Joshua Cohen, MD, discusses advanced cardiac imaging with 3D guidance and what they will be capable of in the future.
All right, thanks Matt for the, the kind introduction. Um So, as Matt said, I'm Josh Cohen. I just came from the clinic. I'm here to do kind of all imaging um CT MRI Nuclear Echo, but um have a specific interest in um structural heart procedures. Um So my goal today is one to kind of show you, I think just what we um are and will be capable of kind of in the future here. Um And the things that we can do with, with 3D guidance and how that adds precision to um what we do. So, lots of plugs for 3D imaging here. Um In my mind, that is the way forward uh in terms of structural, see if this will advance here. I don't have any disclosures. Um So the first thing I would say is I'd make a plug for a 3D utilization in diagnostic te. Um And the reason being is that um you can acquire one image, one good 3D image with and without color and then you can always go back and reconstruct that. So if you're having a tough time with the t the patient's coughing, gagging, if you get one image, you can literally recreate just about any image of that structure from a 3d image. And you'll see when I start my te si get a full volume of the left ventricle and the full volume of the right ventricle. And the point is that I can always go back and reconstruct that if I need to. The other thing is multiplanar reconstruction. This allows you to evaluate every part of what you're acquiring in that data. Um And then we use this and we've used it all the time in the last three weeks and in my training 3D valve areas, this can be very helpful for micro stenosis, aortic stenosis, um preprocedure planning. What are the leaflets look like in the areas you're trying to either grasp or clip? Um What's the mechanism of valvular dysfunction? Is there prolapse flail? There are certain cases. We've definitely walked into cases recently where we thought, you know, Mr was functional and we realized there's some sort of, you know, small flail. Um in addition, um 3D volumes. So uh EFS LVEFRVF, you can do 3D strain, um all these kind of advanced type things and then you can quantify valvular lesions um in 3D as well. Um And there's been some validation to that. So, what's the structural landscape? What are the things that we um like to do and are kind of coming um to the forefront here. So I'll include the left atrial appendage. Um obviously, watchmen left atrial appendage occlusion has uh kind of exploded. There's also now, um you know, uh a small amount of people doing per device, leak closures and coilings. Um on the mitral side, we do valvuloplasty. We do transcatheter edge to edge repair. Same on the tricuspid, we do TMVR, same way we do T TV. R. Um some of these are all clinical trial based um and then percutaneous annuloplasty um more developed on the mitral side, less so on the Tricuspid, although it exists in Europe, um PV L closures, we do more common on the mitral side as well. Um And then on the aortic side, TVER has moved away mostly from um tee kind of because they don't need us anymore. And it's a well oiled machine that being said there are complex cases where you're doing Tavin Tav or Tavin Sa where you need leaflet modification and that can be very helpful to uh see where you are in terms of uh how you're either puncturing a leaflet or whatnot. Um We've used uh some tea and Yana valve cases uh to help with commissioner alignment. Um PV L closure on the aortic side exists and then T PV R in the pulmonic space. We don't do a lot of these. Um Although I in the three weeks here, we've, we will have done two as of tomorrow. So, um it's a fairly high volume of that. So let's talk about the appendage first I'm gonna bring you through kind of a whirlwind of imaging in my mind. This picture is not super helpful, but it's kind of cool. Um Gives you a nice uh just picture of the 3D anatomy of the left atrial appendage in my mind. Eps may have this like on their fridge at home. Um uh So you could do, you know, you can look at the appendage morphology. It can be helpful just to understand if there are extra lobes or whatnot. What's nice about this is with 3D, anything you can create a universal language. So you can reconstruct the exact same way on CT uh And then you can reconstruct the exact same way through modalities of echo. So TT Ice T um and we've definitely done that. We've used surface echo in some of these cases if we've had to, if the diff uh imaging is very difficult, um you can get accurate on phos sizing. I'll show this, you can manipulate your 3D image to show any of the, you know, standard two DM um angles that, that we're all familiar with. In watchmen, you can evaluate compression in 3D rather than kind of chasing it in every angle and being off axis um leak evaluation in my mind is a bit more refined. Um And then obviously assessing for uh device related thrombosis. So universal language here. Um This is kind of the gross anatomy that we mimic and all of these things I would say are not necessarily standard in the field. They are things we either developed um at the Cleveland Clinic during my time there. Um or just ways that I tend to do things during procedure doesn't make it right. I think the most important thing is that you and your procedural list