Minimally Invasive Surgery and Its Role in the Future of Aortic Valve Replacement
Originally Broadcast: Tuesday, September 27th, 2022 | 7:00 PM to 8:00 PM ET
As conventional AVR options continue to grow for young patients, the goal in lifetime management of these patients remains constant – to minimize the long-term risk when selecting valve and procedure type.
The evolution of SAVR towards more minimally invasive procedures has opened new opportunities for patients and clinicians, combining suitable valve type with enhanced recovery is demonstrating positive outcomes for patients who want to live long and live well.
Speakers & Topics
Moderator: Dr. William Kent University of Calgary
Present and Future Lifetime Management of Aortic Valve Disease Dr. Basel Ramlawi Lankenau Heart Institute
Conventional vs. Minimally Invasive Aortic Valve Surgery: Patient Selection and Key Clinical Outcomes Dr. Rodrigo Ribeiro de Souza University of California San Francisco
Postoperative Patient Management: ERAS with Minimally Invasive Surgery Dr. Marc Gerdisch Franciscan Health
Cardiologist Perspective: Minimally Invasive AVR and Lifetime Patient Management Dr. Hector Michelena Mayo Clinic
Hi good evening thank you all for joining us. We'll have our tv in live webinar tonight to discuss minimally invasive surgery and its role in the future of aortic valve replacement. I'd like to kick off our evening with our moderator. Dr William Kent. Thanks erin appreciate that. So welcome everybody. I think you know this is a very compelling webinar this evening. I'm very excited about this. Uh we're focusing on middle invasive aortic valve replacement and the peri operative management of the patient. I'd like to thank our tv in for organizing this agenda with very experienced and dynamic speakers. So I think we'll all have have an excellent informative evening, you know, as a proponent of minimum invasive surgery myself I think this topic is important. Um you know I think as surgeons and cardiologists we need to um you know advocate for patients to have minimal invasive surgery. I think there's data now to suggest that there's evidence for less blood loss uh shorter length of stay, better mobility, post op less pain. All these things are important and uh you know, I'm proud of the progress we've made and it requires teamwork and training and and a real commitment and uh you know our speakers tonight are a real dynamic group. There are leaders in the field. They have expertise in echo peri operative care uh and middlemen invasive techniques. So without further ado I'd like to first introduce our speaker. Dr basil Ram Lowey. Before we do. Before we get started basil. We're just going to start with with with two questions and I think we'll present these questions. Um they'll lead to some uh some thoughts during the course the course of the evening. And then we'll present those questions again at the end and see if any opinions have changed on this. The first one is a case of 42 year old male who is symptomatic severe aortic regurgitation has a very asymmetric right left bicuspid aortic valve with a calcified raph. A. Uh so the question is, what's the best lifetime management solution for this patient? Surgical aortic valve repair with possible late surgical A VR. Or are we looking at surgically minimally invasive? Mechanical A VR with long long long term warfarin or potentially the ross procedure allowing for that risk of late re intervention. Or do you think a surgical bio prosthetic, a VR with future valve and valve tabby would be the best option for this patient? So, so why don't you put your votes in? And we'll see what sort of the majority says at this stage. Uh certainly seems like um mechanical. A VR is the preferred management of the group at this stage. So, that's interesting. So we'll delve into this. And and certainly in more detail. Um So let's let's leave that behind for now. Think about that question a little bit more. Let's go onto this next one. So this is a 60 year old low risk female with an L. V. O. T. Of only 20 millimeters as symptomatic severe A. S. So the the question here is what's the best approach against surgical air valve repair With possible late surgical A. VR. Middlemen invasive mechanical A. VR ross procedure or bio prosthetic with future valve valve tower option bit more mixed. It certainly looks. The majority's tending to favor a mechanical a VR for a 60 year old. So, you know, no right and wrong answer with both these questions and that's why they were posed. So, um so let's move on now basil. If you know, why don't we start with yours. And now I know basil. Well he's a Canadian. He trained at the University of Western Ontario with a number of my colleagues actually. And then went to Houston, trained at the Methodist DeBakey Heart and vascular institute. Very accomplished, minimally invasive surgery. Now, chief at Lankenau Heart Institute. Um he has extensive experience in minimally invasive surgery. Excellent surgery. Real pace center in minimally invasive surgery. And look forward to hearing his talk on present future management of heart valve disease. So go ahead basil. Thank you Bill. So this is clearly a very interesting and hot topic in cardiac care and and aortic valve therapy. So, to look at this and and delve into a little bit more of the details. You can see here that you know the last 5 to 10 years have been a real interesting change and how we manage this. Aortic valve. You can see that in 2015, 16. That was the first time that taverna trans catheter therapy overtook the number of surgical aortic valve replacements based on the STS database. And then back in 2018, middle of 18, they overtook the overall number of surgical aortic valves. Whether they're incompetent isolated or so on. So all a vrs the highest number now is done through taboo. And that trend continues to increase based on a lot of data. And not only that but the number of the age of the patients that are getting tavern is decreasing. So you can see here up to the first quarter of 2020 from the N. C. D. R. TVT registry. You can see that the average age is now probably less than 75 for all Tavern patients coming in. Um you know who are low risk for Tavern. But this trend also increase decrease. You know changed even before then. If you look at even 20 years ago. Um the number of mechanical valves was decreasing based on the STS database. Which is very interesting given the polling numbers that you posed earlier. Uh you know with the two questions, the number of mechanical valves was going down the number of tissue valves going up simply because patients just didn't want to be on cumin. And of course this is a micro subset that's not the aortic valve subset. But you know nevertheless there is a strong trend against or or you know going away from Coumadin for a lot of these patients. But that may be changing given recent data, a lot of the data that we see that in favor of cavity which is obviously the big elephant in the room when it comes to aortic valve replacement. Um is based on these new journal medicine papers. They're highly publicized randomized controlled trial for both balloon expandable and balloon self expanding valves against surgical subsets for high risk, extreme risk and now up to low risk that were approved, you know, several a few years ago. But a lot of this really has to come into which considerations come in and we see these are patients every day in our clinics. Clearly when it comes to decision making in terms of which patient gets what's therapy age is a big you know, consideration the clinical profile as well as the an atomic risk profile. You know, we're used to talking about patients in terms of how risky are there is the higher the high risk or intermediate risk. But now there's a lot more interest in the an atomic risk of that patient. What's their redo risk of surgery? I mean usually all of us do a lot of reduced surgery but not they're not all created equal. What is the angular size, how much calcium is there in the L. V. O. T. And the corner of heights. These are all considerations when assessing whether the patient is a an adequate surgical or even a tavern candidate. That could be a low clinical risk but a high an atomic risk for that patient profile and that category of patients. So the other big big thing to consider is co morbidity. Somebody who comes in with the left main disease or multi vessel disease with a high syntax score or a thoracic aortic aneurysm. You know, other valve considerations or even a fib is somebody that should be considered probably for other concomitant procedures and not just fix the valve and forget about those other things simply because it's the easy thing to do. And then the other option is you know, looking at the overall self expanding versus balloon expandable. They each have their own advantages versus disadvantages from the Taber option from a surgical option. Clearly there's a lot of patients that are getting by a prostheses but we shouldn't really be putting very small bio prosthetic devices especially in small patients who are young in their age where we know that they're going to be coming back. And rather there's a strong, you know, resurgence now of annular enlargement procedures and bio bent tiles and and mechanical valves simply for that reason simply because you want the best long term durability and the best lifelong strategy to manage that aortic valve And in all of these issues you have to consider the experience and the skill of the surgical as well as the tavern team and the procedurals who are doing these things. So this is a clearly a multifaceted decision making process. You know, a 55 year old healthy patient with severe aortic cirrhosis that is coming in requesting a trans catheter aortic valve replacement simply, there isn't enough data to support that therapy at this point, A 75 year old healthy patient with severe aortic stenosis, requesting Tavern. There is data that