Making the Right Valve Call A Physician-Focused Heart & Vascular Care Webinar
Previously Recorded: Wednesday, October 8, 2025, 12:00 PM – 1:00 PM ET
Making the Right Valve Call , an interactive webinar led by Baptist Health Heart & Vascular Care experts, explore the latest evidence-based strategies for selecting the most appropriate valve therapy approach for patients with structural heart disease.
Whether you're a cardiologist or general practitioner, this session is designed to provide actionable insights to help you stay ahead in an evolving clinical landscape.
What You’ll Learn
Key updates to ACC/AHA guidelines and practical application of current selection algorithms
How to leverage advanced imaging to guide treatment decisions
Strategies for risk stratification and long-term management post-TAVR/SAVR
Real-world case perspectives and expert commentary
Panelists
Bradley S Taylor, MD
Carlos Enrique Alfonso, MD
Welcome everybody and thank you for joining us today at the Bell Baptist Health Studios for our live webinar um on making the right call. So, I'm here today, um, and as a brief introduction, I'm Carlos Alfonso. I'm one of the interventional cardiologists. I recently joined the Baptist Health, uh, and I'm the medical director of the Complex PCI and CTO program. Uh, and I'm joined here today by some of, uh, my esteemed colleagues, uh, Doctor Nish Patel, who's the director of the structural heart program at, uh, Baptist Health, and Doctor Taylor, who's the chief of surgery at the North District for Baptist Health, and I wanna give them a moment to briefly introduce themselves. Uh, so Doctor Patel. Uh, hi, folks. Uh, my name is Nish Patel. Uh, I'm one of the interventional instructor cardiologists, uh, mainly work at the, the Baptist Hospital, and I've been a part of this amazing team for the past 3 years. Good. My name is Brad Taylor. I've been a cardiac surgeon for 23 years. Uh, I just recently moved to South Florida and, uh, I'm responsible for the cardiac surgery. A program as well as the delivery of quality of care, uh for Baptist South Florida. Um, my primary focus is on the Palm Beach in northern region of, uh, the Baptist system. Great, great. Thank you guys and welcome, and I think we're gonna have a great discussion today, uh, a brief agenda, so, uh, we've got the introductions uh uh out of the way. So we'll talk a little bit about the valves, uh, what we could do today with, uh, surgical and trans catheter options for valve disease. Uh, we'll discuss, uh, Baptist Health and the heart and vascular Center, what we could do and what we could offer to you, to you and your patients, uh. We'll go through some cases to highlight some of the techniques and technologies that we have available and then finally we, we'll leave about 10 or 15 minutes at the end for questions and answers. Uh, so if you have any questions, please feel free to post them in the webinar. We'll be getting to them as we go through the, the session and we'll also try to get, uh, leave some time at the end for some further questions, so. With that, um, bowel disease has really not changed, but the way we've treated it has changed over the past 20 years and it's really evolved with evolving structural technologies and involving surgical technologies, uh, less invasive approaches, minimally invasive surgical approaches, and, uh, minimally invasive trans catheter approaches. Uh, Doctor Taylor, you've been dealing with bowel disease for a long. Time. What have you seen throughout your career in terms of dealing with valve disease? Well, I think the most exciting thing that we've seen is the trans catheter, uh, therapies have really revolutionized, not just, um, valvular disease, but also aortic disease. Our ability to operate on people at extremes of ages and extremes of diseases that we could not have benefited, uh, earlier in this uh century, it is really remarkable. And also from a surgical perspective, our ability to preserve people's valves. I'll give you a great example. When I was a resident coming out training, only about 30% of mitral valves were being repaired in the United States, and 20 years later, well, we've trained our, uh our, our colleagues across the country, and about 95% of valves are being repaired in the, in the mitral space. Great, great. And uh Doctor Patel, what about the structural space? it's really been 20 years ago, structural heart uh disease was really congenital heart disease and, you know, taking, uh, plugging holes, but how is the, how's the field evolved since then? Yes, the field has rapidly evolved in the terms of the trans catheter valve intervention, uh, since the first taver being performed back in 2002 and 2011 taver being uh. Uh, FDA approved, uh, now to procedure surpassed the surgical aortic valve replacement, but what it has done is, uh, you know, it essentially treated a significant number of patients which were not being treated before at all. Uh, and it has also created halo effect. So the, the interventional cardiologist, structural cardiologists are able to address this patient with the tab, but at the same time, there are a lot of patients coming to the surgeons, uh, also to get surgical aortic valve replacement because not all the patients are ideal candidate for TAR also, um, and, uh, you know. Now we have a catheter-based intervention for the, uh, you know, aortic valve, it's pretty established mitral valve, it's growing now tricuspid valve, we also have, uh, you know, trans catheter options. Uh, so in the future, I think we would have, uh, you know, all this technology available where we can address the appropriate patient with the catheter-base intervention because there is Definitely a role for a team-based approach and individual patient uh based care where some patients uh are better suited for surgical intervention and some are better suited for catheter-base intervention. That's great, that's great. And so I think that you mentioned the, you know, patient selection is uh obviously key for any procedure, any valve procedure, and that that that discussion. Um, and that's highlighted, I think, in the guidelines and so the guidelines have guided, you know, they're not, uh, hard fast rules, but they're guides to guide us in terms of the best uh therapy for individual patients. And what can you tell us about what the guidelines have, uh, how they've evolved over the past 15 years? So now the guidelines have, uh, you know, taver is obviously part of, uh, uh, The guidelines, uh, were, you know, American guidelines actually recommend, uh, uh, you know, Ter for more than 80 years of age, uh, and for less than 65 years of age, uh, the recommendation is surgery, and 60 to 65 to 80 years of a patient, it should be a, you know, shared decision making. But I think what the guidelines sometimes miss is, uh, Age is not just the only factor, you know, the anatomy is a bigger factor. And uh when we do the assessment of this patient, the CT scan, uh, is actually one of the crucial factor which decides which therapy would be a better, uh, for that particular patient. Uh, and I think we'll go through some of those cases and, uh, you know, understand that, uh, fact. Uh, and similarly, you know, trans catheter edge to edge repair is also part of the guidelines. Uh, it's been recommended for the patients who are, um, heart failure patients with the EF less than 50%, and they have a secondary mit regurgitation. actually recommends the trans-cahe X to edge repair, uh, uh, but for the primary MRI, the surgery is the class one indication. And uh the trans catheter to edge repair with the microclip or Pascal is uh recommended for those patients which are