are um are on the same page, right? What do you if I'm calling something anterior, uh he or she should know that that's anterior in their mind as well. And then I can help guide you. Um So here you're kind of staring, staring down the barrel of the left atrial appendage, mitral valve is down, pulmonary veins are up. Uh your aorta is to the right here and we call this anterior anything towards the aorta. We call an interior, the back is posterior mitral valve is inferior. Uh and up towards the top here, superior, you see that, that mimics really well on 3D imaging. The P A is out here uh as you guys know an an interior structure and then you can recreate the exact same thing on CT. So then how do we put this together in the lab? Um Some of you have seen me do this when we do t um But again, this is all what we're trying to do is standardize this process, so we can speak about it the same way and so that I can help you during a procedure, um It's not to say I'm right that, you know, this is, and this is an superior. It's to say that we're on the same page um when we go through procedures. And so what we tend to do is I can manipulate planes and put a 90 degree angle and a zero angle, we call the zero angle, anterior posterior, 90 superior inferior. Um And then we'll say, you know, the 135 is anterior superior, uh infrared posterior. And this helps with localization of leaks. When you're talking about coiling something small. Where's the catheter? We did a case last week, we could not figure out uh where to go. And the imaging was actually very difficult. However, we had ac t before we reconstructed it exactly this way and I knew where it would be on my te before ever getting in there. Um Because of that ct because we could reconstruct it in the same way. Um And that actually helped us get into the leak. So this is multiplanar reconstruction and I'm gonna talk a little bit more about this when we get to the mitral side. But again, we're staring down the barrel of the left atrial appendage, left superior, pulmonary venous here, pulmonary artery, the aortic valves here, mitral valves here, this becomes a little easier to tell in terms of landmarks uh when things are actually moving. Um And we'll, we'll see that as well. Um But you can see my red plane here is through the mitral valve. My green plane uh is 90 degrees or orthogonal to that. And so my red box will show me my 90 degree view that's here. It's labeled for you. My green box will show, show me my zero degree view. OK. I can, while during the procedure, while we're moving, I can flip a button and I can rotate this. So I don't have to change anything about the image or what I'm doing. And we can rotate this so that my green plane is through the aortic valve, that would be a 45 degree and my other plane is through the P A. So that gives me my 135. Those are orthogonal to each other. You see your 45 degree here, uh view here and your 135 here. The nice part too is you can place these lines wherever you think you want to deploy to the device and then you can make measurements there. So you have a landing zone measurement that should be just about as accurate as uh as CT. So we'll get to some pretty pictures. This is a nice picture of a watchman. OK? Um Decently implanted in my mind. Um But you can see how you can do lots of things here. So you don't have to go searching for these compression angles. You have them. All right here. You can do 3D compressions in just about every angle in one shot. One view, get everyone the the numbers they want. Is it good or is it not good? And then you're done. The other thing I would bring up is um per device leak. And so I, I'll just put this out there as a question as more and more data comes out that, that essentially all leaks are bad and there may be some kind of signal with stroke with even small leaks. I think the question is how are we measuring them in the past? Right. So if you look at the original data from protect and prevail when we do tes on these people post, we get an image kind of just like this one. That's the two D GEN generated image from the 3D picture. And we look at this little sliver here and we say, OK, let's measure that it's two millimeters, it's a small leak, right? The question I would pose and, and again, it's not to say I'm right or not to say that I know more. The question is these leaks are circumferential most of the time, right? And they expand around this uh if you will a clock face, right? And so if this is two millimeters here, but it's let's say seven or eight millimeters in terms of its um uh its circumference around the device, does that make it a small leak? Still? I don't know the answer. I don't know that anyone knows the answer. Um But I do wonder if some of these leaks that we're characterizing as small may not be so small when you talk about the circumferential nature of, of how these things leak. So it's just a point to put out there. I think as we get better at imaging these things, these are questions that um you know, we should look to solve. So let's go to the mitral side. This is just a cool slide I made last year um with AC T scan. And you know, I think as you're trying to get into advanced te and understand why angles look like uh the way they do when we do mitral interventions, it's nice to use CT it