Chapters Transcript Video 2021 Virtual Cardiovascular Evening Symposium: Structural Heart and Vascular Surgery Updates 2021 Virtual Cardiovascular Evening Symposium: Structural Heart and Vascular Surgery Updates Originally Broadcast: Tuesday, November 9th | 6:00 – 7:15 pm CST Speakers Mario Goessl, MD, PhD Interventional Cardiologist Minneapolis Heart Institute® Update on Structural Heart Disease Interventions Describe the top three structural heart interventions offered at MHI Discuss when a patient should be referred for a possible structural heart intervention Explain how to refer quickly to the MHI structural heart disease valve team Jeffrey Jim, MD, MPHS, FACS Vascular and Endovascular Surgeon Minneapolis Heart Institute® When Should We Refer to a Vascular Surgeon? Describe clinical situations when a referral to a vascular surgeon may be useful Discuss the management of small abdominal aortic aneurysms Explain the rationale for treatment of asymptomatic carotid artery stenosis Welcome to the Spiritual cardiovascular symposium. My name is dr Mario Gasol and I'm also joined by my colleague Dr Jeffrey Jim from vascular surgery. You're gonna see some exciting talks I think from the two of us about 20 25 minutes. And first of all I really want to thank you that you're participating. I see that We have almost 80 or more now participants. Very exciting. And of course due to Covid this is what we have to do. But I think we're learning more and more and it is actually a pretty good um pretty good deal for all of us. As a reminder, you can ask questions and it should be an option on the screen. You can raise your hand or you can submit a question. I don't think we have a live questions um with voice but you can submit a question online and We will definitely leave 15-20 minutes at the end for questions going to try to advance here. Uh huh. These are two presenters today. Dr Peterson was unable to join us today. Um you will see my slide soon. Dr Jim who is the chief of vascular surgery. He's going to talk about karate disease, abdominal aneurysm and peripheral vascular disease. Kind of a hot berry and gives you an overview also um what is appropriate for a referral and I think it's going to be a really great talk as you saw in the video and for those who were probably not able to see the video up front. You can see that our programs and services are really comprehensive. When I looked at this today, I really didn't see anything that was missing from a cardiac standpoint. You see that we have 55 locations, outreach locations. Um and we're trying to really as you saw in the videos to cover the Minneapolis and outreach area quite well and we're always adding new sites as well. Um important here I think it was mentioned as well is that if you have an urgent question is cardiology curbside. So if you want to write down this number and I think chris and his team can share this later again or keep it up a little bit. This is the number down here that you can call monday friday 7 30 to 5 p.m. And there's always a cardiologist on the phone you can help you with maybe easy decisions like what's my next test but also if you need to uh but needs some help with the transfer of a patient. If you're using a smart smartphone then I can really highly recommend this one. Uh the image of a mobile app. It's very simple. It's really not complex. You can see the most important screens actually here displayed and it's really that simple and if you have a transfer patient you are connected directly to that physician there. So very common questions like for example a level one steady protocol for er physicians or if you have which tests when more simpler question everything is is anglicized is really a nice app that was developed a few years ago. We have also a web page here. I checked this out today. If you go to our web page the image I web page you can eventually get there to to for further links if you can't write this down. Um Those videos are really interesting. Um there's some videos about more complex procedures but also some very easy conversations about for example trans catheter or replacement. So I think we're trying to really get into all kinds of social media and media rounds to check it out if you if you like, if you like. Um there's a podcast as well. It's called cardiovascular conversations. I listened to this one today James callback very nice overview. He's one of the United Hospital structural heart disease physicians and that's all of the about tab for instance. Um There is a virtual compulsory um also on eight December at the same time. And um as you can see here, the invitations are coming through soon disclosures just keep it up here for a moment. So I think we can go to the presentations as I said dr jim is going to give you really a port Perry and my first slide is going to come up here very soon. So I'm the director of the trans catheter valve therapies for the Abbott Northwestern group. Um and I'm going to give you the update for a structural heart disease interventions that I think are very important to know and also to simplify it as much as possible. We still see that um Unfortunately many patients youtube probably busy practices are not referred for these interventions which are often much easier than a surgical intervention, but also sometimes it's just not penetrated yet. The guidelines are not penetrated or the knowledge that these therapies actually exists. And you are definitely available to send these patients for these specific therapies. So we're going to talk to about Taber quickly then trans catheter mitral valve replacement, which is really new and exciting. Um Also a option for a bicuspid valve uh repair some sometimes even replacement now and very important. Still left atrial appendage closure. I think um at least when I'm when I'm an outrage, I recognize that the knowledge penetration there is not really deep yet. Unfortunately. So for Tavern. Um I think the most important slide is almost this because and through very rigorous studies it is now possible to offer literally every patient trans catheter aortic valve replacement. And if you think about um how scared sometimes people about open heart surgery. It took a while. But we are now in 2021 at a stage where everybody can at least be considered. Sometimes it's not the best option and that has to be discussed with the patient. But any risk patient even the low risk patient Who might be 65, years old can now have a trans Kathy biotic valve. It's a very important step I think very important also for a primary care practice to know that. And if a patient shows the signs of severe aortic stenosis, maybe even close to that, don't hesitate to send them to a cardiologist because there's many options. Um brief videos, just brief really. What is trans Kathy aortic graft replacement, literally a catheter across the aortic valve there in the middle. Here's a video of a self expanding valve. Those are just different technologies that we use in various scenarios. But here you can see how a self expanding valve is placed within the patient's diseased aortic valve. And this is another example of what we call a balloon expandable. Well the difference is that in this scenario here the valve will not expand on its own. It needs the inflation of a balloon. And you can see this happening here shortly. Just slight differences in technology that we use as I said as necessary. We always have a very rigorous salve conference for every patient every thursday. So every patient is being considered there by a group of 20, sometimes 30 cardiologist insurgents before they undergo this procedure. And here you can see how the balloon inflates and then this particular valve is implanted within the anybody out these procedures are done now under conscious sedation. Important to know. So if you even if you have a patient who might be a little late by with the lung function you know is afraid of general anesthesia. Um much more than 90, of our cases are now conscious sedation. The procedure usually in in an experienced hand which all of us are Usually about 40 minutes if it's really without complications or any other extra procedures. And the patient usually leaves the next day. So all of this is very important I think to know how easy it has gotten and don't don't hesitate to refer a patient. Even if you think there's frailty in in the game or an age where you're unsure. I think it's very important