Live TAVI case transmission

Added: 2026-05-22

[00:00:15]Today we have a tab case and we are going to use Vienna 29 wall and today we have our structure. You can switch off this light. Switch off this light.

[00:00:30]Uh today we have our structural specialist and very close friend of mine Dr. Anandra Aman. is going to give us tips and tricks about this uh tab case and uh go to the first case uh first slide. This is a 73 year old female patient known hypertensive present with occasional episode of giddiness and exal disna. We did an evaluation about 10 days ago. Uh angio was uh it was not revealing any significant disease. Go to the next slide. So echoc cardior you can see the gradients echo gradients almost 90 systolic gradient. Go to the next.

[00:01:12]Now this is angographic evaluation angog no significant disease. Uh go to the next. So whether to go for surgery or tab this patient because 73 plus female patient we thought tabber is the ideal procedure. So angioraphic analysis showed there is a reasonably good sized fipal axis and calcium is moderate about 4 70 calcium score 470 calcium distribution more along the non-cornary cusp and right corner less than the left coronary cusp and the height of the corner is very good 13 on the right side left side 14 14 mm so the depth of the sis valalva adequate more than 29 mm So here the chance of coronary obstruction is very low and there is no significant calcium in the LV distribution and because LV size uh the annular diameter is coming to about 22.9 and LV is about 24 so reasonable good size LV and uh uh other anatomies are fine and I will ask Dr. uh already we have access the left femoral axis and right femoral left femal artery we kept it for pigtail and we also kept the pigtail temporary pacemaker through the left femeral vein approach we access the right femoral artery initially six seven print sheet was inserted and we inserted two profiles at 12:00 and 11 10:00 position and we already we have placed the uh 16 French sheet and now we are ready to go ahead. Already we acquired the pile injection and uh this is a horizontal iota because the horizontal iota the uh the plane of annulus to the plane horizontal plane is about 69° that the reason uh prophylactically we have kept the uh mainly we anticipate difficulty in crossing the wall that the reason we have kept the uh the 30 mm uh even uh snare also to retrieve. So next I would uh like to request to Dr. Anat to discuss in detail about the case and to give throw some more insights of the case.

[00:03:37]>> Thank you sir. Uh just go back and show the CT please. Yeah. So here obviously the left top corner uh this is most important. This is the annual uh sort of measurements. So you have a perimeter around 73 and area is of around sort of 400 plus. So the perimeter derived is coming around 23 and area derived is 22.8. And this patient is around 70 plus. So we want to talk about the lifetime management. Uh that is most important thing. Now when we do tavi it's about uh the lifetime management.

[00:04:07]And then the second thing about the anatomic suitability.

[00:04:11]So for uh surgery also she will fall into a lowrisk surgical candidate. And for tavi also she will be a low-risisk tabby candidate. For the lifetime management for her body surface area she's around 75 plus kg. Body surface area is more than 1.7. We want to give a valve which will have a larger effective Riface area. So if you use a balloon expandable, we'll use a 23 here. If we use a self-expandable, we are going to use a 29. So that is the reason behind using a self-expandable which will probably lost her life. In case if this valve degenerates in about 78 years or 10 years down the line, we can still go and put a balloon expandable sort of as a tab in Tab because the coronary height and all the diameters are good. So the selection is the self-expandable 29 val.

[00:04:55]There are various platforms available.

[00:04:57]We'll discuss about the platforms. Now coming to the right side, the STJ height is good. The ascending iota is good.

[00:05:02]Cornary heights both sides are more than 14. And the STG diameter is more than 30. So we will not get any coronary obstruction. So the major sort of factor is the horizontal iota. It's almost 70°.

[00:05:15]When you see it's 70 in the city. Most of the time once we cross it looks like 90. So it is proper horizontal. We will show it. It is proper horizontal. So the horizontality means among the self-expanding platform that is available in India at the moment there are four of them is there. So aaton is a highly flexible and then the evolute FX is flexible. So those cases we probably can take 90° angle but still better to keep a snare as a backup in case if there is issues. couple of other platforms. Obviously the releases is a val which we are going to use. So the advantage of releases, you don't need a clinical specialist to prepare it. You just take it like a stent, wash it and then use it. That's it. Uh so for emergency cases where you don't have time this is probably the best way. The second advantage because it's a dry issue obviously it comes prepared in the company. The previous version there was a little bit of uh stiffness to the delivery system. The current version it is flexible. So we going to see the flexibility of the current generation.