is favorable to support that in the right patient subset. So if you look at this, we do obviously a lot of minimally invasive therapy, aortic valve replacement either through a minister anatomy or a mini thoracotomy approach. And you know, we can use a variety of either a mechanical valves or bio prosthetic valves. You know, and and also, you know, we should not forget about aortic valve repair, an aortic regurgitation when a patient is a candidate and is uh you know, a uh the ability to get a good surgical prepare with good durability and a good long term outcome. That's probably the referred the preferred option in a pure Ai patient Um Ross procedure. There's a lot of certainly interest in that recently. There's a resurgence of that procedure with the potential for higher long term durability of this and less re intervention. But that's still pretty early on. We've had, you know, a big interest in this back in the 90s and now there's a resurgence of that based on new data that make sure that it's a possible good option for these patients. So, you know, in our hands, you know, middle invasive surgical aortic valve replacement. You know, that is the standard for all isolated A VRS. We have about a 1% load and medium risk mortality for these patients. We have, you know, single digit transfusion rates, average length of stays about 3 to 4 days. So with excellent human dynamics across all of these, that really should enable a valve and valve strategy later on. But clearly we're not doing this in 50 year olds were doing these in patients that are, you know older that can be um in a planned for later on for a valve and valve strategy. So a 55 year old lady that comes in or a man who comes in with an isolated surgical aortic valve who's otherwise relatively healthy. You know, we usually go for a mechanical valve, which is a one and done option, a stent ID bio aortic valve followed by valve and valve tavern. Later on a stent lys surgical valve, a ross procedure. We know that there's incidents and then and options then to re intervene on both the autographed as well as the home, a graph, you know, that's being used for the demonic or the aortic valve or you know, some patients may, some people may advocate a Tavern. First line therapy followed by savage and then a Tavern later on, You know, again, I guess there's data lacking for all of these. But these are all you know options that are available out there and the decision making really depends on the track uh spit versus bicuspid anatomy of that patient calcium distribution. You know and whether there are good tavern candidate to begin with um you know that becomes you know the big consideration rather than you know the the clinical risk, whether they're high risk or surgical or low risk based on the clinical candidacy. There's also an atomic candidacy that should be considered um size does matter. You know, putting 19 millimeter valves at this point is not the best option and um you know because that will limit the future options for a lot of these patients, likelihood of patient processes, mismatch, coronary disease and comorbidities should highly be considered when choosing the best option for these patients and whether the patient is a candidate for Coumadin and choosing a mechanical valve. Um you know, which is still a very viable option for many young patients. The experience and the skill of the procedural ist, whether it's tabby or surgery. And then the patient preferences increasingly in the guidelines, a consideration that should be considered for lifestyle, social and and things that come up with these patients. You know also the fact whether the patient has a thoracic aortic aneurysm. This is a patient of mine that has a leaky aortic valve um you know with severe ai but also has thoracic aortic aneurysm of the root and in this case, you know, the best option for that patient in in in my opinion was to do a david procedure, a valve, you know, valve sparing root replacement and and then the patient has their own um you know, durability and their own valve in place which then leads to the best hopefully long term solution without a bio prosthesis. So if you can see this, you know, an 85 year old will have certain things that they consider. You know, they don't want to have a stroke, clearly they don't want to die, they don't want to have moderate severe PPL um whereas a 60 year old has all of these considerations plus they want to have, you know, ppm revascularization gradients, uh and durability as main questions for a lot of those issues. So these are real questions and you have to always consider not just the immediate short term outcomes like the database show us, but also 20 to 30 year, 30 year horizon when it comes to these younger low risk patients, you know, and we know that all bio prosthetic valves fail and the younger the patient gets a bio prosthesis, the earlier is likely to fail. And based on this data, you can see that, you know, for a 50 year old, they're likely have, you know, a 20% chance of being intervention within, you know, 10 to 15 years. So it comes to, you know, there's a variety of options and variety of considerations when it comes to decision making about these and you know, when it comes to this, there's a lot of new data, you can see here that the SAPIEN valve, you know, initially there's no difference in terms of outcomes between surgery and and tabby. But when it comes to surgery at four and five years, surgical valves actually did a lot better in terms of human dynamics on all cause caused by prosthetic valve failure compared to a tabby option. So there's long term data. And again, here, you know, there's a residual aortic insufficiency and you know, the self expanding valve. So again, these are all things that do matter and there's clinical outcomes that have been correlated with these for both residual gradients as well as residual aortic insufficiency. So it's there's a lot to consider. There's a lot in terms of a lot of metrics and a lot of guidelines in terms of who to consider for surgery versus Davey. And I'll close off with, you know, a summary slide whether the patient has been commenting disease or not. You know, generally for somebody who has over 80 years old cavities. Generally the consideration Somewhere between 70 and 80, most of them are getting tavern at the majority of centers if they can have a good result and they can both have, you know, if both adequate, then, you know, we usually consider patient choice in there. But anybody who's less than 50. Um or even in their 60s surgery is still the standard of care, especially if they can get a high or large aortic valve size with or without an annular enlargement with a mechanical valve or even a Ross procedure. So when it comes to this, you know current, you know, this is all based on to finalize at 2022 data. Not all tavern server procedures are created equal. There's concomitant disease that does need to be addressed. Mechanical valves in the Ross procedure are to be considered in patients in less than eight of 60. And patient preference and considerations must be factored in and you know, with on going to tavern device improvements. This may all change, but clearly this is a moving target. Thank you very much. And we're happy to take questions after. That's that's wonderful basil. I think you raised a lot of uh you know important questions that I think we'll have a good time discussing at the end. But I think you make the right point. Let's let's move through to the next talk and sort of focus some of those questions at the end of things. So I'd now like to introduce dr Rodrigo DeSousa. Um He is uh you know a fantastic middle invasive surgeon, he trained. Uh now he works at the University of California trained in Brazil worked in Rio de Janeiro for a number of years had a tremendous experience there. I mean you did uh a lot of minimally invasive surgery. And you certainly have since coming to San Francisco like 2000 minimum invasive cabbage procedures. Also a valve expert as well, admirers approach to minimally invasive surgery. A true innovator. So we're lucky to have him here today to discuss with us aortic valve replacement and minimally invasive surgery. So go ahead dr D'Souza. Thank you so much Bill. Um so my my role here today is to talk a little bit about comparing the minimally invasive aortic valve surgery approach versus the conventional while patient selection and clinical keys key clinical outcomes. You know disclosure closures because I'm in our T. V. And consultant right now. So a few things that I should mention in the beginning is that we should know that um it's some kind of competition. Not about market competition but so who can do best for patients. This is what drives us all. So and and the thing about that is that you don't have to be the fastest one. But you just can be the slowest one. Right? And um if you have um a lot of determination, anything is possible if you have the intelligence and willpower to make it happen. And I can tell you really well because I did Started being invasive abroad male invasive program in a third world country like Brazil with absolutely any support. And we turned out being after 7-8 years. The most experienced program in the in the Latin America. Probably so and and everything about me and non invasive procedures are about teamwork and and and sometimes your team just sucks and you need to do something else to to to amend and to correct the path. Because it's like if you have one just one uh bad fruit it can disturb the whole the whole um other fruits. So you need to focus on what you're doing right and wrong and and correct that as soon as possible. So the principles of minimally invasive aortic valve replacement is that developed. Pathology is still the most common between the devolved pathologists and not here just here in United States but everywhere A VR is traditionally traditionally done through Full Sir Anatomy which