to at least give the patient the chance to discuss. That doesn't mean that they definitely go get it. This is our show this because it's not just data from some fancy paper and the new England Journal. We have to submit these data in rolling quarters to a registry. So this this is what our data um you can see here death between one and 2%. That change is always a little bit in the running quarters. A stroke 1 to 2% basket complications where dr Jeffrey has to help us Maybe 3- 4%. The pacemaker rate. That's wrong. It should be 8-10%. It used to be really high and then we had to really work hard on that But we have now 8-10% and as you can see the length of stay is about one day. My chocolate. So if we talk about now the mitral valve we're moving quick but I think it's just to give an overview about what is possible. You don't need to know I think you know all the intricacies of these therapies but many people have heard about it again a trans catheter option for now every kind or any kind of much about disease whether or not it's a degenerative disease or more functional disease in a patient who has heart failure. Many trials have been done and this is now also commercially available. Typical picture at the end of the procedure looks like this literally like a clip. So you can see the two components. The bacteria posterior leaflet are clipped together by this white um clip my chocolate. You can place two clips sometimes three. Um The procedure is also about Um 16 minutes. Sometimes a little longer patient leaves the next day. But this is a general anesthesia procedure. Trans catheter. My autograph replacement. So this is new um or relatively new but you know may not be known out there very well. So the metro clip has been approved for a long time and now um devices are being investigated in pivotal trials or like here in early feasibility trials it actually replace the mitral valve again. Trans catheter technologies. No open heart surgery. Some will come out soon where we can do a transept oh through the ground formal vein procedure right now the most advanced systems often still plays through the apex like the first tavern studies that you might remember but still a much lesser invasive and much more tolerated procedure. Um We have for example participated participating in one of the most important trials out there. The summit trial with the belt that's called 10 9. As you can see here as an example you may have seen or heard about patients who have um mitral annular calcification. So this is a C. T. And moving CT or relationship is with me in the middle. You see something white which is basically born bone structure within the heart that signifies the annual list of the mitral valve. And this corporation has so much calcium developed that it develops in this all key mass. If there would be a surgeon here on the phone or on a computer he would probably tell you there's just no way that this patient would have um Surgical approach simply because the mortality rate would probably be 2030 40 to de bark this calcium. But with a 109 valve and you can see again I'm not going to go into all the details but you can see a metal structure here like a frame here as well. Been here you can see that this valve actually fits into this calcium structure and ring and can be deployed. So this patient now is symptom free and it was all done through the apex of the heart. Then the trick a spit valve and still a lot of work in progress there. But we're early, very early here. This is probably if you think about aortic valve was really the first completely taken care of. Now mitral valve very close of being taken care of with trans catheter technologies and now we're moving to the hospital which is a much more difficult valve and not anatomy wise, but even there we have options and it's basically the same company that makes the mitral clip has now a version of the catholic system, networks in the tri caspit about and I think I'm going to get help here when we move to a clip. That's just it's not long. Just maybe a minute. Keeping an eye here on my time, we apologize for this, but I could not download a video of this yet. This is so new. Um See if we can make this work. Otherwise we can maybe do it at the end. Yeah, here we go. So as you can see here, it looks like in my chocolate, let's see if I can Yeah, here we go. Super. He works. Yeah. So all of this, you know, is of course still um in trials. But you can see here again we go through a trance catheter system and we can explore them. Trick a spit valve. Usually three maybe sometimes four components again much more difficult imaging is more difficult and getting a very perfect result is also more difficult but you can see that the catheter is similar to the matrix. Very similar. It can be simply moved about the bicuspid valve. This is done under t guidance and with general anesthesia but you can at some point see that the clip is being opened, this is signifying the regurgitation, it can be rotated and you see that clip structure there. I'm sure the video is gonna switch over now so we can see how we get grass. The same idea with my chocolate. Right? So this is how we do my trick too. Who can grasp these leaflets and when you like it you can release that clip and you have a reduction if you don't like it. By the way, you can take the clip out and you simply refer the patient to a different procedure. Once you place the clip, you can't take it back so we can go back to the slides and sorry for some advertisement here and there. But you have to understand that this is so new. There's just no way this can be generic at this point. So as you can see here, these are really the first papers about the trick clip and I don't want to go into much detail here but you can see that um most of the reductions are really significant. So you can see that most of the patients who are going there are actually called massive or torrential TRS and you can see that some at least have a reduction. And now you would say, well does it really make a difference for these patients who really have no other option? A mild reduction of maybe one or two points in the trick. A spit valve makes a huge difference. Clinically they may use less Lasix. They might finally have an option to actually use Lasix again because it works. So I think we all think that despite the fact that we know we're not going to be surgical in this and that the track it might be a more crude method. But from a symptom standpoint we will be able to definitely help many patients with this procedure if I can get the control back and then um watchman. So again we're moving here fast but I think it's interesting Watchman for a tribulation. Um as I said in the beginning, I think I still see that there's too many patients out there that have atrial fibrillation for some reason are unable to take oral anti coordination and most of them when we talk about patients in a certain age would have high enough risk or that they should be on enter Corporation. But if you think that the patient is overall suitable for just a short term of warfare and just for some certain reason long term is not a good candidate. Those patients are ideal for Watchmen, it's a included device that will discuss here. But in my eyes, except for very few patients, there shouldn't be the patient in your patient panel that is not treated for stroke prevention when they have a tribulation. You either should have them on oral inter population or you should refer them to the watchman program giving them aspirin or something is just not enough. That was like five years ago. What we said, okay, we don't have anything, let's just do aspirin. It's just not appropriate anymore. There is another option and that is watchman. So anybody who has a defibrillation is either on oral anti cooperation and if not the first thing you should think about is Watchman for a similar device but we implant watch. So watchman flex um, is the new development on the left side. I'm just showing that because this on the right was Watchman the first watchman and some of the trials you might have seen right now coming out for competitors have been with the watchman the first one and the watchman flex definitely has some really nice new features that make it even better than the first version device. It is shorter, it has more coverage. The implantation is easier. It's a very elegant uh, device, here's some details about