Originally Broadcast: April 20, 2023 | 6:00 - 7:00 PM ET
Join us our cardiac surgeon panel of speakers, Dr. S. Chris Malaisrie, Dr. Justin Schaffer, and Dr. Marc Gerdisch, as they discuss the following topics:
How I Do It - Minimally Invasive AVR; Surgical Keys to Success Moderator/Presenter: Dr. S. Chris Malaisrie Northwestern University, Chicago, IL
Current AVR Landscape - Patient Selection and Complex Aortic Valve Surgery in Clinical Practice Presenter: Dr. Justin Schaffer Baylor Scott & White Health, Plano, TX
How I Do It - Minimally Invasive On-X AVR with Root Enlargement Presenter: Dr. Marc Gerdisch Franciscan Health, Indianapolis, IN Please Note:
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And welcome everyone to our Tian live webinar on aortic vibe replacements and minimally invasive aortic vibe replacement. We've got this exciting agenda today. I'd like to introduce uh my cos speakers today. Our agenda today will be uh in three parts, 15 minutes apiece. We'll stick to it. Uh Doctor Justin Schafer will be, is a cardiac surgeon from Dallas and it'll be a great perspective for him because unlike Doctor Gerdes and I, he entered practice in the middle of Tay, Doctor Gerdes and I entered practice way before there was Tabby and Doctor Schaffer will talk about what we should be recommending for patients when they need aortic bowel replacement. Should it be aortic bowel replacement or Tavi? And Mark Gish is a cardiac surgeon from Indianapolis and well seasoned expert surgeon and um clinical trial leader in multiple clinical trials uh across all of cardiac surgery. And doctor Gish will be speaking on valve choice. So we're looking at a lifetime of valves or a valve for a lifetime mechanical versus biologic valves. So we'll launch into Dr Schafer's talk. Good evening, Justin Schafer cardiac surgeon, Bala Scott and White Heart Hospital. Um I've been asked to give a brief overview of the current surgical landscape for aortic valve diseases. So let's take off from there. Obviously, trans gather technologies have undergone massive improvements over the past decade. And as a result, we've seen a concomitant increase in the use of Taber, particularly in older Medicare type patients. As this graph kind of shows with the red line. The benefit of this is we've seen an increase in treatment of all patients with aortic disease uh in this elderly population. This is this black line. So all aortic val disease being treated over time. Um but unfortunately, this rise in tar is seen with it a reduction in both isolated saver, which is this purple line that we see reduced over time in Medicare patients as well as incompetent saver plus other operations, which is codified in this blue line. So it's been a benefit to patients. We're treating more minority bowel disease. But the incidence of isolated saver and complex multivalvular operations is starting to decrease over time. And with tar now established as a viable and you know, um well adopted treatment modality for a or stenosis, you know, discussing treatment options with patients now requires a more complex discussion that involves life expectancy as well as valve durability and value their options, a patient's age. And unfortunately, for me, also their gender um sort of informs one's life expectancy and this now needs to really heavily factor in in terms of how in depth of a discussion we need to have with our patients, the younger the patient, the more complex our surgical or the more varied our surgical options are and the more complex our discussion of the treatment modalities needs to be with that patient. Um So in folks 80 years and over, you know, both the European and American guidelines and I think most of us in practice uh uh are saying that if these patients have anatomy, that is amenable to tar without, you know, significant con constraints or concomitant disease. These people are getting the tar without a second thought. In general, these people end up being at least intermediate risk with other comorbidities, their functional status, uh oftentimes is somewhat reduced and they do well with tar and you know, early outcomes, at least at five years tend to support that sort of decision making for those patients. Um With more recent data. Now we've kind of entered into the range of these uh younger patients. These 65 to 80 year olds who uh with that sort of age limit have a 10 to 25 year life expectancy. Um And these people require a more nuanced discussion of treatment options, particularly, we need to start thinking about these people in that high, medium and low risk sort of uh buckets as opposed to with the 80 year olds who probably they all kind of fall into a higher risk population. And people who are at high or intermediate risk for surgery. And we have good five year outcomes on these patients with tar. And unless they do have some of those an atomic constraints or other limiting factors, they tend to be getting ta as well if they are at intermediate, at high risk for, for surgery in people who are low risk. However, they probably have that, you know, 15 2025 year life expectancy and these people require a very complex discussion because um they're gonna need most likely a second valve intervention and possibly a third valve intervention in their lifetimes. And we need to with the heart team, with our cardiologist colleagues, you know, have a long discussion regarding you're younger now. So surgery for you at this point in your life being 66 is lower risk. And when you're 76 or 80 it's gonna be a higher risk endeavor to go in there, explant a tar valve and put a new surgical valve in Taber valve valve options are, you know, improving, although they are not as good as tar in native uh or stenosis disease. And that needs to be discussed in depth with the patient and depending on the patient's comorbidities, preferences and current lifestyle. Um, you know, uh that decision needs to be made certain patients, they, they just hit 65 they just retired. And the last thing they want to do at their first year of retirement is undergo an aortic valve surgery and they'd much rather, you know, bounce back in a couple of days after a tavern and deal with the surgical reintervention, you know, 10 years from now when they're more likely to have kicked off their bucket list. Um, and it's a personal decision that needs to be discussed with patients on a case by case basis, which means a lot of talking from the surgeons, which is something I'm, I'm had to, had to get used to over time patients younger than 65. So the young patient population requires a tremendously complex sort of decision making process. Doctor Belay should recognize this slide from one of his papers from a couple of months ago. But basically, patients have five main options depending on what type of aortic valve disease they have. Um and for these younger patients, you know, complex and advanced aortic valve techniques, including the ROSS procedure for people who have bad aortic stenosis and are, you know, 50 years or younger or maybe even in the 50 to 55 year range. And the people that have aortic insufficiency or repairable valves, a complex aortic valve repair or valve spring aortic root replacement warrant some