0:00

For this next case,

0:01

we're gonna look at performing measurements of the annulus as well as some of

0:05

the supra annular structures for a patient valve and valve.

0:09

So you can see that this patient has had a prosthetic aortic valve.

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You can see the ring here,

0:15

this metallic ring on which the prosthetic valve so been attached.

0:19

And you can see the,

0:20

these additional metallic posts here from which the prosthetic valve is

0:25

suspended. You can see the calcification of prosthetic valve,

0:28

which is degenerated by echocardiography.

0:32

And the way we approach these cases is that we use that ring on which the

0:36

prosthetic valve is suspended.

0:38

That's gonna form the annulus for these patients because that's this rigid

0:42

structure that's gonna basically dictate how large the device is that we can

0:46

place.

0:47

And for this particular type of post-processing software that we're using,

0:51

these little color dots show you the point of the most inferior aspect at the

0:56

coronary cusps. In normal case. In this case,

0:59

we're gonna place these dots at the most inferior aspect of the surgical ring so

1:04

that we can define that plane really nicely.

1:06

So that's gonna be our annular plane.

1:09

And you're gonna use the bottom of that surgical ring to define all the

1:12

measurements you do. Um, subsequently.

1:14

So first what we usually do is we do a measurement of the actual annulus itself,

1:18

um, just the same as we would for a patient with a normal aortic annulus

1:23

and without a history of surgery. And it looks something like this,

1:27

you get a minimum and a maximum diameter as well as a perimeter in an area.

1:31

Those are the sizes for our sort of new annulus in this patient with prosthetic

1:35

aortic valve. The other thing we really wanna do,

1:37

and the most important thing is look at the coronary arteries.

1:39

So in this case you can see here's the left coronary artery,

1:43

and on this stretched vessel view,

1:45

which is part of this particular type of software,

1:48

it allows you to look at the distance, um,

1:50

by moving this little bar between the annular plane,

1:55

also known as the basal plane and the, um,

1:57

whatever thing is marked by this line.

1:59

So in this case can put the line at the bottom of the left coronary artery.

2:02

And you can see here the distance is three and a half millimeters.

2:04

That's really, really low. So these are very short coronary arteries.

2:08

So we have to be, um,

2:09

really concerned about risk of coronary artery obstruction in this particular

2:14

patient will do the same with the um, right coronary artery.

2:18

And you can see his right coronary artery has sort of a funny anterior origin in

2:22

him. And so if you look here right next to that green dot,

2:26

you can see the right coronary artery over here. And it's also pretty low,

2:30

six millimeters above the, um, annular plane.

2:33

So we should also be concerned about the right coronary artery.

2:37

Now another thing you do, which I've mentioned in the video,

2:40

is you can create the virtual transcatheter valve to coronary distance.

2:46

And so what I like to do for that is actually I try to create a circle and you

2:50

can do it, um,

2:51

fairly easily with these cases that approximates where your

2:56

new transcatheter valve's gonna live.

2:59

And then from that circle you can measure, um,

3:01

this is basically the outer edges of the, uh,

3:04

expected location of the new valve.

3:06

And you can see what I'm using here is landmarks are these posts which are gonna

3:10

be basically restricting the size of the valve.

3:13

So these posts are gonna represent the outer edge of the valve.

3:15

And if I use that information and then measure a distance from the

3:20

outer edge of this r o i to the coronary,

3:23

I get a really small number in that case. Three for the right coronary artery.

3:27

And for the left, it looks like it's gonna be a little bit bigger about,

3:30

you know, three and a half, well, not so much bigger. So there several reasons.

3:36

I think that this is going to be a really, uh,

3:39

risky procedure for this particular patient.

3:41

He has very low coronaries and also the distance between a virtual valve

3:46

to the coronary arteries is quite small.