Deepak Talreja, MD, presents on the topic of coronary access for transcatheter based aortic valve replacement.
Good morning. Thanks for attending cardiac grand rounds at the heart hospital today. Uh, this is Deepak. Tell rage on talking today on the topic of coronary access after trans catheter based story valve replacement. Hi. This is a two part grand rounds. I'll be giving 20 to 30 minute talk on accessing the coronaries after Tavern, which I think is a broad interest to the general population of everyone putting catheters in the heart and anyone ordering catherization test. And then Paul Mahoney is gonna talk afterwards on controversies in bicuspid valve disease. He's at a meeting now, and I actually have to run the meeting during the second half. So we agreed to fill in for, ah camper grand rounds, and I hope this will be interesting. Relevant disclosures way have had the good fortune of having access to all the three major, commercially available Taber platforms. Now that's Medtronic, Edwards and load this and we've been involved over the years and trials with a number of other platforms in various stages of development. Um, there's a ton of animations in here, and some of them run a little bit slowly so towards the middle of the portion of the program. I'm gonna actually come out of power point and just play them, uh, through a blank PowerPoint slide that seems to run faster. What I'm showing you here is three separate images. One on the far left is a surgical valve. In the middle is a Medtronic core valves. And on the right, you can make out the outline of a SAPIEN Edwards SAPIEN valve, these air, three valves in aortic position and the point of these slides and I'll play them again as we dio, is that, uh, we have become used to an increasingly wide array of complex technologies and coronary access. You think about augmentation devices like the impeller device, you think about IV's catheters, rotational and orbital a threat to me. You think about the generations of stents. We have the complexity of bifurcation, stenting and coronary physiology measurements. As time has passed, what we've evolved of, what we can do in the coronary circulation has gotten more complex. And with that challenge, for example, with an impel a catheter across the aortic valve or with a valve in place, there could be an atomic obstacles that are not in president. A normal circulation that we have to work around and think about guide selection. And we've become increasingly adept at that. Regardless of what kind of valve you have in the aortic position, there's a potential for interaction with the coronary Ostia. And so these techniques are meant to be sort of broadly accessible across the different groups of platforms. And while we're used to, as Judkins said, when he developed a jail catheter engaging 90% of coronary Ostia unless interfered with by the operator with that guide on the first past in the current era, it really behooves us to be able to think about where we're trying to get what are the obstacles and what we need to do to modify our approach, depending upon what's in the way. And here in all three of these cells, you can imagine a situation in which is more difficult to cross, whether it's a surgical valve, the core valve or the Edwards found. All right, so if you think about now, there's obviously variability in the heights of coronary Ostia and in the world of Trans catheter based or valve replacement would carefully analyze this ahead of time and project where will the valve be relative to the coronaries? And there's two issues. One is the height of the coronary, and you see here the median hide the coronary artery has the possibility of interacting with any valve frame, and also, sometimes we deploy the valve frames higher or lower. There's an increasing movement to deploy. Deploy the valve higher to impinge less on the conduction system that has the potential to bring the valve plane in mawr interaction with coronary Ostia In addition to simply the height, which is easy to measure by C. T. The second factor is the effacement of the coronary. When the valve in place, how much space will there be between the entry point of the coronary ost IAM and the outer sections valve? Now you can see of the three valve. The core valve is going to be the one that virtually all the time overlaps of coronary Osti. Um, whereas your other um trans catheter valve may or may not interact directly, although there is always potential for it to make it so that our standard catheter choice has some interaction with the valve, and that has to be thought about if you think about the current era, This is data. Over the last several years, there's been a lot of publications looking at successive coronary angiography. And the good news is, in the vast majority of cases, about 9500% of cases across the Siri's theon graters were able to engage the coronary arteries. There obviously exceptions, but in general, coronary access is successful. If you look at UH, success rate of PC I in these patients again, it's relatively high, You know, in no technology form is the success rate 100% even when there's no valves in place. But here you see a high success rate and calculations of adverse outcomes because of inability to successfully performing PC, I show the number to be very low. But this is a point of of concern amongst cardiologists and interventional cardiologists, and so we'll focus on some techniques that air widely available to anyone around. First of all, understanding the shape of the valve where the potential obstructions are for the various valve platforms is important. We'll talk about that more detail. Here you see the core valve on top and the SAPIEN valve on the bottom, and you see, we can use a lot of different forms of imaging. We can do non selective angiography to at least identify the portion of the coronary. Ostia, as you see on the top, right? We can use T, E E and C T to get analysis again, not necessarily in the semi case, but when pre planning In a complex case, that's certainly reasonable to do. I have to admit, I don't really do a lot of that. Usually I get in the lab even for an