[00:06:19]In this case we will not use the snare up front. We will try without that and see the crossability.

[00:06:26]If there is difficulty then we'll bring back and snare it and then use the snare assistant to cross. So that's the logic behind keeping the snare ready. If you think there is going to be difficulty, it's better that you keep the snare cross through that because once you pre-dilate the valve, sometimes you get acute AR that time it will be difficult to rush in and do things. So if you are anticipating any difficulty, keep a snare. If you use it, you use it otherwise you can always remove. So the only sort of disadvantage is one more additional access like this one left radial otherwise there is no other major disadvantage. So that is the basics. Go to the next slide please.

[00:07:01]So this is the annulus and the lv. So in this case if the lv is smaller than the annulus because the perimeter is 73. If the lv for example was 70 I would have used a 26. Well so the lv is larger here. It is 74 than the annulus. That is the reason we are using a 29 because the 73 perimeter is a cusp where you can use a 26 or a 29. Based on the lv we decide.

[00:07:25]So if the lv is larger than the analyst we use the larger valve. So we going to use a 29. The LV was smaller. We would have used a 26. Next please. So the predilotation will be 18 because the minimum diameter was 19. So we'll predilate with an 18. It's a triricuspid valve. And next please. There is moderate calcium in the leaflet. Uh people will ask why do you want to predilate? Because there is moderate calcium. U obviously you can go without p-ilotation but sometimes recapturing does have a downside. When you start recapturing the infolding as well as the conduction abnormality is more when you pre-dilate you probably don't need to recapture you might get in the first time itself deployment. So that is the reason and pre-dilation is always better than a post dilotation. Next please.

[00:08:12]So that shows the calcium distribution.

[00:08:14]There is some calcium in the arch as well. We'll try to avoid that calcium and the valve calcium is there which will hold the valve. Next please. And this is the showing the horizontal iota around 70° but it's more horizontal once we crossed it looks like 90°. Next please. So the femorals are adequate femorals are more than sort of six to seven here. So for this particular well you need a 16 French so you need at least a six mm femoral uh around less than that probably it's better not to try directly sometimes surgical condone is better. So next please.

[00:08:50]Yeah. So there is no significant calcium. There are some small specs of calcium otherwise no significant calcium. The left femoral is high bifocation. So it was alone guided puncture and it is just above the bifocation. The right is below the sort of femoral head. So it was fluogated. So the puncture is already taken. Next please.

[00:09:09]So the current uh setup as sus shown is so the right side is the main working access. We have two proglides 16 French sheath is already there. We've taken an AL1 straight wire crossed it and then a double length J wire. Now the pigtail is in the apex. On the left side we have a seven French sheet through which the pigtail is there and then the TPI is there through the six French and the left radial is shown through which a JR4 guide is there and a snare is sparked in the thoracic iota through which we crossed. So it's ready. So the next thing we are going to do is we'll put a safari extra small wire in the LV. and then pre-dilate >> and then take the valve.

[00:09:50]>> So the ACT is already checked. ACT was 280. So we given additional,000. We are rechecking the AC before putting the stiff wire.

[00:10:01]>> The invasive gradient is coming around 60. You can see it in the hemodynamics.

[00:10:05]The invasive gradient is around 60. The echo mean gradient was more or less the same. So the invasive gradient is similar to the echo mean gradient.

[00:10:14]>> So that's another thing. If the echo sort of invasive gradient is more than 50, it's better to pre-del it. Uh it makes your valve implantation much safer as well as much comfortable.

[00:10:30]So the safari extra small wire will allow you to move the wire inside the LV freely so that you can adjust it when you're taking the well. Uh previously we used to use lenderquist for all these cases. Uh Lquist has its own downside.

[00:10:42]So it's better to use for extra small which gives the flexibility of moving it inside the LB ready.

