guys tell us where you are. It looks like you're doing right now. There you go. Perfect. And let's stay there for a second. So, basically what we're doing now is we're doing a uh um septostomy uh balloon. So this is a 14 millimeter peripheral balloon that we're just trying to uh balloon. The septum. Obviously, we need to come with our valve apparatus and it usually that's a bit tricky to push through the septum. So we're using a 14 balloon and here Kyle is, um, you know, up with the balloon, we're gonna give it maybe about, um, maybe 20 seconds or so, just to make sure it doesn't recoil. And, um, I think it's been 20 seconds. All right, let's go down. So you can see that septum right there. I think we'll end up hitting it one more time. This is really key because the challenge of, you know, if we run into challenges, cross crossing the valve with the uh and I'll just try to kind of floss this a little bit here and then I'll come back. All right. And let's go up one more time. Mhm. And is looking at us just making sure that we actually got the system. Are we need to come back or do you think we're OK? We're good. Yeah, and perfect. Come down. All right, we can walk this guy back. So basically um yeah, so it's uh say Habibi. Yeah. Uh when we're gonna come with our Edwards vow, um we wanna make sure that we're able to um get across the septum smoothly and not really uh get stuck there. So dilating helps. Perfect. Yeah. And now we're actually ready for the valve. So we uh we have our, our is she in, we have our Safari V, we uh dilated our septum. So now we're gonna go with our 29 Edwards valve. Ronnie. Maybe you or, or uh anyone from the panel can comment on the sizing of the valve. You said it was uh the old uh surgical was at a 33 mosaic, right? And then tell us a little bit about the thought process and the sizing of this 29 SAPIEN as you actually know the exact you have the surgical report and you're confident. Um uh just one thing. So here um uh habib, typically when we go with the system, the E is up, which is the Edwards logo. Here we flip it because when you go aortic, you, when you flex the system, you're gonna go across the aortic arch that way. Um But here we're trying to go the opposite way. So you just flip the system uh and now we're going in with the valve. So, yeah, as long as you actually know what your valve um is the surgical valve and you're certain about it, it's a relatively straightforward. There's an app uh that tells you what um valve would be recommended, whether it's a electronic or a Sapient valve for Aortic uh for aortic position and obviously for, for uh Mitr SAPIEN is uh you know, the only transcatheter choice available commercially right now for this indication. Valve and valve. Got it. Well, listen, just while you're working, let me take about 10, 15 seconds and make sure because I see some folks in the audience who are potentially non cardiologists or cardiac surgeons, um to sort of reiterate what they're doing in this room, right? So, as you know, the patients had a prior open heart surgery and has had a mit valve there and also has had a bypass. The bypass is closed, the mit valve now many years later is failing. It's leaking as well as has a bit of a gradient. So what Doctor Ramadan and the team are doing is they're going through the um inferior viva. So they got access and the vein on the right side, they're navigating up to the right side of the heart and that's where you saw them. You can see the trans stuff to LEGO there. They're going up to the right atrium and then they're punching across to the left atrium and then going down into MIT valve. So this repairs being done. Um I just want to make sure that everyone's on the same page. Ok. Back to you basically loaded the balloon on the, on the valve, which you can see there. Um You can see our pacemaker going there. So we just want to make sure that we keep an eye on that, right? Because as we cross, if our pacemaker comes back, we need to make sure we adjust for that. So right now, what we're gonna do is we're gonna get across the septum across the um the MIT valve with this prosthesis and uh go from there. So Kyle is gonna make sure that the wire is held tight. I'm gonna flex here and come across maybe give me some tension there. Perfect. Yeah, so we're good actually. So this was pretty uh smooth crossing. Uh And we are interacting a little bit with the um base maker, so we'll test it, but I think we're still OK. So now for our position, if you guys remember we want it to be somewhat um lined up with those ventricular lines and the challenge with these things are they're never coaxial. So if you want to just come back on a pusher Ronnie, when you're saying ventricular lines, are you, what are you referring to? Uh Yeah, so, so if you see those three circles, uh those are the post from the surgical valve. So now we're deep. Yeah. So that's, that's the surgical valve, right? So we basically, what we wanna do is just line it up in a way where we're, and either it's a clock or um a push and maybe here just a pusher might actually help us a little bit. So just a little bit here to just get some. And Kyle, if you want to just work with that wire. Ok. So, so here you can see we're, you know, obviously hemodynamically stable. Uh let's just test the pacemaker, just go to 1 50 very quickly, make sure that we're still there. And so um while they're doing that, so Benny, are you looking more at Floro or more at the te at this point? This is entirely for me, Fluro guided this, this valve is a challenging one because you don't, most of the valves we deal with are radio opaque at the base of the valve. So, you know, where you're positioning, this is having to rely on where that base lies in relationship to those three dots which are at the top of the post. So, you know, you