it and you can see that there's some Trials being done. You can see that the successor is really, really high closure in 100%. I know that there was just a paper coming out where a small percentage point made a statistical significance and made another competitor really happy. But you can see that um, watchman is There are good and watchman has been out there for a long time but you can see you have 100% closure and really low event rates very safe procedure for your patient. You can see that the event rates have even come down over time because of course patients and are more better selected and the procedure lists are getting better and better and you can see that really at least trials. The numbers are really impressive. It's important also to know if you already are thinking about a Washington patient in the beginning it was warfarin alone. Now it is any oral anti pregnant and ideally the patient after the watchman implantation is for Is on all integration for another 45 days. And I know that for some patients that's tricky. And we can always talk about options. There there are efforts being made to simply say the dual anti platelet therapy is probably enough as well. But more data have to be submitted first to make that happen. Right now We try the oral integration as good as we can from 45 days. That seems to be the safest. And then we switch as you can see here to do an anti platelet therapy for a while and at some point just to the BBS. So we went through that quickly. It's um 15 minutes or so and I think um if someone has questions about this in the future or at the end of the talk I'm happy to answer anything you may have again. We talked about tavern trans catheter mitral valve repair and replacement the watchman device and some trick a spit options. And I think my my last sentence is really if you have anybody with valvular heart disease, no matter what age, no matter what rest, please give them at least the chance of being evaluated by a cardiologist so that these options can be discussed and number two really nobody with atrial fibrillation should just be on aspirin for this prevention. We have we have better options with that. Um One of my partners here, doctor Jim, the Chair of vascular surgery is going to take over. Excellent, thank you Mario. I hope everybody can hear me. Um so you know, it's a great symposium until they invite the surgeon to kind of make it confusing. So it's my pleasure to spend some time talking everybody today. And the question I was asked was you know, a lot of times people don't really know when we should refer to a vascular surgeon. So the hope and goal is I can try to clarify that a little bit. If not make it more confusing, I'm gonna try to get control of the slides here. Um I do some disclosures, I work for various device companies teaching other positions how to do procedures. Um all the opinions are obviously my own, it doesn't represent many of the societal committees that I'm on. So variety of objectives really talk about hopefully give everybody a sense of when a vascular surgeon may be helpful in the care of your patients and I'll talk a little bit about some disease processes. Obviously with this about 25 minutes, I'm not gonna be able to get too far in depth, but I did want to give some cursory discussions about common things like small aneurysms, carotid disease as well as lower extremity, arterial and venous disease. Um with that being said, I think, you know, the question always is, you know, when do you want to refer to a vascular surgeon? And I think most people think, you know, really the word surgeon thinks, you know, you're going to get an operation from that referral and I think, you know, this is what everybody thinks about. You know, once you send them over, that's pretty much it, your patients going to get operated on. I think the first thing I want to kind of ease everybody's mind is a referral doesn't always mean, you know, your patients going to get an operation. I think it's a consultation that discusses some of the options and some of it may be including surgery, but oftentimes is actually not. Um people always ask what a vascular surgeon and to this day, um I try to explain to my mom and I always use that as a benchmark of how it explains. So basically my specialty essentially treats all blood vessels in the body with the exception of the heart. That's why we have our cardiology colleagues and a cardiac surgery colleagues and anything within the skull. So intracranial e every other blood vessels sort of within the realm of what I'm supposed to take care of. And really when you look at it, the way we treat patients, it's not just, you know, how to operate, how to do procedures. There's really kind of understanding, you know, the disease process and then hopefully, you know, combined with some technical surgical skills are great as well as using good judgment. But when it's said and done, I think one thing that may surprise a lot of physicians about my specialty is we actually provide a lot of larger general care and depending on what the patient needs. Sometimes this traditional open surgery, the classic served in that you think of very similar what Mario was talking about. We do a lot of endovascular techniques for vascular diseases as well. But I think more importantly, a lot of our patients and managed medically. Uh and then we follow and hopefully, you know, they don't need an operation. But when some, sometimes they do, we'll get to the point, we're ready for them. Um so here's what I want to talk about some of the more common diseases that you may see in your patient population or two. And venus diseases of the lower extremities, creative disease, probably the asymptomatic variety. Most of us don't work in an acute stroke center. And certainly aneurysms you may discover from other imaging. I want to talk a little bit about, you know, classic patient presentation, a little bit about the diagnostic confirmation if you're not really sure what your patient may or may not have this disease process or not. And certainly a little bit about the treatment options. I certainly understand that patients trust you guys. If you kind of relationship with your patients quite a bit, they're gonna ask you, hey, listen, when you're gonna send me to the surgeon, what does it mean? So it's good to have some idea of what those treatment options are. So, the first one I'll talk about is pretty common peripheral arterial disease. Um, I think one of the things that we always tell people, it's actually pretty underdiagnosed estimates are somewhere between 10 million of the population have it. Um, but it ranges in presentation. I think a lot of people don't have symptoms. Um, that kind of closet hiding with some peripheral vascular disease, but certainly the ones that you may see in patients in clinic would be one clarification or even more severe diseases where we call it critical limb ischemia. When you go ahead and look at the box on the right, You know they're very typical cardiovascular risk factors. You can actually see, you know these are men, older smokers, diabetes, hypertension. These are the people you always think of having you know, blood vessel problems. You know I always tell my patients when you have risk factors, you're not only going to get the coronary type of disease, you're pretty much going to get at different places. Now the challenging is you know, leg discomfort. A lot of things causes. And you see a lot of patients that have that particular complaint and it really kind of a lot of different you know things in the differential right? Musculoskeletal as you get older, some arthritis you may have pulled a muscle neuropathy is a pretty common thing. And we'll go over venus disease as well. I think one of the things that you have to have certainly is a you know, changing your physical examination really not having a great pedal pulse. A lot of people equate lack of a pedal pulse as an extreme situation actually. You know if you kind of come hang on my clinic waiting room, a lot of my patients don't have pulses but they do find um so it's not always just an extreme situations. Um if somebody has a palpable pulse, the likelihood of them having arterial disease is very low but you can really confirm with some noninvasive studies these are vascular lab studies. Um all of us remember you can even check your own blood pressures, check your A. B. S. Or we call them