discussion with those folks. These patients also have to be made aware of sort of the gold standard, which is a mechanical valve that has, you know, excellent uh long term durability. Um albeit with that small but real risk for bleeding and you know, uh thrombo complications that comes with a mechanical valve that I'm sure we'll discuss in more detail later. These patients also need to be offered uh an option for a bioprosthetic as well as for possibly to have a valve and having this complex discussion. Um, and it's important for surgeons to be heavily involved in this because we know these treatment options best, better than the cardiologists. And we're the ones who can best provide our patients with the right decision for them in this very personal choice, depending on what your comorbidity Abbi are, what your overall life expectancy is kind of and what you want in terms of whether you can take it in whether you're willing to tolerate a reoperation in the future, when having these discussions with patients and when argue with our cardiologists, we need to be able to discuss the data underlying uh why we make these decisions. And so we should briefly review those data, five year outcomes for the intermediate risk tablet trials are now out. That's the part in the two trial for the and the trial for the core valve. Um I think it's interesting to note that clearly there's an early risk that comes with surgery, there's that early hazard that we see no matter of kind of what you're looking at in terms of surgical intervention. But we do see this sort of crossing of curves at least in the part of two data at three years similar to what we've seen in, in, in other uh surgical trials. Um And in both of these studies, right, the late hazard has started to be more in favor of surgery than in tar, they require more like, you know, uh 10 year outcomes to get a full sense of this. But there's gonna be cases where that early upfront risk of surgery is probably worth the late benefit that surgery may provide. We also have two year outcomes for our low risk trials. That's the part of three trial for the C P N S3 and the low risk trial for the er um, and again, we're starting to see a signal now that we're going out to two years of, of potentially these curves starting to converge. And these are important data for us to follow and to know and we're gonna need those 10 year data given that the event rate in these young patients is so low, right, a 3% event rate of death or disabling stroke at, at two years means we're gonna have to have a lot more time accrued before we can fully know which option is best when we're talking about 10 and 20 year outcomes. But to me, these findings appear analogous to what we started to note with coronary artery disease over the past 20 years. Yes, whether it's for left Maine or complex multivessel disease or in diabetics or if we have I F R guidance, there's an early benefit in terms of lower hazard with PC I. But there is a real potential late benefit when it comes to long term outcomes with surgical approaches that can more completely treat this disease. More, perhaps even more importantly is that we need to be cognizant and quite aware of the high screen failure rate that was noted in both lowest lowest trials, both the SAPIEN, you know, and the eu 15 to 20% of patients in both of these trials were excluded from the, the trial due to an atomic uh constraints or patient factors. And we need to be good stewards of this knowledge. When we're in our transcatheter clinics, talking with our cardiologists and thinking about, you know, which are the 15 to 20% of patients we see in our multidisciplinary clinics that need to be sent to surgery due to an atomic constraints. So let's delve into the major reasons to advocate for surgical aortic valve replacement over tar. I would say that these reasons break down into three categories and that's number one concomitant cardiac disease. Uh Number two would be high risk tar anatomy, which will go over in the most detail. And then number three would be patient preferences and there are factors which would include but not be limited things like Cobalt or nickel or titanium allergies, those sorts of things. And you're gonna need to be well versed in these as you are. These clinics argue with the cardiologists about what the right intervention for these folks is um the C T heart that you get for your ver gives you amazing images of your coronary tree and should be evaluated before you start to talk about the treatment plan with the patient in general. When you see these patients in the clinic, you will not have a coronary angiogram, but you will have that C T scan to give you a sense of their burden for coronary disease. And it's your job as a surgeon to look at these coronary trees for heavy calcium burdens or proximal disease burdens. And then to advocate for the patient to say before we talk exactly what they're going to get. The, the decision for tat surgery needs to be tabled until we have a left heart cath. And to remind the cardiologist not to stand first and ask questions later in these patients to get them the best long term outcomes incompetent disease. Um the calcium burden of aortic valve um will often extend along the amital Curtin and onto the uh annuus of the MIT valve. Um And oftentimes you will see um even milder or moderate mitosis and or regurgitation in these patients. If the patient is a reasonable, reasonable surgical candidate, strong consideration needs to be given to perform an a transesophageal eo to better characterize the MIT valve and other valves. If you can turn it off for those diseases, I'm sure our center has many others. We now have a growing series of Taber valves followed by robotic or heart mit valve repairs and replacements. And I can assure you that this is not the ideal way to treat these patients. If they are good surgical candidates for initial operation, that deals with both uh valves at the, at the initial operation. Um The American Heart Association guidelines advocate that experienced surgeons should consider replacing acid in the oric aneurysms at 4.5 centimeters. Um if they are getting a concomitant aortic valve replacement, and so if these patients are identified in your tater clinic, you need to advocate for them in particular because you know, uh driving uh large transcatheter devices and placing wires across these aortic aneurysms, put you at higher risk for asic aortic dissections during the Taber procedure. So you need to be advocating for these patients that they need a surgical approach if they have this concomitant aortic disease. All right. Uh let's move on to an atomic constraints in very small aortic roots or in very small sinuses of valsalva. Um You can kind of see here a couple of examples. Implanting the 20 SAPIEN or a 23 core valve is not a good option in a patient who has a life expectancy of more than five years. Strong consideration for something like an aortic root enlargement, which I'm sure we'll be talking about a lot more later today or perhaps an aortic root replacement should be given to these patients depending on their anatom considerations, very large aortic annu while there is anecdotal evidence