Transcatheter Aortic Valve Replacement (TAVR) – Essentia Health

Transcatheter Aortic Valve Replacement (TAVR) – Essentia Health


Good afternoon everybody welcome to Essentia
Health St. Mary’s cath lab. It’s a beautiful Tuesday afternoon. We’re really happy and excited to bring you
this case. We thought everybody would be really interested
in what it is we do kind of behind the scenes and this is a procedure that’s kind of taking
off right now. And we’re really happy to bring you one and
show you what we do from start to finish. So, I’m going to start by introducing the
team, it’s a relatively big team. Dr. Atul Singla is one of our fellows so we
actually got pretty good at this over the last five years and thought last year that
we were good enough that we could start training people how to do it. So, Dr. Singla is spending a year of his life
here with us learning how to do these and he’s gotten the case started for us and doing
a great job. Dr. Denton Stam is to his right he’s one of
our great cardiovascular surgeons. We’re really lucky to have him here. Sherry is one of our tech-extraordinaires. Behind her is Laura, one of our Edwards Life
Sciences reps who support all of our cases. Amy and Shelley are somewhere in the background
back there, the coordinators of the program who all of our patients get to know really
really well. Faith is one of our great PA students. Caroline is in the back one of the newest
members of our team is one of our great tech’s. Jude is hiding back there somewhere one of
our great nurses. And then our excellent cardiac anesthesia
team Dr. Eskuri is up at the top. Greta is our great perfusionist she’s been
with us from the very beginning and really does a
fabulous job. So that is our team. With that I want to introduce you to the patient
so this is a delightful 81 year old lady who came to us with worsening shortness of breath
and was found to have aortic stenosis, which essentially means that the aortic valve the
one between the heart and the rest of the body was narrowed and not opening appropriately. Part of her medical
history is that she’s a survivor of breast cancer and as part of that treatment had radiation
therapy to her chest which makes her extremely high-risk to have a sternotomy or open-heart
surgery, which in many cases is the treatment for these folks. So, we decided that she would be better served
with this procedure called transcatheter aortic valve replacement which is replacing the heart
valve using balloons and catheters. So, if you zoom in kind of here on my hands
Dr. Singla has a set up really nicely. So, in order to do this procedure, the patients
don’t need to be put all the way out our cardiac anesthesiologists and CRNAs are fabulous
here so Emily is just taking a nice snooze right now. Oftentimes if we actually need to talk to
the patient’s we could do that, so we just use numbing medication to keep the patients
comfortable and Dr. Singla has a nice big tube put in the artery right here. This is how we’ll deliver the heart valve
and then a couple of tubes over on the other side which help guide how we’re going to do
this. So let’s show you how far we’ve come here
we got all of these tubes in which takes a little bit of time and then we put a pacemaker
in the heart because although we never stop the heart to do this we need it to go really
fast as we’re deploying the valve so that it doesn’t pop out and we’ll talk about that
a little more later. So, the first thing that we like to do is
take a picture of our best view so that we know exactly where we need to land the valve
and we get kind of a perfect angle so are we ready to take a picture here guys. Okay. And inject please. Okay so we’re not a hundred percent happy
with that let’s go just a little more cranial here. We want to make sure it’s very very important
that we have everything lined up appropriately so that we know for sure that when we put
the valve in its going to be a perfect job. I think this is probably good. Alright ready, inject please. That is not terrible. So, I like to make sure there’s consensus
with whatever we’re doing anything here so it’s a big team so to not ask for everybody’s
help would just be foolish. So, I like to get a consensus. Dr. Bishu is somewhere probably standing right
behind me. He’s the medical director of our program. Very, very important we do all these cases
together, so I like to ask him things as the case goes along and he is shaking his head
that he approves of how things look. So, after that the next step is, we actually
need to cross this valve in order to in order to fix it, so we’ll get a catheter here and
cross the valve. We’ve actually had kind of a number of questions
come in that that we’d be happy to answer and as we do things here with our hands and
there’s a little bit of downtime I’m probably going to kick it to Dr. Bishu to ask a question
and if he stumps me I’ll actually have them answer it. “What kind of material are these valves
that you’re putting in through the leg made from?” So here we are a comprehensive valve center
