0:00

Again, this one was another one of the cases

0:03

that we wanted to include.

0:04

And this one is a bicuspid valve.

0:07

And I was surprised to see how many folks in the course, uh,

0:12

had a, a more difficult time identifying the,

0:15

the morphology of this valve.

0:17

So I kind of wanted to, to go over that particularly

0:20

because I saw a lot of reports with that.

0:23

I tricuspid tried leaflet or functional by cuspid.

0:27

So you saw how I lined up to the aortic root.

0:30

I wanted to then get it there

0:32

and then I would play the image.

0:35

And a lot of it has to do with whether

0:37

or not this Raffi is moving or not.

0:39

But you can see here as you come to the leaflet tips,

0:42

which is where you wanna assess morphology, add the tips,

0:47

you can see that this is indeed fused

0:50

and they have a single Raffi.

0:52

So this is a bicuspid valve by definition.

0:55

And, and, and the Seaver type, which is one Raffi.

0:58

So Seaver type one. Okay?

1:00

So that's one of the, of the findings that I wanted

1:04

to be able to discuss with all of you.

1:07

The other reason why we picked this case is, again,

1:10

bicuspid aortic valves tend to be very,

1:12

very difficult to size.

1:14

And you wanna want to look at when this

1:18

valve is going to have the largest dimension

1:22

and when phase in which phase.

1:24

Now remember we say normally 20 to 40%,

1:27

so sometimes 15% will come up, and that's reasonable,

1:31

but you wanna see it when it's largest.

1:33

And in this particular case, 20% tended

1:35

to be the the largest area.

1:38

Once you have that, the other issue

1:41

that came up on this particular case is the degree

1:43

of left ventricular outflow tract calcification.

1:46

There's a lot of calcium in this valve,

1:47

but I want you to follow this.

1:50

And you can see how there's a very prominent amount

1:52

of calcium single, it's protruding,

1:55

it's got quite the length, but it technically meets the

1:58

criteria for severe left ventricular outflow

2:00

tract calcification.

2:02

And, and we discussed that on, on the, on the lecture series

2:06

that I first you to review.

2:08

The good news is a lot of

2:09

that left ventricular outflow tract calcification,

2:11

you get a better appreciation

2:13

for the extent you're like in that short axis view.

2:15

Doesn't look to be that significant,

2:16

but when you look at it on this view, you're like, yeah,

2:18

that, that's a lot of calcification in the left

2:21

ventricular outflow tract.

2:22

It's the location and the risk of annular rupture.

2:25

So that's why it's important to ensure that we categorize

2:27

that correctly now in this valves.

2:30

And again, I want to kind of go over to

2:33

how do we align our planes to where they need to be?

2:36

And this is a really, really

2:38

challenging step in bicuspid valves.

2:41

And it's one of the things that tends

2:42

to be the most difficult things to be able

2:45

to do when doing TAVR sizing.

2:48

You want to be able to line up in this direction

2:52

and in this direction,

2:53

and you see how we keep missing this particular valve here,

2:58

See how we bring one in this direction?

3:01

And you're, you're kind of almost playing whack-a-mole with,

3:04

with this rotation.

3:05

And that that's kind of expected

3:07

because of the nature of it.

3:09

And that's why in bicuspid valves,

3:12

there's always this additional step to kind

3:14

of center your planes

3:16

and then once it's center to adjust it.

3:19

Because without that additional step, without

3:22

that adjustment, you are going to have issues with,

3:26

with getting the proper annual.

3:28

So see right here, almost there, right there.

3:34

And then in this particular valve,

3:36

you're gonna wanna center it.

3:38

You're gonna want to rotate to where this is, right?

3:42

And you see here how this is coming, just smooch

3:47

right here and a little bit this way.

3:52

And that's it, right, right in here.

3:57

There we go. Okay, this is our annulus

4:01

and we can see it large.

4:02

We can see it sharp.

4:04

And then we go to our tavr, uh, workflow.

4:08

Again, I would not click the oblique, I would go straight

4:10

to the measurements, right?

4:13

I would go to my landmarks, I would say left,

4:16

I would say, right?

4:18

And I would say non coronary cusp.

4:21

From here I go

4:22

to my three cost view, okay?

4:26

And again, you can change this from full to half.

4:31

Okay? Don't panic. Just click the landmarks.

4:35

It will show you that and you'll clean up the model. Okay?

4:41

And then your three views, check,

4:46

check, and check.

4:49

Okay, last

4:50

but not least, ends up

4:51

with your annulus diameters and measurements.

4:54

So again, you get into this

4:56

and you can start to appreciate this centricity

4:59

of this annulus.

5:00

Now the calcification is gonna make it quite challenging

5:03

for us to do that.

5:05

'cause obviously you can see

5:06

how the machine is having a little bit of a struggle

5:09

with it, but it is, it is an option.

5:12

One of the things that you can also do if you don't want to

5:16

have too much of this,

5:17

and again, this is more of a, a preference of mine,

5:23

is once you find your valve plane,

5:26

you can actually come in here

5:27

and use the, uh, polygon feature

5:30

and you can draw dots around it to be more in control

5:36

and, and have your measurements, uh, the right,

5:40

see, see, it'll give you the average diameter,

5:44

it'll give you largest, smallest.

5:47

And and you'll have this information readily available.

5:50

You can always also measure it manually.

5:54

So one, you can

5:57

Also measure this the other way too.

6:01

Okay? So that way you have your measurements right

6:06

from here, you actually don't have

6:08

to worry too much about the, the height

6:10

of this being inaccurate

6:12

because as long as your valve plane is set,

6:14

which it is, it's locked.

6:17

You don't really have to worry too much about like

6:20

where the annulus geometry is made.

6:22

'cause your, your height's already locked.

6:25

So you can see this height is locked

6:28

and then you can go to the right

6:30

and then again, get the, get the height

6:33

properly locked into place or measurement.

6:36

Okay? So we've done enough TAVRs for this,

6:40

but the most important measurements is ensuring

6:42

that your annulus dimensions and diameters match.

6:45

Here. We got 32.4, 24.5 with a main diameter, which again,

6:49

it's your average diameter, 28.5.

6:52

The area is rather large, 637 millimeters squared.

6:56

It's a, it's a pretty big annulus.

6:58

So the valve is going to be different.

7:00

The derived perimeter of 92, again gives you,

7:02

you're gonna be looking at the largest size valves

7:05

for this type of anatomy.