that there is feasibility of tar in very large annular areas up to 900 milli millimeters. It is certainly pushing the limits way beyond the tab I F U. And in these cases, balloons are expanded dramatically to over expand these Taber valves. And that results in the necessary consequence of central A I anything above 800 millimeters in these uh annular areas. Uh Strong consideration should be given to surgery over if the patient is a is a reasonable surgical candidate. Obviously, bicuspid aortic valves would be the most common. And for me, they are now the most common uh um etiology of the tic God disease that I now see in the operating room. But as we all know, bicuspid valves represent a spectrum of disease with varying amounts of calcium and varying amounts of fuse graph. Each bi custom valve should be evaluated by a surgeon that really understands the both the tavern and surgical implications of having um um um the bicu valve and the and where that calcium burden is distributed and where the Raffa is. Um and in patients with only mild or lower calcium burdens and mildly fused, you know, type one sort of Raffa, these patients probably are reasonable candidates for uh transcatheter technologies, particularly if they have symmetrical morbidities on the older side. However, in patients with very heavy calcium burdens or with you know, type zero sorts of uh bicu valves. Again, we need to advocate strongly for these patients to get a surgical or valve replacement. I personally think the most underappreciated nuance in patient selection for tar is heavy calcium burden in the uh left particular outflow tract along the aorta miro Curtin per baal leaks. When you try to Taber, these are very common and these patients almost always have mild to moderate mitosis that is probably underappreciated on your trans drastic echo. So if you see this sort of distribution of calcium from the aortic valve onto the omit Curtin, you need to be very wary and advocate strongly if these patients are good surgical candidates that they at least get A T E to better assess their mitral valve and probably push hard to get a surgery for these patients given the high risk for valve erotic inefficiency, post, post tab. These folks um similarly, you'll see heavy S TJ and or coronary calcium and these patients, there's a high risk for having balloon ruptured during balloon expandable valves or stent frame in folding and self expanding valves of a table is performed. So again, these are cases where you should navigate strongly for assessment for a surgical valve. One thing to note is debulking. These sort of heavy calcium distributions can be a little bit risky, particularly around a coronary a and particularly when they are uh really nasty tenacious calcium. And so sometimes these cases you can consider a stent, um consider something like a Sulu particularly like a personal, which for all its warts does have a pretty low diameter delivery profile and could be somewhat navigated around this Callum and delivered in a surgical approach, low lying coronary arteries and shallow sinuses of valsalva, um lead to low V T CS. That's the valve to coronary ostium distance and should prompt surgical consideration. You can see anything less than eight or 10 on the Coronary heights is worth considering surgery. And you can see there's like a ta sort of embedded uh view and you can see a very small V T C in something like this. And for these patients, you know, they're probably gonna need some uh uh coronary artery interventions if you try to tavern them and if you try to put a Taber valve in them and you get away with it. Um inter intervening on these coronary down the road is fraught with uh with risk. So, in these patients, my practice tends to be a stentless route with mobilization and higher coronary reimplantation to facilitate future tavern valve and valve interventions if it's possible. And then finally, anomalous coronary arteries, um you will inevitably run across the um anomalous circum flex off the right coronary artery in your Taber clinics. Obviously, putting a Taber valve applies a high, a strong real force during an implantation. Um and this can be risky and these patients strong consideration for a surgical implant should be given. And then finally, you should always be worried about tab or valve and valve interventions, particularly in smaller valves. There's clear evidence that implanting smaller uh valves for whatever reason is, is associated with higher rates of morbidity and mortality as compared to larger valves. So in these patients with smaller roots requiring smaller valve implants. If you're doing a val and valve, you should really highly consider explaining the Taber and performing in a replacement to allow for a better Taber valve and surgical root down the road. And with that, I will yield my time back to doctor. Thanks, Doctor Schaffer. Uh We'll take a couple questions for Doctor Schaffer. The first is um ok. Ok. I'll ask the first one. I think a couple of points I took from your talk is um consider the longevity of the patient that's very important. And the second is, don't leave concomitant disease behind. So you went through all those and it goes some of those favorite tabbies, some of those favor A V R. What I wanted to ask you is um you entered practice in mid 2 20 tens. How do patients get to your office? I remember back uh when we started mark that uh patients came to us with aortic stenosis. It'd be an echo Cath and book the patient within a week. Is that how it works nowadays in your um clinic? Doctor Schaffer, it very much depends on the referring cardiologist and your relationship with them. I would say only a third of my practice comes through my clinic and these are patients that have already uh been evaluated to be contra indicated for tavern for some reason or the other, whether it's concomitant coronary artery disease or whether it's clearly a really young patient that needs a mechanical valve or an evaluation for a ROSS procedure. The other two thirds of the patients that I that I perform aortic valve uh um interventions on I meet them in a multidisciplinary clinic that involves me and my cardiologists. And that is sort of the default pathway. Now for people with aortic valve disease to come into our hospital is to come through this clinic that we staff with both the surgeon and the cardiologist to get a good heart team approach to evaluate them. And it's been mostly good as long as you're willing to, you know, stick to your guns when it comes to, you know, advocating for what you think is right for the patient. Yeah, I think the hard team approach is really important. And one of the things that I like is the um imaging that we get now preoperatively for award participations. I never get surprised in the operating room just because the C T scans are so good mark. Yeah. How's your practice change over the past um 10, 20 years? Yeah, I, you know, honestly, uh it hasn't changed a great deal. We're, you know, we have a good fortune of having a really fluid team. Um our intervention cardiologist with whom we do the transcatheter vows, uh make a really good team. We get along super well. So when we have our tab around, we kind of bang