Coronary access & revascularisation in patients undergoing TAVI: from work-up to lifetime management

So hello everyone. So thank you very much for the coming to this session entitled coronary access and revascularization in patients undergoing tabby from worker

to lifetime management sponsored by ABOT. Uh I'm Ker Hashid from K

ABOT. Uh I'm Ker Hashid from K University Tokyo Japan. I'm very much honored to co-chair this session with Dia Chuche from Tulis. And we also have

distinguished team. I'd like to

distinguished team. I'd like to introduce Yohi Ono as a procedure analyst. We also have the discussant

analyst. We also have the discussant like the uh Jun Han from Korea, Kazu Shimamura from Osaka and Marissa

Terramasu from Italy and Stefan Rossley from Australia and Nat with Wra from Thailand.

The session objectives are to discuss management of eskeemic heart disease in patient undergoing tabby to learn about

the importance of coronary access of the tabby to understand how web design influences the ability for coronary access of the tab and tab in tab. So

it's quite relevant to a daily practice.

Moreover, uh our patient with aotic stenosis sometimes have coronary artery disease is quite relevant to our daily

practice to learn how we can uh provide best practice to our patient.

So DAS, so uh maybe we can uh encourage the interaction.

>> Yeah. So uh as you're going to see this is meant to be quite uh interactive uh session. Uh so you will be asked to uh

session. Uh so you will be asked to uh answer a couple of polls throughout the session. So be ready uh to uh to do so

session. So be ready uh to uh to do so with your app. Um if you have anything that comes to your mind during the session if that you would like to uh

emphasize on comment explore whatever you have in mind feel free to either post it through the hub or grab one of the microphones and uh directly uh uh state what you are what you want to

share with us. Uh one last thing uh remember we still have this AI uh translation real time. So if you feel more comfortable uh reading or hearing

uh the the discussion through your mother tongue feel free to do so. It's

another feature that we have implemented this year. So super important to uh feel

this year. So super important to uh feel free and make yourself comfortable for the session. Uh so uh let's start with

the session. Uh so uh let's start with the u uh patient presentation. So it's a it's a kind of challenging patient but

this is a real life a daily patient uh with a severe AS combination of a severe AS and a coronary stenosis. Uh and it's

going to be illustrated through a live case from Nagoya Heart Center. So 89

years old female that has been symptotomatic with NY class 3 diaspa and an increased in his uh uh her probn

level.

So uh initially she was considered as a asymptomatic severe and progressively she became symptotomatic during the watchful surveillance that is recommended and we've seen that through

the recently updated uh ESC ESCs guidelines and ascobilities combination of hypertension dysipidemia and some

autotopic surgery.

So you see you see that this is a typical Asian patient 150 cm 53 53 kilogram but still active despite being

close to 90 still active person. So here

are the medications quite regular for uh this type of patient nothing noticeable and laboratory wise we already uh told

discussed a high probnp level uh but also mildly decreased hemoglobin level it's quite frequent to have a certain degree of anemia in these elderly frail

ladies and the renal function is mildly impaired with an EGFR of 35 ml per minute 1.73 m square

uh ECG. So you can see the uh the ECG

uh ECG. So you can see the uh the ECG and the chest X-ray overall narrow QRS.

So uh there is a uh maybe a decreased risk of a conduction disturbance. We may

discuss that afterwards. Here is the uh uh the u uh echo of the the the patient.

So you can see the severity of the uh of the ES with the normal uh left ventricular function 8 cm square high

peak velocity mean gradient even even if it's not reaching 40 clearly you can I guess everybody will agree that this is a severe as patient

so uh get your phone ready we have a a first question for you guys and because it's all about sharing experience so the the question is about the way you assess

your patient coronary wise uh before a a a tavy procedure. So option A do you only use invasive androgram

if the CT shows a significant uh coronary disease?

B always invasive androgram during the workup and C always invasing ediogram invasive androgram during the tavi procedure.

So I don't know how many people uh responded but it's 100%. So I I guess you are not playing the game. You should

respond. [laughter]

[gasps] >> Yeah, it's it's it's kind of interesting because it's it seems that the number of uh responses is increasing

but there is still a predominance of only invasive androgram. if the city shows significant coronary artery

disease cano uh so um >> so it remains quite stable so maybe that's something that we can uh we can we can discuss and uh who would like to

address this uh first Stephen what what do you do because this is u you are still from Asia as well >> yeah you still represent Asia [laughter] >> correct correct

uh look if I almost do D but it's a it's a good discussion point I There's there's contention around obviously, you know, why would you do an invasive angiogram? It's it's because you you

angiogram? It's it's because you you want to know the coronary anatomy more accurately and and potentially consider revascularization. I mean, look,

revascularization. I mean, look, personally, I don't do we don't do everybody. It's not a 100%. Um, but we

everybody. It's not a 100%. Um, but we do have a low threshold to invasive angography in our center. um you know why um you know if if I had a CT scan

that showed pristine coronaries uh you know no calcification no plaque we would not do it but that's there's not many patients like that in the in these

patients that we see we have a low threshold two reasons one look notion three is probably the most contemporary data around revascularization in and

around tavy uh you'll remember that's 450 patients u predominantly they were revascularized uh before tavy, but they did have to

have at least a 90% lesion or or hemodynamically significant disease. So,

it's not just 70% patients. Um look, the second thing, you know, we do we also do use um sentinel emolic protection in patients that are deemed to be higher

risk. So, if they're having a

risk. So, if they're having a self-expanding valve, if they've had a prior stroke, have got arch atheroma.

So we do like the radial coronary angiogram to give us some information around the ease of delivering the sentininal device in making that decision. So so so in summary I might be

decision. So so so in summary I might be option D which is not up there which is low threshold to invasive angography if there's any disease that we see on the

CT planning.

>> Perfect. So uh I would like to ask the question to Netwood. So if there is some significant coronary artery disease would you [snorts] perform PCI before a

debie or you leave it? Um I think depend on the clinical presentation patient if the patient came in with acute cor syndromes I think that need to be done first but if it's chronic syndromes I

would like at the symptoms and then the second uh I will look will be uh how the bat of the stenosis if the gradient is 40 I think you have the choice but if

gradient is 80 mean gradient I think how we should be done first I think the trend now I think we probably try to do it after but I think depend And also on the patient anatomy if you think you

have difficulty to reaccess maybe STJS is low uh is nllo and the current high is low I think might I might even do it before >> and PC also require additional

anti-traotic regimens >> right right I think that that would be the cons on the do it before because I think when you do tavi in elderly I think it's single antiplatlet would be

best >> uh if you do uh dab I think uh um then put them more risk of bleeding >> and there is already a certain degree of anemia for this.

>> Exactly. So

>> yeah. So I think there is no dogma but usually the uh the aerottoxinosis in quite fatal disease on the other hand the coronary artery disease sometimes is

not that much as far as this table. So

we can prioritize the treatment for stenosis but we should take into account the anatomy of the coronary arteries for each patient.

>> Right. Right. Right. I think the trend is due after but I think uh you have to look in the whole picture and take everything every anchor and it size on each patient.

>> Yep. And recently that we can uh get the uh much more and more information from CT scan and uh in most centers uh as you

can see in the slido uh we perform CT scan and then there is no significant coronary artery disease we proceed to tabby. uh this kind of the streamlining

tabby. uh this kind of the streamlining the uh screening process is also quite important for a patient with the aerotic stenosis and coronary artery disease. So

DD so uh can we ask to proceed to the uh the presentation including the CT findings.