can really help you. And so, you know, you say, well, why at 60 do I tend to see a bi commercial view? Well, this makes sense here, right? You're across the anti lateral poster media comme in your 60 degree view, you get a view just like this. Sometimes it includes the appendage which is up here or not. Um And other things too is like probe manipulation. How do we get really good at that? And so when you come down in a zero degree view, you have something like this, you're trying to chase an Mr jet and you realize you're pushing it in or out or something like that. When you go in that jet is more medial, right? When you go out that jet is more lateral, imagine if you're just raising this zero plane, so down, more medial, up, more lateral. But when you're doing this, you're not necessarily thinking about that. Um But it helps you localize leaks. Um As you're doing that, if you kind of understand what these images are. So let's move forward. Now, we get some, we're gonna get this playing, we get some pretty 3d pictures. OK? Um And the point of this is really to just detail um how well we can see these things now, right in my mind, the world of two D two D echo is amazing, right? And, and to be honest, if you don't have very good two D echo pictures, you're not gonna have very good 3d echo pictures. So they're both very important. However, I would argue that when you're starting to plan procedures and even just from a diagnostic clarity standpoint, this kind of makes it easy, right? Is the flail P one, is it P two? Is it both, is it commercial? Uh This can tell you pretty easily. So if we look up here, this is just a really nice example of bioprosthetic valve, you see the leaflets opening and closing the way we tend to orient things. And again, it's, it's not that it's right. It's just what we do from a standard is this is a 3D on FOSS view surgeon's view. The aortic valve is up here. Um And so anterior is this way posteriors this way, here's a nice view. This is both the atrial and then um uh underside of the mitral valve. You see a really nice P two prolapse and flail. Ok. Again, aortic up front, anterior leaflet here, posterior leaflet here, P one P two P three. This is looking at the underside of the valve. You see that P two portion kind of coming up and prolapsing. Here's a really nice prolapse as well and some of these filters are just in my mind, mostly fun. Sometimes. Um these true view filters can really bring out what's flailing. If there's a small thrombus that um is highly mobile, sometimes that's easier to see on some of these views. So that's why we will use them. Um So again, a nice really kind of focal P two prolapse and flail um here in N pr the same thing and I will explain the N pr in one second here. Uh a really nice mechanical uh mitral valve, you see the leaflets opening and closing. Uh really well, we tend to uh this is not how I would normally align this, but I would normally align this so that I'm along um the mechanical leaflets and then perpendicular to it. And in that way, you can really assess uh normal uh function of a mechanical valve. This also becomes very important when you're doing PV L on a mechanical valve. Um because um it's not uncommon to have one of the leaflets stick after you place a plug and you need to know that um because obviously you can't place a plug there if that's the case. Um And then this is actually a really interesting case, a patient who had a, a complete annual Plasty Ring. Um and uh it deh which you obviously see here. Um And it was actually never uh dealt with further or anything because the guys got kind of trivial to one plus Mr under that. Now, why it was replaced in the first place? I, I don't know um this wasn't done here obviously, but um just an interesting case where you can see this really well. So let's talk about multiplanar reconstruction for a second here. Um The point of this is to just describe what are we doing when we go into multi planar reconstruction and this is the screen on the right is probably your your most typical view. So again, you have this mitral valve, you have a P two prolapse and flow. But what are we actually seeing? And how are we setting this up? What I tend to do is I tend to mirror my blue plane or my blue box. So this one here to the 3D image um And you see these are exactly the same except this is the two D rendered image from the 3D. OK. So it's a short axis mitral view. I tend to put my aortic valve up top, you can kind of get a sense that the aortic valve is there. And so anterior is here and posterior is here. Now, you can manipulate all of these lines. So your red and your blue line, your green and your blue line and your red and your uh red and your green line here. Now, uh that kind of standard for the mitra would be that you put your one of the lines across the commissures, right? So you see this red line is essentially across the commissures that will produce for you in a red box, which is this your bi commercial view, right. So this is the the classic by commission review that everyone's used to looking at in two D. Your green line here is across the aortic valve across a two cross P two. This is your long axis view that everyone is used to looking at. And so you really have 32 degenerated images from your 3D. Uh you know, at the cost of