through the list and then some folks will show up in my office and some folks will, you know, be seen by my partners, et cetera. We kind of know the path that people are gonna take. Uh We have not been aggressive in what we would consider younger people. So uh anything below 80 years of age, we give a hard look at a surgical intervention quite honestly and certainly 75 below. And as was was mentioned earlier, bicuspid vowels make up kind of the lion's share of our surgical vowels and certainly are minimally invasive. And then if somebody has concomitant disease, we also see a lot of second opinion. So right now, when I look across my practice, about 40% of my cases come from outside my system. And it's because people are shopping, they're aware of what's going on and they understand that there are options and they want to hear about the options. Um My task is to talk about minal invasive erotic bob replacement and how I do it. There's gonna be a lot of surgical video here. So I'll talk about approaches to minimal invasive eric bob replacement. Uh The key steps for mini thoracotomy A V R. So I'll call it also ram T right? Anterior mini thoracotomy A V R is my app preferred approach for patients with isolated aortic disease. And I'll try to put it all together in one video. So there's two approaches to A V R upper hemio toy and right, an interior mini aat depicted here. The um there was a meta analysis that was published uh showing benefits of minimally invasive replacement over uh full Stroot toy A V R. So this uh this slide from the S T S database shows not only the benefits of a upper hemio toy A V R but further benefits from a right thoracotomy. Uh It would valve replacement with reduction in renal failure, length of stay blood transfusions and interestingly new post op atrial fibrillation. And this is from the S T S database. But the single most uh compelling factor for Mitic valve replacements is that if there is no sternotomy, there can be no sternal wound problems. So that includes no sternal wound. A his no deep sternal wound infections, those are terrible and I only give two weeks of sternal precautions for my patients after a ram T aortic valve replacement. So, one of the key steps for Ramy aortic valves, I'll show these in videos for incisions and exposures. I think the preoperative C T. The cross sectional imaging is so important. Uh The approach is viewing the tubular A send in your order that you should be looking at after your um mini Thoro and if you had to guess, pick the second air space. So moving on to the videos the pack systems nowadays are so good. This is provided to me off my pack system with just one click in real time. And you can see from this video, I'm gonna pick the second in the space and disarticulated the third rib from the sternal border. And once you've done that, you could put your finger through the thot toy and palpate the a sending order. Don't get tricked by the right atrium. The goal is to be right on top of the ace sending a order I choose to divide the uh rib from the sternal border that is gonna be put together at the end. I'll show you a video on how to do that. After you divide the pericardium, you should be staring at the tubular ascending order. If you're looking at the right atrium, you're too low, it's gonna be a difficult exposure for you. Uh For two reasons. The first is you're shooting to uh canula the a sending a order as an option. Thermo falter cannula is also fine. Um And you want to have an angle that looks directly to the aortic valve for cannulation. Um You can, I prefer to directly cannulate the order through the incision. But femoral arterial cannulation is also safe too, no increased risk of stroke you may have to contend with growing um pseudoaneurysms. I think the multistage Venus cannula are a big advancement for minimally invasive any valve surgery. Here. You can have your assistant help you by retracting the aorta towards you. So you can place the aortic cannulation stitches. I prefer to use a different cannulation method here. I'll use two horizontal mattress sutures placed at 90 degrees to each other. The reason I do that is because it's only gonna be about, it's only gonna be four bites. Thermal Venus cannula is so good. There's long dilators. Now with a minimal step off, these cannulas get can get advanced very easily through the I V C. But it's imperative that you understand this view to view the Venus cannula traverse the right atrium into the superior Niva. You can't rely on anybody else to uh see this. You have to see this for yourself because this can, it can travel almost anywhere, right? Ventricle coronary sinus through a P F O worse off through the right at pend, which is a perforation. You have your choice of able to cross clamps. Uh Chitwood clamp, detachable clamp, um flexible, the aortic clamp are all available to you. Uh The Del needto cardio pleasure eliminates the need for retrograde cardio plea in a longer time between redosing here is your standard transthoracic cross clamp. Uh the Chitwood clamp. The nice thing here is you can go through a separate stab incision and keep this out of your field. The top tongue should avoid the pulmonary artery. The bottom tongue should avoid the left atrial appendage and make sure you're not clipping the pulmonary artery from the other side. This is the cooly needle, which can also aspirate. And with this, you can place it in the aorta, give your cardio pleasure and then once that's done, take it out. So it's out of your way. This is the formula I use for Delta Cardio plegia, 1500 ccs, initial dose redose with 500 ccs. Um If you're, if you think you're gonna be uh over 60 minutes, I redose it at 45 minutes. So I'm shooting to get this case done in one dose of cardio plegia, 60 minute cross clamp time. The val implantation is by far the challenging part of this um procedure. You will need long shafted instruments to do this. Um You could use this in full stoy cases to get to gain familiarity. But this is a uh instrument that you will need to purchase the auto knots. Um or not pushers are necessary. You will not be able to get your finger in there. And here is one ram T incision and exposure. I'm just trying to show you that the uh length from the incision to the aortic valve is about 13 centimeters. My finger is not 13 centimeters long. So you're gonna need long shafted instruments, auto knots, not pushers, the annual sutures are challenging. You will never see the entire annuus in one view like you do through a full sternotomy. Say, for instance, in a way, a root replacement, you're gonna have to rely on your left hand to counteract for you. So you can see bits of the annuus in order to place these sutures. Once your mechanical valve is in place, uh there's no posts obviously for the ony valve. The knot device saves a lot of time. I like it because the residents can place this without any air knots and without breaking any knots and these are secure knots worth the money. All the cannulation sites can be percutaneous. We've taken some uh leads from our tabby procedures. Um All of our echos, most of our echos are done percutaneously as well. Closure of this is just with the 20 polypropylene and deep