[00:10:56]So we stay in RAO because you want to see the true apex and you place the wire in the apex. After that we can go to the working view that is a copler view and the valve deployment in the cusp overlap and then in the coper you see that it's become now 90° horizontal.

[00:11:19]Yeah. Store that. So this always happened. It will face down and then it will flip on its own. Now it's perfectly positioned in the apex. Walk it out please.

[00:11:28]>> Which is position.

[00:11:29]>> Yeah.

[00:11:31]So maintain that position. Yeah.

[00:11:33]Beautiful. So when you cross through the artifice then when the wire comes to the commissioner it will be closer to the non-coronary pigtail.

[00:11:42]>> So it should be closer to the non-coronary pigtail. Go down and face in the apex. That's a good wire position.

[00:11:53]>> Balloon 18.

[00:11:59]Some ectopics is causing the low blood pressure. We'll sort it out. No, no, don't worry. Fluo.

[00:12:07]So once I pull the wire, ectopics will settle.

[00:12:12]You can start a small dose. Not ready.

[00:12:16]>> Give the balloon please.

[00:12:18]Valve is prepared. Ready? Okay.

[00:12:36]Florida, sir.

[00:12:39]>> Yeah, just one second.

[00:12:50]>> Yeah, that's okay. Okay. Fix the W fix.

[00:13:07]You hold this. I'll just hold the wire.

[00:13:12]It is tight.

[00:13:18]Okay. So, what length is this balloon?

[00:13:22]>> It looks short. Go to the LA view.

[00:13:23]Copelander view.

[00:13:28]I think fine.

[00:13:29]>> Yeah. Center it. That's okay. That's good. I'll keep >> ready. So, he's going to be in pacing.

[00:13:38]>> Oh, no. Just you can >> until the clear.

[00:13:41]>> Until the waste. Oh, I'll tell you.

[00:13:47]>> Okay, sir. S. Yeah. On ping on.

[00:13:53]>> Yeah.

[00:13:55]Go upon up.

[00:14:01]Push it. Push it. Push it. Pass.

[00:14:04]>> Push it. Mo.

[00:14:07]>> Pull. Pull. Reflate.

[00:14:11]>> Okay. Balloon down. Facing down.

[00:14:13]>> Facing.

[00:14:15]>> Yeah.

[00:14:17]>> So, unlock. Push it.

[00:14:20]That's okay. It's open that up. Let's walk it out.

[00:14:26]Bring the valve and cut the suture in that one. The sheet suture >> out sir.

[00:14:40]>> Yeah.

[00:14:40]>> Hold the wire. Yeah.

[00:14:47]>> Give some light for sir.

[00:14:54]So the light proglide watch this one.

[00:15:02]>> H right now it's clear.

[00:15:04]>> Come on.

[00:15:04]>> Yeah.

[00:15:07]>> Okay. So if you press I will walk it out.

[00:15:10]>> Yeah.

[00:15:11]>> Florosa when Yeah.

[00:15:18]>> Okay. I'm walking it out.

[00:15:20]>> Yeah.

[00:15:22]Bring the valve to the table.

[00:15:25]Who is that chatting?

[00:15:27]Go out.

[00:15:34]Ready. Bring the well to the table.

[00:15:40]It's okay.

[00:15:44]Feed the well.

[00:15:56]So this has inline sheet like the metronic but it's slightly bigger that's all.

[00:16:09]Okay. So hold it here.

[00:16:12]>> Yeah.

[00:16:13]>> And take it. So wire fixture control >> hold right.

[00:16:18]>> Yeah. Now it will go. Yeah.

[00:16:22]All the way. Yeah. Okay. Now little bit in so that we'll get the stop there. Now we can connect the pressure to this pressure opener. Two pressures. Yeah.

[00:16:42]Good.

[00:16:42]>> I think there will one second.

[00:16:47]Give one flesh syringe, please.

[00:16:55]>> That's bad.

[00:17:04]>> Okay, that's fine. Good. So, position the table. Release the table.

[00:17:09]>> Can you make it, guys? It's there.

[00:17:11]Right.

[00:17:12]>> Release the table.

[00:17:14]Florosa.

[00:17:15]>> Lock the table. 1 second.

[00:17:17]>> Lock the table.