elective case, and start by looking for the coronary. And my success rates have been high with. The techniques will talk about two other things this illustration makes clear, and I'm gonna focus some of my comments on the Medtronic core valve today off the three valve. That's the one that has had the greatest concern across publications in discussions on re access. I think we're very successful in re accessing with the techniques. I'll show you some of the slides I've put together here. I've taken video using a demonstration platform in the cath lab. I'll show you momentarily, but with this valve, let's look at two things. I think it behooves us all to recognize. One is usually at the level of the coronary. Ostia. The valve isn't sitting flush against the coronary. AUSTIN. There's a space between the frame of the valve and the coronary Austin. So usually we're poking through the frame of the valve and then engaging the coronary Austin separately. Also, the holes are 10 French holes, and most of us are using 56 French catheter. So there's plenty of space to get through the frame itself. And with the right techniques, we should be able to engage the majority of coronary to me, as I think of the analogy of what we're trying to do in the cath lab, these air to images that I think of one of these, uh, these nice fellows reaching through the bars of the jail to do something. And you see, they can use their dexterity and get through and manipulate something complex on the other side. And that's what we're doing is we're finding which bar is the closest bar to go through, passing through it and then doing what we need to on the far end and engaging grass is often described as like a fishing sensation right. You see the catheter stabilizing the position, and you can feel the tug of it when you don't have too much attention on the capital. In some ways, it's like strumming a guitar. If you're trying toe poke your pointer finger into the central hole of the guitar, you might strum up or down until you find the space. You think it is going to get you exactly where you want to be, and then you push your index finger through that space, and it's the same thing you're trying to do with feeling the cats that are getting in here. I already alluded to the fact that if you think about it, there are capacious and crowded sign a tubular junctions and depending upon which you're dealing with, that can affect the complexity of engagement. And in fact, as we've gotten better at putting in valve, we've developed techniques and participate in techniques like the basilica Technique, where we create a laceration in the valve again. The analogy here and this is not the point of today's talk. It's just to show you there's a lot of creative things we do snorkeling stents above valve, creating tears in old leaflets on old prosthetic valves, and we put a new valve in and you can imagine if there was a shower curtain separating me from the audience and I was trying to talk to everyone. It will be hard to talk through that. But if I took an Exacto knife and made us slice through it and it folded open, then you could imagine us having a better communication. And that's what we're doing with this technique. And so we actually use catheters without an open procedure to open up a coronary. Often in those cases where we pre predict that they will be because of a crowded son, a tubular junction area, um, difficulty accessing the coronary. And this is what that actually looks like with the two most often used platforms. Religion. So two years ago, there was a nice article in Jack, and at that point this was really cutting edge discussion about coronary access and PC I after trans catheter aortic valve replacement. Since then, there have been a lot of different discussions, and this paper came out with some nice algorithms. Um, remember when this first came out, we hung them in the castle but beach and would have this available for anyone that needed it well long ago. Took those down because Manchester, actually fairly simple. If you're using a Judkins guide, which is effectively done by putting in, for example, of core valve is narrowed the size of the aorta. And so you downside by 0.5. Whatever Katherine you would normally initially go to you can certainly often get it with the standard catheter. But if you're having difficulty going down from a jail, four to a jail 35 to potentially be helpful in the algorithm has more listing there. There's also an android and iPhone app called the Cast Taber Aid. You can easily download and has nice videos of a lot of information on this, as well as the algorithms in place for those that might find that help. As far as equipment we really use the standard equipment we have E. C. I wires, guide catheters and under sizing by a half centimeter can often help guide extensions could be very useful using your J wire to point yourself in the right direction when you first engaged and then coronary balloons to track if needed, we'll go into this in more detail, actually, for a second, like I said, coming out of power point. So what we're gonna look at in the next couple of flies is early on because, as I said, we've. But only then thinking about the basis. Of course not. We're trying to develop a heart way models, models, a little beating pump. It's all made of plastic, so you can actually see the pump feeding. You can see the valve with your eyes that sits on the table that has a simulated radio access and assimilated them a criminal act. And he looked. You can actually see your catheters moving through it, and you can simultaneously floro it so on one of the opportunities that brought it down. But I'm going to show you a slide I made with floral clips of engaging the coronaries and with with iPhone video of the model itself so you can see outside of for what it looks like. I think you'll find this interesting. Um, the other thing I would tell you is that funny? When I when I was starting, I was hoping to make a slide presentation showing tricks success you'll see from some of the engagement, but actually, a lot of the standard catheters found their way into the coronary very quickly. And