is fine because it's safe. We know how it works and there's no no sin on doing that through stern economy. Um It's it's it's actually our bailout when we are using any kind of minimal invasive approach. But the sts database states that any procedure not performed with full synonymous or and cardiac bypass support would be um called minimally invasive. And it stands only for T. V. Right? Because anything you do involves um surgically, you need to put the patient on bypass and do an open heart surgery. So the american heart association 2020. Oh wait uh stated that a small chest wall incision that does not everything that does not include a conventional full Sir anatomy can consider minimally invasive procedure which is more adequate, not perfect but more adequate to our reality. So the main principle for that I think is the minimum invasive cardiac surgeons should not be related to a specific procedure or way to do that. But rather like a concept or philosophy that requires an operated specific strategy aiming to reduce the degree of surgical invasiveness and it brings us to the next speak. That is minimal invasive procedure does not start in the awards start way before and it does not finish also in the O. R. And it finishes as we try to make the patient back to his normal life as soon as possible. Much sooner than with a full standards to anatomy. And the approaches that we recognize now is mainly invasive are the direct view approach where you can see what you're doing through your with No no um no other like video cameras or or thorough scope. The video assisted when we can mix both like a direct view and use the video assistance to help you guide to guide you through some steps of the steps of the process. A totally endoscopic view which is the when we don't have any direct view. Like for instance if you do a totally a VR totally endoscopic a VR with only a three centimeter incision with no rib spreader, you're not going to be able to see anything inside the chest unless you you're guided fully through the through the rock a scope. Um And and the last last uh fancy step is would be the robotically assisted. Which is great because the robot can level mostly of the surgeons because it can correct all kind of tremors. We use it uh three D. Visualization with super nice cameras with the robot. And it's good it's fancy but it's good. So it would be the last step. So direct view access for minimally invasive. We have a few um We have a partial person's anatomy. Like you see in A. In B. We have a small interior to economy. Uh C. And D. Transverse anatomy and par uh parsed anatomy. There's not they're not used anymore but the most used in most of the services or what I would say would at least give the best impact regarding the evolution of the patient during the post post op care is the interior economy. Right? In terms of economy because the partially partial upper partial tsunami it doesn't provide too many advantages over a full turn on to me. And we're just like sparing like two or three centimeters of stern. And so it doesn't make much sense if you think about what you're doing. So. And one thing that people used to say about minimally invasive A VR. Is that it has a longer cardiopulmonary bypass times. And it doesn't mean the question is that okay so it's it is a longer cardiopulmonary bypass time. But does it mean um the worst outcome? And on this paper we can see that they did like 503 cases with half of them. Minister economy uh And one quarter Minister one quarter convention astronomy and mainly invasive Our replacement um is safe doing using all the three approaches. Um And the mini ther economy showed decreased operative time, decreased land of state increased incidents of prolonged ventilation time a tran Towards lower mortality when compared to Minister Minister NAMI and conventional tsunami. What stands for is that what we know is that um we can bring down a recovery time from about I would say 3-4 months to 15 days if a patient doesn't go to a full tsunami and go to a minimal invasive access. So uh longer carpenter bypass doesn't mean longer worse outcomes of course. And and how about patients with small L. D. O. T. That need rural enlargements? Um Are they like doable feasible with minimal invasive approach? And this paper is very nice showing that um the arctic enlargement which is which may be necessary is always feasible so to be performed during minimal invasive arctic procedure. Uh Like replacements. Uh And of course that it's a one step ahead of the skills needed to be done but it's it's it's very useful so you can do like uh Manoukian or a um um um enlargement with no issues if you have a good experience on minimally invasive procedures. So the other thing that comes to our mind is if the patient is frail and old can we should we go directly to have ever um the answer is maybe we don't have the answer yes or no yet. So because the the concerns of high risk complications are always present. And so this paper that they compared octogenarians like um with patients less than 80 years old and what they they saw is that of course that the patient that patient dies uh in like 34 months 34 years more than the younger patients. But the point is that they don't die for from complications valve related complications. They die because they're old and frail and not because of the surgery they were submitted to. So it's safe on frail and outpatients. And comparing to conventional conventional versus minimally invasive access. Uh When when we see all the data that we have like in this matter matter analysis we can see that minimal invasive invasive approaches are have excellent outcomes. Especially high volume centers like we have an aortic cases. Micro cases, everything that you that you do like every day brings you so much experience that you know how to bail out for complications during the procedure. So uh the A. V. R. The many A VR approach can reduce hospital stay instance of uh post op arrhythmias like atrial fibrillation and should be considered in patients going to A. V. R. Like like was said before. It should be considered like a standard approach for a VR as long as you have some surgeons who are skilled enough and used enough to do that. So. And one thing that is that is not different is that mortality. And also um the stroke rates. They're not different from minimal invasive A VR. Versus conventional A VR. Which is not bad because we're expecting this to be better and it's not it's the same but it's also not as it's not not bad and it's good because it means that it's not you don't bring a higher risk to the patient if you do minimal invasive approach to the A. V. R. So how about obese patients? So if we have a patient who is like £270 is it more complicated to the to the procedure? Uh probably the access will be a little bit more difficult but the procedure by itself it doesn't have any any changes inside. I mean patients can safely be submitted to me if you are despite of of their weights. Um But and we see significant benefits because we all have seen like obese patients suffering from complications regarding um full Sir anatomy like wound complications. Um Some kind of falling and hitting the sternum and difficulties of mobilizing getting out of the bed. So it comes with pneumonia and all of complication. That comes with a patient who know who not who does not mobilize. Uh So we can of course doing a mini a VR approach in this patients they can mobilize much sooner. So we can offer a better quality in the post op care of these patients. So and and the direct view in my point of view at least it has severe limitations because when we talk about direct view a VR we we need to find the perfect patient for this procedure. And the point is that uh the order should be appropriately positioned inside the media steinem. It has to be the proper angle. Of course it can be done if you have experience on that. It can be done a little bit different. But if you use direct view, if anatomically is kind of challenging, you're gonna have much more difficulty to execute the procedure. But the good thing is that if you use an endoscopic assistance like robotically or not, there are no anatomical limitations. So even if the order is located on the on the right side of the of the sternum that's fine. If it's close to the sternum it's fine you're gonna you're gonna use card upon our bypass. You're gonna have plenty of view of everything because you're not seeing directly using the camera. So and the surgeon needs to fight to to know the device that they use like the valves like mechanical valves or a lot of options like rapid deployment valves that can be used. The surgeon needs to use um to know how to use long shaft instruments. A little bit different needs to take time for you to to be able to to get used to how to operate with them. Uh It's super important to use um soft tissue retractor especially in obese patients. And it helps when you use a totally endoscopic approach because it keeps the few the working part open. And you can even if you do like like we use here like a three centimeter working part. You can you can squeeze evolving without no issues despite of all this mechanical or tissue. No worries. Um And also you need to to get expert expertise on calculating patients from a peripheral approach uh to establish carnival in our bypass. And sometimes it's not that simple needs some kind of expertise on that. So you need to know the cannula says the views of the T. E. Everything that can help you not to get in trouble during the calculation, which is to me part of the like half of the surgery. So so the the great question is when we compare minimally invasive A VR versus Tarver who wins. And this is a very nice paper that I found with 1 to 1 to one propensity score matched analysis comparing minimally invasive A VR. Trans Ap Call a VR and transfer moral a VR. Sorry. And the patient was Matched with with three groups of 177 