Ai depends on where you which part of the country you are really just looking at blood pressure at the arms and the legs to see what they measure. We do know it doesn't quite work sometimes in patients with diabetics with really calcified blood vessels but it's a good way to measure that because screening tool, once you think they have the disease process, sometimes we try to make them do exercises. You can bring out some of those symptoms of discomfort with exertion. So they'll actually walk on a treadmill with a little bit of an incline or if you don't have that available just make them do calf raises to really exert the muscle to really show the differences. A lot of times you just look at wave forms as long to really show that. So a lot of vascular lab studies can really confirm this diagnosis and this is some of the stuff you can see besides. Just actually getting blood pressure measurements and looking at you can see the quality of waves and this is something that we look at. You know this is just a scan of a print out that you can get in some of the laboratories where you can see a very beautiful try basic waveform we always remember from medical school and what I do on a daily basis. When you put the DACA program you hear that nice kind of wishing back and forth sounds as you get disease process that goes from trifles it beautiful waves up down and up to just up and down to buy a phase. It just certainly significantly diseased to monetize it. So this is something we can tell very quickly using a noninvasive study. The worst the patient gets us a little jelly on them for the Doppler exam to be able to identify arterial disease. You know I think the major consequences of having peripheral to disease is overall well being is not as great and the quality of life really is poor. They can't get around very well. They can't you know go to work sometimes for severe cases. Um They can't do the postman deliveries the classic board exam questions or sometimes as simple as you know some grandmother or grandfather wanted to play with the grandkids. They can't really chase them around the park. And the other one probably more important is this is a marker of their overall disease burden. So really we see significant cardiovascular morbidity, immortality not purely from ph. D. S. Not necessarily the legs but more important to talking about you know worry about heart attacks, strokes and all that kind of stuff. Um All patients when you see them when they had diagnosed with peripheral arterial disease. And we asked all of our partners in primary care cardiology wherever anybody else to die of ecologists. Endocrinologist to really help us with everything. The first and foremost is best medical therapy. I think the biggest one is usually smoking cessation. Most of these patients are still smokers. Um you know, that's really important. You want to control all the risk factors, so blood pressure medication medication and make sure their capital eczema control high dose stands, you know, put them on the anti platelet therapy. All those things have been shown significantly decreased, you know, not only limb problems but obviously for overall cardio protective effects. Really, what we recommend when we see these patients just get them on an exercise regimen. Um I always tell them it's almost like the training to be an athlete when they were younger. Um they have to walk a little bit more and then to the point where the legs are hurting, you can actually keep walking a little bit. I do caution my patients that if you start developing leg discomfort is okay to keep walking, but if you have chest pain you really got to listen to the cardiologist, stop. And that's a different situation. But with exercise, a lot of patients are able to walk a little bit further and overall it's just a better thing for their overall fitness. Um sometimes though we have to kind of do some treatment and this is where it comes into, you know, maybe endovascular versus open treatment. These are just some of the examples where sometimes we're able to do, you know what they puncture in the groin, taking pictures? An angiogram, you can see some narrowing disease there. We have a variety of different tools and toys. Um, to kind of burrow through this little diseased area, it's almost like going through a tunnel you can see we've got across, we go ahead and put a balloon in there and a completion picture really restores the blood flow Lot of times. Now we have much more advanced tools even than when I first started training 10 years ago, we constantly have newer device that really allows us to be able to successfully treat patients this way and more importantly, get a durable result. Sometimes though it doesn't work. The block is drilled and drilled and it's just not amendable for it. It literally is like a a concrete wall and you're trying to dig through with the wire, it's not going to work. And then we do here is an example of a bypass procedure. So that's still something that we do only if we really have to a lot of times we certainly prefer to do endovascular treatment because it's much safer in terms of the lower risk of complications for the patients. You know, contrast that. Now the venus disease. Now, obviously arterial disease people talk about quite often, actually, venus disease is actually more prevalent and probably even more underdiagnosed. Um, if we say somewhere between 8 to 10 million of us, adults have arterial disease up to 25 to 30 million actually, a venus disease. Um you know, now it's getting through the winter months, nothing will see it very often, but in the wintertime, when you go to the, when we used to go to the mall, go outside, walk around, um you look at people's legs and you see a lot of legs that look like this. Um this sometimes it is quite concerning. Um I think certainly there is a cosmetic concerns we can talk about a little bit, but more often if you actually the patients present to you will tell you they've had these for quite a bit of time. They kind of been watching it for maybe a decade or even two, but now we're starting to bother them a little bit. They notice, you know, sometimes relatively non specific things. Sometimes there's particularly localized in the vein. Um Itching the legs are heavy, they have some swelling. Um sometimes it gets really irritated. It's almost like an infection to get a phlebitis where some part of the superficial being caught off some pain, bleeding alterations are much more significant obviously presentations, but being this disease is quite common. I know a lot of patients go to the primary care physician uh to kind of talk about this and really if you look there's a lot of different ranges. So this is a clinical classification. I like always showing that because it tells you kind of the range of disease processes. Um, spider veins, One of those things you just kind of get as you get, you know, a little bit older, a little bit more spots in the legs. Um pretty safe things you can put your finger on it, there's no bumps in the legs. Um They may be kind of on site lead. You know, sometimes it can cause discomfort and then as you move down this clinical classification, as you move down, you get a little bit more severe varicose veins are these patients where you actually get the lumpy bumpy veins? Um you know, if you look at most people's like, there are normal to have some veins just like in your arms, but certainly varicose veins is a significantly higher degree. Very um you know, big dilated curvy veins. That's what you're looking as you get more symptoms though, people have more advanced disease, you're going to start getting some changes. People had, you know, being this disease for 2030 40 years, they'll come in and they're late, late, late middle age lives, they'll come in, you know, 50 sixties and be like, hey, my legs, it's just gotten worse over the past 20 years, you start seeing that and even more severe disease, you actually get people with alterations and those are usually people that have at some type of venus problem in the past. Maybe they were, You know, had a DVD when they had a car accident in 2030 years ago. So those people usually have a much more significant history of this disease process here is the underlying problem, babies are supposed to bring blood back and it works really well against gravity because you have valves built in the valves open up, blood goes up as you're