so that was. That was funny from my viewpoint, because I was trying to prove it was difficult with the standard catheters and easier with intelligence collected catheters. And it turned out it actually wasn't too hard with either way, thank you. So this is the model. If you look at the model here, it's in the box. It has fluid in it. There's what looks like a radio access and the femoral access. There's a beating pump, and if you look, this is the valve Opening and closing as we go through the aorta is in this view oriented to the left and that little beating pump. Heart is oriented to the right, and you can engage catheters and get through the frame and do exactly what we do in real life. So now let me show you some some attempts. An engagement. I flipped it now because someone's photographing from the opposite side while I'm pseudo scrubbed in the pump is to the left. That's the simulated left ventricle. The valve is opening and allowing blood to go out the order to the right. Picking up towards the top is the right coronary artery, and sticking down towards the left is the left main coronary artery. So as we go through these images, in each case, I'll show you a floral images. Well, here you can see a moving floor. Oh, the only thing you can actually see moving here is the outline of the cardiac shadow at the bottom. There, you can see the valve frame in place. So let's look at some techniques. So here we're gonna see an engagement with a standard with a standard J L four catheter and you see the catheter moving up through the pretend aorta tracking over a J wire and you'll see that the first goes up. It really goes into the right neo cussed there of the new valve on the right side. And of course, this is a jail catheter. I'd like to move my way over to the left main coronary artery. The way to do that is what you just saw. There is. I just pulled up directly. Now it's caught in between those cells, so it's in a spot that's not perfect for engagement. And the trick here is to use the J wire in the in the Diagnostic castle or the guy point yourself into the correct cost. I'm pushing the J were there, and I know some of this is a little hard to see. I'll show you the floor, a version of this in a moment, but I'm using it to position myself down and move down, frame by frame until I get into that left Neo cussed and in the second you'll see that happen. Now, there I went too far, and I moved towards the opening of it. And oftentimes you'll get across the valve into the left ventricle and there when I pulled back and push forward it engaged into the left main coronary artery. And if you look carefully, you can see the guidance in the left main coronary artery. This was a jail four. I really wanted by recommendation to use a jail. Three five. I'll show you that neck. All right, this is the the simultaneous Floro, and what you see on that you see on this first image coming across, I'm too high up there. And if you just push the guy down all it does is catch on the frame and buckle down. So what you want to do is use the coronary or use the J wire. Position yourself lower and I'll show that in this next clip in this next clip. What you see is I'm too high up and what I'll do is use the J wire toe angle myself down, and then it just folds right into that space where the coronary is. That's actually jail four. I didn't switch guides on that one. Next, we'll switch and use a different guy. Now, this is the jail 35 which by the algorithm, would be the recommended catheter. And just see it actually does engage more easily. Now I'm starting out here with my J wire. First it was in the ventricle. I pulled it back. Now I'll track over in the live scale images. Hail 35 Going from a federal position. I will show you radio as well, talking a little bit while we're doing this. So that's why occasion I paused while I'm working. And so you see, I come down. I'll use the J wire now in position in the left Neo Cuts. I just tracked down to the left Neo cuts right over the guide wire with it sitting in position there, zooming in a little bit that you could see a little bit better and you'll see once I'm there. Then, as I pull out the J wire boom, it pops right in and you see that this does it better than that last calf into the jail. Four did, although both would give me a good diagnostic images if I were doing an intervention. This would obviously be a little bit easier looking at the Florida again. Here, this is tracking up. In the beginning, my J wire is called a little bit in the area of the frame. I'll come back with the J wire, angle it towards the left, Neo cuts the little pressure track down, and on my second image you'll see a fold into place. So I tracked down. When I come back with the J wire, it pops right into place. And so that downsizing trick works very nicely for getting in with the standard jail position in jail catheter. This one now is left main coronary engagement actually is another jail for Let me keep going down. Other. This is engaging the right coronary artery. Now with the JR for the right coronary artery is traditionally the more challenging one both when there's a valve in when there's not because it requires more capital manipulation. So here what I'm gonna do is the same thing you saw before, which is to use the J wire guide myself into the right Neo cuts. Basically there you noticed this, of course, points in towards the valve. And so it takes a little more manipulation, and patients sometimes angle it using the J wire when you have to, and you see them up and down, as we do in standard technique, angling through and using the guitar strumming thought process as I go. And now I'm engaged. Now here. What you see is the jail is pointing down. So I'm angled towards the right cuss the native right custom through the valve struts. But it potentially could be difficult to get into what I want to in that space. Let me show you what I would suggest that this was a patient now that needed an intervention. All right, so this is the same thing for Skopje. Klay viewed tracking up tracking up using the J wire. It's in the correct neo Cups there. This is the J. R. Four going