prohibitive risk for uh surgery. And uh so far we don't have uh the guidelines about uh the tricuspid uh edge to edge uh repair, but that should be coming and similarly the tricuspid uh valve replacement, uh, uh, but this uh sort of uh highlights, uh. The, the difference in the American guidelines and the European guidelines also there are some subtle changes uh in American and European and some uh disease arena, the American guidelines are more aggressive and some the European guidelines are more aggressive, uh, like, you know, if you look at the regurgitation, uh, patient population. Where the LVN uh systolic diameter, more than 50, but the EF is less than 50 is required for the European guidelines to do the valve replacement versus in the American guidelines, EF less than 55%, uh, the recommendations is to perform the aortic valve replacement. Great, great. And that brings up a, a, a question I've always had. I mean, it's always been a class one indication to treat patients that are symptomatic with heart valve disease, right? But what about the asymptomatic patients? We're pushing, pushing, and trying to get them treated earlier before they develop some of the long-standing pathology, heart failure, HPE, or he ref that we see in these patients. And so, uh, Doctor Taylor, can you comment a little bit about treating patients with micro valve disease that are asymptomatic, you know, they have degenerative disease. Sure. I, the way I look at it and the way I discuss it with patients is, is, by the time patients become symptomatic, there's already have some degree of remodeling that's occurring to their heart. And we're relying on then reverse remodeling, getting patients better or improving, and not everybody reverse remodels. And so I think operating on people while they're, and look, symptoms are a surgeon's best friend, it's, you know, it's, it's easier to make someone feel better if they're symptomatic. But what we really, our ultimate goal is having people survive as long as possible, doing durable long-term operations that don't require interventions on the road, but also keeping people on this planet as long as possible. And once people start to remodel their heart in a negative fashion, everyone remodels their way back. And what keeps people alive is for a long term is a good ejection fraction, a normal ejection fraction. So I, I think that's the, the way I look at it. The other thing I want to point out about the guidelines I think is really important. It creates a space where we can then rely on collective intelligence as interventional cardiologists or as cardiac surgeons and we start to have conversations that are in the best interests of individual patients and then deciding therapies um that uh we can agree upon in conversations as opposed to, you know, if you're a patient, you want to come to a place where people are making decisions together as opposed to one person making a single decision. Yeah. And then so let's talk about the aortic space a little bit and the asymptomatic patients. There's been some recent trials, uh, the early taver trial, you know, looking at asymptomatic patients, treating them before they develop symptoms. So, Doctor Patel, can you tell us a little bit about, you know, is that trial gonna change your management or our management of valve disease? It, it sure would. Uh, and, uh, not just early to, there was a surgical AVR trial also, Avatar trial, uh, that was also positive for, uh, you know, treating, uh, patients who are asymptomatic, but with the severe aortic stenosis. Uh, and, you know, sometimes symptoms are so subjective, you know, it's Uh, even in the trial also, if you can see that, uh, uh, so many patients actually, uh, you know, switched over to the treatment arm, uh, just in, uh, uh, you know, a few months. Uh, so that tells you that, uh, sometimes the patients are symptomatic, but if you want to avoid any sort of intervention. You would reluctantly say that you don't have any symptoms. Uh, if I don't want a procedure done, I would probably shy away from saying that I have the symptoms, uh, and, uh, you know, if you put those patients in the treadmill test or so you'll recognize that how symptomatic they are. Uh, uh, but I think, uh, in South Florida, I think we discuss about it and we see it often also that, uh, there's a, a significant issue of undertreatment, uh, uh, and, uh. Uh, first, I think we have to address, uh, the symptomatic patient. uh, so on a national level for sure, uh, uh, you know, asymptomatic patients would be treated, uh, and, uh, that for sure would be in the guidelines also in the near future, uh, but, uh, you know, at one point when we moved. To South Florida, we actually looked at, uh, uh, the treatment penetration of the AVR itself. And the treatment penetration is only 15 to 20% of all the aortic stenosis patients. So first, our job is to address those symptomatic, uh, uh, patient, uh, but the asymptomatic patient for sure would be coming into the guidelines in the future. Great, great. So, let's switch gears a little bit and let's talk about the the Baptist Health Center for Heart valves Center and uh the heart and vascular Center across the, the tri-county area, you know, and uh it's One of the things I was uh surprised, you know, I'm really impressed with when I, when I joined was that the, the multi-collaborative, you know, nature, uh, you know, the collective intelligence that, you know, that we're talking about, really the discussions that happened, you know, in the conference room before, after, uh, you know, and really kind of the process and the buying from everybody to, to be a part of that. So, um, If you look at the center, it's one of the busiest centers in South Florida doing over 700 valve cases and that's actually we're gonna exceed those numbers for 2025 looking at the numbers. And, uh, based on what the, you know, we were talking about earlier, Doctor Taylor, uh, if you look at it, the mitral numbers, there's much more repairs now than there are replacements on the surgical side with excellent outcomes, um. So I think that's important if we look at durability, um, and if you look at the trans catheter options, uh, Taver and uh tier, uh, they're with excellent outcomes less than 1% in terms of all, uh, adverse outcomes, less than 7% pacemaker rates. So I think the outcomes are excellent. Doctor Patel, you know, what goes into that achieving that, those outcomes? Yeah, I think, uh, you know, here it uh outlined those four pillars and uh one of the The unique thing about the Baptist Cel is that, uh, you know, comprehensive vowel clinic, uh, which, you know, surprisingly doesn't exist in South Florida, uh other than the Baptist South South Florida. Uh, and when we say the alclinic, what it means is, uh, when the patient gets referred to a valve clinic, the patient is Undergoing all those prerequisite imaging before the appointment to the valve clinic and the patient is seen with the interventional cardiologist and the surgeon simultaneously and they're reviewing the images together and making the decision in the real time so the patient is not. Uh, in the confused state, uh, what happens at the, the national, uh, programs, majority of those, uh, patients are seen by the intervention cardiologist on one day, then they'll, uh, they'll talk about something about in the manners of, uh, catheter-based intervention, won't say anything about the surgery, and the patient goes and speak, the surgeon, surgeon speaks about the surgery. Now, the patient's confused that what is he or she is having, uh, in terms of uh the intervention. Is it the, the catheter-based intervention or the