each group and with with age around 78 8 and 79. So mostly very comparable ages. The older, older and probably frail patients too. And what we saw is that there are no much difference on on on all the all the the outcomes. Uh And when we compare the three um strong outcomes like like survival probability we have the worst outcome on the trans femoral group. And and the best outcome. It is not the trans trans femoral it is the minimal invasive especially in long term the minimal invasive approach and the trans femoral Tarver have the same outcome. Survival probability in the first like 2-3 years. And then the curve start to trend to trend and spread and the minimum that sustains the results. And the tower starts uh presenting some kind of problems on the on this here. So what do we know so far about meeting invasive A VR. Is when we use it in disk optically or robotically assisted. You have a much less surgical trauma. Much less transfusion index. Is much less arrhythmias. Much less morbidity with shorter hospital end of stay shorter iCU land of state and faster. Return to full physical activities and of course much better cause missus. And so um I'm gonna show a small video from one of our cases here. Oh I didn't know. Oh I'm sorry let me come back here. Uh Yeah so I'm not gonna be able to bring the sound down. Okay so um patients already calculated, we opened ricardo with the patient cumulated. Um So it's a report um technique. I can explain that after. I don't have a picture of that unfortunately. But we repair the prick argument isolate uh and and separate all the to show the aortic root. Uh We put event on the left ventricle through the right super. We do uh the clamp the aortic clamp above the level of the pulmonary artery. So we do integrate card up legia when possible. And when it's there's A. R. A. I. We do um act like given some integrate through the costume. And then we open the the aorta to show to expose the vault. And you can see that we're gonna see a very nice view of the aortic aortic root and evolve which can be safely resected. So we can see the edges and then the planes that we need to put the stitches. And we use a different technique to put the stitches in. We use a partial averted mattress technique when we put 22 of the sinuses with the pledges on the aortic face and one of them on the on the ventricular side of of the aortic ring or analysts. And it is just because it gets faster and um it shortens the cardiopulmonary bypass time and claim time to also so as you can see here the visualization is really good and it and it and it it's not a problem to use to tie the knots and you can see the evolving in the aspect. It was not used core knots, it was tied by hand and then we can just close the order. We always close the order in two layers. It takes a little bit longer, but it helps with the bleeding and that's it. Okay. Thank you very much. Okay. Uh Thanks Rodrigo. That's a phenomenal video. Fantastic job. So the the next speaker tonight, we'll move right along and then if I haven't seen too many questions come up in the chat box, please do happy to address those as we as we move forward or address them at the end as well. So by all means put some questions in if you'd like. So our next speaker is Dr Mark Kurdish um dr kurdish trained in cardiovascular and thoracic surgery at Loyola. He still actually is a social professor there but but he's also chief at Franciscan health and really built a center that's known for innovation, particularly in valve surgery. So he's a real expert and he spoke in Calgary once and dr Curtis was, you know, really inspirational the way he really understands the sort of the artistic side of valve surgery and and help me understand sort of try to spit valve repair concepts. And he's a he's a he's a great resource. So lucky to have him here tonight. Um tonight he's going to talk about another area of expertise and this is in peri operative care and and fast track. And he's a he's a real leader in in the enhanced recovery after surgery uh particularly for the for cardiac patients. So doctor Kurdish, look forward to your talk. Thank you. Thank you so much for that introduction. And and also for those superb talks. Um I every time I hear basil and Rodrigo, I learned a little bit more and gain some insight and make some notes for myself. So, you know, um I've kind of given a little bit of this type of talk before specific to minimally invasive. I'm gonna broaden it just a little bit because I think it's important that we do have a little bit more all encompassing view. And I think it's important that, you know, again, we were mentioning the focus on the patient. Um it's not necessarily true that a little incision is always the best thing. I love minimally invasive surgery. But there are scenarios where you can balance things out and you can figure out what really makes the most sense for you and your program. And I'm gonna try to get into a little bit of that. So you can see this list here. In addition to me, there's Janis johns who's our ear s nurse, my partner's mesh and Andy a spectacular surgeons and great great partners. And I see a cast of thousands because, well you'll see our ears program is all encompassing and it's ground up for the entirety of heart surgery. I thought because the last time I talked on this and minimally invasive, I felt like I should have talked a little bit more globally. So that's what we're gonna talk about a little bit here disclosures. So one thing you can always do is you can go to our website. So arrest cardiac dot org is a fabulous website. Is actually an award winning website. And you can you can find all the articles, you can find all the authorities, you can find global authorities on cardiac arrests and you can connect with them and with our society. Uh this is the guideline paper that many of you have probably seen because it's the most downloaded and cited paper in the history of Jama surgery. And uh it has it made a splash and continues to do so because I get emails about it all the time. So what are we doing? We're not, we're just, we're not just accelerating recovery. That was that was a big part. That's really been more a part of it in the last couple of years. But our first drive was how do we smooth it out? How do we make it a better experience? And so you see all these different components preoperative education explaining the measures that we're going to take to diminish discomfort and increased mobilization. I put in big letters, minimally invasive approaches with crowned earth block which I'm going to focus a little bit on but we also use rigid plate fixation for every single patient as a star anatomy. So I'm gonna start out by telling you if I walked into a room and the patients got their gown on and I can't remember what I did. I won't be able to tell if I did a miniaturist anatomy. That's how much we've changed the experience for both of them, minimal opioid usage. We're almost down to none. And then of course early mobility and I see everybody thinks that multidisciplinary teamwork is key. So this was very early in our experience. I'm gonna actually show you pictures of early things that kind of got me going. And these are two gals, the two best friends that came in for the middle invasive mitral valve repairs on the same day and went home day four. And this is when I had started using cryo intercostal blog. And that was an absolute sea change in patient experience because my nurses will tell you that they come out not having pain and they continued to be comfortable. And so we're able to excavate in the operating room almost flawlessly. So the rest is how we battle what I call surgical pTSD when you think about it. Having heart surgery might be the most traumatic thing that a person ever has. So what do we do? How do we conduct the surgical experience and affect the patient in the subtle and obvious ways to improve that outcome that will affect them for their entire lives. Same people The gal in the middle now is the gal on the right's daughter who came in several months later they have her mitral valve repaired and then they went home and had a nice day and then they went to her ranch. She was from Wyoming and then they went and climbed mountains. The reason I show you this because we all have experiences like that where patients follow up with their with their experiences. I just had a guy show me send me a picture of him with a Moussi bagged in in Canada. My point is that the trauma that happens with surgery doesn't have to linger and that initial trauma doesn't have to be as scary and difficult as it can be for patients. Multidisciplinary team work. All of these people are invested and involved in our process and all of this revolves around that center point. Right. Early mobility. How do you get there? Get them excavated in the operating room? You get them up that night walking the next day and we all can think of patients that we have like that. But what about if we can do that for everybody. So this is what we do every month. We have a multidisciplinary rounds. We used to do it in person. Big room now of course we do teams but we cover every subject that you'll find in our guidelines from eras. So it's not just the minimally invasive? Everybody gets treated the same way are minimally invasive and our star anatomy patients get treated the same way. So everybody gets pre op evaluation, everybody gets smoking cessation, everybody gets evaluated for the walking schedule and everybody gets correction of their nutritional status. Everybody even people who are very healthy, you know as you know, we can have more of the obese patients who have major nutritional deficiencies. So unless you're so smart that you can figure out everybody that's gonna need uh enhanced nutrition, then you have to do it for everybody. So we do it for everybody. Um The care bundle for managing the the wounds goal directed fluid therapy center. Readies on