just getting one acquisition of a 3D image. Now, I can move this anywhere if we say, hey, is there actually Mr at the media commissure, I can move these lines over here and see what do the leaflets look like here. Is there a leak there? Right. So I can evaluate this entire valve from one picture in real time. And in my mind, that's the benefit of of 3D N Pr. So I'm gonna go through some cases, some of some which were done here early on and um some uh elsewhere at the clinic in my former side. Um But so here's a case of rheumatic mitral stenosis. Um really nice to image these. Obviously, you see the gradients are through the roof here um albeit at a slightly higher heart rate in 94 but 2313. Um you see how tight this valve is, you see the comers are fused. Um And what's nice is you can do a 3d valve area here in my mind, I think this is one of the most reproducible points for for grading of micro stenosis. Otherwise you're left with gradients. We had a really nice case the other day of a gentleman with really severe uh rheumatic MS who had a gradient of two and a valve area of 1.2 or 1.3. Now he was in a FB and his stroke volume was low. And so you know that that is how we explained away those gradients, but he had a super tight valve looked even worse than this. Um And so I I'm not so sure and this is why I think guidelines have gone away um from just grading things on gradients, you can have a high flow state with higher gradients or a low flow state with gradients. And then obviously they're very heart rate dependent. Um So here, valve 1.2 severe micro stenosis, we move forward here, we have an N a balloon, um which is what's most commonly used to do these procedures. You see the balloon blowing up, goal is to crack the commissar here, not induce too much Mr but obviously relieve. Uh MS here's our result. Again, I'll take it at a, at a slower heart rate, uh 14 5. But we have a, a nice result that we can kind of prove is different, right? So you're at the leaflet tips, your valve area is now 2.4 we did, we've done two of these now here. Um At least in sorry, in my short time. Um So then we talk about mitral, tear, transcatheter edge to edge repair, excuse my uncut nails here. But um you have uh multiple devices XTXTWN TNT W these are just different size clips, different width clips. Um And then there's also uh also on the market are pascal, so pascal P 10 and then the ace implant one is smaller in terms of differences between the device. Um You know, the theoretical difference is there's a spacer thought to induce less MS on the pascal side and thought to have less uh leaflet tension. Whether or not that's all true is I think up for debate. Um All right. So here's this case, you've seen this picture multiple times, but there's a nice uh P two prolapse and flail here it is with color, you can see the color really nicely. So where does the jet originate? Where does it go a lot of times the the direction of the jet helps you understand what the etiology of Mr is prolapse and flail tends to be a highly eccentric jet. If it's coming from the commissar, it tends to split. Um and, and kind of be a bidirectional jet. Um You see this really nicely here, so you obviously have an anteriorly directed jet, I would say kind of an inter laterally directed jet um and A P two prolapse fo And so this is us in procedures, how do we guide things in real time? 3d. Um So what we tend to do is I'll align my uh my planes with the um with the device coming in and you can see this really nicely. So in 3D, you see the clip here or oriented anterior here, posterior here, uh lateral here, medial here. OK. And so what this allows us to do is plan trajectory, right? So is that, do we have a good medial lateral trajectory of, do we have a good posterior trajectory? Um Are we kind of standing the device up and down or are we doing something different? And then how do we actually orient the device? So, you know, should we be more counter or more clockwise than this and we go back and forth all the time during procedures? Hey, I think you clocked a little bit. Hey, we should come back a little bit. Hey, I don't like the way we're gonna uh clip this, you see here, we're, we're kind of directly over the color and I don't actually show us deploying the clip, but we've then deployed the clip and kind of this is our result. So we've taken, you know, four plus uh Mr to, you know, I don't know, one plus Mr, OK. Um In my mind, which is AAA pretty good result. The other thing that, that allows you to do and I'll talk about this in a second is just um you'll, you can maintain your orientation and know exactly what you're doing. If you come out of this into two D in that, that last picture, it's very possible you can rotate things and then you can kind of zipper the valve or clip the valve in an orientation that you don't want to. And so we tend to stay in in 3d for the majority of this. There are definitely times where our image quality is such that we have to come out into two D and we just do our best to make sure from a floral standpoint, we haven't rotated or anything like that. The other thing. So this is a nice cla uh case is an incomplete annual plasty ban with uh severe kind of recurrent um Mr multiple years down the line, you know, what do you do with these people? So incomplete