surgical intervention? But here, the patient's been seen simultaneously with the intervention surgeon and they're reviewing the images together and making the decision based on the, the evaluation of the patients. So when the patient leaves the office, they leave with the, you know, a conclusive plan that this is the procedures being done with the scheduled date, right? That's such a powerful message because it actually improves the efficiency, right? And it takes away all the confusion. Uh, the patient is, uh, well informed, the referring physician is well informed, and you also optimize, uh, the, the referral to the treatment time. That's also very important that once the patient gets referred to you, what's the timing to the treatment? We don't want to have that time more than one month. Uh, you know, the longer the patient wait, uh, the more anxious they are. They're also exposed to mortality and also, uh, you know, heart failure, uh, readmission or so. So, uh, That and along with that, uh, you know, as we discuss, uh, Along with uh the surgical approach and the surgical approach itself also, we have multiple options, right? The other programs, uh when the patients are offered surgery, the only option they have is the conventional surgery. Doctor Taylor can uh outline what other options that they would have because here, you know, if I, uh, if the patient requests uh a robotic surgery, we can refer to a robotic surgical repair with doctor. Uh, you know, Taylor, Doctor, uh, Hashimoto, Doctor Wen, uh, Doctor Wen also, uh, does minimally invasive, uh, aortic mitral surgeries, uh, and a lot of repair also, so, uh, that's also an option. Uh, so, uh, you know, we have a lot of options available which I don't think any program in the country, there would be a minority of the program in the country uh would have those options available, and that makes our job easier and uh the patients benefit from that. Great, great. And yeah, Doctor Taylor, I was gonna ask you about, um, I, I was impressed by how system-wide, you know, and really kind of collaborate with the surgical approach. I mean, you, you guys really work together as a team and double scrub on, you know, complex cases, you know, and work together and really find the best option for the patients, whether it's robotic, minimally invasive, you know, traditional, uh, open heart, and so tell me a little bit about that and also tell me about what's evolving in the North District, uh, a little bit. Well, you know, to, to elaborate on what, what you had to say is. When I look at how things are, the physical plant, the arena that we work in it, particularly at Baptist, is we're all co-located. We're all in the same space. We're circulating through each other's operating rooms or procedure rooms, and we, there have been times where I've had a vexing problem in the operating room, and I look up and there are, you know, people from other disciplines who are pitching in or diving into, to, to help solve the problem for the patient. It's in Baptist mission statement and and people live that about being patient centric, which is very different from any other place that I've that I've worked previously. And it's really been to me, uh, uh, it's not just a statement on a wall. People actually, um, express it on a daily basis. So that's been the biggest, uh, uh, uh, driver for me and like my enthusiasm for, uh, working in this space. The other thing that I've really noticed in, in, in the north. is, you know, there's, we're, we're doing the same things and our ideas having the same programs that are in in Miami, in Palm Beach County, you know, Palm Beach County is a, a very unique, uh, place. Um, we want to deliver the highest level of care in Palm Beach County just like we do in in Miami. And not to put patients in a position where they have to travel outside of the region to get world class, uh. Cardiovascular care. Great, great. Thanks. So, why don't we go ahead and get started now, you know, just kind of see uh the idea is to go through a few cases on aortic mitral and uh tricuspid pathology. We'll kind of, uh, go through the case, um, and then discuss what the options are and kind of as a hard team, make a decision, uh, what's the best option for these patients. So, Doctor Taylor, I think the first case is yours. So the first case is a is a 49 year old male who was actually seen in in an outpatient clinic uh and was undergoing an echo. And in that echo, the cardiologist was concerned that the patient had uh uh type aortic dissection and they had noticed that the patient had a 7 centimeter aortic root. And at that time, I thought the patient had severe aortic insufficiency. The patient, uh, is a renal failure patient, uh, was grossly volume overloaded, was admitted to the hospital, diaries, um, and medically managed, and this is a preoperative echo which shows about a 7 centimeter aortic isolated aneurysm, um, and they have actually mild to moderate AI. Um, if you look at the CT scan, which is next. You can see this large root aneurysm, um, that's just isolated. So, first order of business is, we already genetic testing on this patient. This is a connective tissue disorder. Uh, it's important to know that, um, he had other, um, manifestations, not just his aorta. Um, and we subsequently took him to the operating room and, uh, the, the goal, we thought we were gonna do a valve sparing root replacement. That was the initial plan. Um, but it ended up doing a bioenal, and we can discuss the, uh, the options there. But I wanted to show you his intraoperative leaflets and why we didn't do a valve sparing, uh, procedure in him. And if you can see, if you look, you can see his non coronary cusp, but all of his leaflets are extremely thinned out. His aortic wall, you could actually see blood flow through his root, uh, because it was so thinned out and there's actually dissociation from the, from the annulus and the aorta. um, and it was just, I mean, how he had not ruptured his, his, uh, uh, a phenomenon, to be honest with you, but you know there are two large holes in two of the leaflets and, you know, I didn't think there was a sufficient quality to patch those leaflets and have him leave with a durable repair. And again, what we wanna do is we always have an eye towards particularly in young patients repairing their valves, but if they're not gonna be durable, there's nothing more dissatisfying than have somebody come back within a couple of years, um, with a failed repair. And so we opted to replace his valve and his root at the same time. That's great. Yeah. So, uh, uh, Doctor Taylor, I, I think we have, uh, done here some of those endomental and end uh procedure also. Uh, what do you think would endo wheat would have a role here or, uh, you know, certainly not with his root. Do an endo wheat would have been a mistake, uh, because, um, you know, you have left his native sinuses behind which were at risk of rupturing. An endoental, so an endobental is, is basically taking a uh uh uh a tower device and a TAR device for the design for the descending res and these are commercial devices that are then being physician modified on a back table, reloaded and deployed. We've only been using those devices, uh, in patients who are too high risk for any open surgery, and they have no other options. And it's so far only for a limited number of patients. The goal is though is to learn and to study it and grow it, and then eventually have it become something that's commercialized years down the road. We've saved a lot of lives though doing that procedure, you know, we, we certainly had to still see a patient uh that we did the end of week uh