So uh the team did a coronary androgram for the time being uh we also do a coronary androgram because with this elderly patient calcium is often present and when you have calcium sometimes it's

difficult to uh assess the uh the real patency of the coronary arteries and as you can identify two many uh very important findings. First anomalous

important findings. First anomalous origin of the right coronary artery arising from the left sinus. So this has

uh uh inherent challenges with a disease a left uh uh image on the uh at the level of the mid RCA but the left is

also diseased. The left uh uh the LED is

also diseased. The left uh uh the LED is severely diseased with quite a proximal lesion and the proximal part portion of the the LED a bit of calcium mid portion

is also diseased. So a diffuse uh extensive disease on the led combined with a disease on the right coronary artery with that anomalous origin. So

city workup is the gold standard where you have had the training if you didn't do so you can go to the training uh labs but when you do uh when they did the the

the workup of the patient clearly it's a small anatomy but that's this is a typically typical Asian uh uh lady a small aic analyst

the sinuses of valava are not that large on average I would say uh 29 um quite significantly or heavily calcified

valves with all three leaflets being calcified particularly the left and keep in mind that the right coronary artery comes from the left sinus.

Uh so perimeter analyst perimeter derived diameter of the analysis super small 19. So this is a smartlike patient but even on the

lower hand in terms of sizing matrix. So

coronary height to uh appreciate the risk of coronary obstruction for the the patient quite uh high both on the left and the right because they arise from

the same region around 15 mm. So high

coronary takeoff calcification of the leaflet and small aic uh aic canalus small anatomy overall

with sinuses of valva that average 20 29 and the membranous septum for those who measure who are measuring that 3.2 two.

So not a very large long membranous septum. Peripheral vasculature another

septum. Peripheral vasculature another challenge. So this is a a daily life

challenge. So this is a a daily life patient with several uh uh degrees of complexity. And you can see that there

complexity. And you can see that there is some calcium even though the diameters are okay uh 5.6 5 u minimal there. there is a certain

degree of calcification patchy calcifications coming from the common femoral artery up to the aorta the aortic arch and if they plan to use a

cerebral protection device it's a type one uh arch so it should be favorable if anyhow the team decide to go for a

cerebral protection so this is the summary 89 years old female symptotomatic for a check class 3 diasp they have small or super small

aotic anatomy with a a calcification of the the leaflets particularly the left one uh with anomalous origin of the the right coronary artery and a two vessel

disease and so the team decided to go for a a trans femoral TV with the naval system that's something that we may discuss canaro yes >> uh what to do how to appreciate the risk

of coronary obstruction for this patient and what is the optimal uh device they made a choice but maybe we can have a bit of discussion around uh that I'm going to leave it there for you guys to

have constantly the anatomy of the patient and we may have a bit of discussion.

>> Yeah, great. Perfect. So uh this patient has a really similar she also had the anomalous origin of the right coronary artery. So maybe Yohi so could you

artery. So maybe Yohi so could you please tell us what is the potential risk of this particular case and how would you consider performing the

additional procedure or something?

>> Thank you cano. Um we have the beautiful movie of the uh whole aric root here and um uh as for the left main it originates

from it takes off from the middle of the left corner cusp while the as we discussed the right corner it uh takes off quite close to the commissioner of

the left and right. So in case of narrow sinus of vala with limited coronary height it could be very challenging to

uh make a coronary access for the right after valve implantation and we we cannot forget that this patient has 75% stenosis at right coronary uh although

it has not been shown to be uh eskemia or not at this stage. uh but fortunately this patient has relatively wide sinus of bowel in in ter in relation with the

sinus of annular size. So I would just focus on commissioner alignment to to achieve commissioner alignment in this case so that we can have full access to

the left um and leave it uh and if we can align the commission alignment I think in this particular case we can

also access the right afterwards.

>> Okay perfect and would you uh perform PCI before a tabby procedure for this case or not? Um as uh Natut and others

discussed I think this patient seems to be uh angifi free at this stage. So I

would leave it because he has uh good LV function. Uh no significant uh angginal

function. Uh no significant uh angginal symptom at this stage. So I would leave it and uh I would perform Tavi uh at at first.

>> Okay. So Marica, do you agree with this strategy?

[clears throat] >> Yes, I definitely agree. I think also the the age of the patient is an important parameter when we consider whether to perform um coronary stenting

before or eventually after in a 80 80 year old patient with no sign of eskeginina I think we can also speculate that with

the let's say treatment of the artic stenosis then the patient will be symptom free and then is is maybe not needed to do anything after >> so if possible to achieve commission

align this is definitely the way to go and I would definitely agree with this approach. Yes. Yeah.

approach. Yes. Yeah.

>> Maybe cano we can ask it's a packed audience >> even though you are having a nice bento I guess you appreciate the complexity of the patient. So maybe ask let me ask you

the patient. So maybe ask let me ask you what would do for a PCI go for a PCI for this patient. Raise your hand.

this patient. Raise your hand.

>> You mean before?

>> Yeah before PCI during the case.

Nobody PCI afterwards slightly more. no PCI at all. Okay. So

slightly more. no PCI at all. Okay. So

there is a a kind of u general agreement that maybe even though there is no proof of eskeemia for this lady there may be a need for a coronary angoplasty whether

it be before for a couple of friends here or mainly afterwards but not during the procedure. So we have quite a a nice

the procedure. So we have quite a a nice overview of the uh uh the the policy within the the room. And another

question cano we have bro the issue of coronary disease. Uh yo has said a

coronary disease. Uh yo has said a commercial alignment the team is going to proceed with an aviator. So is there a consensus on the the the type of

platform? Would you use a balloon

platform? Would you use a balloon expandable valve in an 18 mm? Uh

>> I think we can use the balloon expandable valve as well. Yeah. because

the uh to secure the better coronary access but we can also take into account very smart to analyst the self expanding device is also a very good choice and

doc Dr. an maybe one final question before we go live. Um, if you choose a self-expanding valve, uh, we have different options. What would be your

different options. What would be your choice without being influenced by what the center is going to do?

>> Okay, so [clears throat] there are some considerations in this patient. The

first one is a small analysis and second one is a cor reacability in patient with significant coratory disease and third one is her age 89. Do we really did

consider the second uh valve implantation or cor reintervention in this 90 89 year old lady? Uh but we cannot exactly tell uh the what the

exact life expectancy in any specific patient. So I would to set aside the

patient. So I would to set aside the issue of ag for now. So now we have two issues small analysis and uh coral reacability and each variable uh should

have its own strength and limitation and uh a variable has a good uh hemodynamics because it has a super structure but uh

it has a dense uh frame density uh making the cor reacability probably difficult. Of course we have a uh ev FX

difficult. Of course we have a uh ev FX plus. So there's a large cell in front

plus. So there's a large cell in front of corery. But this patient has

of corery. But this patient has anomalous origin of right corery. So uh

locating the large cell just in front of left coronary artery and also anomalous origin of right corery would be challenging. So uh I think nit would be

challenging. So uh I think nit would be good choice for this patient because it has relatively large cell design and also it has inal structure. So there's

more room to manipulate the guiding caster of the leaflet and also uh even though it has intera structure uh the

EOA has been reported to be bigger than the EUA from uh of the sapient system.

So maybe would be good choices.

>> So thank you so that's a nice summary of the the potential advantages in terms of emodynamics and coronary access particularly for this anomalous origin

of the right coronary artery. Uh so

briefly uh so the the uh the team plans to use a 23 navitor uh system.

Uh so they're going to predilate with a 18 mm balloon aim at achieving commercial uh alignment as uh it has been extensively discussed here and

they're [snorts] going to use a cereal protection device. So here is the team.

protection device. So here is the team.

Uh Masa has been uh online on screen for the m for the mital tier. He's going to be working now with Takahiro. So as they

are ready, maybe we can go live. Yep.

>> So welcome back, >> M.

>> Yes, welcome back.

>> Okay, can you hear us?

>> Yeah, very clear. Thank you very much for backing our Nagoya Heart Center. I'm

so pleased to be here again.

>> We can see you very well.

>> Yeah. Very good. And uh Okay. So that's

the I would like to introduce briefly some uh no introduce my the first operator Takahiro Tokuga and he didn't drink too much last night. So that he

will do best definitely. [laughter]

And uh behind me is the first operator of the Pascal. He's a little bit tired.