supposed to towards the heart and the valve shut off. So it doesn't kind of go backwards. A varicose vein essentially is there is a problem with this valve mechanism, It doesn't quite close for whatever reason. Uh and now blood goes up and then backs down and basically you do not have completely returned. The diagnosis is actually pretty simple. You literally look at a patient's leg, they'll point to an area, you can put your finger on it visually, look at it and if it's a little bumpy, you're realizing they have some varicose veins. Um Not a lot of things to kind of confirm it, but if you worry about additional things going on and maybe worth about to do a venus duplex. So, a quick ultrasound just to make sure there's no deep vein thrombosis, obviously that presentation is a little bit different. People coming in with acutely change under swollen legs and stuff like that. But what we do when we see these patients and we do something called reflex testing in every lab calls it a little bit different. But we really we kind of put these valves to work and see if they're closing and they're supposed to, they're supposed to close within half a second that the valves don't close. That really helps us diagnosed that the patient has, you know, valvular disease, varicose veins, venous insufficiency. All those words kind of means similar things when we put it together, sometimes we treat them. So here's an example I stole from a textbook because I always forget to take pictures. Um you know, sometimes when people despite of AIDS really, most of these are kind of cosmetic issues rarely. Sometimes people will tell us, hey listen, this spot always seems to believe um you know sometimes the ladies when they're shaving the light so that was naked and but they've usually learned to stay away from it. Um most of the time we would do something like this where we kind of inject some sclerosis. Um really predominantly think of this as more of a cosmetic thing um you know, really does kind of makes it go away. It makes it prettier for a little while. But the sad reality is, you know, unfortunately they do come back just because as you get a little older you're gonna get more of these. But the things we really kind of think about are kind of these varicose veins um these are patients that will come in and tell you what a lot of discomfort from it. And sometimes to the point where they really have a hard time again during their jobs, their waiter that really has a hard time standing. People that work in the office, they constantly have to just move around cause they're not feeling comfortable, you know, still as everything in vascular, we try to do this non operatively. We really try to tell them, hey listen, there's a little bit of weight that always helps try not to be, you know, doing whatever it is you do at the same time, you know, without change. Trying to understand the whole day, put your feet up. If you sit, try to get up, try to change the routine a little bit exercise actually helps promote that um you know, blood flow back. It actually works things a little bit better. And people have usually learned to kind of keep the legs elevated anyhow when they're sort of resting at home. Um Usually we recommend compression therapy. So if anybody right now, for the next two months, write your, write a prescription for your patients get stockings, it works really, really well because it's gonna get cold out there and people love putting them on is a whole different issue when you start prescribing this stuff in, you know, may and june so I always like to say there's some seasonal effectiveness just because people always put them on, but that's kind of the primary goal. And sometimes if it doesn't really work, you may consider some surgical options. Um some of these are the classic, you know, surgery and may have heard of, We don't do these very often, but sometimes you literally go into the groin here, make a small incision and cut off all the branches there leading towards this surface pain that sort of flow in the wrong direction. Some of your maybe older patients may tell you that some point they had something like this. This is something that we rarely do now. Um Here's another one that people talk about quite a bit of paint stripping. So anybody who's seen it in the past, you know, or have patients gone through it. This is a pretty awful operation. Um Most of the patients will tell you I never wanted to do that again. This is back in the day where we make an incision in the groin. In this picture. We go towards the knee. But a lot of times used to go all the way to the ankle And you literally have this little device um and you pull the vein all the way basically inside out. I still remember doing this about 20 years ago and as a medical student and even back then I was questioning, are you sure we should be doing? That doesn't sound so great. Um pretty morbid procedure. Patients get laid up for a little bit because your leg hurts but really we replaced it to what we call now an ablation procedure. We're able to go ahead and bring you into their office. Use an ultrasound. Go ahead and put an I. V. In the lower part of the leg. Put a little probe in it. You the whole time we're talking to the patient we're just chatting about what they're going to have for lunch. Um We put this little probe in put some numbing medicine in heat it up and basically cooked the vein is what we kind of jokingly call it. When we heat it we get it to collapse. When that happens the brain doesn't flow anymore And it gets the symptoms significantly better. Usually they're in and out about 40 minutes or so they walk out kind of with the mummy wrapping the leg. Get on with the day. It's very minimally invasive and it works very very well. Sometimes we have to pluck these you know big disease veins out. We also do this in the office setting. There's just some pictures where there's big disease you know tortuous veins. Um You can't really put a Catherine but we literally kind of it's almost like pulling out a little worm in the legs. Here's a series of pictures where we're just taking and when it's said and done you kind of remove that segment of the vein. Um And you can sit there you can see this gentleman kind of just chit chatting with us the whole time with his arms crossed kind of telling stories while we're sort of removing it. Um seems a little protest but it's actually a pretty straightforward thing. It's not uncomfortable at all. And again, we're able to do this pretty quickly. Um and the elevation setting, it actually works very, very well. Uh switching gears a little bit now, you know, talking a little bit about creative disease, I think a lot of times people see patients with creative disease, we obviously worry about them causing strokes and again the symptoms are varied. I think in a primary care type setting usually discovered by either somebody having had a history of it. Or maybe you pick up a corridor brewing. We start off by saying, you know, right now from the US preventive services task force. The overall recommendation is not to just kind of randomly screen your patients. Um the reason for it is the yield is relatively low if you just screen everybody. And ultimately, I think there is some concern that once you have this diagnosis that causes a lot of issues for patients, but when you look at the specialty societies including, you know, the american heart, you know, the basketball surgical group, we think it's reasonable to selectively screen people. Um you know, people with Kurata breweries, um you know, it's not the most accurate, you know, exam right? But sometimes we hear it and this is nice and we find a fair amount of creative disease that way. Another, sorry, another way to do this is, you know, you choose based on people with other diseases. So you know that peripheral two of these coronary disease um you know, maybe aneurysms or you have significant risk factors. You know, those are people you may want to consider because they're obviously had a setup for developing that disease process. Again, really the way to do this, The diagnosis is just with an ultrasound. Um ultrasounds are great. You know, this is what you got to go to the lab that's certified our our text all certified. We have accreditation. We want to make sure these, you know, labs are being checked with the quality control and then they fit the standards. But basically you put a