with the ascending aortic aneurysm and severe aortic regurgitation, and then the patient is uh 6 months old and doing amazing. Yeah. That's great. That's great. And so what do you foresee in the future now? He's, I think it was 49 years old, so old durability and yeah, so. So again, this is a conversation you have to have with the patient, and you, again, decisions about the type of valve is a, it's a patient's decision. A lot, big part of our job is educating patients so they can make an informed decision that they're comfortable with. And in a patient who has um a young patient who has renal failure, Um, they're actually survival is actually better with the tissue valve. Contrary to most patients, if they don't have renal failure, actually, there's evidence that if you're under 65 that a mechanical valve increases your, your duration or your your survivability. The important thing is this though, being on anticoagulation carries a risk of about 1% per year of stroke and 1% per year of bleeding. It's higher in renal failure patients. And so you have to weigh that. A lot of patients just for lifestyle reasons, don't want to be on anticoagulation, but that's their decision. And so if you present that to them, they then can make a rational decision that fits their lifestyle. I, I've operated on patients, young patients who had mechanical valves placed that they had to stop doing whatever activity they like doing and they were so unhappy about that, that, yeah. Um, you know, they've asked to have a tissue valve. The durability of the tissue valves depends, and depends on the patient, depends on their age, it depends on their comorbidities. But in general, I tell patients that, uh, a tissue valve should last 10 to 15 years. So 10 to 15 years from now, you know, what's gonna be the option, you know, for this patient? I mean are we're looking at a redo surgery or a trans catheter is an option for this patient? Yeah. I, uh, for sure, the the trans catheter option would be, uh, on the table and uh what was the valve which was placed? I put a 27, uh, it was a Uh, yeah, so 2. I know someone wanted a 27 in another house. It was 27 millimeter tissue valve. Yeah, it's a good size val. So, uh, so that, uh, plus, uh, obviously the sinuses were big, uh, so, uh, the taver uh valve and valve procedure would be suitable uh for the next time around. And now, the younger patient versus older patient, does that change the durability of the tissue now? Um, yeah, that's a good question. There is some evidence that younger patients will wear out a tissue valve at a greater rate than an older patient because the amount of stress that they put on that valve, how they, you know, their level of activity. But there are other factors that come, that come into play, how people, um, their their calcium metabolism, things along those lines that contribute, uh, contribute to it as well. There's some evidence being on. Um, statin, uh, inhibitors will also, uh, or lipid lowering agents will, uh, increase the durability of some of these tissue valves. So it's, it's, it's more complex and not everybody is the same and you can't expect the same outcomes. I think in this person, you know, he's 49 years old, his options down the road are both transgas or potentially surgical. It depends on, it depends on. Um, you know, if he's on dialysis, if his, uh, ejection fraction, right, those are all things that you're playing to his comorbidities. And again, you want the patient to be in a position where they say, I want to make a decision that's best for me. Yeah. Great. So let's uh move on. Uh, so we got some post-op images here. Yeah, this just, just highlights his route and shows that, you know, he's got good ventricular function, mitral valves working fine. There's no evidence of a paravalvular leak and You know, he's, he's gonna do just fine after this operation. Yeah, it's a great outcome. And so now let's move on to the second case. uh Doctor Patel, you want to tell us about the patient? Yeah. So this is uh a 65 year old uh uh gentleman who's uh actually work in the cath lab, uh, used to work in the cath lab. It's a cat lab tech, uh, a severe bicuspi aortic stenosis. No major history, just a history of hypertension, uh, classic, uh, you know, aortic stenosis, murmur, critical aortic stenosis with peak velocity of 5.1 m per second. And uh being 66 and while we have 0.5. SDS score is very low, 0.7%, and in fact the tower predictor risk is 1.2%. Uh, now, this patient comes with, uh, uh, because of his exposure to the cath lab that, uh, you know, he comes in with the, the expectation that he wants a taver procedure, uh, but, uh. As we discussed, the, the most important part is the, the anatomy and the imaging uh evaluation. Now, if you go by the guidelines, less than 65 years of age, sur is recommended 65 to 80 is that shared decision making. But that here is as a team, our job to explain the patient that which therapy would be better for them. Now, if you look at this CAT scan, what uh stand out is a huge calcium burden, right? It's a bicuspid aortic valve with the fusion of uh right and the left cusp, the uh and the rawfa is calcified and the leaflets are heavily calcified, right? Calcium extend into the annulus and also the LVOT. Those are all high risk feature for to procedure. Uh, if we're seeing this patient, uh, you know, With this images, the risk of the annular rupture is high. The risk of parabowel leak is high, uh, and we'll show you in the next, uh, data where, uh, uh, there's studies also, and if you look at the, the most right image, this patient's, uh, aortic valve is the classic uh picture of that, uh, calcified rafa with the calcified leaflet. And if you look at their two year outcome. The outcome of mortality would be 2025.7% in two years. It means that if you do a tavern in this patient population, the risk of them dying would be 25.7% at two years. Uh, so this patient is not a great candidate for a tavern and should have a surgery, but, uh, you know, as interventionist, uh, and a surgeon speaking together. And telling the patient that, OK, uh, you know, these are the reason that we think that the tab is not the best option for you and you're uh better treated with the surgical aortic valve replacement, uh, and, uh, because our, uh, uh, capabilities of uh performing. Minimally invasive, uh, you know, aortic val replacement, uh, along with the conventional, uh, uh, you know, we referred uh this patient, uh, to Doctor Wen, uh, to perform the minimally invasive, uh, AVR and underwent the AVR with the, the right thoracotomy. That's great. And it's a great point. I mean, I think that uh because patients are coming right now that they know that trans catheter is an option, um, and there, there's a fair number of 60 year olds and 65-year-olds that are being done, you know, now with trans catheter options, but for certain, uh, patients, it's certainly not the right option and surgery may be the right option. And Doctor Taylor, can you talk a little bit about what the surgical approach and options are here? Well, first of all, you know, to put a tab on a patient like that, and it happens. Uh, the most common operation that that's growing in cardiac surgery is actually taver explants. We're doing about one taver explant a week, um, at least with the facilities I've been working at. Um, and in the bicuspid valve, you look at it, that's just a space occupying mass that you put that tower and there's no place for the calcified leaflets to go and, you know, they, you don't fully expand the tower, you put in a smaller tower and then Um, so there, that's just gonna get pressed up against the wall