transcatheter aortic valve replacement

There are other versions of the surgery that is usually not used in emergency situation where very similar to, you know, other vascularly inserted meshes for other vessels.

You have one that basically goes in, I believe it's called TAVR.

I forget what it's called.

But anyway, there's a there's a surgery where it's less invasive.

And then just as a final request, as the CardioNerds tradition, after every episode, we like to ask our experts, what makes your heart flutter about the future of not just the surgical management, but the management in general of pulmonary embolism, where the field is going, especially those with the highest risk presentations?

I think that up until really recently, the highest risk patient population, and we talked about high risk, we're not talking about TAVR in terms of high risk.

We're talking about the massive PE, those who are unstable, about to be unstable.

Those patients, even though we've had a lot of advancement in our understanding and technology, they still have an exceedingly high mortality rate.

So let me tell you guys about the past medical history.

So she has a history of aortic stenosis, and she actually got a TAVR one year prior to admission.

She has atrial fibrillation, and she's actually on a Pixaban and amiodarone for that.

She has hypertension, hyperlipidemia, not obstructive coronary artery disease, chronic kidney disease with a baseline creatinine around 1.2, Heart failure with improved EF, and now the most recent EF, was 60 to 65, and a remote history of breast cancer, and she got a mastectomy and lumpectomy many years ago.

Was there any other headache in review of systems? Any positional change in the headache? Did anything change in this patient's life recently in terms of medication changes? Thinking about those hyperacute schemas, we think about any obstruction or hyperacute electrical discharge, but really understanding the problem.

Of course, we're going to give the volume, we're going to get an EKG, and you're worried about the bleed.

getting the you know hemoglobin and all those basic laboratory thing of course we can get that but trying to understand the problem if this because this patient has more vulnerability in the heart and she has got TAVR so definitely does this patient really have any complications of TAVR I mean, that doesn't cause, that should cause some kind of subacute to chronic manifestation, but that actually is kind of very unusual, but getting that EKG, making sure that we're going to look at all the leads.

I'm sure if she went to the ED, they're going to get the troponins.

I am an interventional cardiologist, a structural cardiologist at St. Anthony Hospital with Colorado Heart and Vascular.

I started our TAVR program about 10 years ago.

Started off obviously slow.

First year, I guess we did anywhere between 25 to 50.

And we're going to be talking about HALT.

And just to go over it definitionally, HALT stands for Hypoattenuating Leaflet Thickening, which really just describes an imaging finding.

So Dr. Aguile, when you hear the word HALT, Well, what does that mean to you and others in the TAVR space?

You know, it's a very interesting question.

Well, I think thinking that TAVR is going to fail and not joining this was the same mistake we made with angioplasty.

Early TAVRs were difficult.

In fact, in the very early, early days, the mortality was 50%, not 30-day mortality, 30-minute mortality.

Either it worked, you did great, or it didn't work, and you died.

It's got a new, um, kind of, uh, automated system that's coming in that can do soft t- tissue surgery, surgery.

It's called, uh, TAVR.

It's reorganizing that in order to make that as the, the main focus of that division.

And yeah, so it, it, it has these operational changes going on in the background, um, a- at the same time as you have certain, um, uh, macroeconomic problems which are affecting it and other med tech companies.

She describes this process not as a passive calcification, but as active inflammation, fibrosis as a very live and active process.

She proposed that maybe using systems biology, imaging, computational drug discovery, maybe we could intervene at the early stages so people with mild aortic stenosis seen on early imaging can be intervened with novel drugs and stop that calcification process it sounded pretty crazy but she says this is real this could happen and may actually happen so you know I actually started cardiac surgery saying well you know maybe PCI will take over from CABG this is in 2000 a while ago but you're never going to take away aortic stenosis so I was completely wrong with TAVR because I never thought that would work and And completely wrong about you could never take it away because maybe clever drug therapy will reverse calcification process on people in their 30s and 40s and 50s before it gets severe.

So well done, Alina Aikawa for scaring the hell out of this if you're a cardiac surgeon.

Of course, the most well-attended session is always the presidential address, and it was by the wonderful Rafa Sadaba.

Uh, but will be a lot of conversation around that.

But I think more importantly is some of these controversial issues that I think will be in the hallways talking about the TAVR and CD, where we're going from here, how do we, how do we make sure that the heart team isn't lost.

I think that's gonna be a lot of...

Because it's fresh and we are talking about it, and hopefully there'll be a session on that.