band, you probably can't put a, a valve and ring in this um can you clip this. So a lot of times you can, you can do a clip and ring. The question is really about the um the length of the residual posterior leaflet after generally after a quadrangular resection. Um And if that is feasible, if you have a leaflet length, that is, is reasonable, you can try and clip these things. Um And so I believe this was a pascal implant. Um And we clipped right up to that annual Plasty Band and had a beautiful result. You saw Severa R before that and we'll let it load, we kind of virtually no Mr after that. And again, this is, you know, this is potentially in place, a lot of these people are higher risk patients, this is potentially in place with another open heart surgery. So that's, that's a big deal. All right, let's talk a little bit about the TMVR landscape. So all of these are, are clinical trial based at this point in time. This is something called the CIA valve. Um you can see kind of severe uh micro stenosis here, kind of tiny orifice. There's also, you know, mixed valvular disease, there's Mr as well. Um And we've placed this Sephia device here, this is a night and all expanding frame kind of a, a double barrel type look um and kind of beautiful pictures before and after you have, you know, MS and Mr and then essentially nothing. Um after so again, another case of of micro steno calc micro stenosis. Um This is an uh an M three case. So this is an Edwards Valve. It's essentially an S3 but uh upside down and then a docking system. Um And what I'm trying to show you here is there are multiple, all these companies have come up with ways that they think it's best to replace the micro valve. There are problems with all of them. Um And it's proven to be a much harder feat than the aortic space. Um So you see here, the, the things I wanted to illustrate here here, we're looking again from that surgeon's view on foss, you see the catheter down valve or, or the valve system delivery system is in place where you can see under the valve are these kind of if you will, these kind of circular lines. And what this is is this is an M three or the encircle trial. And again, you can see these kind of circular lines um here and what they do is they circle the subvalvular apparatus and create a docking system. And then once that docking system is in place, they blow up a valve within that I eat. And so here you kind of see uh there's still a wire in place, but um you see that this is that new brand new mitral valve replacement and this is what that valve actually looks like. And there's, there's a PV L guard and there's an atrial lange. Um and this is all to stabilize the device. All right, this was part of the tri uh twist trial. This is called the inner valve. Um And again, a different mechanism of treating um mitral valve disease. And what this does is it actually entangles the sub quarter apparatus. And, and so we, you, you twist that all up and entangle it and that's actually what holds the valve. Um again, another kind of method of, of implanting um valves. And I, again, I would say that I don't think anyone's found the, the perfect solution. Um These all look really nice. What you don't see here is there's a little bit of paravalvular leak here. And the problem is if you don't actually get a really nice twist on that subvalvular apparatus or if there's kind of mixin change or those um cords are kind of long, the valve can then actually be moving up and down. Um And, and you don't see it here and I didn't show it very well. But if you look that this valve is actually just moving with each bead, it kind of moves up and down. And so you get PV L around it. So this is the kryptonite of all TMVR. Um And we know it well because we deal with it a lot, the vast majority of people who we screen for transcatheter mi therapy screen out. Um And the primary reason is anatomy and anatomy in the sense that it's uh neo lvot obstruction. So when we say neo LVOT, what we mean is that when we put in a new valve, depending on the, the type and the size and what we're doing, you essentially create a covered stent with the anterior leaflet of mi of the native mitral valve. And so when you do that, the question is, what is the area of this here? And are you gonna create lvot obstruction and that can be dynamic or fixed? Um And the question is also what happens to this leaflet. So, you know, some people will say, does it swing open like a door and obstruct things? Does it tent over your um your prosthesis? What does it do? And I, I think the answer is we don't know and we've used CT um to try and predict this and there's lots of publications on Neo LVOT and anterior leaflet length and all this stuff. And what I would tell you is that because it's the best we have, that's probably what we should do, but I do not think that it's that it's the best solution. Um Here, what I'm showing you is this is actually from dossie simulations who we're um heavily involved with now. Um And on the aortic side and they're, they're kind of moving fast on the mitral side as well and they use super cool uh AAA I and um uh tissue dynamics and, and um 3D modeling to essentially try and figure out what is gonna happen when you implant a valve and we, they can measure this as well. Um And then predict the risk