and, and, uh, and uh create uh uh a bulk that uh limits the outflow track. Um, so There are options, uh, from a surgical standpoint. Those include full sternotomy, which is tried and true gold standard, what, what, what, uh, most people are trained to do. There's also options to do a hemistriotomy, an upper hemistriotomy, where you just do a partial sternotomy through a small incision because your aortic valves it's. Right here, just behind the scrotum, it's easy to get to. Uh, there's also a trans, uh, uh, thoracic approach going through a second or third intercostal space which is very popular and, um, patients like that. And then there's a transaxillary approach. Oftentimes that requires using a camera. There's actually people now doing robotic, uh, aortic valve replacements as well, and that's starting to catch on in favor. So we have lots of ways to meet the needs of patients who Uh, for a more cosmetic cosmetic approach to the aortic valve replacement because of where the valve sits and our ability to get to it. Yeah, great, great. And similar to our last question, now thinking about lifetime management of aortic valve disease cause this is still a relatively young, you know. 65 year old, which we can anticipate, um, would have, you know, in 10 or 15 years some uh degeneration of the valves. How do you, uh, what do you do uh preemptively in terms of vowel selection? Do you try to pick the largest valves, um, particularly in small annuli, you know, how do you manage that? Yeah, so I, I think that's a really important point. So we want to put uh as big as a valve and possible in, in, in a patient because uh for there's a concept of patient prosthetic mismatch meaning we put too small of a valve and now the patient basically has a, um, they're unable to provide enough uh perfusion to their body. I We have ways to expand the annuus or expand the, the route to put in bigger valves. Most, most men need about a 25 millimeter or larger valve. Most women, I think, need about a 23 or larger valve. I'm very satisfied if I'm putting 25 millimeter valves in patients and up, because I know that it's very hard for patients to fail that. Yeah. You want, this is what I think you want a big muffler on on your heart, so when it's it's ejecting, it's a lot of free flow and there's not a gradient. Now, how often do you do root enlargement also if you know, the anatomy doesn't allow you to put that size out. So, in particular, it's usually uh older uh women or smaller patients and sometimes younger patients because they haven't, they have an a stenotic valve, but they have a small root or small annus. I would say it's about 20% of the time. Yeah, and we have ways of doing that. There's 3 common ways of doing that, but essentially what you're doing is you're opening the annulus up to see a bigger valve. In general, you can go up 1 to 2 sizes. Yeah. Great, great. Now, we talked about in this bicuspid uh uh case why it's not a good option to do the trans catheter option because of the LVLT calcium, the severe calcification. Uh, but Doctor Patel, a little, a little brief comment on the, uh, the use of transcater options for bicuspid valve cases maybe in high-risk patients or non-surgical patients. So there is uh there's a good data out there for the bicuspid uh aortic valve, uh, and taver working for those patient population, uh, and If you look at the uh the pictures on the left uh side where, uh, you know, if the leaflets are not that calcified, if the rafa is not that uh calcified, uh, then you can, uh, you know, provide a good outcome, uh, and, uh, we have a different options of valve also, we have a self-expanding valve, uh, and we have a balloon expandable valve, uh, so we can choose that, uh, uh, you know, option also if the, the risk of a rupture is high, um, and One thing is, uh, the common is uh that the, the paravalgal leak that you have to accept that you're gonna have some mild paravalgal leak because even in those trials also, the moderates were not that high, but the mild paravalal leak existed, uh, uh, and that's because of how the, the valve is, right? Uh, you know, it's very eccentric, uh, shaped valve, and, uh, you know, sometime our round prosthesis does not, uh, fit well, uh, if you're not removing the leaflet, uh, um. So, yeah, for sure, in the high risk patient population where the surgery is high risk, the tab can be offered, uh, uh, but, uh, you know, if the patient is a younger patient and if the surgeons can uh uh with uh confidence can say that they can deliver the result, I think this patient should go for the surgical valve replacement. Perfect, perfect. Right now, so let's switch gears a little bit. Uh, actually, before we do that, let you know this is a slide looking at US versus European, uh, data. So you want to comment on that. Yeah, so this is basically just outline what guidelines which, you know. I think, uh, you, you guys have heard me saying that, that the age is just a random number. I, I, I believe that in the future, EHR probably would have the biological age along with the chronological age because we have all seen that not all 65 years patient looks 65, some look 85, some look 45. Uh, uh, so age-based treatment recommendation, I'm not in, uh, Uh, favor of, but this is what the guidelines says. The European guidelines says 75, less than 75, more than 75 tavers uh recommended, and in America, less than 65 surgeries, 65 to 80 shared decision making and more than 80 years of age. But along with that, uh, uh, you know, the anatomy is the biggest factor which decides, uh, uh, which treatment strategy would be better. Great, great. So let's move on and uh let's talk about the, the mitral valve a little bit now. Sure. So this, this is a 58 year old uh female that was Refer to us. We had a long standing history of mitral valve prolapse, and she becomes symptomatic where she was short of breath. And you can see that in the mid portion of her valve at the level of P2, there's a flail segment on the first, uh, non-contrast to her, uh, image, and you can see that how that's luffing, uh, with each systolic beat into the atrium and blood is skirting through that across the anterior leaflet on mitral valve and up, and then up along the, the, the side of the atrium, we call the choanda effect. Um, when I see that, that That type of picture, I mean, that's a straightforward, uh, you know, give the patient a 95% chance that we're gonna be able to provide them with a good durable long-term repair to that valve. Uh, there's only a couple of options that we have, uh, on how to do that, whether it's with cortex cords. Basically pull those leaflets down. We put extra cords in, so if they have progression of disease, it doesn't, uh, uh, pretend them to have then a valve failure after uh several years. Um, or we can actually cut out a segment of that area that's luffing and then basically reconstruct the posterior leaflet. Um, we did her through a little, uh, small, uh, mini sternotomy due to the size of her breast and not the desire to stay out of that tissue, um, because that's what the patient wanted. She wanted a smaller uh cosmetic approach. Um, but again, we could have done it through, through her side, um, or through a small right thoracotomy or as a full sternotomy, which she, uh, opted against. Yeah. And um, you know, one of the things that I wanted to point out is we would put a 34 millimeter uh ring in her. So we always support our repairs, uh. this type of uh leaflet, there's a, uh, or this type of pathology, there's a lot of extra leaflets, so you don't want to be put in too small of a ring because you'll actually uh force the anterior leaflet in the left