and we offer all everything that there is to offer so we actually right now have two
different valve portfolios that we can use. The valve that we are going to put in in this
patient is made from cow tissue or the lining of cow heart. The other valve is made from the lining of
a pig heart, so both valves have their pluses and their minuses. We chose for this particular patient this
valve so that’s a really good question. So often the question is do I need to take
blood thinners when I have one of these valves put in and the answer is no. Let’s just go a little more LAO for me here
guys. So if I struggle with this part of the procedure
usually I just hand it off to Dr. Singla who gets it right away
or a lot of times when it recognizes I’m getting impatient too it smiles upon me. So, Dr. Singla came to us from New Orleans. I’ve only been there a couple of times, but
he was actually wearing like a parka or something when I saw him here in Duluth and it was I
think it was like 50 degrees out or something so I’m a little bit nervous for Dr. Singla
once winter actually strikes. So, the next step is to get our wire into
the pumping chamber of the heart so that we can get this heart valve fixed up which we’ve
done here. Sometimes there’s a little tickling of the
heart that we like to let our anesthesiologist know that and you’ll see we kind of methodically
walk things out and put them in. Now might be a nice time to grab another question. “Are the patients completely put out for
the procedure or do you use a different kind of sedation?” So, when we started doing this about five
years ago it wasn’t uncommon for the patients to be completely out with breathing tubes
and everything and what we found is number one most of the time that’s not necessary
and number two it usually just prolongs hospital stays. So, these days, and we’ve
been doing this for about a year for a year maybe a little bit more. We use what we call a minimalist approach
so the less you do to a patient the better the outcome is going to be. And we usually just use some medication to
make them kind of sleepy and a lot of numbing medication in the arteries and the legs to
make sure they’re comfortable throughout the whole procedure. But very rarely do we ever need to use breathing
tubes and we find that patients end up going home a lot faster that way and in general
just are far more comfortable. It’s much easier to wake up from just lights
sedation than it is from general anesthesia. So really good question. So, the next step of the procedure is to kind
of measure what the pressure differences are between the pumping chamber of the heart and
the aorta where all the blood is flowing out. And if you look at the pressure screen here
you can see there’s a very significant what we call gradient, meaning there’s a big pressure
difference between the pumping chamber and the aorta which is exactly the problem we’re
here to fix. And having all of this information about what
the pressures are really guide what we’re going to do as we move along here. So now that we have all the information now
it’s kind of game time so now we’re going to get the valve delivered. One thing that’s really critical is we want
to make sure that the blood is thin enough before we deploy the valve, so I always stop
before we put the valve up and ask Gretta whether or not we’ve gotten the blood thin
enough in order to do this. Okay so Greta is… telling me that we’re
just not quite thin enough so we’re going to give a little more medication called heparin
which thins the blood and prevents bad things like strokes happening when we deploy the
valve. So why don’t we give another two thousand
heparin guys. So, the next step in this process is going
to be to deliver the valve up and then we’ll show you kind of how we put this together
in the body and Dr. Stam’s actually gotten really good at this. It’s kind of like doing a puzzle in the body. I tell people that this is a lot like a dance,
so I always say one of the single greatest things to ever come from the TAVR technology
is the fact that we work as a team. So, I think when Dr. Stam started his career
he probably never imagined that he’d be standing next to an interventional cardiologist doing
cases. It’s really been unbelievably fulfilling for
my career to have him and his partners by my side and learn from a lifetime of what
it is that they do. So, I really enjoy the team-based effort that
we have here it’s phenomenal. So, let’s open that up guys and see if we
can see down to the tip of the sheath. So, this is a relatively big tube you can
appreciate that we’re putting in. We do this very gently and very carefully
so that we don’t damage any of the blood vessels as we’re going in. It’s very important that we keep the wire
exactly where it is because this is one of those situations that once it goes in it’s
not coming out; we have to get it into the right place. Good, perfect. And then I am going to get this into a place
that looks a little bit vertical and then we’ll explain kind of how we put the how we