tonight. I saw his name pop up and he uh he is somebody who has also invested in this along with some other centers where we have switched over to a goal directed fluid management system that allows us to eliminate Swan Ganz catheters. But still have uh detailed information on people's human dynamics and manage them from their stroke volume index out too. The their urine output. Um So we always have to go back to this trauma pain, trauma pain. We hurt them, they hurt that's more traumatic and they have more pain. So how we manage pain also impacts all of these other things. Pain causes delirium. Delirium. How we manage pain causes delirium opioids cause constipation. Constipation foggy minds. Can we get people excavated early when they're uncomfortable? No. Can we get them excavated early when they're on major doses of opioids? No. So all those things kind of influence the big picture. How do we treat them holistically and move them in the right direction quickly. So one of the things we do for everybody is a chest wall block. So this is a simple thing. Our anesthesiologists doing the patient rolls into the room. It takes 10 minutes. They do an erector spine a block. If they're having astronomy they get bilateral erector spinning blocks. If they're having just a mini, you know having one sided surgery, then they have erector spine a block on that one side. Uh And then in the operating room all patients get director spanish black. All patients get ideas. acetaminophen. Uh And we use precedence coming out of the operating room on everybody. We also use a lidocaine drip. Now when we're talking about the economy's minimally invasive incisions, whatever you want to call them. And robotics they hurt. So I know that they're, you know I have a lot of fans of robotic surgery. My partners do robotic lung surgery, which is fantastic. But I can tell you that robotic patients often are uncomfortable and because you're hinging in those various nerve spaces. But whether it's vats or thoracotomy, it takes a while for people's pain to go away from the economy and sometimes it's very durable pain. So this is what we do, you know for. And this is a bigger incision. You can see we are actually in this chest with ribs spread and introducing the cryo probe directly into the inner space and to drive that along the rib space. And then you'll see here in a second, you'll see the freeze. So this is a standard cryo probe that we use for made surgery going in through the inner space. We're not way back by the spine, we're fairly interior, but we're posterior to where the nerve was injured from the operation and we drive it up and apply the energy directly to the neurovascular bundle and then light it up and freeze the nerve. Take it down to 60 degrees negative, 60 C and we stay there for two minutes. And so that frees, Then you'll see it occur here Will give us a block that last somewhere between eight and 12 weeks. People are often worried about what they've heard of stories about the aromas and neuralgia and all kinds of things. We haven't had none of that. We've had the occasional patients whose numbness lasted longer. And I tell everybody pre operatively you're going to be numb, you're gonna be numb in this distribution. I show them where it's gonna be. It'll be gone in 8 to 10 weeks and it always is sometimes their armpit will be numb for a while they complain about when they put the deodorant and it always goes away. So in all of these other issues that you see listed here, we haven't experienced. So the chronic pain after thoracotomy, uh after a thoracotomy or the neuropathic pain that some people have expressed. They've seen with cryo blocks, which we haven't seen. Cryo nerve block works by freezing the axon and that checks out while the rest of it is left intact neuron, the fasting period. Do you remember this from medical school and valerian degeneration occurs. But then the good news is that that axon regenerates, right? So the cell body is unaffected, The axon regenerates down that pathway and re innovates that territory. So and it works. It's worked for us every single time and it always lasts about 10-12 weeks. So these are some of the things that people worry about peripheral sensitization. Central sensitization along Edina is the thing I hear people ask me about the most, like, well I've heard that people can get a durable pain from the freeze. We haven't seen it now, we're not going ultra cold, we go to negative 60 at the most and we're freezing for two minutes. There may be some differential based on how deep the cold is or how long you're on there. The other thing I think that is important. It was alluded to a minute ago by Rodrigo I think was that getting away from growing incisions? I think that if you want to really lessen the difficulty of the recovery for a patient, you get rid of all those aromas and the limitations of mobility to come along with growing incisions. So for several years we've done all our cardiopulmonary bypass for minimally invasive operations. And actually for redus per cutaneous lee. We just made a point of getting skilled at and you can establish your cardiopulmonary bypass per catania slee using a combination of ultrasound. And then we use X ray use radiology a C arm to establish where our wires are and safely perform it every time using per close like we learned during doing taverns to close those close those holes after we take the Kanye was out. So the candles will go through these per close uh temperatures and then later be taken out and closed down with the per close without the thermal incision. I started this right after I had a guy come from out of town for minimally invasive mitral. He was he was very into his body, was a lifter and he was always exercising and um he got a bad Ciroma when he went back home and I had to deal with the plastic surgeon fixing it for me after that. I went to this and never never looked back uh so this this I just thought I would touch on this. I know that we've already seen a video Rodrigo kind of dissed direct visualization. Oh my video is not playing, We're not gonna play it. I was going to show you a little bit of our direct visualization but it's not there. I apologize. Maybe we can get back to it later but there's some simple moves that I think people can use especially early on when they're doing um when they're doing uh that type of procedure and I can maybe get to that later. So um to stay on time, post op mobility depends on minimal opioids. We went after opioids but we didn't go after it as take the opioids away, we went went after it as take away the pain. If we get rid of the pain we get rid of the opioids. Opioids are causing constipation, gut issues, uh hallucinations in older people. It's delirium which we've almost seen complete obliteration. We've almost got completely rid of delirium. Delirium. Post op we haven't used any kind of medication for delirium in a few years to treat delirium. So IBM acetaminophen every six hours for eight doses. Then we switch to P. O. We use precedents pretty liberally and there's been some some bad press for precedence recently. But that was always in the setting of also using opioids precedents. All by itself is a pretty benign drug lidocaine I. V infusion. We used for a little while if we see any neurologic issues going on. We just stop it but here's the here's the punchline fentaNYL only in the first eight hours after surgery and even in our store anatomies. Half of the patients get no fentaNYL the whole time. They're in the hospital, no opioids the whole time they're in the hospital. But we do make it available the first eight hours for any of the operations. Whether it's many or anatomy fentaNYL available for eight hours after that. They're just on gabapentin. Uh And then we use toward all in in the valves of normal renal function. Occasionally in a bypass coronary bypass patients, lidocaine panthers, pressure points. So how often is that? You walk into the room and the patient says, I heard right here, it's right under the right scapula or it's in their neck. Go after that. Go rut, it push pressure on it, figure out what the problem is because you don't have to medicate the entire patient when they have pain in one place. Ice packs work too. So what happened if we look at our minimally invasive postoperative pain scores? I go back to 2017 when we really weren't doing much arrest at all, then we initiate arrests. Were not really paying attention. But we find we realized that the pain is going away and over the next couple of years to the opioids go away. And what happens to the pain scores? Nothing. They go down a little bit. So I can either get rid of eras and give them opioids and they won't hurt. Or I can use a rest and cry a nerve block and they don't need the opioids and they won't hurt. You can see total, you can see total dose of of opioids down there. five is basically the equivalent of one coding Postoperative length of stay kind of steadily drifted down. Now. We've actually become finally more aggressive about that. We never really focused on it. Uh now we're starting to send people home day two at times. Uh and then you'll see that nobody goes home with the new narcotic prescription. zero presently go home with a new narcotic prescription and everybody goes home which is important, discharged home is super important. It's more important of course in this to anatomy because those are the redo double valves in an 82 year old. So that's gonna be I'm gonna actually point that out to you in a minute here. Uh This fellow big dude I think he was a firefighter, 64 years old, cares for his his disabled mother. As a matter of fact we tried to move the date of the surgery. My assistant called him said you're gonna we're gonna have to move the date of your surgery. Said that won't work and he hung up on her and he came in and had his surgery. And so he actually he did not ever want to have another procedure is 64 years old. You got a middle of the invasive onyx. He went home day two and started taking care of his disabled mother. Uh Not every patient can or should have minimally invasive surgery. And I think that's why we talk about here. S and more global terms, why do we do minimally invasive surgery to avoid the trauma? Can we avoid the trump? Can we eradicate reverse or change the experience of trauma in another way? So in folks who have astronomy, everybody in our practice, everybody in our program gets rich external fixation. And you can see what happened with that. The same thing With a 90% reduction in the use of opioids by adding registering fixation to all the stuff I just talked about so minimally invasive to get a crowd block stern on me, get registered a fixation. The outcomes are nearly the same narcotic usage and discharge same thing. We're down to 6% at discharge first anatomies. And here's the really important point. I think that we went from 30% of the patients go to an extended care facility because this is everybody. These are the redo triple vows. He's really sick people. 