ventricular outflow tract. So, um, that's one of the things that, that, that you have to pay attention to when you do this type of repair. Yeah, could also be done robotically, and I, you know, we've been doing robotic mitrals here in South Florida, uh, particularly, uh, Doctor Hashimoto and, yeah. those, those patients, uh, it's only about 2.5 to 3 centimeter incisions and, uh, I mean, phenomenal repairs. So, um, yeah, no, I, I, this is, uh, uh, a slam dunk surgical case. It's a 58 year old young patient, uh, primary MR uh, uh. So the decision should be, uh, you know, surgical repair. And it's very important that, uh, when the patient goes out looking for a surgeon, they should ask uh that what's the repair rate, right? Uh, because we all know that the repair has a better outcome than the replacement, uh. Uh, but how often they have to convert the repair to replacement, right? Uh, so if, uh, a center, center like ours where the repair rate is, you know, more than 98%, uh, you know, the patient can come here and be reassured that uh when they go for repair, that's what they're gonna get. And, you know, uh, a patient like this at 58 years old, this should be a one-time operation. There's about a 10%, uh, 10% risk of reoperation, a patient had a repaired valve out at around 15 to 25 years. So it speaks to the level of good durability, uh, in the majority of patients. And so this is a good option for repairing. And across, uh, you know, uh, uh, you know, as I said at the opening, you know, only about 30% of valves were being repaired 2025 years ago. It's now up to 95%. Yeah. That's great, great outcome and uh you know, great for the patients and I think we see some post-op images there. Yeah. You can see that uh there's no, there's no MR there's no residual MR. You can see the ring, um, and the gradient across the valve is, is too, it's very low. So, and with a 34 millimeter ring, she's got a nice open orifice, so no evidence of stenosis. So great. So through a minimally invasive approach, able to have a durable result and long term one operation and hopefully be done with it, so that's great, yeah. Yeah. And let's move on. Um, so we have another mitral valve case and uh Doctor Patel, this is uh one that you were involved with. Yeah, so this is. The 72 year old female, uh. Comes with worsening dyspnea. She has a history of COPD. She's on home oxygen, uh, has hypertrophic cardiomyopathy, and has NYH last three symptoms, uh, and the echocardiogram shows that, uh, you know, the LVOT gradient is almost 100 millimeter mercury, uh, has a severe micro regurgitation, uh, because of the SAM and uh uh. cardiac catheterization basically showed that she doesn't have any obstructive, uh, coronary artery disease. These are some of the images, and there you can clearly see that, uh, the bottom picture you can see that, uh, the redundant interleaflet, uh, uh, of the mitral valve, and that's essentially causing the LVOT obstruction, not the big septum, but, uh, the redundant entry leaflet of the mitral valve, uh, um. And you can go next and there are some more uh images, uh, so this is the LVOT gradient, uh, almost 72 millimeter mercury without valsalva. So with Valsalva, uh, it probably would be even higher and uh some of those color images where uh you see the regurgitation which is posterally directed uh because of the intraleaflet pathology. Now, this is under evaluation, so, uh, you know, uh, we have treated some of these patients were uh uh you know, putting a mitral clip, especially uh an XTW clip because uh the clip arm, uh, are basically you're gonna be grabbing about a 9 millimeter of the leaflet. If you measure that, the, the redundant part which was causing the LVOT obstruction. That leaflet was about, you know, 10 millimeter or so. So by essentially putting a clip and grabbing that leaflet, now you can, uh, uh, you know, take away that, uh, redundant part of the interleaflet and, uh, open up that LVOT uh space. So by doing a clip, you can address two issues such as, you know, hypertrophic cardiomyopathy, uh, where there's an LVOT gradient and also the mitral regurgitation. That's great. And so Doctor Taylor, a little comment that you know, I know we've talked in heart uh team discussions a little bit about uh hypertrophic cardiomyopathy and the surgical approaches and, you know, the treatments there. Um, what are your thoughts? Well, there's a couple. So, I mean, obviously this lady has, uh, you know, multiple comorbidities and so trying to keep her out of the operating room is probably in her best interest. Um, but looking at her, looking at the images here, first, she would require a septalyectomy just to take away some of that septum, and that septomyectomy has to actually go all the way from Uh, the mid portion of the septum all the way over to where that anterior leaf of the mitral valve is. The other thing that we look for when we do that septal myectomy is, you know, we're trying to open up that left ventricular flow tract, but there are often aberrant cords that are attached, uh, attaching to the septum and the mitral leaflet that you have to find and divide. And oftentimes there's a big thick muscle, a papillary muscle that's attached to that septum that's creating that outflow tract. It's interesting because from a surgical perspective, it's usually the A one segment of the anterior leaflet that's that elongated segment. And many times, particularly in a leaflet like this, you're gonna have to foreshorten that leaflet. You're gonna have tore that leaflet up, and that can be challenging to do through the aortic valve, but essentially we're doing that is the same thing you're doing with the clip, and it's the way I think, uh, over time, the amount of drag that's on that leaflet actually like a sail or stretches it out. And that's the key to understanding, you know, um, and then what we do is when we do these operations, we measure the gradients pre and post-op or pre and post myectomy procedure, and then when we come off, we measure our gradient again and we can't leave the operating room with a gradient because it's gonna fail. And the, the other thing is at least what we have seen in the interventional space that previously we used to do a lot of alcohol septal ablation for this hypertrophic cardiomyopathy, but since Uh, we have this new medication which is actually approved, uh, Mavacampin, uh, uh, which is a myocin inhibitor which actually works at the core of the disease. Uh, we see the uh reduction in the LVOT gradient in a month or so. Uh, so, you know, I don't know about if uh the mimectomy, uh, volume have gone down, but for us, uh, I'm not doing that many alcohol septal ablation anymore. Yeah, absolutely. And that the data bears that out, right? So it delays need for either trans catheter or surgical approaches. I mean, for some patients, it may be certainly still indicated, you know, and certainly that's where the patient discussion. I think it's important to highlight the team-based approach that we have the hypertrophic uh clinic and the heart failure clinic that. also helps in those discussions and you alluded to the genetics, you know, for your thoracic aortic aneurysm patients. So this is a patient that certainly requires genetic testing and other, you know, for familial reasons as well. So I think that really the whole, you know, holistic approach is really important when we're looking at these patients, so. All right, so let's talk a little bit about the forgotten valve, which is not forgotten anymore, the tricuspid valve. Yeah. So again, uh just to highlight the concept that we're we're looking to repair valves, and our eyes and our mindset is