Download David Duncan, M.D. Chief of Cardiothoracic surgery :36 Walking

David Duncan, M.D.
Chief of Cardiothoracic surgery
:36 Walking through the procedure [you know] it starts in the office first and :40 the
first thing that we’re going to be doing is assessing the aortic valve, looking to see if
the patient has critical aortic stenosis, that it corresponds to their symptoms, that
things make sense :50 there’s specific criteria that we look for in the cardiac echo as
well as the cardiac catheterization and we take that information and make sure that
that all lines up with critical aortic stenosis 1:01 at that point then we start trying to
go through the education component of things 1:07 giving the options to the
patients on what we can do, how we go about treating that 1:12 typically I’ll explain
to the patient that basically the heart is a pump, its purpose in life is just to circulate
the blood and nutrients around to the rest of the body, and that the heart is
composed of four chambers 1:21 there’s two on the right hand side, two on the left
hand side and there are a series of valves, or doorways, that direct that blood
through in an efficient manner 1:30 occasionally one of those doors or one of those
valves doesn’t work right, occasionally one of those blood vessels might have a
blockage and that’s where I get involved as a plumber to either fix that door or to
bypass one of those blood vessels
1:45 so for aortic stenosis, typically what’s going on there is the front door on the
left ventricle, the valve coming off the left ventricle leading into the aorta [where all
the blood flows that goes to the body other than the lungs], 1:58 that doorway is
tonetic or doesn’t open the way that it’s supposed to 2:02 and that’s something that
we can manage some of the symptoms from with medications but there is no
treatment outside of surgical or mechanical repair [of that valve] replacing that
valve 2:16 so historically what we’ve done is we’ve gone in surgically, put the
patient on the heart and lung machine which does exactly what it sounds like 2:24 –
takes over the function of the heart and lungs and would put the heart to sleep and
stop the heart 2:29 – and then make an incision in the aorta, which is the big pipe
coming off the heart, go down to the aortic valve, excise it, [take it out] and then we
would put in another valve 2:39, a man-made valve – either a tissue valve or a
mechanical valve 2:43– and once we’ve got the valve in perfectly the way we want it,
then we close things up, tidy up, come off the heart and lung machine then we’re
done. 2:52
2:53 For patients who are maybe older, have some co-morbid issues, that are not
candidates for doing surgery 3:02 – and if you look at the STS data based for 20112012, there was a little less than 100,000 aortic valves done in the United States
3:09 and it turns out that there’s about another 30,000-40,000 folks who’ve not had
their aortic valve treated appropriately or by recommendations because of their age
or these co-morbid issues 3:27* such as, maybe somebody who’s had previous
bypass surgery and had radiation to their chest or maybe they have severe lung
disease and they can’t be on the heart and lung machine or maybe they’re just very
frail and they’re not able to walk and get around 3:40 And those patients [um, you
know] it’s very important for recovering from open heart surgery to be able to
ambulate and to help rehabilitate your lungs from that perspective. 3:51
3:52 So these patients that have these co-morbid issues that would not be
candidates for having surgery then are referred to me to talk to them about TAVR
4:02 and we start assessing their valve size – there’s two particular areas that I’m
going to be looking at 4:12– one of them are the characteristics of the aortic valve
itself, the size, what size valve we would replace it with, the calcification that’s in the
valve, the height of the coronary ostium, where the blood vessels that come off the
heart are located 4:27 because we have a very precise landing zone that we have to
put this catheter based valve in 4:32 so we need to know [the very…] have specifics
about the valve and the sizing to do that 4:39
4:40 The second thing that [sort of] where I become a bigger part of the team is in
the access 4:45 and the access for this typically is going to be through the groin – the
transfemoral approach – or occasionally we’ll go just below the breast on the left
side and go through the apex of the heart 4:58 where we put a PER string in the
heart and and put the catheters directly through that PER string up into the aorta
5:05 [aortic valve…] and occasionally taking off on some of the minimally invasive
procedures that we do, we can make a very small sternonomy 5:15 instead of
making a full sternonomy the length of the chest we can make a stenonomy that’s a
couple of inches in length and you can access the aorta and put the valve in directly
through that 5:26
5:27 So the assessment of the vascular access is very important 5:32 and the
catheters that we use for placing this valve, the delivery system, are extremely large
they’re [in order?] the size of your thumb 5:42 so a lot of folks, particularly if you’re
in your 80s or 90s, those vessels may be very calcified and smaller and you’d have to
be very careful on how you handle those blood vessels so that you don’t injure or
rupture those blood vessels and create additional problems 5:56
5:57 So we’ve gone through the process then of assessing the valve, the character of
the valve, the access to get into it and then we’ve talked to the patients about the
risks and benefits associated with the procedure 6:08 [prior to getting to the
operating room] 6:12
6:39 So once we get to the operating room, we use a different type of operating
room. It’s not the typical operating room that we usually do heart surgery in, 6:48
it’s a hybrid room that combines some of the special characteristics of the cath lab
along with the ability to do an open procedure with the heart and lung machine in
there 6:59 And we also take advantage of a lot of people’s different skill sets 7:03 So
there’s interventional cardiologists, such as bob preli and there’s cardiac surgeons
such as myself and Dr. [Roshel??] and Dr. Morgan, there’s a perfusionist that’s here,
there’s a excellent operating room team that does open heart surgery on a routine
basis, the cath lab team is here, 7:24 we have a heart failure specialist who also does
a lot of the imaging – Dr. David Small – 7:29 We have cardiac anesthesiologists who
specialize in doing cardiac anesthesia and TB(?) echos 7:38
7:39 So we have a group of people who have special skill sets that we use and we
combine them in this hybrid procedure 7:46 So once we get into the operating room
we prep and drape them just like we would do in an open heart procedure – we are