So that's [laughter] this is a sad one. Okay. So first of all I would like to uh explain what we did

now. So we now know the setup please.

now. So we now know the setup please.

Okay I going to try to explain the setup system. Can you see the uh our system

system. Can you see the uh our system >> do? Mhm.

>> do? Mhm.

>> I can't find any. Okay.

>> Yeah. Yeah. You you see >> okay it's okay.

>> Yeah. Okay. So the left side is a six French already inserted and right side femoral artery is 18 French dry seal and four French sheets uh just only for the

hydration and the left side ladial arteries inserted the four French sheets and for the pigtail and the uh contrateral injection and pacemaker is

used for the jagura vein the six French inserted because this patient is membranous septum is 3 mm so intermediate risk for the pacemaker implantation. So that reason why we

implantation. So that reason why we choose a jagura bane and uh okay let's move on the angio but a little bit challenging for

inserted the dry seal during the inserting the dry seal it's very difficult to insert because of the calcium so that we choose the uh uh PTA

using the eight 8 mm balloon inflation after that the dicey is go through the uh abdominal artery okay Next, please.

>> Okay. Yeah, that's good. Okay. And then

go. Next, please.

Okay. Anyway, this is very standard technique. Okay. So, let's uh try next

technique. Okay. So, let's uh try next please. And we deploy the sentinel

please. And we deploy the sentinel device, but it is still a very diff little bit difficult because you can see the uh very calcification on the uh

inominate artery. So that it's a little

inominate artery. So that it's a little bit difficult to manage it. But finally

we closed the uh both of the uh blame protection and we seted the sentinel devices. Okay. In case of the self

devices. Okay. In case of the self expandable bulb we want to uh usually use the seable protection devices. Of

course evidence is limited but uh in our ocean data a little bit higher incidence of the stroke rates for the such kind of particular case. So that we prefer to

particular case. So that we prefer to use it and then we choose a amplat left one and standard spring coil wire to

insert the left ventricle side. Okay.

And can we see the uh peakto peak gradient? It's obviously showing the

gradient? It's obviously showing the severe aortic stenosis at this moment.

Okay. This is our summary our side and okay please before the procedure can I do a angulary because >> okay okay

and also you need to uh uh disclose the your >> okay uh >> sorry it's a Japanese local uh guideline okay

>> uh my is uh Edward Abot uh ka uh medical Boston that's all many Okay. [laughter]

Okay. [laughter] So, please go move on to the angio.

Okay. Yeah. [laughter] So, we need to check the perpendicular line. Okay.

Let's go.

And contrast memesia is a seven and 14.

Okay.

Okay. Very clear. Very clear. Okay. And

go back to the uh uh cas viewing.

Okay. Uh little bit horizontal. Okay.

Go.

[clears throat] >> Okay. Good.

>> Okay. Good.

>> So these are two very nice views. We

clearly understand the distribution of the leaflets and which is going to be your working view the casper projection for the deployment or are you going to combine both views?

>> Okay combine both. I will try to firstly we want to start the cas viewing and the final deployment we move on the the perpendicular line so that the first of

all we want to try to deploy the stiff wire in the left ventricle. Okay.

>> Okay. While you are uh uh proceeding with the safari maybe can tell there is one uh uh point masa that we can also discuss you when are you what are you

going to do with the coronary artery >> uh the for the issue of the coronary artery.

>> Yeah. Yeah. Yeah.

>> Okay. our team decided the PCR after tabby uh some uh commentators or panel mentioned about that uh prescription antiplator therapy and meta analysis

showing the increased risk of the bleeding during the procedure so that we prefer to do the PCI after tabby in our daily practice first one >> check

>> and also we want to choose the navita device because in annular device is very easy to close the coronary access. That

is a very good advantage. And could you please show us the echo image for the audience? Echo images.

audience? Echo images.

>> Okay. Can you see the image?

>> Yeah, we see the echo now. Nice.

>> Okay. So, what about the what do you think about the position of the left uh stiff wire?

>> Mauricio, is are you happy with the >> um Yeah, I I think is acceptable. the

the curve I guess this is a extra small it's a small ventricle so probably it's compressed by the hypertrophic ventricle and I think I would not reposition I think you can accept it even if it is a bit

>> agree yeah >> and canal this wire is a uh easter wire manually uh handmade stiff wire yeah very

classic one yeah sorry And three years ago I failed to make it but now my skill is improved so that like a safari. Okay. Thank [laughter]

you.

>> Yeah.

[snorts] >> So this is 18.

>> Okay. 18 local Japanese balloon is ka tribal 18. Okay. And very pay attention

tribal 18. Okay. And very pay attention for the very slow inflation because a little bit sleepy. Okay. Very good.

Okay.

So what do you think the pre dilotation some physicians sometimes prefer to do the pre dilotation twice or three times but I think it's a decade what do you

think >> kazu do you do it once or several times and another additional question do you uh give contrast at the same time if the renal function is okay

>> yeah thank you we usually do only once if the is fully expand >> and And uh we don't do any contrast injection during the balloon palopy

because this is this case has a very wide sinus of alaba and we don't fear about the coronary fraction and maybe one one thing that I would like to ask

is that we don't use but this case has a significant coronary disease so maybe the rapid pacing could be uh a little

bit uh concerned. Yeah. So yeah, so maybe one option is to use the uh inway balloon without using the rapid pacing for this kind of patient.

>> It's a good trick. Yeah. So the issue of uh compromising the hemodynamics due to the coronary artery disease and yeah >> and I also I would like to focus on the

diastolic pressure immediately dropped after the preation. So significant AR could be happening. That's why they're a little bit >> fast in the procedure. Yeah, actually

the if we see the calcium non coronary cusp it stood up.

>> Exactly.

>> Um >> but there okay.

>> Okay. Thank you very much. And the

question is how to align the commission at this moment. So that this is a caspar viewing the device is in in in inside

the uh descending artery and the marker is located the left side two and right side one. This is uh if the uh

side one. This is uh if the uh theorically it's a commercial alignment is achieved when we do such procedures but we are not so sure this is very

effective or not but we want to try to do that. Okay let's go.

do that. Okay let's go.

>> Yeah we try to do that as well. um in

case in this casper view the descending art and the annulus overlaps in the same um frame I think it's quite effective

and predictable but in horizontal aorta just like in this case it's quite separate >> so it could be a little bit challenging >> so um it's interesting because we have a different um technique we do it across

the valve >> across the valve because the protection provided by the capsule is enough we didn't experience higher stroke rate And even this patient has a cereal protection. So it's a

protection. So it's a >> it's another way that to achieve that if you need it.

>> Stop please.

>> You can share.

>> But that this is a casual view. Go back

to the cas.

>> This is a perpendicular line.

>> Yeah, it's a freasco plan of view I guess.

>> Casper view.

>> But you are already 111. So potentially

it could be well aligned in a custoap >> for regarding the commission alignment we can use three measure program to make three imaginary commissions at the level

of the descending order. So we can make uh calculate two angles to make a good >> alignment at the descending and then we can keep that angle uh during the

pushing the castor.

Thank you for sharing that always. It's

not good. It's not good.

>> No, no, no. Please stop.

>> Okay. I have a misunderstanding. This is

a cast over viewing. So that the commercial alignment is not so good. 17.

>> It's fully misund.

Okay.

And uh so at this moment ascending artery the navita also can move it so that I want to try to rotate it but it's too difficult. Yeah. Yeah. Yeah.

too difficult. Yeah. Yeah. Yeah.

>> You can you can you can it's very important for the audience that device is so flexible >> that if you need you can do the commercial alignment.

>> Okay. Go

>> either above I tend to come closer to the valve or even be uh when you are within the valve here is still misaligned. Two of the dots are in the

misaligned. Two of the dots are in the opposite direction.