30% going to extended care facilities and now we're down 9% with single digit readmission rates out to 90 days after surgery, comfortable. Is astronomy After surgery comfortable. This guy goes home post op Day two after astronomy goes home driving a week later back to his life. And this guy goes home post op day four after a big operation, aortic valve maze goes home and you can see what he can do. Look at the size of that guy he's comfortable. So I'm gonna close with this. Hopefully I wanna have gone too far over time. Uh This is the guy was just in my office 66 year old physician severe by custody valve stenosis. He's got a deep cleft so he could be done with the tavern, normal coronaries, symptomatic paroxysmal atrial fibrillation. A standing order 43 millimeters. Doesn't make the cut off right for treating directly during surgery. He's got cardio metabolic syndrome, which folks will tell you I'm a big fan of with respect recognizing its consequences. So you see the menu there, I think we're gonna do more of this later. But you see the menu there and you can tell you can probably guess what I decided to do for this guy. Oh sorry. There's supposed to be a slide in between there. I did this do Anatomy Sabir maze, a standing order possible route. So which one of these two fellas had a stir anatomy. This guy with this nice golf swing or this guy hitting fast pitch or left. The guy hitting fast pitch. Had the anatomy. They're both three weeks out from surgery. So my point is that I love minimally invasive surgery. Like I said, I did the I chose to do everything for this guy. I think minimally invasive surgery is wonderful. But I also think that there are ways to equalize and level of playing field so we never feel timid about giving somebody the big operation. The operation that might benefit them over the longer run sleep well every night knowing you did the right thing. Thank you. Oh this is a video. Did you guys want to play this? You can cut me off if you want. But this is a video of a gal. She's 52 years old. I'll clip through it active gal. And was trying to decide what they have done and she of course had an onyx develop implanted because otherwise they wouldn't make a video of it. But the point is really that combined number one virtual visits number two minimally invasive surgery number three year asked going home, lives her life. She's a very happy person. You guys can see that video on the site anytime I'm gonna sign off of there. Thanks. Thanks very much. Dr british. I think that was a wonderful presentation. I think you know it really highlights that you know you can do the technical things in the O. R. Which you got to pay particular attention to is the peri operative care and things you do afterwards really really make a difference. And uh that's um that's that's a great talk about that. So we are running short on time. There was a question the chat box about management of pain control with monogamy relative to mini thoracotomy. Thank you. Address that later in the talk with talk about rigid external fixation. So let's move on to dr Michelle Lena. Dr Micheline a. Is uh works the mayo clinic. He's a cardiologist, echocardiography for chair for research division of structural heart cardiovascular ultrasound. He's the director of intra operative echo. So he's got a real special specialization in valvular heart disease, bicuspid aortic valve. Lots publications over 240 peer reviewed publications. Real thought provoking. Excellent speaker. So look forward to hearing what he has to say. Go ahead Dr Michelle Lena. Thank you. Thank you so much Bill. And I'm the one that learns the most and enjoys and enjoys the most these webinars because evidently I'm a cardiologist. I'm not I'm not a cardiac surgeon. So so it's uh it's fascinating all the stuff that that we have heard. So just a brief comment on the lifetime management for our patients with aortic valve disease and why it is that we need to be have the acumen and know the data and be very very astute in what we recommend and how we look at all this business. These are my disclosures but in reality I don't want to make anybody happy but only look for the truth and in that regard it is very important for surgeons and the audience in general to know that the proactive trial which was a trial of the onyx valve in the position randomized to a pixel bon versus continued warfarin. After enrolling over 100 and 850 patients of the 1000 goal. And after two years was halted due to the fact that the absolute um, margin for non inferiority was likely not not going to be below or equal to 1.7 per patient. Here. In other words, there was a signal of more thrombosis, uh, which resulted in more strokes in the picks up an arm and therefore it has been halted. And all patients that participated will go back to um, to, to their Coumadin. This was a humbling experience which broke many of our hearts because we were a counting on this to be a life changer for patients. But unfortunately it was. And at the end of the day, we're not looking to to promote anything. We, we want to find the truth and we found the truth. And the truth is that a dog attacks do not work well even with the best available aortic valve in the market. So the wax for mechanical valves are definitely out of the question. And this trial, I think I think proves that which is, which is a very important uh, point in getting to the truth. I don't know if Mark Girders wants to comment because he was also heavily involved in the product trial. Mark. Well, you know, thanks Hector. I think that you delivered the message perfectly. Well at the end of the day, um, even though like you said, 850 patients were enrolled and a lot of those are our patients. Uh we did not get to the to the goal that we were seeking. One of the things I think it's important to recognize is that just that warfarin works well and we've already shown with this valve that you could run it at a lower dose of or from the lower I. And R. And still be very safe. So that combination is uh is just hard to beat. And these weren't crazy numbers. It wasn't like you know, 10% of the people were having strokes but the numbers that were projected and being generated for the annual incidents were although they were still below the OPC, so the objective performance criteria, it was still below that. In other words it meets the criteria if you just want to have a mechanical valve. But what we set out to do is to show that it would work as well as Warfarin and we just couldn't do that. So maybe there's something else in the future. But like you said with the best valve on the market where we already demonstrated, it had a lower incidence of thrombosis, bolic events, even at the lower dose of of Warfarin, we couldn't do it. So that's all I can say where everybody's disappointed, everybody's hoping for it, but it's still we still have a great valve use. So so um let me just let me just continue after that and just uh make sure that everybody understands that the patients with aortic valve disease depending on a R. Or a. S really has a lifetime of planning for management. If you look at patients coming with c significant aortic regurgitation with bicuspid valves. Their their ages are in the thirties, forties and fifties while try caspit are in the fifties, sixties and seventies. If you look at patients with moderate aortic stenosis, they're coming in their fifties with bicuspid and in their seventies with try caspit and they reach severe in there sixties at bicuspid and in their seventies and eighties with try caspit. So we need to try to plan ahead of a potential lifetime or residual lifetime that the patient has. And therefore we need to look at these questions again a little bit. The first question was 42 year old. Male with symptomatic of your a are of a very asymmetric right left bicuspid aortic valve with calcified rafei. Best solution, surgical valve repair, surgical, minimally invasive mechanical a VR ross procedure, surgical by a prosthetic a VR with future valve in valve and then a 60 year old. Lower risk female with an ele bot of 20 millimeters. And that's where we have to be astute has symptomatic, severe areas of a bicuspid aortic valve. Again surgical bio prosthetic A VR with future valve involved surgical minimally invasive or conventional. It's the same mechanical a VR with lifelong warfare. And we just saw the differences between conventional and minimally ross procedure or at the end of the day. It's just up to the patient whatever the patient wants. And I want to show you why these ones that we have underlined are probably not the ideal for these patients that we have presented and tell you why so that we can practice our our our students. So there we have published a new international consensus statement on nomenclature and classification of bicuspid valves in these four journals. And we have recognized