[00:17:19]>> Okay. First, we'll try without the snare. Yeah.

[00:17:21]>> You take it. If it's not, >> then we'll going then we'll take this.

[00:17:28]>> Wait. So, don't push too hard. No.

[00:17:29]>> No. No.

[00:17:30]>> Then we'll >> No, we need snap. Store that fluro.

[00:17:37]Store. Store the fluuro.

[00:17:40]It's going headwards.

[00:17:41]>> Pull it slightly.

[00:17:43]>> Wait.

[00:17:44]Let me tighten the snare. Oh, just move the torque. Move. Okay, moving back.

[00:17:51]>> Close. Close to my finger. Close to my finger.

[00:17:55]No. No. Tighten it complete.

[00:17:58]I'm holding it. Tighten that.

[00:17:59]>> Tight.

[00:18:00]>> Take it closer and tighten it.

[00:18:03]Okay. Right.

[00:18:04]>> Right. I'll hold it, sir. And then >> shall I advance now?

[00:18:07]>> Fix the wire.

[00:18:11]Wait. So, it's it's it's slipping.

[00:18:15]It is snipping.

[00:18:19]Okay sir.

[00:18:22]>> I think still you have to pull it. I think >> now it's going. Now it's going.

[00:18:32]>> Yeah. So that's the thing it needed.

[00:18:38]>> Now try it sir. Otherwise the V advance the V slightly >> try it otherwise you'll have to snare it again >> I think it will go now >> no I think >> it will go sir slowly slowly the nose cone will go store that store that store that let me reposition the pigtail it should not be underneath and all those things Okay. Floros. Floros.

[00:19:09]>> Yeah. Floor on.

[00:19:14]All right.

[00:19:16]>> No. No. It's completely caught.

[00:19:18]>> You want give the wire?

[00:19:20]>> Wal.

[00:19:36]No. No. It's outside.

[00:19:43]Yeah.

[00:19:52]Hold the wire.

[00:19:58]Hold the wire tight.

[00:20:02]No, it's buckling somewhere else. Down.

[00:20:05]Showdown. Otherwise we'll come down and push it again slightly pull your side.

[00:20:11]Ah okay.

[00:20:13]>> No come to PA and show the groin.

[00:20:16]>> PR and show the groin.

[00:20:19]>> Let me see where it's catching. Okay. Go back to the top.

[00:20:24]>> Now go to the LA.

[00:20:28]>> Now it's gone.

[00:20:42]Show the arch.

[00:20:46]>> Oh, >> keep it there. Don't move the table.

[00:20:50]Pass away.

[00:21:03]There's one minute, sir.

[00:21:13]>> Yeah. Moving.

[00:21:17]>> Just pull the wire. I think it will go.

[00:21:21]>> Yeah.

[00:21:26]>> Pull the wire. It will it may go I think otherwise it shall be totally withdraw and push it again.

[00:21:35]Uh now it's fine I think I think somewhere is looping because >> one second sir let go.

[00:21:45]>> Ah we'll withdraw totally and push it.

[00:21:47]>> Now you give me the wire.

[00:21:52]Oh >> take it sir.

[00:22:00]It's not going. Huh?

[00:22:01]>> Not going.

[00:22:02]>> One second. So FL.

[00:22:08]Try that.

[00:22:13]Yeah, it's coming in that inner C. Take it now.

[00:22:15]>> Yeah. Right. So not going advance.

[00:22:22]Yeah. Try that.

[00:22:26]Now it's going >> the torch. There is no space.

[00:22:35]>> No space. That is I will try once.

[00:22:38]>> Yeah.

[00:22:42]>> No, it's not going.

[00:22:44]Shall we withdraw totally and replace alignment different?

[00:22:56]Yeah, I got Okay, let's close that.

[00:23:12]Forward this aspirate.

[00:23:19]Okay. Don't do anything in that cuz >> you want 10. Huh? Injection >> cuz this is open.

[00:23:27]>> Uhhuh.

[00:23:28]>> Close it.

[00:23:30]Now take it out with a flash. Okay.

[00:23:33]Let's sort out the valve. We'll do that later.

[00:23:36]>> We'll take injection.

[00:23:37]>> Yeah. Ready for injection?