>> We want the uh the inverse two on the left >> and one on the right. And sometimes you need to rotate like 360 and then release the tension. Sure.

the tension. Sure.

>> But uh DDI uh or the uh panel audience that we should give up this moment because uh I want to I don't like to go back to and realign because that we are

also avoid the stroke risk so that we do continue during this procedure but even though the misaligned probably we can get the coronary artery

>> because of the very yeah large cell of the so and uh so the question There's a uh okay go and injection. So this is a

caspo viewing and we can see the uh t marker just below the uh NCC part and someone do the uh no pacing or someone do the uh control pacing or someone do

the similar pacing. Okay. So let's go uh no check it and do the control pacing.

No no now control pacing please. Yeah.

So, and similar Pacing, please.

Yeah. So, what do you think about your impression for the movement of this one?

Okay. No, no pacing, please. Okay. Let's

go back to the caspography.

>> So, generally the device the device is quite stable. So, if you need a the

quite stable. So, if you need a the pacing here could be interesting because you have aic regurgitation. So that

would decrease >> uh the amount of regge and improve the patient. So

patient. So >> okay. So now the position seems very

>> okay. So now the position seems very excellent. So that we want to try to do

excellent. So that we want to try to do deploy. Okay. So control facing please.

deploy. Okay. So control facing please.

A little bit deeper inside. Okay.

Control facing please.

>> So do you do the dist opening >> semi facing please?

>> No. I I generally speaking try to sort of position it exactly where I think is the right spot. So let's go. Okay.

>> A little bit of wire forward, a little bit of pull back to try and maintain coaxiality too.

>> Just as a comment, they're doing a good job.

>> Okay. Perfect.

Control facing off.

Okay. My trend now is during the deployment very shortterm but similar bit pacing. I prefer to do that because

bit pacing. I prefer to do that because the uh valve movement is very shortened.

and consider the uh membrane septum length three. So that now the tant

length three. So that now the tant marker is just a little bit below the >> Yeah, it's a bit >> Yeah. Okay. Okay. Anyway, we need to

>> Yeah. Okay. Okay. Anyway, we need to check the angel. Okay. Go.

>> The nice thing about uh naval is intra device once you deploy. I think this in this situation patient have a lot of AR.

So pressure drop. So I think once you deploy you get hemody and >> I think you want to get the marker. Uh

uh I think that vision marker is about 3 mm. So I think that will be alive with

mm. So I think that will be alive with endless last weekend.

>> Oh, watch out. Okay, so we need to check the incomplete center opening at this moment. But the stand th is open. Okay,

moment. But the stand th is open. Okay,

go back. Okay, go back. But I think everybody considers a little bit deeper position. Okay, go back. Back.

position. Okay, go back. Back.

Mhm. Okay, go back.

What do you think? Is there any incomplete center opening or >> no?

>> It seems to be fully open. It's only the depth that is that is a bit >> very good opening.

>> Okay. So the second question is can we recapture or not?

>> How about the conduction? It seems to be okay right?

>> Yeah. Uh uh QRS is widen but uh still a sinus le and maintain.

>> Okay.

>> So who in the audience would would go a little bit uh higher? Raise your hand.

Please >> we would leave the device where it is.

>> Okay. There are slightly slightly more of the audience.

>> It's like a 6040 that would uh recapture not recapture but reshift a little bit just to be u a little bit higher and I would I would do the same but it's uh you are in charge of the patient.

>> This patient has a relatively small membrane septum. It's all about 3 mm. So

membrane septum. It's all about 3 mm. So

there's some risk of conductor abnormality and also function is that good is 30. So I think it's acceptable 5

mm depth is good accept.

>> Yeah. So you want to do >> you decide what's what's your choice.

>> Okay. So we need to draw the dist. Okay.

Angio sketch please. Angular sketch

please. Uh no no control facing please.

Why don't we uh yeah go control spacing?

>> Yes, sure. And okay, 80 80 or 90 control pacing please.

>> The other nice thing they're doing did is just letting it they're taking their time, letting it settle into the annulus, letting it fully expand. So I

think that's an important part of delivering this.

>> Don't do it too quickly and release.

>> Okay. So the down Okay. D this part.

Okay. B. Okay. We want to do BA.

No, now we identify the correct position of the digital part and your images to do uh to uh sketch in in in in the screen.

Okay. On the screen.

So my colleague Yeah. now doing now to identify the correct position where is the valve is.

>> Yeah. the comment that did it's it's um it's a very calcified valve. So actually

to have the tiny bit of extra depth they may need to post dilate this. So that

gives them a little bit of comfort in terms of lower risk that they'd embolize it after.

>> So maybe it's not a pretty good position on reflection >> and we can easily identify the level of because yeah le is so castified.

>> Okay.

Okay. Go. And semi pacing, please.

Please.

Okay. Now, no, no, no. A little bit.

Okay. Now, go.

Control facing off.

[snorts] Off. Not for changes.

[laughter] Yeah. No. No. No. No. Okay. You go.

Yeah. No. No. No. No. Okay. You go.

Please make sure >> because sometimes there is some interference with metal and calciums. So maybe we need to make the B much much

smaller to adjust the position.

>> Yeah. Okay. Last one. Okay. Last one.

Again. Again. Similar pit facing please.

>> Yeah. And push by a little bit. So for

the audience the you can focus on the line they've drawn or on the marker that is related to the pigtail >> and that is going to help you

>> I think a little bit I think so it's a little bit deep on the left side you might push the device

>> it's better okay okay okay now control facing off >> you can see that the shape of the device didn't really change. So there is the expansion is the same. The depth is

better.

>> Yep. Much better.

>> Okay.

>> No, no. Again. Okay. Check the

>> puff. Okay. Good.

>> And immediately you have no regurgitation. That's why I

regurgitation. That's why I >> Yeah. Sure.

>> Yeah. Sure.

>> Perfect.

>> You are talking about post dilotation.

It's part of the uh discussion. But the

death we know we've known that if you um address a proper death, achieve a proper death, you get no regurgitation. And

apart from the conduction disturbances, >> yeah, very good comment and very good point. Na'vi seal is a little bit larger

point. Na'vi seal is a little bit larger seal and uh even we uh even the 23 mm

>> but uh 8 mm N seal we have. So that's a very good uh >> uh yeah yeah yeah

to reduce the uh if we proper the deploy the proper positions the AR is decreased so that it's very good point because we want to avoid the postation as much as

possible so that very good very good suggestion thank you and now we have to wait two minutes according to the guidance so that we have a 50 [laughter]

second Is it >> is it something that you you do you do waiting a couple of minutes before the final result?

>> Just wait a little bit and get it settle and then we have time hemically stable and then we can just >> and there is another point of discussion

talking about the the good practices.

Mauricio do you check in two views the depth assessing to in regards to the left side or do you rely on the caspo?

We we always check into two views. Yes.

And I think it's really important.

I mean it's a tri-dimensional structure that we we look through a bi dimensional screen. So I think it's really important

screen. So I think it's really important to check in two views. Yes.

>> But we don't wait this two to three minutes.

>> But it also gives you something to do to pass the two minutes.

>> Yeah. Yeah. Because you're doing something else. Yeah. [laughter]

something else. Yeah. [laughter]

>> Okay. I will move on the uh final release. Okay. I will move on final

release. Okay. I will move on final release please. 100. So yeah, okay

release please. 100. So yeah, okay the the wire back 100 facing >> and most important part of the

deployment of the Navita is uh this part is very slow. I I think I think >> that's a very very important comment that you provide masa most of the the

cases when you have movements because we go too fast for the outflow.

>> Yep.

>> It should be super super slow.

>> Okay. And uh so because of the horizontal uh anatomy so that the uh opening is not so uh a little bit

delayed than usual. So that we need to pay attention for more. Yeah. Like this.