might look at echo. But I mean, I think we often find the echo probes just in the way and I, I typically just use Floro for this. I mean, you got it. Yeah. So, so clocking gets us a bit deeper. Countering. Let's see if I can take someone back to flex, go back to the first. So really what we're trying to do now here, Habib is just to see if we can actually get a little bit more coaxial because it's a bit challenging. Um We definitely don't want to be too deep, right? Um And it's gonna have to like sit. So the question is what maneuvers we can do to help us make it sit a little bit better and usually it's a clock in here. The system might be. Ok. So, what do you think? Yeah. II I find it very difficult in many of these cases to get this coaxial and I think you just kind of have to go, you know, make sure you're in the right ballpark, get ready for a long pacing run and it's very much a two person job where the person at the front, uh there has to be good communication. There's often a lot more manipulation of the valve as you're blowing it up. Um, a much different than aortic where, you know, you're pretty much in position and you're good to go So, uh I've, I've often find that, uh, you know, you try twisting the cat that are playing with the flex, it's just the angle that you're coming in makes it very difficult to get this thing coaxial. So I think you're just, I mean, it looks like you're in a good starting spot now and I think it's just a matter of going up slowly and, and manipulating as you, as you advance as you're inflating. So I found that it's better to be uh a bit higher, right? Uh or sort of more atrial than ventricular, right? Because it's much harder to pull back the valve once you're um inflating versus pushing it in, if you think you're, if you think you're too atrial. So I think, um, you know, so I've tried all of the things I can, so I'm clocking the system, right. So, counter, right? One thing, I don't know, I, I was curious about your choice of here and I, I think one benefit is the skirts taller. So you're more likely to get the seal that you need at the base of your valve in case you're off a little bit, just keep the wire. So I don't know if that was your thought process here or if you're just using resi routinely, but uh which we, we are not, but uh get rid of. Yeah, Greg's got a quick question about the uh septal. Hey, Ronnie, it looks like, um, I just wanted to help out for orientation purposes that uh when you say coaxial, you've got the three dots of the, the surgical valve and you're really trying to get your, your valve lined up perpendicularly to that and, and, and really, it's predicated that puncture across the septum and how important that is. Um So, so just so people can see the angle of entry here is so important and, and Ronnie and Janie uh work very well together using echo to cross and maybe Benny can comment on that can really set you up for success and, and it's really important and that's what they're doing here. These minor manipulations to align this perfectly. OK. Great. I think, I think Ronnie go. Um So, um everybody's happy with it. Um On the panel, you think it's a good starting point here? Looks good. OK. All right. So what we're gonna do guys are we're gonna pace at, uh let's base at one, maybe um 80 here. And then uh Kyle is gonna go really slow and push the wire a little bit from each chance. That's good. And then we're just gonna have to adjust, right? So we have to see where it kind of lands and where it goes. Ok. All right. So let's uh pace a 1 80. Go ahead, Kyle. OK. Here we go real slow. OK. We're gonna push in of it here. Perfect slow. Keep going, keep going, keep going. So guys, we're pacing really, really fast so that we bring the heart to stand still pretty much. And I would go all the way now, all the way, all the way, all the way, all the way looks good. Go put it all in and then they're deploying the balloon down and chase her off. Perfect. Ok. All right. All right. So we'll just watch her pressure here, make sure that she's ok. And so this was plus two and pressure is back so we can walk this back guys just uh a little bit. Let me make sure. Ok, let's go. Perfect. Or pressure if you can, guys can see it's uh I mean, obviously it's a long pace and run. But um um and you can see that the valve is a little bit constricted, explain to about this. Uh We are plus two. So it's kind of flared on the ventricular side, which is always good. Uh Just fy i the skirt of the valve here is at right. So the valve kind of pour shortens from the atrial side, we'll just replay that for you again. So the valve portion from the L side. So really, our positioning is all kind of, we're looking at our ventricular side where those dots are and um and here really going really, really slow. Um At this point, I was like, oh, maybe we can go a little bit more atrial. So I'm pushing, um pushing on the wire a little bit see if I can move me back. Uh But from experience, typically, it's really hard to move back. It's easier to move in. Um And I think we landed uh uh decently here. Um So yeah, I was gonna say, let's take another like 90 seconds to show us the te that was fantastic. Um, display of kind of all the aspects that need to go into the deployment because I think Sloan is waiting for us um in the or so, take about 60 to 90 seconds, please. It's uh be very well deployed. Uh Again, there is in, in these cases, there is always a concern about the LVOT abstraction. So once I quickly assess the valve, I didn't really see any significant para leak. There's still a little bit of uh which is related to the wires that they are through the valve and the LVOT appears to be wide open. I'm gonna go to the stomach in a little bit and uh get some great. But um so far the result appears to be very good and that, and that leak