of neo lvot obstruction. They've done it on the aortic side for um you know, coronary occlusion and risk of aortic root rupture and have all of that validated in data. Um And I think they're getting there on the mitral side. Um So it's really nice that we're partnering with them. Um And using them and I highlight this case because this was a case I actually did on my very first day, I think I had just been credentialed and I came in just for this. Um But this was a valve mac case. You can see this yellow here is near circumferential mac. Um And we were gonna put an S3 in that um our colleague Div Patel had previously. So this was a case that even before my time here, um he had done bipolar ablation on the interventricular septum to get reduction in the uh septal muscle with so that we could actually increase the neo lvot here. Um And so this is a post all of that this lady had, you know, I would say 34 months of procedures and work up to even get to the point where we could screen her uh for another valve because we didn't want to obstruct her, her uh LVOT which, which can be a fatal complication So, um so this is that case on my first day here. I don't think I have moving images because I don't think I've figured out how to get it from snaps yet. Um But severe calc stenosis, you see a ton of Mac here, you see the gradients are 29 and a valve of 1.4 and we went in here and just, and put in a val and MAC, This is an S3 and MAC, our gradient is one at the end, we had a beautiful deployment. Um And in that case, I think in imaging looks simple, right? There's, there's Mac and, and it's severe MS and we just popped in a new valve, but there was tons of work, multiple CT scans, multiple things, uh 3D simulation software to try and make sure that this um patient would be OK. And I think that's a testament to the team here. So let's talk a little bit about the Tricuspid sign. So this is kind of the forgotten valve uh except for maybe the last 5 to 10 years where it's exploded. Um And, you know, so we have learned a lot about the Tricuspid valve typically has three leaflets, but in reality, doesn't typically have three leaflet. Um you know, so most of the time we get down there and we find that these, these valves have anywhere between three and six leaflets. Um And you can imagine that we, you know, clipping mitral valves is not the easiest thing in the world. But now you start to figure out how are we gonna clip a valve that has four or five leaflets and if we, you know, connect one to another does, does tr come out the other way? And so I actually think these are some of the more complex procedures um to, to plan and to carry out. So this is a 3D model. This is how we or I should say I I orient the valve. Abbott does this in a very different way where the aortic valve is down here. I like to keep things an atomic in the sense that I like the aortic valve an interior. But again, it doesn't really matter. We've done it the other way too. The point is that we're all on the same page while we're in the procedure. Um So aortic valve is kind of out of plane here. Your coronary sinus uh is here uh your, your station valve is here obviously here, septal leaflet, anterior leaflet, posterior leaflet. You can kind of mimic that with 3D. All right. So how do we do this? And how do we set this up? So similar to the mitral side? But again, using 3D uh multiplanar reconstruction, I've included some labels here which I think are actually helpful. So this image here, I've, I've kind of highlighted the different boxes and the different colors these just represent um the planes I just made them bigger. So your red plane, what I tend to do or any plane I tend to align across the commissar again. So Antero seal commissure, postero seal commissure. If you look at your red box, you should now have a what we call tri commital view, right? This is essentially your commital view of the tricuspid valve. The aortic valve is just out of plane here, but this is your Antero seal commissure. This correlates to here in 3D. And then this is your postero seal commissure. This correlates to here in 3D and you can manipulate this in any way you want. But this tends to be our standard plane. Then what you do is you create a grasping view with your green line. OK. Do you want in this, in this instance, we would say we're gonna grab septal and anterior. OK. And then here you have your septal and anterior leaflets and it's important to know what the leaflets look like in that area. Sometimes a septal leaflet can be super tethered. Sometimes there's a flail. How do you actually identify that? And then how do you go about clipping it? Um So this is how we set things up. This is just um to show you that we can also guide the entrance of catheters into the heart. And so, um here we have the catheter and the delivery system coming in from the IVC. Again, AORTA would be out here. So anterior lateral septal, you see the inter atrial septal uh septum kind of bowing to the right in this case. And then posterior and you see the catheter actually coming in through the IVC, we can then follow this catheter as we make manipulations both with floro and then our procedural list to come down to the valve, right. So you see as we come down, we're coming down to the valve and then we do the same thing on