Yeah. Very shrink

>> and we never touch it now that the device is automatically open. So that

reason why we uh we have to wait for a short time because I I never touch it but the device is open but now it's okay. Yeah. Very good. Yeah. Very

okay. Yeah. Very good. Yeah. Very

perfect.

>> Okay.

>> Very good demonstration.

>> Yeah.

>> Yeah. Thank you. Thank you.

>> Andrew.

>> Okay. The position of the Y is not so good.

Okay. [laughter] Okay. Yeah. Okay. Now

good. Okay. Release. Okay. control

facing off.

>> So we need to check the hemodynamics and the echo side. Please measure the uh measured EOA or something to define the uh echo derived ppm or mean pressure

gradient something >> while you are working on the emodnamics and echo. Mas I have a question to you.

and echo. Mas I have a question to you.

Uh this device uh is meant to be utilized shiftless because there is an integrated shift. Uh what was the the

integrated shift. Uh what was the the rationale for the go shift that you have uh inserted within the patient? Is it

the the complexity of the peripheral vascule >> or is it your routine practice?

>> Sure. my looting practice many times using the of course an uh no no we don't use the largest but in this particular

case of the a little bit horizontal case we do the uh you use the logicis and also the I'm also sure but the commission alignment to achieve the

commission alignment some a kind of logic is sometimes helpful to define but unfortunately we cannot do that or I'm we are not so sure we need to check it.

But that that is a large advantage maybe.

Okay.

But most of the cases can do without the Okay. So heodamics probably showing the

Okay. So heodamics probably showing the perfect result. Okay.

perfect result. Okay.

M should we go down to 50 or 60? Okay.

Okay. Facing facing down.

>> Okay. So to align the this part stand.

Okay. Okay.

Oh, a little bit. Yeah. I here

it's obviously the uh P. Okay.

And no disturbance so far.

>> Yeah. And also the QRS prongation is a little bit improved.

>> Yep.

>> Yeah. After the last attempt.

>> Yeah. Because of your repositioning.

>> Yeah. Sure. And we are also minimized I think.

>> Yep.

>> I think it was very good decision.

Mhm. Thank you. [clears throat]

>> Sometimes during the live session. Yeah.

Okay.

>> Four in a small anatomy. Yeah. Wow.

>> Yeah. Yeah. Four. Extremely low. Okay.

Okay.

Okay. Now the me and you can you measure the uh EA? No. Okay. Anyway, it's okay.

So that the question is uh can we get the coronary arteries so that uh okay JL3.5 please okay we we we do the angio

okay and coronary and okay no no no firstly uh actually [clears throat] consideration around the PVL I mean this

is a not very elderly patient you know mild PVL is probably not going to be a big deal but >> should be acceptable Oh, >> and often it's better the next day, too.

>> Okay.

And okay, this is a final angio.

Okay. A little bit with very small amount of leave.

>> Okay. Thank you. And we want to try to get the left coronary artery. Of course,

this case is very interesting. the right

coronary artery located in the anomaly side just in front of the left coronary artery. In this very specific situation,

artery. In this very specific situation, we want to try to get the left coronary artery first and then the guiding if the very difficult to get the right coronary

artery. the left coronary first and the

artery. the left coronary first and the guiding cate inserted and wire is inserted the left coronary artery and guide is floating and then we cross the

right coronary artery that is a tips of the such kind of anatomy if we face a difficulty to cross that so that in case of the PCI it's very easy if we get the

left coronary artery so that's the most important thing is we uh can we get the left coronary artery after the procedure I Is this a C overview?

No, >> it's a only simple uh uh uh AP view. No,

>> can you go to C rep you to check the misalignment misalignment?

>> Okay. Okay. Okay. After the uh NGO we are try to do that because we don't have enough time. Mhm. Maybe you can

enough time. Mhm. Maybe you can >> sometime I this is the last cell but sometime I think I use the just the 035 Y to guide into the cells and then

engage that help. And I think the other issue with the normally from the left sometime on this case cor is very high but sometime if you have really low cory

height you have to check that the uh the RCA it's not wrapped around the anulas because it's wrapped around anulas. I

think you when you uh uh ti with the balloon expandable I think you might collapse that coronary but I think on this case is high coronary height so it's no issue

>> and additional comment from my side it's if the uh alignment is good or not that after the coronary insert insertion it's sometimes helpful to identify the

alignment of this >> super easy to get access to the left >> and it should be for the right as well Nice. We we already see the right. So no

Nice. We we already see the right. So no

no worries. We we we trust you. You're

going to be able to get it.

>> So that is the reason why >> you can spare contrast for the patient.

So it's a very nice demonstration.

>> Okay. Okay. Okay. Okay. We can spare the contra. Okay. And okay. Can you see this

contra. Okay. And okay. Can you see this image because the uh left coronary artery obviously no no this one. Okay.

Obviously located on the uh very far from the tantal marker. That means the alignment is not so bad.

>> Yeah. Yes.

>> Yeah. Okay. So, that's a perfect result, Dr. Tokuda. Okay. Very

Dr. Tokuda. Okay. Very

>> very nice outcome for the for this patient.

>> Okay.

Okay. So, we skipped the light coronary artery injection. Okay.

artery injection. Okay.

Okay.

>> So, maybe one without even without contrast one final view in the casp projection to better see the distribution of the markers.

>> Okay.

>> And then view. Thank you. But that was excellent. Yeah.

excellent. Yeah.

>> Casper, please.

Ah, very strange.

Okay. No, no, no. Uh, please align the line. This line.

line. This line.

>> Yeah, a bit of codle maybe.

>> Okay. Yeah, a bit of cod. Okay. And time

off.

Please no >> but even yeah alignment is not so bad but the colon access is very easy that is a very good advantage for the interran

>> yeah that's a very uh very important point >> okay yeah okay >> okay nice >> yeah almost perfect thank you >> very good congratulate them

>> so masa and uh okay congratulations >> [applause] >> Perfect.

>> So that was a fantastic transmission.

One uh one more to go. I think they have another live case uh today. So go take a rest, a good lunch, and we will see a little bit uh later on. Thank you guys.

>> Y thank you so much >> again. [applause]

>> again. [applause] So I'd like to ask Yohi uh to debrief this procedure using smart screen.

>> All right. Uh it was really a beautiful case. Um they managed the tough anatomy

case. Um they managed the tough anatomy very well. So now I'd like to move on to

very well. So now I'd like to move on to the procedure of feedback debriefing. So

as you may know um in most on self-expando platform we use this uh uh view so-called cusp overlap view which means the left and the right corner cusp

aligns overlaps in in this fashion. So

so that we can isolate non-cornic cusps here. Uh the advantage of this view is

here. Uh the advantage of this view is that the conduction system lies just below the non-cornary cusp. So uh in this specific case the pre-procedure CT

scan showed 3.2 cm of memor septum length. So therefore the initial aim for

length. So therefore the initial aim for the team was to implant the depth a little bit less than 3.2 mm in order to

avoid new onset conduction disturbance.

Oops sorry. Um and then uh they crossed the uh heavily calcified valve with amplat one catheter and the

next next uh procedure was the uh pro uh predilotation uh using 80 mm uh balloon.

So maybe there was some room for which type of balloon to be used and which size of the balloon. um but they uh respected the minor axis uh of this uh

heavily calcified valve because some of the uh calcium was extended to the lvot.

So just to avoid the aortic root injury.