bites, horizontal mattress sutures, uh save yourself money. You don't need to use any pur closes for that. Um You can reapproximate the ribbed external border using a thick number five merline or theon suture. This is an orthopedic stitch that uh orthopedic surgeons use to bring tendon back together. Um and it'll save you some money from uh sternal plates. So putting all together in one video, everyone loves watching video of surgery. I'll show every single step of the rat aortic valve replacement. So, right. Anterior mini thoracotomy A V R. So ask your anesthesiologist to do single lung ventilation. You could do it with two lungs but it's just painful uh opening in cannulation. After you studied your C T scan, you will have to identify the memory vessels, double click, double clip the artery, single clip the vein here, locating the ace order with your finger, you can divide the, the rib from the sternal border. This will allow you to put a soft tissue retractor and the drop sucker on the outside. Use your rigid low profile retractor of your choice. This is a Geister retractor. Now, we've changed to a Wexler retractor. You want to be seeing your ace sending your order as your primary view here. After you have this exposure, the stay stitches help a ton. So stay suture is on the para carum. You use that to pull it, pull the order towards yourself. This is a carter thomason suture. Uh retriever, you could bring this anywhere through the chest wall. They are invisible to the patient. Here. You can see 123 and four stay sutures that'll help frame the incision for you. Have your assistant gently pull the aorta towards you and you can cannulate the a sending a order through here. Alternatively, you could do, you could absolutely candle the femoral artery. I use pledgeted horizontal mattress sutures times two here. Uh I've never had a problem with closing this after over 200 ram T A V R s. Um I do the cannulation Salinger technique. So over a wire, you dilate, you dilate, you dilate. This is a femoral arterial cannula and that passes smoothly in this is the femoral Venus canal in the groin. Again, you dilate, dilate and dilate and the multistage venus cannula passes very nicely. After these dilators, you must look at the T E E to see where this cannula is going. You flush some saline through just to make sure there's no static blood. So go on pump after I'm on pump, I will go ahead and put a small blake drain in the right plural cavity below the right breast. And you could use that to inflate co2. Venous drainage is most of the time pretty good. If you need additional venous drainage, you could put an S V C candle in here is a Chitwood clamp going through a separate stab incision, clamping the aorta don't clip the P A, don't clip the left atrial appendage. Once the clamp is on, you use a cooly needle. For those of you who trained at um Texas Heart Institute, you'll recognize this as the bang ga needle. You could also use this to aspirate at the end. So it's gives cardio plegia and will also aspirate air. But the great part about it here is I just put it through my aortotomy line, which means that I'll take it out after the heart, stop beating and make the er toomy. Exactly where that hole was a toomy. For me is a oblique aot, don't cut towards the um clamp stay sutures will help you frame the incision. This is the stay sutures at the top of the another state future at the left, right. Uh mier heavily calcified aortic valve, it put a drop sucker through the valve. If you're at all worried about the cardio plegia, don't worry, give direct coronary as um uh cardio pleasure. Respect the uh this in this case, a bicuspid valve, You can't do this in transcatheter valve implantation. Carefully de breed and decalcified. No need to oversize the mechanical valve. The hemodynamics through these valves are fantastic. I'll place uh horizontal mattress sutures, non averting. No pledgets. You really don't need pledgets for this. The valve will sit there almost like a cork. I've never seen Perry valve or regurgitation around this mechanical valve. Uh And the core knot is worth it. Spend the money. Once you look through the valve, you should see no annuus. You should see only L V O T and then closing the air. Toomy can be a little bit tedious but roll up your sleeves and take your time because you don't want to have to repair this. Once you're off pump, I use two rows of 40 at the bod suture. There's some pledgets on either end. It's got to be secure dear. It, place your cool needle back. Continue to DEA take the cross clamp off. You don't need to read. You don't need to do a warm shot with Del Nido before you come off. If you haven't placed, placed the pacing swan, you better place your pacing wires now because you won't be able to do it once the heart's full and beating de cannulation. The uh Venus cannulation, please do this percutaneously. You really do not need to uh do an open cut down just for ephemeral. Venus cannula cooly needle is just an 18 gauge needle. So this is easily closed with this horizontal mattress suture, arterio cannulation should not be a problem. And um I never liked these mounds of pledges. But then again, I've never had to fix this uh cannulation site. You could use the Chitwood site to bring back, bring through another blake drain. This will serve as your pericardial drain. I think pain control is really important. Here is some beating going internally at the 2nd and 3rd, interco 2nd, 3rd and 4th, intercostal space. If you have the money and you want to spend, you could use cryo analgesia. This is FDA approved. This analgesia lasts for months and it is very effective. There's a castro stitch to reapproximate your rib to the sternal border. Alternatively, you could use plates to reapproximate this, take your time. You don't want to see lung herniation, postoperatively, the paravertebral block I think is better than er Rector's spine eye. So, in conclusion, I think the most compelling thing for ram T A V R is that there is no sternal wound complications. I get patients back to normal activity in two weeks. Um This rivals of tavy restrictions. Uh some things you're gonna have to buy some multi side thermo venous cannulas. The long shafted instruments are expensive. The core knot, auto knot is definitely worth it. Uh Key technical steps is take a look at your C T scan because picking the appropriate rib space is important. Pick which cannulation site that you want. Arterial femoral does not matter and you gotta practice placing those suit. Um the annual sutures. Thank you very much. We'll move on to doctor Gish who uh entered practice way before all of us. Although he looks younger than all three of us and I like this talk because it's um really the first discussion I have with a patient and that is valve choice. I think we make the mistake of jumping automatically talking about approaches tabby versus a V R when the first decision that has to be made is well, what sort of valve do you want? Do you want a mechanical valve? You want a tissue valve? Do you want a Ross procedure? So I'll hand the mic over to doctor Gish. Thank you, Chris. Uh That was a fantastic presentation. I'm sure people have questions about technique and things