[00:23:38]>> Ready for injection.

[00:23:42]>> Sa.

[00:23:44]>> Ready. H.

[00:23:48]Uh-huh. And slightly we have to go down I think.

[00:23:53]>> Yeah.

[00:23:56]Shall advance.

[00:23:57]>> Yeah. Little bit. Uh enough sir.

[00:24:00]>> Give one more injection.

[00:24:01]>> One more injection.

[00:24:06]>> Ready? Huh?

[00:24:07]>> Yeah. Give please. Yeah.

[00:24:11]First, let me release the valves and then we'll get I should hold it up.

[00:24:32]>> Yeah. Yeah.

[00:24:32]>> Yeah. You can see release.

[00:24:44]Is it opening?

[00:24:45]>> Yeah, opening. Open.

[00:24:49]>> Yeah, opening.

[00:24:53]Shall we give one more ination?

[00:24:55]>> Is it opening?

[00:24:56]>> Yeah. Opening there.

[00:24:57]>> No, I'm not seeing any movement.

[00:25:02]>> I'm not seeing anything. It's not moving.

[00:25:05]Something system >> total system.

[00:25:09]>> No, it's not moving. Go away. I knew that fluoros.

[00:25:14]>> Okay, I'll hold this one.

[00:25:19]>> Wait there, sir.

[00:25:22]>> No, it's disconnected. So, this delivery system is not opening and closing.

[00:25:29]No.

[00:25:29]>> Yeah. Is it not?

[00:25:34]Yeah, I'm holding.

[00:25:34]>> Sorry. Hold. Hold the sheet.

[00:25:35]>> I'm holding. Holding.

[00:25:37]>> Shall I hold this one?

[00:25:38]>> No, no, it's okay. Ready? Ready with the sheath? Yes, sir.

[00:25:42]>> Next sheet. Ready? M.

[00:25:46]Next sheet ready.

[00:25:47]>> Sheet ready.

[00:25:50]>> We stab this case in between.

[00:25:53]Ready, brother?

[00:25:59]All of you keep quiet. Then I will start.

[00:26:07]Okay.

[00:26:10]All of you keep quiet.

[00:26:12]Uh this is a very complex anatomy. Due to horizontal iota we faced many problems. Even first device small function was there but again it retrieved and we went ahead with the second device. Now I request Dr. Antraan what are the difficulties and challenges we faced while doing this case uh mainly through uh to throw some of the highlights of this case over to you Dr. Raman. Yeah.

[00:26:49]>> First thing is should a very clear device.

[00:27:05]We assessed the whole We tested the new device outside the new device show.

[00:27:38]was coming near the across the compared to previous That's what we trying to not I don't think it got disconnected.

[00:29:36]Call that guy.

[00:29:39]Now it's coming. Yeah.

[00:29:43]>> Hold it like that.

[00:29:47]important.

[00:30:02]I love Andy.

[00:31:05]Next.

[00:31:08]Next.

[00:31:35]capture start.

[00:31:39]Next, please.

[00:31:54]So this is the task we have here.

[00:32:28]Forward. Forward.

[00:32:33]Not moving.

[00:32:45]started because of the next deployment it was down. So what we've done is we went and brought the valve almost opening it like this initial.

[00:33:22]So recapture and went on rapid pace rapidly brought it to the bottom of the next rapid rapid satisfied.

[00:33:46]Next please.

[00:33:49]This is the als next next.

[00:34:05]So as you see once at this point we check it.

[00:34:34]So the system was captured on the next multiple has to considering I have to anatomy.

[00:35:06]There's no dissing the groin.

[00:35:34]for the use of the current normal PR settle access.

[00:36:14]>> Yeah, thank you Dr. Anad Raman for uh showing many highlights of this case. It is a very complex anatomy with a horizontal anatomy. Actually we started case at 9:00 and it took almost 2 hours 45 minutes because of the uh snaring device malfunction retrieving and putting second device. Finally end result is excellent. So I'm also thankful to my associates uh Dr. Aparangji Kabia and all the technical staff for helping uh in in conducting this wonderful case. Thank you once again Dr. Raman. Thank you very much.

[00:36:53]And