this time that when we're talking about fused bicuspid aortic valves which are the most common, They we need to define whether they are symmetric or not, particularly if they have pure regurgitation. And we're thinking about the potential of repair. So what is symmetrical means that the angle of the non fused is between 100 and 60 and 80 Asymmetrical and very asymmetrical. Which is our 42 year old first case. Very asymmetrical. What happens to a very asymmetrical well this is almost just one line of co optation, much easier to repair than two lines of co optation. And even almost three lines of cooperation. Plus this patient has a calcified raph, this 42 year old. So it is possible that this patient is not the best candidate for repair. So we need to know these things who are the best candidates for repair in bicuspid aortic valve, no Rafic or not calcified Rafic no significant calcification or only minimal calcification of the aortic valve patients with symmetric valves were easier to to repair and the use of a systematized way of doing it as our european colleagues have done from Belgium and Germany which is now gaining relevance in the US big time and all of our surgeons here in the panel a do them. So as you can see here, the survival of this german cohort after Repair at 20 years was the same as expected. But if you use the an atomic repair concept which is just like we systematized the repair of Mitral regurgitation And now it's a systematic way of doing the mitral valve repair with certain variations. Well it's the same thing for the aortic valve now not only bicuspid but try caspit as well. Okay, so you can see here that if you follow that an atomic repair concept, the survival at 10 years is excellent. And You don't want calcification of that valve. Like our patient who has severely calcified graphic because as we see from our own data from Mayo it is calcification. What leads to re operation. Okay, calcification, fibrosis in 68%. Now I had the great uh delight of writing with Mark kurdish. This review for progress in cardiovascular disease which was published this year of the role of mechanical valves in the current era of bio prosthesis and tavern. And this we we we we have the opportunity to revise the promise and the reality of bio prosthetic aortic valves and that includes surgical bio prosthesis as well. As It is very important for you to understand that the biological and mechanical valve and the aortic position treated with Coumadin has a thrombin embolism rate of about 0.5% per year, which is exactly the same as the one we have shown for bio prosthetic valves. Okay furthermore, it is important to look at the two year outcomes of the low risk partner trial. Okay. Showing that the primary endpoint remains significantly lower for to versus surgery. But initial differences in death and stroke favoring Taber were diminished And patients who underwent tavern had increased valve thrombosis as they very honestly show in this slide here, you can see by 24 months the benefit, the benefit of tavern is gone. Why? Because there's more valve thrombosis in taverns than surgical and it also affects the mean radiance. In addition, we were extremely surprised to see that of nine studies, including two meta analysis where there were head to head comparisons. Either observation. All okay with propensity matched cohort or meta analysis. There was a mechanical survival advantage in 50-65 year olds. In six of those nine studies, there is no study shown such that that that that shows benefit of bio prosthetic valves over mechanical valves. And this is Just this is just the data that there is out there. In addition, two of the three older randomized mechanical survival. I'm sorry randomized trials show also a survival of mechanical over bio prosthesis, it seems that survival is better with mechanical valves up 60-65 years old. And let me tell you something else, There is exactly the same which all these trials have shown. Okay, observational or non observational. The same trumbull and bolic percentage and the same endocarditis percentage for both mechanical and bio prosthesis. It's exactly the same. Okay. But the survival seems to be better up to 60 to 65 years old where you don't see the benefit after that. And that is very important for us to know and to transmit to our patients. Now there's also the valve in valve. Well, let me give you a bio prosthesis and we'll give you a valve in valve when you need it and then we'll continue giving you valves and valves forever until we complete your lifetime. Which evidently is not possible. I think probably one can do a maximum of two valves valves because then you start having problems with coronaries access to coronaries and all that stuff. But valve in valve tavern is a good thing. It works. It's associated with better short term Malcolm's than Redux suburb. Okay. And in long term follow up, there was no difference between the two treatments. Now, what's the problem with valve in valve that we need to be astute about in this large registry european. Okay. What was shown is that when you do valve in valve in small by prosthetic valves, you have a survival benefit. I take it back, you have a survival disadvantage or more mortality in the patients that you put valve and valve that have a small bio prosthesis. In fact, mortality increased for one millimeter, decrease in internal diameter of that bio prosthesis. Okay. Therefore there is this new push for surgeons to implant valves that are 23 millimeters or more because you cannot do a valve and valve in the 19 millimeter valve, a bio prosthesis. And you can potentially do it in a 21 millimeter but you will have some obstruction to it. Therefore we need to be very astute. Our second case is a patient, 60 year old female with a 20 millimeter L. V. O. T. So either you get a surgeon that can do the L. V. O. T. And enlarge it. Or you need to think of something else in that regard. The onyx valve. Mechanically, maybe the prosthetic valve imposing the lesser disease in the appropriate patient. And don't get me wrong if I get an 80 year old male status was 25 millimeter by a prosthesis. Good size by a prosthesis. 10 years ago, I would choose a value valve evidently there's no doubt about it. But this 60 year old female with severe a. S. And L. V. O. T. 1920 millimeters unless I have a surgeon that can guarantee me, they're gonna put a 23 millimeter valve. I cannot recommend honestly and and and and with using data and intelligence because she's not gonna be able to get a valve involved in the future. Why the onyx valve? Well the follow up of five years of patients randomized to lower intensity Warfarin plus aspirin versus standard warfarin plus aspirin showed that there was less bleeding in onyx valve patients treated from 1.5 to 2 of I. N. R. And there was the same amount of thrombosis. So there is a to be an indication for decreasing the anti coagulation intensity in onyx valves. Only in the aortic position to 1.5 to 2. Now you will find resistance in the community from physicians that are not aware of this and some of them will leave them with an Rs from 2 to 3 even I. N. Rs 2.5 to 3.5 in aortic valve which is clearly not needed by anybody. So what I usually do is I keep them 1.8-2 and we can keep everybody happy that way. And the patient has less bleeding and has the same protection. The other thing is that it's not just what the patient wants. Shared decision making implies a bidirectional communication and a bidirectional exchange of of of of clear data and information from you and of wishes and principles of the patient. Such that together They can come to a decision and your our job is number one to be 100% truthful. But number two to protect our patients you see. So we need to have very clear what the data says and we know that the data is not perfect. But it's what the data says and it's what the truth that we currently have. I do want to make one final comment about the ross procedure. The ross autograph. Because you can see here that the ross Is could could be potentially offered to this 42 year old, could potentially be offered to the 60 year old. Now it is very important that even though I am advocating for younger patients, potentially for mechanical valves. Okay. It is also important to know that mechanical valves even though they seem to provide better survival in younger patients than bio prosthesis. If you have a mechanical valve, your survival is not to be expected of your age and sex matched a cohort you see. And that has been shown clearly. Alright. And in that regard there comes the important number one of repair. Okay. Which can potentially have that survival exactly the same as what you would expect for the next 20 years without having to take any medications with decreasing endocarditis because you don't have any strange material in you. You have your own valve. Okay. But I want to mention besides repair the ross procedure which has been the subject of controversy throughout the ages. But there is some very impressive data coming out particularly in younger patients. Okay. Which is probably Why are 60 year old lady is not the best candidate in the world for a Ross. Because Ross the experience in Ross has been mostly in younger patients. Now in this recent propensity matched comparison, they did something very nice. They were able To match for for future prognosis three groups, one group of Ross, one group of biological, all in the erotic position and one group of mechanical and more than 400 patients per per group. And something very interesting emerged. Which is the patients that underwent a Ross procedure had the same survival as expected at 15 years as expected for their age and sex. Okay, so survival reestablished to normalcy while mechanicals and bio prosthetics had worse mortality both of them. Okay. Not one better than the other. Now this is not a randomized trial and there could still be confounding variables that are