in, and then on the next slide, I will angles here. I'm making fine motor adjustments because I don't love the position of it. What I'm gonna do is I'm trying to show you what I would do an intervention. I'm using a coronary wire to go through that pretend coronary artery. This is what it looks like on floor Oh, and the equivalent image of the model itself. You'll see. So I the last time I showed you the Jr sitting in the beginning of the right coronary. Now you'll see me threading that wire through because presuming there's a lesion in the distal vessel that I want to get to, and I think it's gonna be tough. It'll be helpful to have that guide catheter down the right, and I'll push it all the way down the coronary arteries to pretend one. So it's short. So I got my I'm not perforating. Obviously, I'm just going past where the normal continuation of the artery would be. Now that allows me to push the, um, guide or diagnostic catheter further in, and I've already got better engagement. But on the assumption I have a really tough decision. Actually, what I want to prove to you and show you is it's possible using the right techniques to get very good guide backup support. Already where the guide is sitting, there's really no significant interaction from the frame, but what I'll show you here is in this case, if I really wanted to get down, what I would add is a extension guide extension Kastigar. And if I had to, I'd use a balloon tracking technique. Go down over it and I'll show you both of those on this. No, there's the guide extension catheter, and now I have it right all the way to the bend. So that may be enough for some interventions. But assuming you need even more than that, the next step would potentially be path of balloon. No, through that over the guide, I'll show you that in a second, pass a balloon down, inflate the balloon and use it to track the telescope even further. So now you can see how easy it is to pass the balloon with that level of support. But again, I'm just trying to show you in the extreme most situation. There's a balloon going up, and now watch the extension catheter track even further down. That kind of the mid vessels on that should give us enough support to do almost anything we need to do in that vessel or deliver anything as easily as if we were engaged with no valve present at all. You see the guide extension catheters cracking down to the mid portion of that right coronary best. And just to show you this, the fourth topic images. I took it the same time. That same thing. Now you see the balloon is being inflated. You see the guide catheter with the coronary extension kind of at the level of the outer portion of the frame. And then, as I tracked that in further, you'll see that I could get the Guide extension catheter far enough down to remove any interaction with the frame. With any anything, I'm passing through a couple more slides. This is again start to feel repetitive, but I'm just showing you the variety of techniques that exists on this is now going with a E. B. U guide and again showing you that if that's your preferred guide over a jail type guide, the same technique using the J wire to get you close and into the right. Cussed now there it went into the into the left ventricle, so I just pull back a little bit. Use it to redirect into the space I want. And then I'm engaged again, and you see them well through the frame and into the left main coronary artery and ready to do it. Whatever intervention I would need, Thio and the and jail I took it. The same time is here, and you'll see it pop in nicely with support. So I'm using the J wire again toe guide me in that direction and then right into the coronary. So I think regardless of what Val platform using the's air, these techniques are the same at the end of the day, using our full retinue of experience. The day that I did this, it was interesting. I had a case running afterwards, and then the very next case with a three year old tavern patients who have developed new angina and a small non semi. He had a lot of corner disease. Before you concede there's sternal wires and you can see there's a lot from his previous cabbage and so at all. And so I'll show you. They're just as I showed in the sample techniques. The same exact thing happened. What we did was we used it. I use the jail for diagnostic and engaged with that same exact techniques we saw earlier. And then I'll show you what the pictures look like before through that jail. For there's a tight left main lesion. And as as we're taking care of younger and younger patients and these valves will be in for a longer time period, this is something I think we'll all gain more comfort with Andi Seymour. Often it's something we think about carefully and planning tight left main lesion. It's partially protected because the patient did have previous bypass, but I did ultimately feel that was what caused his, uh, non stem me and felt it was worth intervening on. So then I switched to Anne Bu Catheter here and you'll see again, this is the engagement. It looks exactly like what I showed you with the models. I've now got the EBU firmly in the left main and finishing up my flag just to finish the story here. Stance being deployed in that left main lesion and a good final result with deployed stent covering the unprotected portion that anatomy. There's just a vessel disease, but I've opened up what we aimed for at the beginning, So you've been patient. While I've shown you a lot. I've gone through some of the relevant literature on this fact that will all be seeing this a little bit more. As more and more patients have tapper valves and younger and younger patients are being operated on, I think it behooves us all to know some of the techniques again. The simple thoughts are downsides. Or at least think about where you're meeting an obstacle and think about engaging, Um, carefully watch under flora when you d engage your guide because the have been rare reported a specialist pressure valve case of adjusting the valve position in an unfavorable way. E think that's most of what I wanted to share. Turn over the floor to Paul. Yeah, thank you