we see on just the wire, right? So we're gonna take that wire out. Uh No LVOT obstruction. Obviously, we kind of predicted that based on CT. Uh so I think what we're gonna do um Well, we'll take some gradients initially, we're thinking maybe we'll hit this with a 28 true, which I think we might still do that just um to make sure that it's nicely flared. Um, and then, and then, uh, and then I think habib, if you can come back to us, because I think we'd like to show the, uh, assess the A SD and the closure. I think that's a, a very well, we'll, we'll certainly, yeah, we'll certainly try our best to, we have about 40 minutes and, um, I, hopefully we'll get back to you, but that was a fantastic, uh, live deployment of a valve and valve in the mit position. So excellent work. Um, let's go now to the structural room. Ok. Ok. All right, perfect. All right. Well, um, Kyle had to leave us because he got pulled into the or, um, so, uh, uh, let me just kinda tell you what we did. Um, so as you remember, this was uh our deployment and after that, we decided to go with a true balloon. So this is a 28 true balloon and we just, uh, wanted to kind of expand the, develop a bit more, you know, obviously, um, you wanna try to get the best uh optimal results you can and I don't know, uh, to Vinny's question from uh before about resi, I mean, obviously there's the whole question about, you know, durability with these resi valves, which, you know, obviously, we, we, we're not certain about that. But, um, that was one reason and then the skirt for the 29 which the ultra did not have So those were two of the reasons we post dilated. Um And then we evaluated uh and I have talk about this, we evaluated the, the A SD, the A SD and we only had uh left to right shunting. So we didn't have right to left and hypoxia. Uh but just given the fact that her RV is really bad and her tr is bad, we just didn't want to be in a situation where she's struggling uh in a couple of days or weeks. So we just opted to go ahead and close it. So we did a measurement ended up using a um a 10 millimeter, a SD device. Obviously we're posterior, right. So the location um of closure is a bit tricky than your kind of typical location. So uh and we think we had a good result and here is our release. I think it is, here's our release. So we did a tuck test and we basically release the A SD. And if you wanna just uh show us uh images, just look at the valve, how it looked at the end and uh the A SD part as well. OK. That was an excellent deployment. The valve uh is uh functioning well. This is a three dimensional 3d te picture of the valve that we can see all the leaflets open well and the position is good and the valve is well expanded. Um We don't have any significant baler or para leak um Then we went ahead and we uh uh decided to close the A SD. Those are the explained pictures um at the end of the day after we closed, the A SD, we looked, this is the final result. Um And this is the 3D picture of the A the closure I went uh to the stomach to look for lbut abstraction. And the L BT is wide open with a mean gradient of one or two millimeters of mercury. Uh So the valve is not interfering with the lbut. There's no shunting anymore and there's no pericar fusion. Awesome. And then uh our left at pressures. If you remember our baseline, we had a V wave about 50 um and uh a mean pressure of about 35 we were down to about mean pressure of 18 and we didn't really have much of a V wave after we placed our valve, which is uh which is really great. Uh You know, patient is doing very well, you know, dynamically, you can see she's doing, doing well, her heart rate, it actually came down. She's been tachycardic for the last few days. So we're, we're doing well there. We actually ended up just closing. So we got our um Venus sheets out, we took our Sentinel out and we actually put a tr band. So we're uh practically done. Um And uh that's it. So I just wanna uh I don't know if you guys have any more questions for us. But I just before we, you guys uh come off of us just want to thank our team. This is um you know, really sick lady that we um you know, we're, we're proud to be uh you know, part of her care. Uh And I really appreciate everybody, everybody's uh uh done a wonderful job. So thank you very much. Let's give my hand. Let's well, um let, let me do this. Um I was gonna ask doctor Clifton Hastings as our floor moderator and as all of you, many of, you know, he's um head of cardiac surgery for us. Um Obviously, he's been around for a long time, super experienced. So, Clifton, we, we can you make some comments on sort of this uh you know, the two mit cases we saw, right, the, the sort of robotic uh elective patient that came in, but everything we learned and all the innovation that goes into doing that procedure versus this uh cardiogenic shock patient that was stabilized and then underwent the percutaneous procedure. What are your comments? Any reactions, advice? Uh First off, I'm, I'm just thrilled to be here and to see the progress that we've made over the past several years in developing and growing the heart team, which is the key component to this because if you have one component of the heart team that's excelling and the other is not, then you really run out of options. So this is just a great example of that. I mean, to re operate on a 92 year old and try to fix the issues that she had um would be a surgical disaster. On the other hand, to have the ability to do the minimally invasive approaches that Sloan is doing, doing complex uh repairs. So I think it just underlines the importance of the heart team. And that's the, the the greatest achievement that I think we've achieved over really the past 2 to 3 years is the growth and development of that and having all those opportunities available to do