So as you can see here uh we don't want to have the waste after the dilotation of the valve. So we appreciated a very nice dilotation of this 80mm balloon. So

I think there was a discussion whether we go for another addition of a uh ballooning but I think it was okay uh with this single uh ballooning predilotation

and then we had a discussion whether how to uh align uh commission align this navar valve in this horizontal aorta case. It was quite difficult usually as

case. It was quite difficult usually as they performed in this descending alert uh aorta this two markers

uh two markers on the left one marker on the right uh in most of the cases uh let's say the aortic angle is more or less like 45 50° uh if you bring this

catheter at the cusp overlap view at the descending aorta it nicely overlaps with uh aortic root. So that means uh if you align the valve in this orientation with

the two markers on the left, one marker on the right uh you cross the arch as it is and it comes back that means that in the caspor if you cross the annulus you

have one marker on the right two on the left. So most likely to achieve

left. So most likely to achieve commission alignment but uh actually it was not the case with this horizontal or

>> discussion. Okay. and then um their

>> discussion. Okay. and then um their initial attempt was recorded as here. Uh

so the one of the uh advantage of this uh navigator system has a a little bit slightly bigger uh marker compared to

the other selfex platform. It is 1.5 mm in uh diameter. So if you try to align the uh the bottom of the NCC cusp at the

bottom of this marker, it means that you will achieve 3 mm depth as a implant. If

you align the bottom of the cusp at the top part of the marker, uh you will achieve more or less 4.5 mm. So it's

quite easy to guide your depth.

So initial attempt was a little bit deep. So they tried to uh

deep. So they tried to uh recapture and finally uh they were able to achieve a very nice depth as you can

see here more or less 4 mm in depth >> and also we were able to appreciate a very nice expansion of the above. So uh

the key of the success of this uh valve implantation is to avoid uh under underexpansion. it's so-called uh

underexpansion. it's so-called uh incomplete stent opening nowadays. So uh

we were a we were able to appreciate this nice opening of the frame. Uh

mostly we go for RAO uh cranial view in order to achieve this kind of let's say emphasis view or uh so-called short axis

view. most of the uh ISO uh likely to

view. most of the uh ISO uh likely to happen in the NCC side because like in this case the calcium of the NCC is quite heavy but you can appreciate a

very nice opening of the frame. Uh this

is the NCC side. This is the LCC and this is RCC. Uh this is the LCC sorry L N and R.

Okay. And then um uh they were able to canulate the uh left coronary artery uh as you as we appreciate it here. So uh we all have

this kind of experience even though the valve did not completely align achieve a commissioner alignment uh since the navigator valve is an interan uh

structure it is quite easy to uh access uh both left and right corneries. Thank

you.

[applause] >> Thank you very much Yohi for the >> Yeah. Uh very clear explanation of the

>> Yeah. Uh very clear explanation of the procedure. So let's move on to the PC

procedure. So let's move on to the PC port two.

>> So may we see the poll. So uh you've seen the case, you have heard the discussion and uh we want to hear from you guys whether or not your overall

strategy will be different. So take your uh your cell phones and there is that poll you can uh join using the the QR code and the question is how should one

treat coexisting coronary artery disease with severe A revascularization prior to TAVI B

during TAVI procedure C after the TAVI procedure and D nothing don't revascularize >> so please answer to uh it's going to be interesting to better understand more

about you and then we're going to discuss these matters. There were lots of questions that we're going to address because we have still 30 minutes remaining so we have plenty of time. Uh

we're going to address your question but the first first the poll.

So while it's uh the results are uh about to be displayed uh so Mauricio what's what what's your strategy?

Well, in this specific patient, I would definitely agree with their strategy.

So, PCI after I think not all the lesion has to be necessarily treated in an 88 year old patient. But in case like this where you have a tight stenosis of a prognostic vessel like proximal or mid L

of course you need to treat it. I mean I think they will treat it thereafter.

Um and generally speaking uh our strategy is to do it after unless there are some specific as you said acute presentation or then we have to force to do it before but usually we we do it

after.

>> So Natav you noted and you said after you seem to agree with Mauricio but what is after? Is it right away because they

is after? Is it right away because they had a guiding catheter within the the left main? Is it one week, two weeks,

left main? Is it one week, two weeks, one month? What is what do you do?

one month? What is what do you do?

>> Usually I would look at the patient symptoms. Uh this month is asytomatic.

We probably can just leave it and uh uh not doing it. But uh if I have to do it, let's say she still have a an symptoms, usually I like to wait maybe four weeks.

Let's set uh everything's uh grow everything is complete and then I just uh add her on depth and then do it uh as a staging because I think uh she's old,

she's elderly, anemia and some CKD. So I

think we probably can do it uh just just wait. I think uh the answer is really

wait. I think uh the answer is really depends on the complexity of procedure.

If the pro uh region requires a complex procedure like C2 intervention or rotabation then those procedure should be done after Tavi because those

procedure can make patient un unstable but uh this patient has quite a significant region but the procedure should be simple so why not so we can uh

perform the PCI before the tavi so we can eliminate any risk of proial instability originating from the corery disease during uh tabby procedure and second

consideration is enormous origin of right coronary artery. So uh whatever whatever you implant after the tabby procedure engaging the the right

coronary artery with anomous origin should be challenging. So I would do uh the PCI before the tab in these patients. M y

patients. M y >> so it's uh if we come back to the poll it's clear given based on your experience guys that uh you tend to agree with with what has been said after

the procedure in the vast majority of the cases apart from some exceptions that just have been uh mentioned. So

after the procedure maybe one uh one month I would say that I tend to agree because in the past we did the uh what we call the pragmatic initiative and

when we did PCI during the procedure the patient tended to bleed more more bleeding and that bleeding led to an increased mortality. So this is

increased mortality. So this is typically the type of patient for whom I wouldn't go for a same time uh PCI. So

it seems that we have a kind of consensus and it's nice because most of the time we have no clear message.

[laughter] So this one is a very strong message. Y

maybe there is something that we need to um to explore because it's uh most uh it's quite popular here I guess either

IUS Iver assessment and or physiology in this uh situation. Would you do it?

>> Great question Dia. Um in in my center initial approach is using FFRCT. We're

fortunate to have that. So um of course there's a a discussion whether um FFRCT

not using nitro nitro so fully uh uh vasod dilation it it could be the the the FFR value could be different but

still we have uh anatomical information as well as additional hkemia information. So we we basically um get

information. So we we basically um get that uh data as a guidance for assessing the uh CAD. Um and then if there is a

significant left main disease or proximal L we go for invasive angio beforehands. Uh but otherwise we always

beforehands. Uh but otherwise we always implant the valve first and u do the coronary angio immediately after the valve implantation. So if the patient

valve implantation. So if the patient doesn't have any symptom after tabby procedure, >> do we still need revascularization?

So maybe Stephan could you please >> that's that's a very important point.

>> I'm I'm I'm the naughty boy. I would

still revascularize beforehand. So it's

but it's it's look and I think we've but it does highlight that the data is a little conflicting. Um and I and I

little conflicting. Um and I and I mentioned earlier I still at our center we wait notion three. It's you know it's randomized control trial. they they

revascularized before but we've got complete tava to come soon PCI tava I think that'll help us in this patient look it's it's tough there is a bleeding

risk that you take by doing that um so you know in the heart team discussion it's very reasonable I think to have deferred it I I just do worry I mean you

know in her late 80s it is prognostic disease I mean she's got two tight 90% lesions in the L it looks pretty tight that midright too So you know given that um

>> she's otherwise pretty well uh you know I I would be favoring revascularizing uh this patient with the with the burden of eskeemia that she has.

>> Yeah great opinion. So actually we had the many questions from audience so we can go quite quite quickly. uh what to do if there is a new onset SD segment

depression after deployment maybe because >> if you see the uh >> SD depression after deployment the tabby device

>> okay actually that situation is quite rare but I will say that we will go for the coronary angog and see what happens >> and but this in this particular case he

has a very wide uh you know coronary uh sinus of >> vala Yeah.

>> So I think this is a very you know rare opportunity to have that kind of complication.

>> So sometime we see ST depression just at a rapid pacing. So it may happen.

>> Yeah. And the next one is is pressure Y useful for assessing a significant coronary artery disease.

>> So you explored that before. Yeah.

>> Okay. Perfect. And do you really need commissal alignment for interanular valves? That's a good uh question.

valves? That's a good uh question.