put the valve together. So, let’s mag in on that and go a little
bit cranial for me if you would. Good and let’s match up one on the valve too. I think it might need to go just a hair more
cranial Sherry. I think that’s good. So now you can look at Dr. Stam’s hands and
maybe the screen as well so in order to make this tube smaller we have to put this together
in the body so we have to bring the balloon that deploys the valve to within the valve
itself and that’s what Dr. Stam’s doing now. So, it’s like putting a little puzzle together
within the body here. And yeah perfect and then we give it a little
burp to get all the tension out of it and now we’re ready to go up and around and deliver
this heart valve to where it needs to go. So, we’re all locked up yeah? Okay. So, let’s LAO here to cross. Okay, ready Dr. Stam? So, what he’s doing is kind of guiding me. I say this is a dance because it really takes
two people to do this well. So, Dr. Stam is turning a knob here to kind
of guide me around the big vessel in the body called the aortic arch to reduce the risk
of causing strokes or things like that. And then once I get to about right here which
is right above where the heart valve is I like to take a pause and stop and make sure
that anesthesia and everybody in the room is ready so that we don’t have any mistakes
or any miscommunication and everybody’s on the same page. So, we’ll stop here and ask Dr. Eskuri and
Matt if they’re doing okay. And they tell me that they’re okay. So, the next step is for us to cross the valve
which we’ve done here. And now there’s a there’s a big pusher there
that helped me to push and Dr. Stam Is going to bring that pusher back now so that the
only thing left is the heart valve. And then the next step is to deploy this. Perfect. And then you might be able to appreciate that
we have a little pigtail catheter in there the kind of guides what we’re doing here. Let’s mag in and go to our deployment for
you now. And then we like to do a test so as I said
before we never stop the heart when we’re doing this, but we pace it relatively rapidly
as we go so that the blood doesn’t eject the valve out as we’re going. I like to do a test as our final thing so
that we make sure that the pacemakers working and there’s not going to be any malfunctions. So, Ben has joined us in our case. And we’re just going to take a little picture
here while we’re pacing to make sure that the valve is going to be exactly where we
want it before we go. Okay you ready Ben? Okay let’s go pacemaker on please and the
pacemaker rapidly paces the heart. Inject please and pacemaker off please. So that’s a nice little test run and then
once again just like I said before we have a whole roomful of people that have done a
lot of these so we like to have consensus and know what everybody thinks before we make
any decisions to go forward. So, the consensus is it looks good. It’s probably not perfect so we’re not perfectly
happy with it we’re probably going to move it in just a hair and I think that that’s
going to be okay. I’m really neurotic about this and I like
to know exactly where it’s going to deploy so we’re going to do one more test run here
before we do the real thing. So, pacemaker on please. I like to see that there’s a really good pressure
drop here which we have. Inject please and pacemaker off please. And I’m guessing that everybody’s pretty happy
here. We have a little bit of leaking which we’re
going to take care of here very shortly. So, this next one is going to be the real
thing. This is very military-like right now so there’s
usually one voice at the table calling out what we’re going to do and everybody knows
their role and we just do it. So, you guys ready? Okay pacemaker on please. And start, and take it, and one-two-three. Balloon down please. Keep pacing, keep pacing, keep pacing and
keep pacing. Pacemaker off please. Store flouro. So, at this point the valve is completely
deployed and we’re always very eager to check with our anesthesia colleagues how she tolerated
all of this and how her blood pressure looks. She seems to be doing ok, huh guys. And then the next step is going to be to measure
what the pressures are. So, I told you at the beginning when we measured
pressures there was a very significant gradient between the pumping chamber of the heart. I like to call it the engine for people that
conceptualize this like a car. So there was a big gradient between the engine
of the car and some of the fuel lines and what we would like to see with this brand
new heart valve is that that gradient has disappeared now so we’ll put a pigtail catheter
in here and just measure some more pressures. Preliminary we’re really happy with it we’ll
interrogate this using pressures as well as a picture but preliminary we’re very happy
with it. Laura’s probably standing right behind me
and she’ll let me know when she thinks it’s a perfect job. So, there’s a lot of things that go in to
planning for this procedure. A lot of what you don’t see is the stuff that