we want to repair as many valves as possible because We want patients to leave the operating room if we can with their own valve. And this was a patient we recently took care of a 38 year old male who had endocarditis, and that endocarditis resulted in a large vegetation and a perforation of the, of the septal leaflet, and you can see there's a large defect, um, and you can see that in the mid portion of the septal leaflet there, uh, which is around 6 o'clock on that image. And then at around 1 o'clock, you can see there's also another large hole. And when we looked at this, we debrided off the vegetation, cleaned it up, and actually chose to provide two pericardial patches, one at the septal leaflet portion, and then one that that large defect that you see between the anterior and posterior leaflet. And in doing so, what we actually did was just basically created a two leaflet valve out of the 3 leaflet valve. You can see there's a lot of torrential uh regurgitation in this patient and uh. And then once we had patched him and created the two the two functioning leaflets, we placed a band or a ring, to modified ring that supports this repair. Patient did quite well and uh recovered, and it highlights to me that, you know, we can repair the tricuspid valve. Um, and this young person, um, you know, just replacing his valve sets him up for future problems down the road. And um, you know, cause he's continues to be at risk of potential endocarditis later in life, um but the likelihood he'll do that with his own repaired valve is a lot less than by putting in a prosthetic valve. Uh, I think, uh, you know, some of the other thing that we are doing with this uh tricuspid valve endocarditis and also the Even the mitral and the aortic valve endocarditis is, uh, uh, obviously surgeon wants to do the surgery when patients aseptic, right? uh uh when they're not infected, uh, so. Uh, we've been also a Baptist, uh, uh, with the collaboration with the surgeon, uh, you know, radiologist and the cardiologist, uh, all working together. We are, uh, doing a procedure such as angioac or so where we suck the, the vegetation out. Uh, continue the antibiotic for about 6 weeks or so, and once the patient's been treated with the infective endocarditis, treat that valvular disease the remaining regurgitation or so by, you know, repairing or replacing the valve. Yeah. Yeah, that's a great point and uh thanks for bringing that up and I think certainly it allows the surgeons, you know, to have some time to breathe, to come, come back in a more uh controlled elective environment uh for their surgery, so I it's something to, to, to think about. You know, in young patients, you know, their risk of mortality, you know, particularly the mitral space, but in this space, the risk of of perioperative mortality should be less than 1%. I mean, these patients, you know, yeah, um, should survive and, you know, live a long time to get through this. Right. And then, um, so you have uh your post-op images showing, yeah, the repair actually, to be honest with you, if you look at it, you know, it looks very similar to what a mitral would look like after we repair a mitral, right? So, but that's clearly the right side of the heart, yeah. And so our final track case uh Doctor Patel, why don't you lead us through it. So this, uh, you know, this is also currently in the evaluation 68 year old woman who's also uh a nurse, uh, um, trained and that has, you know, comorbidities such as hypertension, hyperlipidemia, also has a history of squamous cell cancer, osteopenia. And the prior basal cell carcinoma, uh, and, uh, has a murmur of tricuspid regurgitation, uh, those are the images and uh. You know, she seek uh for the catheter-based intervention because she, uh, because of her comorbidity, she doesn't want to go for any sort of uh surgical intervention. uh uh. But when we are sort of assessing the patient for the catheter-based repair, imaging is extremely important. Uh, uh, you know, this procedure is driven by the major and uh the procedures are just basically following uh the images uh direction. And here you can see that, uh, there's The tricuspid, uh, prolapse, actually. There's a prolapse of the tricuspid valve, uh, and, uh, severe tricuspid regurgitation. So, uh, you'll see the next image where, uh, you know, where the, the jet's also coming from. And, uh, your further assessment of the tricuspid regurgitation, how big is the, the jet, uh, and Although it's called tricuspid valve, we have seen now that we are looking, uh, with the extensive imaging that uh sometime it could be a 4 cusp valves, sometimes it could be a 5 cuspid valve, uh, and, uh, you know, although it's. Been called tricuspid valves. Sometimes we end up seeing two septal leaflet, 2 posted leaflet, 2 entry leaflet. Uh, uh, this one was a true track cuspid valve, and there in the bottom, uh, uh, 3D image, you can see that the prolapse of all the three sort of, uh, leaflet, uh, and, uh, if you go to the next image there, uh, it also shows that where exactly is the regurgitation coming from, uh, And next, And this is uh the image which It is used for planning of the procedure. It's a transgastric view and it essentially shows you where the leak is coming from. So the leak, predominant leak is coming between the entry and the scepter leaflet, uh, uh, on the, the top frame, you can see that, uh, the jet, the predominant jet is, uh, between the scepter and the leaflet. So from the catheter approach, uh, our approach would be essentially the same as Doctor Taylor did, uh, creating a two cusp valve by putting the two clips in that intercepttal region. We essentially reduce the regurgitation and make this valve essentially a two cu valve by closing the commissioner between the entry and the septal leaflet. Uh, any thoughts, Doctor Taylor? No, I think, I mean, I think this is a, a, a great approach for this particular patient. The, um, you know, most of the time when we repair a tricuspid valve, we're basically putting a downsizing. You can see the anus is very large in this patient. We're gonna put it in a small ring to basically reduce that and just create cooptation services between the leaflets. You always have to have a mind's eye though towards is there a leaflet issue related to this, um, and in particular, if you come off and you still have some TR that you're gonna have to go back after you've done a reduction annuloplasty to do something to the leaflet, um. But I think that that's perfect, yeah. Great, great. And so, uh, quick comments now we have a couple of different options in terms of tricuspid valve therapies, uh, trans catheter, you know, certainly the repair, surgical repair is a possibility, but given her some of her comorbidities prior chemo radiation, you know, to the chest, you know, maybe make surgical approach a little bit more. High risk. So, can you discuss, you know, how you decide between what are the trans catheter options and what's the best for each patient? Yeah. So in terms of the tricuspicaheter option, our first line therapy is the uh tricuspi clip at this point. Uh, uh, the, the reason being is it's much safer procedure, uh. Um, and, uh, you know, usually the patient comes home, uh, goes home the next day after the procedure with versus with the Evoca, it's also a, a great procedure, uh, a first trans catheter valve replacement, uh, uh, however, it has higher risk of, uh, Pacemaker implantation, almost, uh, you know, 26% of the patients uh after the procedure uh had uh heart block and requiring the pacemaker and that doesn't happen right away. So sometime you find that out, uh, you know, two weeks later or so, so all