So, valve and valve taver, so, you know, on the one hand, it's easier. You see the valve. You know where to put the new valve, but it's actually harder. So one of the problems is mortality after valve and valve taver is an issue. The smaller the surgical valve, the higher the mortality. We think that's due to patient prosthesis mismatch. Danny DeVere's, you know, vivid registry shows this very clearly. This is not subtle, this mortality difference, right? If you have a small surgical valve and you do valve and valve taver, you have a higher mortality. Impact of implantation depth. So we kind of talked about it in the native valve, but the higher you implant your taver valve inside of a surgical valve, the better the hemodynamics will be as well. But despite implantation depth, patient prosthesis mismatch is an issue. And so, you know, we've talked a lot about bioprosthetic valve fracture. So it improves hemodynamics, and I think that's very clear in this, you know, series of 66 patients. Baseline gradient is 40. After valve and valve taver, it's 19. That's better. It's not great. And after bioprosthetic valve fracture, the gradient is 8. And so obviously we think that that's beneficial. Most surgical valves can be fractured, and we've done this bench testing, and we know which valves can be fractured and which can't. Some valves can be remodeled, and I highlighted a couple of, like, nuances. So mosaic valves, for example, are made out of one of two different polymers. You don't know which polymer the valve you're treating is made with. If the polymer is a darin, it can be fractured. If it's peak, it can be remodeled, and you don't know that until you do it. And so I'm not going to have time maybe after to talk about it. So the older generation paramounts don't have the ribbon like a Magna valve has. Those are going to be remodeled. The ones with the ribbon, like a Magna valve has, those are going to be fractured. So you just kind of have to know these things going in. Apart from hemodynamics, we think that THV under expansion, regardless of hemodynamics, can impact long-term durability, right? So on the left, you have a constrained valve. And the leaflets open, they're scalloped. When they're closed, they're pinwheeled like this. And on the right, you've got no scalloping and no pinwheeling, right? And so hopefully that improves long-term durability. One of the, you know, questions we talk about a lot is whether we should do BVF before or after valve-in-valve TAVR. So this is just recently published. So data using sapien valves only from the TBT registry. It appears that if you do, so if you look at the bottom left panel, if you do the BVF first, there's higher mortality in hospital mortality as compared to not doing BVF at all. And there's very little difference in valve area and valve gradient compared to not doing BVF at all. On the bottom right panel, if you do the valve-in-valve TAVR first and then BVF, no significant difference in mortality. And now you actually have a difference, a larger aortic valve area and a lower aortic valve gradient as compared to not doing BVF. And we think that's because doing that high-pressure inflation last is what really, you know, optimizes expansion of the THV. So I already showed this slide. So if there's a difference in valve-in-valve TAVR with a surgical valve, there should be a difference in valve-in-valve TAVR with a THV and THV as well, although it hasn't really been studied yet, right? So the smaller your THV, the more patient prosthesis mismatch you might have with your TAV and TAV, right, even though we haven't really studied this yet. So this is a case we did a few years ago. So we haven't, you know, this is all coming. We're going to get all these TAV and TAVs, but we haven't, it hasn't hit us yet, right? So one of our cases from, you know, a few years ago. So original sapien valve, okay, 23 sapien. I think it lasted eight years, something like that, severe AS, and, you know, I'll be honest, I didn't really think about it. 23 sapien, we'll put a 23 sapien in, right? No-brainer. So look at this. It's not expanded, right? So we hit it with a true balloon, didn't do anything. Our mean gradient was 16, our AVA is 1.4 afterward, you know, so better. It's kind of like the BVF slide I showed. It's better, but it's not great. And so, you know, when you look back at the CT, the 23 sapien wasn't 23 in the body. And this is part of the, this whole conversation, I love the conversation, but it's not 23. And the height that you're talking about is not, that's the height on the bench. It's not the height in the body. And so we need to like, you know, figure out these nuances. So in retrospect, if I had to do this case, I would have put a 20 sapien in, you know, maybe 20 plus one or something like that, you know, and I think that would have been better long-term. There is some talk, just so you may have heard, that if you want to put a 23 sapien in, do the balloon dilatation first, okay? So if you want to make this a 23, before you put the second sapien in, do the true balloon inflation and try to get it to 23. I don't love it, okay? So the reason BVF, I'm going to go over time for sure, the reason BVF is relative, you know, we think safe is because the valve is super annular, okay? And so when we fracture the valve, it's fracturing, you know, it's expanding into the sinuses. This is annular. And I don't know that you can make this 23, what the safety of that is, okay? So Molly went over the coronary stuff, so I'm just going to say, you know, one of the issues with coronary protection, so this is what we used to do, right? Protect the coronary. We've got a stent in the mid-LAD. We put our sapien in. Patient has hypotension, anterior hypokinesis, LVDP is 55. This patient is crashing, right? We put the guide in. Is this, is the left main obstructed? Doesn't look like it, does it? So we stented the left main, everything resolved. So it's not occluded. It is for sure obstructed, and it is very hard to tell, okay? And the problem is that when you coronary protect, so we've got, you know, we may have a guide. We've got a wire. We've got a balloon. We've got a stent. That's helping to prop the leaflet away. And so we've had the issue where you can't tell, and you're actually protecting, you're protecting the left main by protecting the left main. And so it's not an ideal situation. We've also had this issue, you know, everything was fine, but we can't get the stent out. Stent is stuck, so we deploy the stent, and that's the only way to get out of that problem. And that's why, you know, basilica and other things are, you know, potentially beneficial. Molly went over this stuff. This is a different way of saying what Molly said a little bit in the native. It doesn't matter if it's native or not, but the coronary artery has to be, you know, kind of in the middle of the leaflet that you're lacerating. Otherwise, basilica is not going to help you, okay? So it's all about orientation too. And then the issue with basilica for TAV and TAV is that if you do a basilica, and the leaflet is supposed to splay, right? That's the whole point. But now you've got the frame of the THV that prevents it from splaying out. And so you don't get the same benefit from doing basilica in a THV. And so, you know, we're not quite sure what those, you know, like what, you know, how protective it'll be. So we have, you know, we have this balloon-assisted basilica where you, when you traverse and then inflate a balloon to kind of increase the splay, maybe that'll help. And then, you know, unicorn, but the shortcut, you know, maybe really the, I mean, this is super cool. So, you know, just very mechanical, you know, almost like scissors really, right? When you say to slice the leaflets, you know, it doesn't take long, very, very much easier than basilica. So does BVF increase the risk of coronary obstruction? So it depends where the coronary is, right? So think about your, like, look at the, you know, right hand panel, right? Your sapien valve is like a flower pot, right? It's constrained where the ring of your surgical valve is, but at the outflow, it's fully expanded, right? So it's 23. It's 23 up top. It's constrained at the waist, and it's, you know, not constrained in the LVOT. So if the coronary is here, right? If your left vein is there, BVF is not going to change your risk of coronary obstruction. It's not going to do anything up there. It doesn't change anything. If your coronary is here, then yes, BVF may affect the risk of coronary obstruction, and you have to look at your CT in advance and make those measurements and determine what your risk is. So summary, valve-in-valve TAVR in small surgical valves, you know, is associated with PPM and higher mortality. High implant depth improves hemodynamics. BVF and BVR result in lower valve gradients. Need to assess for coronary obstruction and protect. And we need a lot more research into TAVR and TAVR, I think, to understand, you know, what the best practice is. Thank you. Thank you. Thank you.

valve-in-valve TAVR

mortality

patient prosthesis mismatch

implantation depth

hemodynamics