and maybe we'll have a minute later to go back to it because uh I do the same operation only a little bit differently as is always the case between surgeons, right. Um, but well done. Um, so, yeah, you know, as the O G I'm gonna wax philosophic a little bit and we were talking about my clinic a minute ago or a little while ago. Uh, one of the things that I think stands out in the experience being in my clinic is that I have long visits with my patients, uh, because we are talking about them making a decision. That's the biggest decision they'll ever make in their lives. I mean, you can get divorced, but you can't undo your heart surgery, you can sell the crappy house, you buy, you can't undo your heart surgery. So when they make that decision, they're making the biggest choice of their entire lives. So, um, you know, I think there's gonna be a little bit of a broad conversation and I'm gonna do my 15 minutes and anybody wants to catch me in a bar sometime will do what I usually do in a bar, which is just talk about this stuff, but to start out with isolated aortic valve replacement. So we, we mentioned earlier that we're heavy on the bicuspids, right? So this kind of younger cohort of folks that are really good candidates for right, anterior thor economy tend to be bicuspids for the lie of their aorta for their health, their excellent access if we're doing uh thermal cany, which we do percutaneously with per clothes. But we have to recognize and that's 70% of our isolated A V R so isolated, somebody might show up as an isolated A V R but they need a cabbage or they need a my Children or you need something else. So isolated. A V R s don't always stay as isolated a V R s. But those that do the vast majority end up with the right anterior economy. But if we're on a mission, for example, we absolutely have to close the appendage. Of course, if somebody has a fib, they get amazed. But my point here is that if there's something else you need to do and you want to be certain about it and you see those things below there, you're gonna do as sternotomy. So, ok, many sternotomies, astronomy, astronomy. So I think that there are things we can do to mitigate the issues related to astronomy. And people who have been in my operating room will see tiny Ronon and they'll see bigger sternotomies. And it just depends on what we're doing inside the chest and who the person is now. 90% of tissue A V R do not get the right size valve. What I mean by that is we put a bigger valve in. I mean, we are, if you're getting a tissue early valve replacement, it is incumbent upon us to ensure that the patient has a big enough valve, they'll give them durability and give them access later. If they need to have a valve. Valve. Uh this is not a mini, right? So this is a 58 year old guy. He comes to me uh with bike C A S, he's got a fib, he's already been offered a ver at another institution. I said, well, let's do the menu. Yeah, we could do tar. His bike custard was actually amenable to a ta we could do a right answer your throaty and I'll just do your air to valve and we got to leave your a fib behind or we can do a maze and an aortic valve replacement. And then you could choose your valve, which he chose an onyx. And actually, when he did his first post on this site, his words were, I'm going with an on valve and a maze. In other words, he made the choice. We had a conversation and then day three, he leaves the hospital, gets back in his car, drives four hours away, back to his house. We let people drive right away after surgery unless they're gonna have a uh visiting home nurse. In which case, we ask him to wait five days, so that the nurse will come and see him. But we don't have really have much in the way of sternal limitations because we rigidly fixate every sternum. So they really don't have any pain. So it's really kind of the size of the incision and still some risk of having a, a sternal complication. But the thing is, we can, we can give them everything they need. We just have to think a little bit about those issues. So non isolate A V R, right? All these other things that we do that we need astronomy or he astronomy or partial astronomy or whatever you wanna call it. We need to split the bone in. This is a guy who got a lot of other work done, right? He's posted out day four. He's going home. Look at the size of this dude. He had a lot of work done. And again, I just want to make the point that yeah, super sexy to do a minimally invasive operation. Love doing them, do plenty of them. But that isn't our primary goal. Our primary goal is to give them exactly what they need. And you know, look at these two guys, they're both three weeks out from surgery. The guy who's golfing is the one who had the mini, the guy hitting that ball three weeks ago, I had a sternotomy, a full sternotomy. So we're making two sets of predictions when we see our patients, the acute situational predictions, the aid and decision algorithm. So where's the er position the dimensions, the aero annular architecture? What's our perfusion access look like? And then we have long term predictions about valve durability and next valve options if they're needed, we make these predictions on behalf of our patients. So we can't just say, oh, well, I'll do a tissue valve, you have a tab or later. Can you do that? Is it true that the patient is gonna be able to have a valve valve? So where is the or is it in the right place? Yeah, this patient's got an order in the right place, gets a beautiful valve in and out through a small incision. But when we move over to tissue valves, we have to have these more complicated conversations because the clock is different for every human being. How long will that valve last in that patient? Based on their age, number one predictor the size of the valve because a smaller valve doesn't last as long. We all understand that right? Even if we're not thinking in terms of valve and valve, a smaller valve has a shorter clock on it. Because if you upsize, you gain that time as the valve deteriorates in between sizes, cardio metabolic syndrome, a major player in valve deterioration, we have to think about it, diabetes, systemic inflammatory conditions, rheumatoid arthritis, and callos spinalis. These people show up patients show up with these conditions and you have to be able to address that in the scheme so that you're not redoing their valve suit so that they're not going to somebody else to have their valve redone soon. How long will this patient last? Right. So what is, how long is the patient gonna live? We talked about this earlier. This comes down to a an in depth conversation about the patient's personal aspirations and what their modifiable risks are for their longevity. We talk about that but a minimally invasive operation with a velvet valve option does not absolve us of telling the story of the sinus. We must develop a framework for discussing valve durability and concomitant disease based on what we know what we expect and what the context is for that particular human being. We have to do our storytelling. So this actually I stole this slide from my son. My son just gave kind of a uh uh a talk on the convergence of science and art. And I love