the micro side, we want to evaluate what does our trajectory look like? Are we, you know, over the valve? Are we offset from the valve? How do we get into a spot where we're kind of standing up over the valve and can clip the area that we would like to clip. All right. And then, so what we do is we bring our um clip ventricular. So we come past the the valve, you see us both. This is again our tri commercial view, this is our grasping view. You can see our orientation of the clip. Ok. And so right now we're septal and anterior. You see it really nicely here in the 3D. And the goal is that we're gonna try and bring those together. So we then bring the uh device up. We like to see the leaflets bouncing on the clip arms. We still have that same orientation, we haven't rotated in any way, which certainly can happen. We have the um leaflets bouncing in the um and the grippers you see this here, you see those bouncing, we have the same orientation, we've grasped them and now we're going to close the device and we close it and we've grasped the septal and the anterior leaflet. And then of course, we would normally evaluate with co color, see what um uh see what kind of result we got and then decide if we need to plan for a second clip. So let's talk a little bit about the to TVR space if we can. All right, let's see if this will play. OK, good. So, um more recently, uh there's, there's actually now a commercially available transcatheter Tricuspid valve replacement. This is the evoke device uh based on the trend trial. Um This is an Edwards valve in the Tricuspid space. Again, I think what I'd like to highlight is the vast majority of these people screen out, the vast majority of these people screen out. We tend to get to these people very late in the game. Their RV is super dilated. They're often significantly dysfunctional. Um And most of the time the annulus is too big for these valves. And so, you know, kind of before this was available, our, our uh general train would, you know, train of thought would be, can we clip it if we can't clip it? Can we put them in a, in a trial screening process for um evoke most of the time they size out and then you're kind of left with either a palliative procedure or some sign of type of other trial, you know, potentially like a cable valve implant or something like that. Um But this, this therapy is kind of rapidly evolving and, and coming to market. And so you can see here um this evoque valve, what you do is you're, you're below the valve, you see all these kind of little tins here and what you wanna make sure is that you're, you've been captured all the subvalvular um apparatus and what they have you even do in the procedure is you go one by one by one by one and you make sure that you're actually under the leaflets here. Um This is actually really helpful in N pr and, and it's one of the only ways you can do it so that the company actually kinda mandates that you do this during the procedure, assuming you can see it and you go one by one and, and confirm and you say, do we have leaflet, do we not? Um you know, are we captured, are we not? And then once you do that, uh you deploy the valve and this is the valve kind of fully deployed and you see here with and without, with and without color if we can get it to play. But essentially, there's no, there's no tr now the question is, does that come with issues too? We'll go past that because it's not gonna play. Um, you know, so when we do Tricuspid clips, we tend not to get a result where there's zero tr um, we tend to kind of shoot for two grades of reduction, um, and something meaningful that will likely keep people out of the hospital and, and reduce their symptoms. Um, but in that same sense, like I said, most of these people have RV dysfunction, um and their RV doesn't suffer much when you, you know, take the tr two grades down here when you put these in. And again, most of these patients were even bigger, anui potentially worse RV dysfunction. And, and so you put this in, you go from having severe or massive or torrential tr to having zero tr and a lot of these people struggle immediately post procedure. Um And so the question is who, who gets these? Um and I, I don't think that's borne out in the data yet. There's a lot of question in terms of RV to P A coupling and, and P A pressures and, and their fancy formulas. Uh I think in my mind to simplify it, what I'd say is if you have more than moderate uh RV dysfunction, it has to be a discussion. There are certain people who will bring people in for kind of preh have put them on Milone, um tune them up and then do this kind of as a, as a pre uh way to you know, keep them from failing post. Um The other question is, do you just clip first. Do you take, um, you know, do you take data from the surgical side and say maybe repair is better than replacement off the bat? I don't know, obviously there's a different, different forms of repair, um, and replacement, but, um, it's something to be considered and something that's not yet born out in the data. Um I'll highlight this just quickly. This is inter atrial septum and, and if you can't, if you don't understand this yet, I I tend to like to do things in 3D. I think you just get to s to see things. Um And I think it makes you precise about what you're doing. We