that. And II, I think that's the thing I'm proudest of. And uh so uh that's kind of my comments on that. Great. Wow. Well, listen. Um Absolutely fabulous work um with all 33 teams. Um I think we're just gonna have to wrap up this wonderful session, three live cases for you. Ladies and gentlemen, to my trolls going head to head in a way, a relatively elective patient, but with very complex um robotic repair, relatively complex robotic repair, excellent result. A cardiogenic shock, severe Mr patient, elderly patient Calvin valve with a percutaneous mit valve and then uh eventually uh a retrograde CTO after having gone through the hybrid algorithm with a little distal hematoma that they're, they're working on, but uh fully uh revascularized. So big hand for the three teams. Um maybe we're a couple of minutes over but any uh final thoughts or comments by Mike or the team. Nothing new from my side. Uh Thanks for having me and uh congratulations to all the teams with uh great results. I, I just had a quick question. I'm sure Doctor Guy is gone now, but um we don't do a lot of robotic at our institution. So what is the expected discharge time for this patient? When do you tell them they can get back to normal life? He, he slumps out a couple of guys to go home the next day and get back to playing golf within a week. So usually it's about, you know, it depends on the complexity of the case and the severity of illness of the patient. This guy probably will go home one day three. Yeah, it's amazing. Yeah. Well, very well. Um I think we have a break now for uh 20 minutes. Uh Let me just take a quick peek before I let you all go. Um Yes, 20 minutes, please. Uh visit the exhibit, stretch your legs, get a drink and then we're gonna um have the coronary and valve therapy session, incredible speakers. Um Our own Doctor Sunil Rao will be here and um Greg Stone is talking and then we'll have Azim lab and Vino Tarai really world class speakers. Um So we look forward to it. We, we now will turn our attention to our, our next um operator. Yesterday, you saw Doctor Ramadan do a percutaneous mit valve case. And a 92 year old lady in refractory cardiogenic shock who's admitted to the hospital. I mean, honestly, I was really worried when he was doing a case yesterday. She's about as sick as they get. So tell us how she's doing well. Uh did not tell me that he's doing a, a zoom until like five minutes ago. So I was like uh uh yeah. Um so my zoom link is not working. Um But I wanted to actually show you if we can pull up a picture of our patient, not this one. Um This one. So yeah, so, so obviously she was uh really, really sick. Uh one of our sort of sickest patients in the hospital. And um as soon as we were done with the procedure, her hemodynamics improved quite a bit like we could see it immediately. Uh We were able to wean her off the inotropes and oppressors that she was on. And uh basically, uh she is feeling great. She walked around, she looks good. Uh And she is no longer in shock. We got some repeat numbers on her and her actually, she's, she's recovered. Um So and she's 92 but she's awesome. She's been very functional before all of this happened and her decline was really rapid over the last few weeks. Uh So we really knew that if we can get her out of trouble, uh that there's a big chance that we can get her back to her um sort of quality of life that she had before. Um Yeah, Ronnie. Well, actually I was gonna ask you because, you know, when uh Chris White gave his talk yesterday about value based care and how we should be thinking about value and then you're doing, you know, an incredibly sick lady at 92. Um but you see her picture there and she could be any one of our parents or grandparents. And um it looks like, I mean, it's really like clutching her from the jaws of death, right? Um So talk to me a little bit about how you all make decisions about these, you know, very advanced patients. So, um actually, uh she was referred to us by uh slo so she actually initially saw Sloan and Sloan called me and he said, uh you know, you gotta see this patient, she's really sick. Um And uh so for us, I mean, really from the time of uh seeing those patients, especially the sick ones to doing a procedure is really quick. Uh We try to expedite the process as much as possible because if you wait too long for these patients, unfortunately, it might be something that you can't do. And it's the same concept for, you know, when we talk to our referring docs, uh it's always better to send these patients early in the process because we've seen plenty of patients where it's just too far gone. Um And she was definitely on the verge of getting there. Uh But luckily we're able to kind of get her off of, uh off of that. And it's interesting when you hear Dr Ramadan Doctor Guy, the whole team talk about the heart teams. It's, it's so critical to think about not only the pathology that's going on, is it a prolapse leaflet in this case, is it a failed by a prosthetic leaflet with severe Mr but how sick patients are on that spectrum? Right? So sometimes when people are not that sick, they have single vessel disease or you know, they have normal efs or non diabetic with normal efs, we think percutaneous approaches are better, then people get sicker, they have multi vessel disease, they have low efs, they have diabetes, then surgical options for revascularization are definitely better, right? And then sometimes at the very tail end of illness, when we think that they can't safely undergo surgery, then it kind of falls back in that percutaneous realm. So you're not only thinking about pathophysiology of disease as to whether it's better for percutaneous or for surgical, but you're also looking at that spectrum of disease anyway, a lot to discuss. But um thank you so much for that big hand.