probe in the neck with some jelly and you're able to identify pretty quickly where the rat And we look at velocity criteria, how fast the blood is going to be able to determine how disease they are. The baseline than normal. Usually is considered less than 50 or normal, but anything higher than that. Usually we follow the patients and then ultimately they have severe disease. We potentially talked about interventions rarely do we jump right to something else. Like a cat scan or M. R. I. Obviously we find a lot of information. You can find some blockages, you know, lower in the chest. You can find disease in the brain. But obviously these are studies that require contrast radiation. Um and obviously higher cost. That's certainly not necessary until we actually plan potentially doing an operation. Again, management is medical, really important to tell the patients, Hey, listen, you got some disease process. Let's go ahead and make sure you take care of your whole medical things. So again, the same type of, you know, medical therapy and really we we go ahead and really most of the time interviewing only for symptomatic patients in very selectively now. I think over the past, You know, 10 years that I've since I've been practicing, but even 20 or 30 years before that, I think we're not lot less aggressive about intervening. Now, I think back in the day, people operate on anybody who had a karate diagnosis were much more reserved now because medical therapy is better and we know that people aren't having as many strokes. Here's an example. All of us remember sometimes we do these classic operations. I'm the plumber that takes down the wall, get control of the blood vessel, kind of move the plaque. Sometimes you do it by basically unfurling it and pulling the plaque out. That's certainly one way of doing it. Another example is always putting a stent to him. This is something that we've done for about a couple of decades. Now go from the groin. You find some narrowing. Here's a little basket what we call filter, your balloon, put a stent and you obviously open that up. Not done as very as often anymore. We know this procedure has a higher stroke risk. Um, to really reserve this in very select situation. And finally something called the T. Car procedure, which I think some of you guys probably heard about. It's kind of a hybrid where we make a small incision at the base of the neck and with protection from that standpoint to go and deliver a stent. And this is the newer procedure has been around for I think next in february we might you know, 10 year anniversary to the last time, the first time I did it. Um and it's been you know, basically been shown to be um you know much better in terms of outcomes. So and the last disease I'll talk about. I know I'm kind of jumping all over is aneurysms. By definition, aneurysms are when you have a blood vessel that's 1.5 times the normal diameter. A normal humans should be about two centimeters or any time a study shows three centimeter, everybody knows to call an aneurysm. Um We know again they're related to risk factors, you know, presentation certainly begun to paint and rupture. They hopefully you're seeing them in the emergency room. They've already started calling somebody like me at a different hospital to fly him in but you may feel it on and patients are thin enough to be able to feel some pulse utility. Um you know, here's a screening guidelines. There's one time screening that we recommend or the US preventive services task force. So this is a lot of times routine. Welcome the Medicare is up in the top right here. You know, one time screening with ultrasound for somebody, you know, the 1st 10 years when they welcome to Medicare and people that I've ever smoked. Um, days so far at this point are not recommending, you know, additional screening. However, a lot of data has been coming out in the past couple of years that realize if you're only screen based on this criterion to look at all the people that have presented for elective repair or ruptures. We're really getting at such a small amount. So there's some call to maybe expanding, You know, looking for this disease process a little bit more. Again, ultrasound is great. You slapped the ultrasound probe in the belly most of the time you're able to to do it. Um, and look for this big aorta that's sitting there normally. Or you see is much smaller, tube big, ultra big, you know, order a bigger bigger circle. Um You know, sometimes you're not sure because of the body habit. This is a little bit tough. Then a lot of times we'll use a contrast a ct scan if in this case you can see the contrast to study with the bright white there, but if people have some issues with um, you know, contrast, maybe allergy or maybe kidney issues and non contrast ct works real great way we'll look inside the abdomen at least tell us the size. Um, you know, treatment again really kind of depends, we want to focus on morbidity and reducing risk factors, smoking. There's some pretty good data from a couple of decades ago that we know that people that actively smoke have a higher risk of progressive enlargement compared with people that don't. And certainly that may actually put you in a little bit higher risk for rupture when you have the aneurysm, smoking cessation is definitely on the top of the list because patients always ask, what can I do? Is there is it safe for me to have this aneurysm? And I can honestly tell them the data says if you actively smoke, that's one thing we know that causes rupture. You know, the intervention list. This is just something for you to know. Um you know, we call aneurysms an aneurysm at three centimeters but we don't fix it for quite a bit of time. We think an aneurism grows pretty quick if it grows five millimeters half a centimeter per year. So we don't start even thinking about fixing it until I guess about 5.5 centimeters from men. And that's just because a lot of the old studies have done that when you do it, you know, sooner than that patients aren't necessarily doing any better women. There's some data now, potentially treat them when they're a little bit smaller. Um We do have some data that shows maybe they rupture a little bit earlier than men. So there's some lowering of the threshold, but a lot of patients they'll call you and you get diagnosed, you may see a smaller aneurysm uh and you can at least kind of give them idea, hey, I'll definitely send you the surgeon. But again, you know, you may probably not going to get an operation. They're just going to kind of follow you. And this is kind of the guidelines we follow. This came from my society and this came out earlier this year or a year ago. Looking at if you have a small aneurism in the three centimeter range, we usually have them kind of talk to them a little bit explained the disease process. Although no, most of the time they really much, hey, listen in three years I'm just going to call my primary and get it done. And I always say, hey, you can always call me and we'll order that study for you anybody with a 4 to 5 centimeter, which is the middle range here. We'll ask him to come back in a year and a lot of times you can just do an ultrasound ultrasound gives you enough definition, enough of the range of sizes that you don't need to do a ct scan. They'll come and get the ultrasound, you know, and then you know, right after come over to do the clinic visits as a one stop visit and then it got a little bit bigger aneurysm. Um that may want to follow a little bit closer and I started having some discussion potentially of the treatment options. Um here, you know, we love doing endovascular repair very similar to what dr Gossel um was able to show we're able to do everything through the groin. You can see basically there's an aneurysm. We put a little device in. This is a good contrast to see. Sometimes we have to make a decision, but nowadays we literally have a single hole that we make and put a little band aid on it. So it's very, very low invasiveness and people do very, very well. Um Sometimes though we got to do a big operation. So it's kind of cool to look in any order and you have to kind of go in because the anatomy is not great. But obviously this is a much more invasive procedure. The patient sits in the hospital instead of going home the next day. They're probably spending, you know, uh you know, a few days in the ICU just getting better and then eventually