this slide because you know, even the most scientific of us wants to hear the story. We want to understand the interweaving of the science with the human side of our experience and the patient's experience. So let's tell some stories. What about this story? Transcatheter versus surgical valve, replaced with a low uh young low risk patients with severe ear stenosis. What's wrong with this? The problem is here at Ta Ta Ta Ta. What about just saver? What about just getting an onyx valve? Yeah, you have to be anti coagulated. Well, you're gonna have to think about it and decide if that's the path that you want to take. Now, here's another story. This just got, this just came out from AC C transcanada versus surgical valve. This is low risk. Yeah, with the evolution valve. What's the story that this tells, this tells the story that at least after three years you're better off having a tapper. Now, we think that maybe there might be some convergence later, but we don't know that. And these don't look like they're converging like the Sapiens did. So what's going on here? What, what's the story that we're gonna tell? What's the story that's gonna be meaningful to us in a long term scheme for these patients, all cause mortality, disabling stroke, readmission to the hospital. These are all things that we have to wrestle with both as, as physicians, human and as human beings. How we're treating people. Now, this is an important slide because it shows up every time you compare to a to surgery and the first year sucks. So as what we were, what we're just talking about with Chris Justin is when we get to a minimally invasive incision that doesn't take the steam out of the patient that they go back to their lives in a couple of weeks. Or if we approach through astronomy and we mitigate those issues that we don't have that year. It's the sternotomy. It's the sternotomy that changes their life in that first year and sometimes beyond Tara wallops saver and cost effectiveness. If, if we get the bundle care, you get look at 90 days. Tara does better because is expensive. After the patient leaves the hospital, they go to extended care facilities, they get readmitted and again at one up to one year and to some degree beyond their overall health status is better with a transcatheter valve. We have to compete with that window. So that means minimally invasive and mitigating those issues related to our approach. AC C A H A don't help us. The balance between valve durability versus risk of bleeding and thrombolic events favors a choice of mechanical valve less than 50 unless anticoagulation is not desired. Nobody desires anti coagulation that just takes everybody off the table. Nobody wants to be an coagulate cannot be monitored or contra indicated. So they're not gonna help us help our patients. No one wants to be an anti unless it saves or extends their lives and still they're not happy about it. Right. So we have to think about those things, but you also have to mention that clearly, at least one third of patients who have tissue valves or transcatheter valves doesn't matter which one are gonna be anti coagulated in some fashion. So we're treating diseases. We're gonna take the really bad valve and give them a new valve and that's gonna be a mechanical valve or a tissue valve and that's their new burden. So we have to look at it in the complete composite of that patient's life and what their expectations are. 20 millimeter SAPIEN three that failed in a 72 year old woman. They did it because she had radiation to her chest. We went and took it out and put a valve in her. But what was gonna be the next thing? She had a 20 millimeter SAPIEN when she was 72 years old or the, the clock that can run quickly on a transcatheter valve for calcification in somebody who has renal failure. This was a younger person with renal failure. We took that out and put a uh an onyx in them or this is important 50 year old guy, six years after his bioprosthetic valve, who now has L V hypertrophy and diastolic dysfunction that he would not have had if he didn't have a valve that deteriorated over time, if it performed the same way from the time it went in then on. So we know that every time we look at a study or a series of studies, the mechanical valves do better in younger people. And we also know that there's never been a paper that showed that biologic valves prof that confer a survival advantage for anybody over time. So that still exists as a truth even in the context of valve valve. This is something that I've been working with for the last couple of years. I think it's important to recognize that when we want to strategize for the patient's entire life, this is, it's a three dimensional program for implanting valves virtually that if we want to think of somebody over the long game, this is a bicuspid valve and I'll just flash these images at you. I actually had the model for me, a tissue valve and a mechanical valve. This is basically set up for transcatheter valves. But I said, cut the valve out, put these in, show me what it looks like. This is what it would look like. And then after that, I did secondary modeling to look at what it would be like to put a transcatheter valve. This is in the native valve as the index operation. But I looked at what it would take to what it would be like to put a transcatheter valve inside. I'm gonna get to that because this will take a long time otherwise inside the tissue valve. And basically, you can model root rupture, you can model what happens to the calcium. You can model where the membrane septum is. But for example, this is the modeling of a trans gather valve inside the bioprosthetic valve that I would propose putting in the patient. If I did a bioprosthetic valve, this patient ended up with a, with an ionic valve, but it gives me information. And in fact, we go on to model various iterations and as it turns out, there's an iteration in here where we, where we include the left, the left coronary artery, doing a valve valve, not good, right. So if we figure that out later, when we're doing the valve and valve, then we either have to do a basilica ahead of time, figure it out or we can't do the operation that we promised the patient that we were gonna be able to do the valve and valve operation, right? Or we could look at, you can place any valve you want in there. It'll model it for you. Now, one of the things I'd I'd like you to, to notice is that because we're doing a valve and valve, you don't have that bulky prior, you know, the patient's original valve tissue in there, eating up the s sinus space and affecting the vertical flow there. And with this, you can predict what the model will look like. And this is, this is tar and tar. So you see that big chunk of calcium that's filling up the coronary sinus there. You have to recognize that we don't know the implicate the implications of that. When we stuff a native valve into the coronary sinus, then put a valve in there and then put another valve in there, we should have no idea what the consequences are for coronary flow, for thrombosis to the leaflets and risk for the patient. So, lifelong planning, what does it look like? Does it look like that? Does it look like