>> Uh it's a good question. We need a good answer. So do you really do you do we

answer. So do you really do you do we need commercial alignment? What's what

you're feeling?

>> I I would think so. I think there will be situation that I think anatomy is difficult. I think when you have the low

difficult. I think when you have the low cory height uh when you have the small STJ and I think uh young patient more complex I think uh future tough in tough

is uh I think index post year is very important. I think this is 89 years old

important. I think this is 89 years old and we have Lassel. So I think this is exception but I think in rarity I think you need it depend on the patient.

>> Do you agree Ma is after Dr. Han?

>> Yes. uh based on the license from the sapion valve implementation I would say yes because uh even the sapient valve uh

the 10% there's a 10% of uh uh query inaccessibility and is most of them originating from the misalignment of valve so even in the uh valve with

intrastructure uh intraanular structure then uh coral alignment should be important >> so these are two uh very uh important questions that are going to be addressed

into uh within two videos that we're going to show afterwards. Uh so I strongly agree with you depending on the age and the risk profile and most importantly the life expectancy of the

patient even with intraanular valves commercial alignment keeps a very important uh uh position because we need to think about the future. If it is misaligned fully misaligned it may be uh

tricky to do a redo procedure. So uh

it's always patient centered and uh but it has to be part of our uh mindset.

>> Great. So uh the next one is for coronary axis uh slightly lower position might be better.

>> Maraicio is it something that you consider it it may be important for the superanular devices? Is it

superanular devices? Is it >> sure but there is this uh this concept also that in term of retavi possibility

if you have high risk of retavi there is eventually the tendency to implant slightly lower the valve to have then less I mean let's say less high neoskirt

but I I do not agree with this approach I mean I don't think we should compromise the index procedure to to make the second one easier I think we should rather

aim for commissional alignment and optimal positioning and then eventually do leaflet modification in case of tav in the future. So I would not on purpose implant deeper uh because of this

>> for coronary access they already demonstrated that the uh they can kindulate to the coronary very easily.

So it should be okay and the last but not the least uh aggressive torque of the livery system may damage the stand frame by professor lunderat.

So this is uh I think it's uh it's it's quite it's super important u it's all about how aggressive is the talk and we are conducting a we did conduct a trial

in u in tulus and couple of centers 100 or 150 patients achieving commercial alignment by talking just above the valve uh and if needed slightly uh

within the valve but as long as the device remains protected by the capsule so the risk of stroke is virtually the same as without this maneuver. And we

did a post implant CT scan. So we

assessed the stent uh frame overall and the commercial alignment. So it's going to be uh so I'm not going to disclose the outcomes but it's quite quite

efficient. So maybe it will uh uh teach

efficient. So maybe it will uh uh teach us and um provide additional data to support the fact that you can rotate close to the valve and to to uh because

commercial alignment as we said is important. So we need to be efficient at

important. So we need to be efficient at achieving it >> and from the descending out doesn't seem to be efficient enough. So we'll uh so let's wait I guess in couple of months we should get the the data

[clears throat] but um let's move to uh one of the it's super interesting because it really echoes the discussion that is ongoing.

Let's go to one of the the videos that we have coronary access with Navitor.

Hello everyone. We're going to take just a few minutes to look at currently access in in terms of anatomic samples.

So um to start with just to show you some uh the sample we're going to make the implant into this is a normal valve a normal heart admittedly and you can

see the two coronaries coming from the sinuses there. Now if you just look at

sinuses there. Now if you just look at the origin of the left coronary you can see it's just below the sinotubular junction which is not atypical and it's

sitting within the middle of the sinus.

So that's the left coronary. see the

ridge of the sinotubular junction above and there's the leaflet. So turning

around show the right coronary slightly smaller. It's probably just above the

smaller. It's probably just above the sinotubular junction in this case and there's the leaflet tissue. So you'll

appreciate the leaflet tissue uh is is not covering not able to cover the complete sinus. And now you'll see the

complete sinus. And now you'll see the post there is aligning with the left coronary artery. So let's deploy that

coronary artery. So let's deploy that fully and see if we can still access the coronaries. And you know if we're

coronaries. And you know if we're talking about a small aortic route of course the effectively the space to access the coronaries will be less the

sinuses will be smaller. So what you can see this is uh navore. You can see that the the big open cell design there even though the post is over the coronary we

can still run reach around that to get into the left main uh stem coronary.

The sinuses as I say are are fairly large in this in this particular sample.

Um if the auto route is smaller, there'll be less space behind the post and so it might be better to do uh a proper alignment.

And um here you can see the leaflet tissue push pushed to the back and then we'll look briefly at the right coronary. There's the the right coronary

coronary. There's the the right coronary artery. So again you can see that that's

artery. So again you can see that that's not over overlapped by the post because remember leaflets and coronaries are not always in the same position. and uh we

can easily access that.

Now um one thing we've noted at least in the samples is that with a bit of dilotation you can get a bit of realignment of the of the uh commissure

with the post. So with a bit of dilotation you see that shifted that post has shifted now um rightward and we've got we've got nice access to the

to the left coronary artery. So that

sort of has improved the access.

However, the right now is partly overlapped by the post. So, um they can be shifting it seems at least in our hands uh if you if you um uh post

dilate. And there's the skirt of tissue.

dilate. And there's the skirt of tissue.

Remember this would be a calcific valve in the real situation sitting behind the the valve.

So that was quite interesting because the device was uh fully misaligned almost in regards to the left main. Uh

first uh information we can still get access to the coronary arteries given the large cells that we get and second and this was kind of new that uh the

potential for some degree of realignment after post dilotation. Is it something that could uh impact uh your practice Stephen?

You know what I was actually I was slightly surprised to see that because it's not been my experience that there's been much material change with post-dilation. So um no I'm look I'm not

post-dilation. So um no I'm look I'm not sure that I would therefore post dilate to get some change in it. Um but uh you know I would still I think a comment Mitzio made earlier you know ultimately

just getting getting a good first results the key piece around positioning and and and post dilating if I need to um for uh you know PVL for example

>> because you we have that uh policy of double tap for the balloon expandable valves um do you guys believe that this is something that we could translate to

the self-expanding world and uh if so what type of guidance would you provide because balloon expandable valve you use the same balloons you have the same

diameter self-expanding you need to make to decide first do I go for a double tap so post deal and second what is the balloon size that I would use

>> I I usually don't do the post tap but I think the naval I think it's important for pleilitation >> pre-deal yeah >> I think that's is key once you get good

pleilitation I think you will get a a good uh perfect uh align Right. And the

postitation if we do it only like have to have some PVL some calcium maybe some NUDRI if you we've been prep. So I think that and again I think the more you do

on the uh on the things I think you may have more conduction more symbolize I think I would think before I routine doing it.

>> So there may be a cost to pay in terms of uh device stability. Yeah. And uh

yeah it's true. and conduction

disturbance here predilotation predilotation and commercial alignment.

So these are clear messages that you guys provide to the uh to the audience.

Um okay so do we have a couple of questions >> one addition? Yeah,

>> there was the there is a question about uh does anyone uses the left cusp isolation view? Yo, do you use that left

isolation view? Yo, do you use that left cusp isolation?

>> Left cusp isolation after um point of no recapture with the cusp overlap view. I

go to left coronary cusp isolation view to confirm the depth of the LCC side or in case of left main let's say high-risisk case of occlusion we should

have also have a left main isolated view >> perfect thank you >> uh so there was a a question a com maybe more comment maybe one need to be careful with postalitation routine

postalitation with the risk of coronary obstruction so it echoes what you said about the tradeoff and the cost to pay.

There is something that you guys uh discussed before is the potential uh we are all saying we mustangopodize the index procedure because there may be

something else in the future for the patient. We are in Asia. So even if we

patient. We are in Asia. So even if we are treating a 80 years old patient there may be a need for a redo procedure.

