and I want to teach tower a rose rule
and Michael Riordan from the Houston
Methodist DeBakey Heart and Vascular
Center in Houston Texas every case
starts with the brief with the team or
we discussed the patient what we plan on
do I'm doing and how we plan on doing it
we make sure that every team member can
do the measurements required to do the
case in fact if your implant or both in
planters redo the measurement at the
beginning of the case to make sure we're
still all on the same page as to what
we're going to do what the help we're
going to use and how we're going to
approach this we start by using
ultrasound and micro punic technique to
assess the access the artery on the non
sheath side we find this to be the
safest once we get micro puncher access
this allows us to then put a Jay wire
and a six French sheath this six French
sheath will allow us to use a five
French pigtail as well as having a 1/8
safety wire sheet the sutured into place
it is flushed out and then we'll take a
Lima catheter and a glide wire go across
their bifurcation into the opposite
femoral artery the glide watch removed
in exchange for an 1/8 steel core wire
which remains as a safety wire for the
rest of the case until we removed the
large sheath the order in the opposite
side is punctured again using micro
puncture technique and the safety wire
as a guide once we get micro puncture
access this would be switched out for a
long Jay wire and heparin will be given
we give enough heparin to get the a CT
above 250 once we have a long Jay in
place and heparin in place we will then
deploy 2 pro glides at 2 and 10 o'clock
you see the first pro glein going in
you'll see good blood coming out of the
tubing approximately on this we then
deploy the foot pull it back to the
blood flow goes away meaning we're up
against the wall deploy the needles pull
it back
cut the thread let the foot down
partially remove this until we can
capture our sutures we take them down
with sterile tape then we'll put the J
bar back in so employ a second proline
again watch them practically on the
ProGlide close to the black and I don't
see the good blood
in there re lumen we deploy the foot
then we're gonna pull this back into
that flow goes away that means we're
against our wall we deploy the needles
they cut the thread we let the foot down
we capture our sutures again we're gonna
tape them down to hold them out of the
way you want to undo those two tykes you
don't want to pull up on the locking
thread and we're gonna put the J wire
back into place and we put 10 French
dilator in all the way this will go up
past the aortic bifurcation this will
allow us to remove the soft J wire put
in a implants an extra stiff wire with a
slight curve on the end that we've put
on there this can then be put in under
direct vision into the proximal decent
in any order again everything we do
inside the vessels is done under vision
now the sheath is put in place this in
18 French sheath you can see we usually
just pressure and a slight wiggling
motion of us to go in and once it's in
we remove the guide wire and the dilator
and suture the sheath in the place we
have a checklist we do now to make sure
that everything that we need up to this
point and for the next steps is already
put a pigtail on the other side and to
the non-core neck custom we've taken our
tree aground to make sure the customer
lined up remember eyes on the prize
means an intervention watch the imaging
it's not like surgery where the prize is
the patient here everything happens on
the imaging so you always keep your eyes
on the imaging now we're gonna take an L
and a L on Catherine it's soft J wire
through the large sheath I put it lace
in the aorta a wire we exchanged out for
a soft straight tip wire which is then
used across the valve we do this in La
oh so you can see if the wire enters the
left main we just make several passes at
the valve changing the attitude each
time into a cross as you see it crosses
easy
the own catheter goes in we put an
exchange J change that for angle pigtail
and hook up to manometry now we're
looking manometry don't get in thrall
with aortic stenosis look at the end the
destin lved p the distance between these
that this heart rate should be the same
at the end of the case now we're going
to take our pre-curved stiff wire and
put it through the pigtail and remove
the pigtail once the stiff wires in
place we're going to take our balloon we
usually sized the balloon off the minor
axis of the aortic annulus from our CT
scan and once we get them blue in into
what we consider proper position we're
use rapid pacing usually about 180 beats
a minute with rapid pacing the blood
pressure goes down we're going to
inflate the balloon and then we will
deflate the balloon and then we'll turn
the pacemaker off rhythm returns and
then we'll remove the balloon be careful
at this time again to watch this in
their imaging make sure you do not pull
the wire back out of the heart and lose
your access now we're in put the valve
in in this case we're using a Medtronic
evolute or valve it's a recap sharable
repositionable valve when some position
and lined up properly we deploy by
turning the handle let's pull the
capsule back on that's this night and
all self-expanding valve slowly expanded
is not obstructive in any but a very
small part of the deployment we usually
take a picture when it's one third
deployed to be sure it's lined up we
deployed it 2/3 and take another picture
and then we're happy there will usually
wait several minutes to the 900 hits up
let it go and take this our chair Graham
showing good valve position and no leak
whatsoever once it's been fully deployed
we'll then pull this back into the
decent Naora
and then we'll make the nose come back
to the delivery capsule so that the
device can be removed
now we've got the nose come back we'll
remove the valve once the valve is out
we're gonna put the pigtail back in the
heart and we're gonna repeat the
manometry again looking for the distance
between two a saline and acid so now you
can see there's no gradient distance
printed ashen and then the LV EDP is the
same as it was before this is also
confirmed by echo it showed no leak and
a final arteriogram which showed a good
implant depth with absolutely no leak
once all this has been done we remove
the large sheath over a wire and we pull
up on the ProGlide blue strings not the
white ones which lock it
once the sheath is out there's no
bleeding remove the wire we get
protamine we hold this for two minutes
into a final art to your ground to make
sure it's no obstruction or bleeding at
this site remove this small sheet of the
underside with either ProGlide or an
angio seal device
you