this? It really kind of comes down to that lengthy and and somewhat indulge in conversation with the patient to make sure they see what they mean to see sinus vertical flow. We need to know that they will have sustained good coronary blood flow. We need to know what the pattern of blood flow is like in the root. And we're looking at that, the ionic valve, I just want to touch on a couple of things here. If you don't know the story, that's Jack Buck Ross, who's about the coolest guy you're ever gonna meet in the history of mechanical valves. He invented pyrolite paralytic carbon when he was figuring out how to store nuclear energy. He went on to develop the uh the pyrolite carbon that's on the ionic valve. This is standard paralytic carbon that's on any every valve on the planet except for the ionic valve. This is onyx carbon which is pure carbon has no silica doping. It's a smoother surface. And as most of you know, the mechanism of the onyx valve allows for laminar flow unlike any other mechanical valve. And that laminar flow uh and the, the way that the leaflets close and don't waste uh the physiological insufficiency that we see or physiological insufficiency that we see with mechanical valves. They use that up in washing jets on the uh on the uh pivots. And also because the skirt goes across the annuus, uh we've largely beaten the um development of panic and growth for the mechanical ionics valve. The blood only sees the outflow tract and ony pure carbon. And you all know that we did a study several years ago that proved that we could run this velvet and I N R 1.5 to 2. But when we put it, when you put an ony mechanical valve in somebody, we try to get everybody home monitoring and then we just tell them, just shoot for two. Your target is an I N R of two. And that allows us to eliminate or at least dramatically decrease the bleeding. Remember, people with tissue valves bleed too and this, we reduce the bleeding events by 65% thereby leveling the playing field. Bleeding risk doesn't change in this relationship to I and R it's driven by it. And I always say, you know, people say, oh, can I still do stuff or what about patients that want to do stuff? This is a guy that, you know, a dozen years ago had his routine, a sending order replaced with an on and you know, ran his first marathon in 2007. And this is a guy six weeks prior to this had is actually this is not mitral valve, but you know, showed up, sent me a picture of him at skiing in Switzerland, uh six weeks after having that operation. So it's not the end of the world. It is not a rate limiter for their lives and coming in for a valve, valve is not coming in for a haircut. So I think that we just have to be honest with patients. So they understand the landscape. Thank you. Thanks. But I thought I saw a poll question come up. Um do we have enough time for people to answer that? And while we're waiting for that, uh I wanted to ask, um, in a couple of minutes we have left uh mark. So I'm surprised nowadays about the resurgence of aortic annular enlargement as a additional procedure for patients getting a bio A B R. What strikes me is that it's still an uncommon procedure even nowadays. So, uh when the surgeon out there is faced with a small aortic root and they have to do an aortic root enlargement. And people are saying, oh, you gotta put a 23 25 bio valve in there. Why not just put in a mechanical valve without an aortic root enlar and call it a day? Yeah. So I think we could all, you know, make that argument uh certainly in a, in a, in, in a reasonable age group, I think, honestly. So it, it really, yeah, it's really kind of dicey, right. You get over 70 you talk about to put a mechanical valve in and admittedly if they had been 62 you put the mechanical valve and eventually they're gonna be 70. So, uh yeah, if I'm being absolutely honest, I do have conversations with patients where I lay out every possibility and there are times where we will agree that if I can't get, you know, a monster of opera that velvet him, we're gonna put in mechanical velvet him. Uh and they, you know, because we've had this conversation, we're balancing back and forth and they're just like, you know, what doc just do, what you think is right at the time, what you do for yourself. Um And I think you're right. I mean, we saw Justin showed earlier some calcification distributions are just a bear to work with even if you're gonna do a root replacement. Right? Because the Coron are, are affected or a root enlargement. When you got to chop across the calcified sinotubular junction, those things get dicey. And uh I think, you know, it makes perfect sense uh for a patient, especially if they're not sure to have that as you know, part of the dynamic conversation. That's my polling question. Yeah, I just wanted to kind of see what people thought. Yeah, the question was the information on a V R patient will not uh will find most valuable is and it looks like mark. Um But I'm gonna read this correctly. Most important is B so that's the uh green, the future strategy of managing the erotic valve disease. The second most important to people were pat of physiology and anatomy of their condition. Third is if present the significance of concomitant pathology and the least important is the incision and associated debilitation is that what you're expecting? You know, uh I actually wasn't but it, I find it favorable. I think it's, this is, looks like a very rational kind of approach where you know, doctors are thinking in terms of what's really good for the patient. So that's great. Well, I think I'll give it to Doctor Schaffer to, um, close this seminar out. He, he'll have the last word as the youngest person. I think it's clearly the right thing for me to have the last word here. I think one thing that Doctor Malay, uh, Doctor GERD myself all agree on is that in these young patients, this is a long uh fraught conversation that you have to have. You gotta be personable. You've got to review all of the options. You gotta put them on the table and you gotta make it. So the patient has full informed consent and that they buy into what the treatment plan is that they're gonna decide on and it ends up being their decision. You say here are the options. Here's what I think. Here's where your risk profile and what your preferences lead me towards. But what do you think? And, and you gotta pick it? And then like we said, you gotta live with it. Once you make that decision, there's no going back. Well said, well, thank everyone for joining us on this art Tian live webinar on complex aortic replacement and minimally invasive or V replacement. So, on behalf of uh the speakers, Doctor Schaffer, Doctor Gish, please have a uh good afternoon and evening. Thank you. Thanks Chris. Thank you all. Appreciate it. I would like to thank all you panelists, Dr Malay, Doctor Doctor Schafer. Thank you for your time and um amazing input this evening, we truly value um you sharing um all of this great information with our viewers. Thank you for everyone uh who joined us. And um this webinar will be available on demand in two weeks at heart resources dot com. Um On behalf of everyone at we hope you have a wonderful evening. Thank you all.