>> So we understand the uh impact of the commercial alignment the perfect death and so on. Uh and we have a video that is uh interesting and I would like uh

you guys to comment on afterwards. It's

um a redo procedure. They simulate uh Andrew simulates a redo procedure. So

let's see what it uh >> what it looks like.

Now we're going to look at valve in valve procedure and we're then going to assess the access to the coronary arteries. So, what I'm going to do here

arteries. So, what I'm going to do here is put a 23 mm nav in a 25 mm portico.

So, the portico is already in place and we're going to now deploy the navore and I'm going to try and get it again. So,

the posts are aligning with the coronaries. So, not in an ideal

coronaries. So, not in an ideal position. And again, I want you to

position. And again, I want you to imagine this is a smaller aortic root perhaps. Um, and we're going to look at

perhaps. Um, and we're going to look at the space behind the uh the the the the Portugo leaflets in just a second. So

there's the Navore which is now deployed and you'll see that the two frames are not overlapping each other.

>> At least initially they're not overlapping each other. Let's look at um uh with a bit of dilotation. You see

they're now aligning a little bit more.

We've still got access though to the left coronary there. So above the skirt of the first valve and um there you can see you can access through these sort of

large cells even though the posts are not aligned with each other and there's the right coronary. So perhaps the right um is a little bit more a little bit

closer to the to the original valves post um and there's better alignment. So

actually, you know, if we just shift this a little bit and now we get the the two valves overlapping each other. They

really do fit together beautifully. So

there's no loss of space there between the two the two valve cages. And there's

the left coronary. So uh you could argue that the first valve is pushed back and is perhaps slightly obstructing that left coronary, but certainly there's good space there behind between the

cells. And there is the right coronary

cells. And there is the right coronary which we know was slightly higher initially and there's good access. So um

that shows you the coronary access and then just pulling the leaflets of the valve of the new valve down you can see that skirt of tissue and the space the

sinusal space behind there. Now again if this is an a smaller aortic route the space behind the sinus is going to get a little bit more crowded um partly by the

the first valve and also um perhaps by the initial uh aortic valve. So uh but certainly access to the coronies through

those that large cell design is okay.

Okay. Okay. So that's what that was interesting because uh we have a kind of superimp position of both 10 frames that is kind of counterintuitive.

Um if I start with sharing my exper experience when I have a degeneration of a tall frame device I tend to put a

short frame inside. So if we uh maybe we can have a a round of discussion around that. Uh starting with you uh Yo, for a

that. Uh starting with you uh Yo, for a redo procedure, do you go for short in toll or having seen that toll in toll could be a what would you uh do?

>> Um unfortunately in Japan we don't have the short and tall combination yet.

>> Yeah.

>> So um I only have a one uh bailout uh sapion in aviator. Uh well it worked very well but so well it depends on the

baseline anatomy I guess. And this uh video clearly shows that um na navar has advantage even with navier and navar if

the root and uh root anatomy allows I think the corner axis is good >> and uh as I mentioned in our daily clinical practice immediately after navigator implantation we go for corner

axis. So we now have better

axis. So we now have better understanding. The only situation that

understanding. The only situation that coronary access even after navar is difficult is if the patient has narrow coronary sinus, low coronary height and

misaligned valve. If all those are

misaligned valve. If all those are combined, it could be difficult but otherwise it's quite easy.

>> Thank you casual.

So actually in Japan if we see a SVD after the long and stand frame uh device usually the coronary occion risk is quite high and uh in our experience we

underwent two cases long and long with with the our private >> uh uh uh surgery using and in that case we have to do the uh uh coronary bypass

to the both right and left before we implant the uh uh uh Tow device with that we can you know eliminate the cop

palmer bipus but we still have to open the chest. So it is not a very quite low

the chest. So it is not a very quite low inbasing procedure but it's just one option to treat this kind of very high risk uh case and who are not candidate

for uh open repair. So this is a kind of hybrid solution with a trans catheter treatment of the aortic valve and then surgical correction of the coronary artery

disease. Yeah. What would be what do you

disease. Yeah. What would be what do you have in terms of combination naturally would you go to in toll or short in toll?

>> Well I mean traditionally that's what we've done and and what we've learned.

But I think that the thing is that the the tall valve is is an evolute. That's

what we've always when we've been doing the maths on or the or the geometry of of short and tall and tall and short. I

think Navore potentially changes that paradigm. I mean it's it's an intranular

paradigm. I mean it's it's an intranular valve. Um and as you see there I mean uh

valve. Um and as you see there I mean uh so you know I think Navatour itself is is a good solution for for either a failed Navatore in the future or or a failed um uh balloon expandable in the

future. The other thing too and where

future. The other thing too and where it's the big advantage I mean the the hemodynamics you know they had a 4 mm mean gradient in a 23 mm navore I mean uh that it would be a double digit for a

balloon expandable valve in that small annulus.

>> I agree any additional uh feedback you would like you would like to provide on this side.

I think a shortening to should be better in general compared with the torin tol because uh as you know if we do the torin toll the nail got height will be

way higher than uh 21 mm or 23 23 uh depending on the previous valve type and in this previous video the cor reacessibility looks easy because he

used a very stiff motoric uh material to uh get into the coratory but in reality we use very flexible coriding custo to engage the coronary artery it's a

totally different thing so in general I would say shortening [clears throat] to is a better choice the valve n is very forgiving you have

the last cell but I think you have to look at patient anatomy is forgiving or not as y have mentioned I think some certain anatomy is not my forgiving we have the case in Asia uh that in

Thailand we we have like very small we do basilica and after basilica used to have lilet tanking in front of the pin because there's no space to go.

>> Yeah, >> I think um uh so in that situation I think shutting maybe out.

>> Just a final comment. I think also the size of the first valve matters as Steve said. I mean having navitor is excellent

said. I mean having navitor is excellent theodynamic in small anatomy. So if you have a we have also some cases of degenerated short valve like 20 or 23 degenerated sapion and I think to put a

nav so having a intraanular with excellent thermodynamic in small anatomy is a great tool and seeing that we can do toll in toll easily >> with navitor is a really good method

>> so it's it's it's true that this is a a new learning the fact that with this self-expanding intrao valve you can use the same device by the time it fails I

would still continue to believe that if we can do short in toll it would be better but keeping um still keeping the commercial alignment as a key focus and

uh luckily the so the same company is coming up with a balloon expandable platform with active commercial alignment. So we should have in the

alignment. So we should have in the future a very nice combination to uh follow the patient and to ensure to cover the lifetime manage lifetime span

of the patient. So super interesting. Uh

so we are coming to the end. I have to say that I didn't see the time fly. So

that was a [laughter] a very uh very important and interesting discussion because we had to share all together and thank you for your input through the polls and the questions very very nice

questions that raised a lot of very dense uh intense discussion. We had to deal with this patient with coronary artery disease. So we could al together

artery disease. So we could al together understand uh what is the management of severe as patient with conccommittant coronary artery disease and there seem to be a consensus uh towards treating

those patients after the procedure uh [snorts] because sometimes PCI bears its own complexity. So uh dividing

own complexity. So uh dividing separating the procedures makes makes sense. uh we had a very nice uh

sense. uh we had a very nice uh discussion about the key steps uh contemporary steps of a nav proced navar vision uh uh implant uh trying to

achieve a proper commercial alignment and in case uh that wasn't achieved with the large open sales it's still possible and we've seen that through the uh uh

expplant cases to get access to the coronary arteries we had the chance to discuss about the future options in terms of redo procedures with the various combin nations and it was a a

very important and very interesting uh uh session. So we hope that you are

uh session. So we hope that you are going to go back home with new elements to help you treat your patients. Every

single patient bear its his own challenges. Uh but I would like to thank

challenges. Uh but I would like to thank you for attending the session and thank all my very good friends here for sharing your experience. Uh it may be

time for lunch for those who haven't do so do so. [laughter] So

um thank you very much and see you for the next session and thank you Abot for supporting the session.