leaving home. So, you know, I think in terms of vascular disease, I'll wrap up here because my time is up, I really want to maintain an index of suspicion. You know, people that have, you know, vascular risk factors. These are the people that basically have the cardiovascular risk factors, they're probably going to have some vascular disease. Um clinical presentation is challenging. Sometimes have no symptoms. They just have the disease process or sometimes they get pretty significant. So it's always kind of tricky to figure out exactly where they're at. What's nice is vascular lab studies are very quick and really no risk to the patient. It takes a little bit of their time and make us some jelly in the clothes. But really no risk for them to really diagnose the disease process. And I always want to reinforce the fact that, you know, when you refer to a vascular surgeon, that doesn't mean an automatic survey a lot of times. I'll see a patient before I even kind of go through the discussion with them. I know that they're pretty concerned. I'll just start off by saying listen, we'll talk more, we start to do an exam. But I'll start off by telling you you actually don't need serving. It kind of makes them a lot more comfortable. You know everything I say after that though, I actually remember but really, you know, our role here is to as vascular surgeons is to help you manage your patients in a collaborative fashion to kind of make sure there's somebody kind of guiding them through their vascular disease process. And with that I want to thank you and I'll stop there and obviously again welcome questions that come through the Q and a. I see some of them are throwing throwing them on there as well and I guess Mario you want to join back as well. Kind of dressed some of the questions yeah great talk. I learned a lot. Um I see one of the first questions here just to make sure exactly. So you know anonymous candy it was saying. So are you saying a low V. A. S. Corp patient? I'm sure you mean the chance pass score less than 65 years old with no comorbidities are no longer a candidate for aspirin therapy alone. And then there's a question about watchmen, they ultimately end up on aspirin. Um Yes a very good question. And of course I don't want to confuse anybody. What I tried to say is patients who should be on oral anti coagulation. So we're not talking about the patient that you specify here, no comparability is less than 65 years old. That's a different question. You can argue that also for a long time I think if you would have a specialty panel about E. P. They might argue with you how strong the data really are about patients who are in atrial fibrillation and low risk. But for the watchman discussion for sure whoever wrote this is correct. But remember that I said patients who should be on oral anti coagulation. So that means they have a high enough chats vast score. It's the new chats basque or not an older score. So for example A female who has hypertension and diabetes is three. They should be on oral anti calculation or 65 year old male who has hypertension is three or 2, some chf symptoms and told em i it goes quick, right. But yes, those very, very low risk patients, you can certainly discuss and have aspirin. Um let's see if you're going to refer a patient to vascular or venus insufficiency, which you prefer the reflex testing an ultrasound to be done prior to it seems this can be difficult. Yeah, I know that's a great question. I think, you know, unfortunately it is a little bit of a specialty imaging. Um You know, most labs across the country are able to do test to rule out DVT is but to do actually the reflex testing, it's a little bit takes a little longer. Not all labs do it. So I think that's always nice to have it because sometimes it doesn't show much reflux and is something else. Um And the other thing I would say it's not necessarily mandatory because all the time re arrange for that to kind of make it so easy for the patients. Um and a lot of times if the patient just wants to talk about it, A lot of things that we try to do is not waste their time ordering a study if they don't really have very severe symptoms that they just want to discuss it. Um the reflex testing doesn't necessarily need to be done because it doesn't change our management. So it just saves them a little bit of time to but you know prefer but again we do realize depends on the different actors locations. Um not necessary. I think the next one is for me to um you know when a patient has a mild moderate stenosis of what interval do you recommend follow up ultrasound? So the guidelines a little bit all over the place I usually look at the first time I diagnosed, it depends if it's really diagnosis, relatively mild and moderate, I'm pretty comfortable waiting one year for it. The risk of stroke is significantly low, very very low um that we don't see really much benefit to doing it much more sooner than that. Um And we just a lot of times just tell the patients hey we can get it back within a year or so to kind of keep an eye on it. You know the care be careful sometimes even when you get a duplex that says, you know because they really only have three categories less than 50, 50-69 and greater than 70 and a lot of people fall right into the greater than 70. Um if they're truly asymptomatic, we're actually a pretty conservative and not operate just because it's that's greater than 70. Your numbers have to be much higher than that and that's something you won't be able to necessarily tell based on the conclusions. Um so a lot of times, even with the severe stenosis we will watch on a yearly basis as well. But another question about a defibrillation watchman, I I'm glad that there's these questions because I'm sure there's some confusion out there. Um Can aspirin be used for prevention of atrial fibrillation or is it no longer recommended for prevention? And I'm sure you mean prevention of a stroke? Right? Not not just because obviously any oral or whatever inter curriculum does not nothing for the fibrillation rhythm by itself, but I'm sure the stroke is missing here twice. But anyway. Um, so it's not as easy. What I would recommend is no matter what age, no matter who is sitting in front of you once at least go an epic or on your iphone or online and do the chests fast for the newest score. Um easy to find. I don't know if I can show it here on on a web page, but you have to do that score unless you know it all in your head, which I sometimes forget, For example, if you're 65 hypertension and your mail, that's already enough. So then aspirin absolutely is not. Okay. Right. Low risk patients who have A chats, vast score of zero and one and again one, you can argue with some folks, but let's say zero. Aspirin is okay or it appears to be open But anything other than that. And again, in a male, a score of two. And in a female, it has upgraded to three. So fema has a little bit more leverage. They have to be on oral anti calculation aspirin is not okay. Um just to make sure so again if you find a patient who should be on oral interview regulation but you cannot give it for whatever reason Ask us for help so that we can at least evaluate for the watchman and the patient may not want it but at least have that discussion. So be careful in who you prescribe aspirin For stroke prevention. It cannot be for the higher risk patients with chats vast for two or 3 cannot. So I was just I don't know if you guys can see but I always go on the computer. There's always some random website you find the chance to score because that's kind of what you're talking about. Just punching it in and stuff like that. No it's uh yeah and I I'm able to punch it all in but I still end up talking to my friendly cardiologist. Any help is sometimes I'm not quite sure. Hey I do have some questions for you to you know mara you guys uh obviously partner you guys quite a bit and seeing the growth of this whole field of you know um tavis and trans Catherine interventions and stuff you know compared and can you talk a little bit about the durability of these procedures Obviously you know as a surgeon we always traditionally thought, hey you know when you do surgery, you do this big thing up front but it's going to last you forever and maybe these, you know less invasive things you may have to pay back later. You know, can you comment a little bit about the durability of of these valvular things? Mhm. Yeah for for tavern it's the longest of course out there now almost you know 10, 15 years. Well what the data show off the first patients in these first trials is that Within 10 years we don't expect any significant deterioration. Of course there's always the bell curves. Unfortunately there are some people who deteriorate earlier and some who don't at all. So there is the bell curve but But um 10 years seems to be for tab are absolutely doable And I'm guessing we're going to approach something like all the other bio prosthetic valves. 