these patients will receive the tricuspid valve, uh. Uh, they need to go out with the, the monitor to monitor their heart rhythm to make sure that if they have a hard block event, uh, should be, uh, presented to the hospital sooner. But how we approach that is, let's see. It's very difficult to treat the leak between the entry and the posture leaflet. So if, if there's a jet, the significant dry the regurgitation jet is coming between the entry and the poster leaflet, that is, uh, not well treated with the clip. So in that situation, the TTVR should be, uh, you know, looked at. Uh and obviously, these are, uh, the procedure should be only uh reserved for the patients who are really High prohibitive risk for uh surgery, right? Uh, because the surgeon can uh potentially do the valve repair and the replacement in a much safer manner also. So this patient's uh uh clip is all very safe procedure, but with the evoke, uh, the outcome still needs to be improved significantly before it can be the mainstream, uh, procedure. That should be only reserved for the patients who are very high or prohibitive risk for surgical valve replacement. Perfect, perfect. And so with that, I think we've uh come uh to the question, uh Q&A session. I think we have a couple questions uh in, in the um in the chat. And so one of the questions is, what's the long-term durability of valve repair versus replacement procedures and how do we select. Patients, I think Doctor Taylor, you talked a little bit about mitral valve repair and the durability there. What about aortic valve repair? We were talking about that earlier. Yeah. So, first thing when we think about durability, the thing I think of durability is the durability of the person, right? So their survivability. So people who have repaired valves live longer than patients who have replaced valves, um, particularly younger patients, and we know that both in the aortic space as well as in the mitral space. When we look at mitral valve repair and aortic valve repair, you want, we want a good how we define that is having um returned to the operating room or need for surgical or catheter-based intervention greater than 10 years. And in the mitral space, it's less than 10%. In the aortic valve space, it's around 10%. So those are the 10, 10% at 10 years is kind of the numbers I can keep loosely in my head when I, when I talk to patients. But ideally, and, and we have data out, particularly in the mitral space out to 25-30 years now of low recurrence of need for reoperation. Right. Another question is, uh, so in the first case, how do you preserve the coronary osteon when you do an endoental? Yeah, so, again, we, we use, I didn't, we didn't really talk about the difference between endoental and an endoheat. So in an endoheat procedure, you're preserving the sinuses and you're basically creating a defect in the TAR graft, basically creating a fenestration or a hole that then allows blood to exit the tar that has a tavar in it. And blood fills into the sinuses, then from the sinuses fills into the coronaries. And if somebody has a normal route and um doesn't require any further interventions, and that a further intervention would be putting a stent through that fenestration or the hole in the T-bar into the right or left coronary artery. It adds a level of complexity to the procedure, um, and can be, um, with Uh, you know, half the patients that we've done endoentals on, we've also had to do endototal endo arches to create a landing zone distally for the benal, and it can be very challenging to negotiate and to get into the osteum and then actually get past the, the, the cells that are In the taver that had been placed to then actually put a device in to then actually treat the, the coronaries. But the reason you'd have to approach the coronary is if you had a sinus problem or a sinus issue, whether it was aneurysmal or dissected. So in the end to what uh The most important thing is the precision because you have to, uh, you're not opening the chest and you want to make sure that the, uh, you make the hole, the physician modified the prosthesis that you make, you need to make the hole in the precise position, and those holes should be landing in the precise position right uh opposite of the left main osteia and the right osteia. And then we go with the catheter and engage, uh, uh, the, the coronary artery and then put a covered stent which papyrus is the coronary artery stent that we placed when somebody has a perforation. But here that would be used to put the, the stent into the coronary artery and to preserve the profusion. So, so one of the things, you know, we, we studied this very closely because we spent a lot of time on. Uh, on back tables and models and, you know, they're stored energy when you're, particularly when you're coming in from the femorals, where we were always about 20 degrees off. In 20 degrees, you could negotiate catheters and wires, but if you get to over 20 degrees off, it's impossible. And so several of the patients we treated, we just could not, uh, to the best of our abilities. So and some of the patients we got to the point where we we put 3 fenestrations. Access to the coronaries and then plug the 3rd because the the ability to be precise with that delivery was the vexing problem. We learned a lot though from from lining up our commissures and things along those lines, but a lot of time and energy put into those thoughts. Great. Couple final questions before we wrap up. Uh, so what about Taver for pure AI? Where are we with, uh, the treatment of pure AI trans catheter? There's no FDA approved device. There's one, which should be coming, uh, it's a general valve, the Uh, but if the anatomy allows, uh, you can use the current prosthesis if the patient's too high risk for surgical intervention, but those will be off label at this point. Right. And another question for thinking, um, so how are we using AI or are we using AI in terms of these complex patients to pre uh predict and to prepare uh for our procedures? Great question. So we, uh, you know, we use uh uh in the process of implementing, uh, there's, um. Company DC simulation which basically does, uh, uh, in a computational simulation of the procedure like TR or uh you know, TMVR and would tell you that if this patient is at high risk for particular proc uh, you know, complication of that procedure and uh the, the more sophisticated version would be in the future, it can precisely tell you that this is the risk and this much. Uh, this is the percentage of the risk of the complication. Uh, we're not there yet, uh, uh, but slowly it's coming in, uh, our space. It's coming, yeah. So, so great. Well, with that, I, I wanna thank you, um, you know, for joining us today for the session of the webinar. Hopefully you found this, uh, instrumental and informative, you know, and we'll help, uh. Treat all of our patients. Uh, I also want to remind you to save the day for next year for our, uh, 43rd annual echocardiography and structural heart symposium. It's a great session. We just had it this past year and we learned about about a lot about the imaging for structural heart procedures and the treatment of structural heart disease. Um, and so if you are interested, please, uh, join us next year in October. At the Lowe's and Coral Gables. And then finally, thank you again for joining us. Uh, if you're interested in referring a patient, uh, here are the links of the Baptist Health.net heart referral or Baptist Health.net/heart. Uh, once again, thank you and uh thank you for my colleagues and panelists for all answering all the questions. Thank you, Carlos. Thank you. Appreciate it.