published on this. This is, this is 3D transept puncture. Um We've been doing this a little bit in the lab and it, and it's nice because you have a sense of where you're going exactly in relation to the fossa, which is, which is where we tend to uh puncture. There's a 3D model here, here's the fossa, here's the medial commissure, anterior leaflet, uh posterior leaflet. Uh Sometimes we'll place a catheter in non coronary cusp just to give us an idea of where things are and we can mimic this on 3D. So fossa, same thing, media commi anterior leaflet, posterior leaflet. Um And what it allows you to do is for certain procedures. Um You need a specific amount of height above the mitral valve and you wanna either be in line with where you're clipping or even posterior to that. Um And this allows me to help, uh you know, both Matt and Doctor Adler and uh Doctor Tarea, it helps us kind of figure out how we can um make this better. And are we in a good place? We've had bad transceive punctures where either it complicates your case incredibly and we kind of can't get the catheter off the aorta or we can't get the right orientation and we spend time after time trying to clip and we just can't do it and you end up having to rep puncture. Um And so this may save you a lot of time up front. My one plug for this too is that uh not everything you see in two D is true. And what I would say is everyone's done tes here. You know, you go to, let's just say Watchman, for example, you know, you go to a zero angle and you do everything you can with the probe to find the appendage that doesn't make it a zero angle, right? You've now manipulated your angle, you do that at 60 or 45 or 135. And so I don't know if that's a true angle, your landmarks become different, but in a similar vein, you know, here are two D images of our, our classic trans seor puncture, right? You have um SVC here, IVC is down here, CS is up here. This is our, you know, B cable view, right? And so you have a, a puncture that's maybe, you know, mid to high. Um And we would say just about as posterior as you can get on, on at least the views we're seeing. If you put that exact same picture into 3D. Again, this is as posterior as we can get, you're actually just high in anterior. So here's the fossa and this is the most anterior portion of the foa, right? And so uh this would not be a great puncture for a MitraClip, great puncture would be back here. And we would never know that based on this two D imaging. Um And so that's kind of my one plug for at least kind of just confirming in three dimensions um with the trans seal puncture and just quickly on the aortic side, I wanted to highlight uh one of the cases we've done here. So, again, most haver uh is done without te guidance. Newer therapies we've been doing the Yana. This is for aortic regurgitation. This is trial based um in high risk patients. Um and obviously a different delivery system than, than our typical balloon expandable or, or self expanding valves. Um And then also we use TE for leaflet modification, something like basilica. Um again, still images here, but this was from a case we did maybe two weeks ago or so. Um kind of dilated root but not dilated enough to need surgery. Large cooptation gap, severe A R um, which I'm obviously not showing you here, but you can take my word for it. Here's a 3d picture of the aortic valve. Here's the inter atrial septum. So this is how I tend to orient this again. It's not the right way. It's just a way. Um uh inter atrial septum which makes this, the non coronary cusps, makes this the right coronary cusp and this the left coronary cusp. And then what we can do in a very precise way is as we bring this valve down, you see, it has this almost like paper clip um like portions of it. I forgot to include a picture of the valve here, but the goal is to actually align these in the belly of the commissures. And so you can see that nicely and N pr can come right across these. I can purposefully put my planes right across these kind of paper p paper clip looking things. And I can confirm are they in the commissure or are they in exactly where we want them to align? Are they on the commissure or are they in the belly of the leaflets? Um And here this was a good deployment, we then deployed the valve. Um And now you go from having, you know, four plus A R to essentially no A R. Um And this is a really kind of exciting um therapy that's, that's coming down the pipeline and I'm sure will be available shortly. Um So we've covered appendage, we've covered mitral tricuspid, some inter atrial septum stuff and then what's left on the aortic side. And so I'm gonna leave it there. Um For questions, I know it's a lot of pictures, a lot of videos, uh the o other plug I would say is I've worked with some of the techs a little bit in the TE lab. The goal is to get uh everyone kind of up to speed on some of the 3D stuff for the primary purpose that we can help be better for patients and we can diagnose things that maybe we're not diagnosing. Um You guys are all welcome at any time. Ask me questions, come in the lab with us during procedures, come into the TE lab with me. I'm happy to show you things on the machine. This can all be done on the machine real time or post process.
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