12 to 15 years um for anything else. Very early. So for example for the trans catheter mitral valve replacement, we are in 23 year data. Now they look good But 10 year data we don't have yet. My check clip has been around for many years now. I think durability there for the device itself is not an issue but you know, is it enough down the road. You know I think when you use a micro clip you have to go to really experience center and even there, you know sometimes you do your very best and after a few years, the dilation of the annuals of the micro bob or you know something else that happened has leaked through again because the matrix literally is just that little clip in one area, right? So I mean it's just not perfect but um the advice is durable for sure but maybe the disease itself is not so durable. Um everything else, yeah, try clip very early, not sure. And watchman has been around for 10 years now with trials hasn't really shown any kind of erosion or anything. I think we have to be simply careful like in other devices too for thrombosis, you know and and and I mean infections and stuff like that, but also no super high signals there another thing I've really enjoyed watching you guys do this, I get the pleasure of you know and you're complication rates are very low so I don't get to actually go participate, which is great. But you know I get to see what you guys do and you guys have been doing some pretty cool stuff with sort of valve in valve, you know, kind of like a repeat tavern, so to speak. Um you know, is that something that you think will become a little bit more prominent as this technology has been rolled out? You know, 10, 15 years now at some point, you know, like you said these valves are just not meant to the last two decades and the disease process, you know the patient keeps they're doing great, but the rest of their heart and stuff keeps not doing good. You know, I've seen a lot of your work in that, so that's great. Um Yeah, I mean, I think the short answer is yes, absolutely doable. Um but I think now the discussion start, you know, what kind of valve, at what stage, you know, how much metal can someone tolerate in that area? Um You know, should you maybe as a low risk patient have a surgical about first then tavern later when you're older. I think there's a lot of discussions out there. I think one thing is for sure you shouldn't be a cowboy, you know, you shouldn't think like, you know, 65 year old, it's going to get like three Taverns and I don't think that's going to happen. Um but someone who had, you know, in the sixties by a prosthetic valve in in 75 needs a tab, I think it's very reasonable to put a tariff valve in a bio prosthetic valve. Hopefully giving you another 10 years, you know, um you know, I think that I think that's that's very reasonable. Yeah. Yeah. So I have a question for you actually because you know, sometimes of course is a cardiologist we don't see a lot of vascular disease is of course also prominent, but I sometimes struggle with this, you know, it seems like there's obviously a lot of pro activism first for some interventional vascular surgeons or interventional cardiologist even to kind of do something about, you know what you for this? Oculus genomic reflex reflex, right? You see something that fix it? Same thing for the coronaries. Um I mean when do you actually fix growth of vascular disease for someone? Yeah, that's a really good question. So, um first of all, I think, you know, the the way you treat a coronary is a little bit different, right? Because if you get the plaque rupture and the, you know, led like that's it. The division is no longer there, Luckily basketballs already doesn't really do that, right. Especially when you talk about lower extremities. So I think one of the things I think really want impressive other people's, we don't treat pictures. Um you know, you can have a picture of the worst looking blockage. They 99 pre inclusive. Um a lot of times, you know, with the exception of carotid disease, that's really the only thing we look at severity of the blackish or aneurysm based on the size. When you talk about lower extremity inclusive disease, we really treat based on patient symptoms because if somebody has some blockage, they have absolutely no symptoms, it's hard for me to say, I'm going to open up your blood vessel that make you feel better because you're walking perfectly fine. And what's nice about, you know, lower extremity arterial disease, you know, very, very rare if at all where the patient goes or they're kind of hanging out at home, no symptoms. The next thing they wake up, their leg is dead. That just doesn't happen. Usually something else has happened. So it's not from the blockage. So the presentation is always kind of a stepwise presentation and it takes a while before you get to the limb threat. So, you know, the right answer should be we really treat patients based on their symptoms because you know, if we just go ahead and treat based on, you know, the plumbing, what it looks like on imaging literally every patient in our, in our waiting area will get treated and that's not appropriate. It's just based on their symptoms. Can we make them better? Are they really limited by the likes because a lot of our patients will come in, they can only walk two blocks, but you really kind of tease out there like, yeah, my chest starts hurting. I get huffing and puffin then, you know, fixing their legs aren't going to actually make a difference. Of course. Got one more question here. Yeah. Someone with congenital by custody, aortic valve disease qualified for tavern. Uh, so yes. Um, it's definitely doable and and um studies are actually pretty good. Getting better on it. I would say it's just a matter of really a thorough discussion because usually those patients will be younger unless for some reason they Outlasted their disease. So let's say they're in the 60s and they have a very bulky aortic valve maybe even an aneurysm or borderline aneurysm. Um I would not recommend to tara about because as you can see in those videos you have to unblock it. Right? So you have to put a lot of power in this area. There's risk of rupture, there's risk of simply under deployment. Not really long term good results. So then you have a big surgery where you have to remove a bunch of stuff. I think it's very important to to discuss it with the surgeon and the intervention cardiologist. Look at the cases and I have to say, I think 80% of my patients end up having surgery actually for my custody aortic valve disease because there's something else going on that makes you need some fixing. And I think long term they're better surf that way then putting a tab of Alvin and that gets really crunched up And then you're really stuck in 10 years because there's only one way you have to take it out. You can't put another bag and that that mess down there. Um that's not good. So yes, it's possible. We've done it and in in in certain patients let's just do it because there's no other option. But ideally I think we would still see them to go to surgery. All right, well Mario I want to say thank you every time I listen to you talk. I definitely learned a lot. I'm sure the audience this as well. It was my pleasure to be able to spend some time. I don't think the audience for spending an hour with us. I'll pass it back to you to wrap it up for us. All right, Yeah. Thanks. Uh Dr jim. Hopefully everybody enjoyed it. We don't have more questions here. If you have more questions, just send them to chris or anybody, we can certainly answer them offline. Or you can call us during business office hours. So thank you for joining. I think we had over 90 patients. Excuse me, participants at some point. Um, so yeah, thank you very much for joining us here, virtually in in this these crazy times. Have a good evening, everybody. Created by