happens behind the scenes before we make it to the table. So, when I meet with patients, I tell them
that the workup to figure out whether or not you’re a candidate and plan this procedure
is relatively comprehensive and it usually takes from the time we meet patients about
a month until we get them to this point. And the reason for that is we want to know
about all the hiccups and all the speed bumps beforehand so that when we reach this point
we’re 99% sure we’re going to be successful. So, the short answer to the question is once
we’ve put it in and it’s in this place the risk is virtually zero that it’s going to
go anywhere. It’s nicely latched into the annulus of the
aorta, it’s perfectly sized because the CT scan predicts what the size needs to be and
that’s why we’re so methodical about making sure we’re in the exact right place, because
the only way that valve can go anywhere that it shouldn’t be is if we don’t take our time
we don’t pay attention we’re not methodical and we end up going up on the balloon in a
place where it’s not okay. Good question. Thankfully we’ve not had that happen here
knock on wood and I hope that we never do, but it is something that that is a potential
problem. It happens extremely, extremely rarely. So, what we’re looking at here is an absolutely
beautiful result from a blood pressure standpoint. So, all of that gradient that we saw before
is essentially gone. The pressures in Emily’s heart are absolutely
normal and we’re really happy with this result. So, the next step is that we take some of
these catheters out that we’re using to monitor and then we will take one additional picture
to make sure that there’s no leaking behind the valve before we before we call this a
success. So are we ready to inject guys? Okay inject there please. And this is just absolutely a beautiful result. So now is when I should hear Laura in the
background saying perfect. She says perfect so that’s what we know we’ve
done a good job. So at this point the valve part of the procedure
is over so the last part of the procedure is getting these big tubes that we use to
deliver the heart valve out and we do that using little suture devices right here that
Dr. Singla put in before we even started so we take these little tubes out and then we
cinch down on these little sutures to close that big hole that we’ve put in the artery. And similarly we could do the same for the
little tubes over on the other side so when Emily wakes up very, very shortly after we’re
finished she’ll need to lay flat maybe just for a couple of hours and I always tell our
patients that you should be eating lunch or dinner in a chair and we expect to see her
up and at ‘em just a couple hours after we’re finished. So just to summarize what we’ve done. Emily was an 81-year-old female who came in
with a very narrow heart valve, the aortic valve, who was not a good candidate to have
surgery because of previous radiation to her chest. So, we decided to perform a transcatheter
approach to replacing her heart valve which we demonstrated here and got an absolutely
perfect result and I just want to thank the team for a lot of good preparation. This isn’t something that comes together easily. Everybody was really attentive to Emily and
this was just a fabulous success. So, thanks for joining us. We look forward to doing more of this in the
future as I said we’re kind of a comprehensive valve program, so we do a lot more than just
this and maybe that’ll be the teaser for future things to come. There’s a lot of good stuff out there that
we can bring you and hope you really enjoyed this, so thanks. Dr. Schultz that was a fantastic case. Would you be willing to summarize how you
think everything went and give a little bit of the history of the program here? I thought it was a great case. It was a really good example of somebody that
would be fairly high-risk to have surgery open-heart surgery that’s better served with
this technology. So, our program is about five years old we’ve
been doing this a long time – Emily’s actually our four hundred and thirtieth case so we’ve
grown pretty exponentially over the over the last five years. I think it’s probably important to know that,
you know this kind of technology while it used to be reserved for people that were really
high risk to have heart surgery now it’s approved for most people that have this problem that
need a valve replaced. So, what we’ve seen is exponential growth
in the number of patients coming because the therapies have become less invasive and they’re
more interested in getting them. So, I think Emily was a really nice instructive
patient because she’s somebody that may have not had other options had we not had this
technology, but the technologies really not limited just to her. I think it’s going to be applied more globally
in the months and years to come. So, we’re really excited about the growth
of the program here. It’s already growing really quickly, but I
think the sky is kind of the limit.

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