that are not accounted for. Such as choosing the most super low risk and healthy patients for the ross while not choosing the other one's for mechanical and buy prosthetic. But the best way that we have to do it in in an observational study is by by um propensity matching. So I thought this was very interesting, very interesting. Would like to see what the comment of my colleagues are and uh and if there are final questions. Okay. That fantastic talk that really brought things home beautifully. Well why don't we do two things? I know we're a little over time but I think we can uh why don't we look at the poll again? See if uh you know, opinions have changed throughout the course of this. So after having heard what you have this evening. So if you've got that 48 year old male symptomatic, severe a. R. And this is an asymmetric custody aortic valve with a calcified Rafay. And we heard what dr michelin has said about that sort of anatomy and its repairability. So what's the best lifetime solution? Yeah, this is this is a really that's that's a really good question because you know you you touched on the repairability aspect and what are the features that make a valve more amenable to repair. Uh So you know, in this particular case it does tend to favor um you know, the durability of repair may may not be may be sub optimal in this type of patient with. I would also add that is our responsibility as clinicians and gatekeepers that we are as cardiologists to know what a good repair substrate is and what a good repair and and what is not. Uh That is very important. In addition, it is critical to know what resources you have at home. I know who my surgeons are that can repair bicuspid valve. You know, you have to know in your center who's your surgeon that can repair an aortic valve. It's a really good point. I mean, you know, it has the potential to have you to have really good longevity for patients. But in the right patient by the right surgeon dr Curtis. You had that comment. Uh Well yeah so first of all I think it's a perfect question for folks and I agree very much with both of you in the sense that it has a lot to do with kind of where the person is and who they're being treated by. But I think we should recognize that uh we are we're pushing ahead with more aggressive reconstruction of more calcified and more complicated bicuspid valves including these even using autologous aorta as a repair substrate. So I think um we'll see this evolve and I think it's important for us to recognize that surgical techniques will continue to evolve as much or maybe at the same pace as trans catheter. Uh so hopefully uh so hopefully folks will kind of keep an eye on all that as well. Great, let's pull up that other other scenario and then maybe basil and Rodrigo can comment. So what about the 60 year old, low risk female L. V. O. T. 20 has symptomatic severe es what about that? Well, I mean this is this is not a very uncommon scenario. This is we see this all the time patients who are relatively small stature. They have small L. V. O. T. S. And they're 60 and otherwise healthy with a good lifespan. You know, the best way to treat those patients is to really clean up that calcium in the aortic valve and put as big of a valve as possible. We know that patients who have a 19 or 21 are not going to have a good result with a valve and valve tavern procedure. I do this every week and so they end up getting redo operations. So if we can get the best biggest valve at the beginning the first time around like with with annular enlargement or some kind of a low profile valve so that we can get as big of an orifice area to avoid a valve and valve problem later on, that's clearly what's best in her interest. Either that or put a mechanical valve and if she's interested in a um if she's able to take Coumadin. So that that's really what the main what I would propose. There was also another question uh Bill that was posed that I got from the from the team the R. Key T. S. And whether there is any data comparing minimally invasive aortic valve replacement versus to V. And and that really does not exist. I mean we do have multiple randomized control trials that have shown um you know equivalence basically in very short term follow ups between Taverner and surgery um with a lot of these patients at various risk classification whether it's low risk or high risk and so on. But we don't have a million invasive subsets of these patients that have been compared to to v in a randomized fashion or any you know, real appreciable fashion um that I'm aware of. We know that a lot of the bias has gone gone on in these patients. And and you know, somebody who comes in who is relatively low risk and is younger um You know generally in most well experienced centers will get a million base of replacement. But unfortunately we don't have randomized trial data to show that its benefit versus tabby. Yeah, I think that's that's a great point. And you know, interestingly this this last question. This scenario changed a bit through the course of the evening favoring bio prosthetic which valve and valve. And and you know, I think given what dr Michelle Lena said and you're touching on basil two key point here is that if you're going to do this, you know, in a annual it's this size, it's gonna need a root enlargement. You're gonna be able to achieve that at least 23. So um so that's that's really interesting. Um The Rodrigo, did you have a comment about that? Yeah, exactly. I would I would I would come uh say something about that. I think that. I mean of course it's important what you're gonna do. But the most important thing is it doesn't matter what you're gonna do, you need to do it big because if you do put a small mechanical or a small uh tissue valve you're gonna bring this patient real real lifetime problems. Sometimes it's not fixable in a long term basis. So um it doesn't matter what you're gonna do. You need I mean if you like we have some techniques of enlargement enlargement nowadays that we have we can put when a patient like this with the L. V. O. T. Of 20 we can put evolve like a 27 involving no issue. So um and very safely so I think that we should always always think about lifetime management. It's a number one thing. And and the first step to be done like surgical step is the root enlargement with patient with smaller L. V. O. T. S. Yeah. You know I would add though. Um As long as there isn't patient prosthesis mismatch. When you put the mechanical valve in it won't develop later. But with a tissue valve it will develop later. And as you all know we're seeing literature coming up now saying that in native valves we should consider intervening on moderate aortic valve stenosis. Symptomatic whatever. So does that also mean that when we put a tissue valve in somebody when that becomes moderately cyanotic which happens to all of them. And they stay that way for several years before we do their redo surgery? Are we supposed to move that up? And what are the implications for the myocardial um So Hector that would go to you, are we supposed to monitor them with MRI's to look at myocardial fibrosis. Are we supposed to look at global ventricular strain as an indication of needing another operation? And or should we just become more alert to the fact that we're gonna damning these people to having myocardial injury by putting a bio prosthetic development that eventually is going to be stain on it? Well, you know I I think that that when you develop trikus speed aortic valve stenosis, this is the final hit of of a complete process that that that includes already damage to the heart from hypertension, from diabetes potentially and and and from potentially atherosclerotic disease as well, you know. So so so that that I believe is why it has been shown that patients with moderate A. S have have already decreased survival. And there is an ongoing trial looking at treating symptomatic moderate A. S. With tavern. Yeah. So few trials looking at modern one with both valves. One with you go. So, so so I don't know what that's going to show, you know, but but the truth is that we may we may be facing in the future a potential decrease in the numbers. An indication for surgery which is a phenomenon that not only affects A. S. It affects A. R. Two because we have shown in our data as well, you know that that that they are lower numbers that give you the best survival, you know, so, so these things are coming and decisions in younger people are coming and and we have to remember also part of the being astute as a gatekeeper that the younger the patient that you put the bio prosthesis in the sooner it will degenerate, which which I think basil mention and and and I think that is also a very important point. And and again, it's our job, our job is to tell the patient the truth based on data and to help them make a decision that is safe for them and that they're happy with for for the for the for the for the long term. I think I think that's great. I mean I think you know, in all our practices, I think dealing with these decisions around aortic valve disease and some of the most complex but but interesting, you know, with with options of repair and ross procedure and replacement, what kind of type of bio prosthetic and uh you know, we could talk all night about this and I think it's, you know, an ongoing discussion. So, um given that we're about half an hour over time now we're gonna we're gonna end it at that. I think we've addressed most of the comments in the in the chat box and I'll turn it over to Aaron for a final word, but great, great job. Excellent panelists and enjoy awesome. Thank you so much, dr ken and thank you to this incredible panel of physicians for their time and engaging discussion this evening on behalf of our tv in. I'd like to thank everyone in the audience for joining as well and spending your time with us this evening. Thank you all. And I hope you all have a fantastic evening.