These are my objectives to recognize the importance of the first valve on future interventions in coronary access and to discuss the prediction of risk plane for the first valve when reintervention on the aortic valve is needed. So TAVR itself may not be the hard part. It's knowing if we should TAVR and how we are going to do it. I say this a lot that I think more and more it's getting harder to know who is the patient that you should do. There's lots of things that we have to think about. And there are three problems. One, we need to decide should they get SAVR, should they get a balloon expandable valve, or should they get a self-expanding valve? The second problem is coronary access. So will there be coronary access once you put this existing TAVR valve in? And then valve and valve and whether or not you're going to get coronary obstruction. So these are the three things that you have to think about when you're choosing your valve in the index case. So problem number one. When you're thinking about whether or not you're going to do SAVR or balloon or self-expanding, a lot of times we think about the age of the patient. And that's the probability of developing coronary disease or if they have existing coronary disease and whether or not you're going to have to go back in and re-access those coronaries. Secondly, you think about the anatomy of the native valve itself because you have to look and see are you going to get coronary obstruction from the leaflets or sinus sequestration which reduces flow to the coronaries and essentially cause coronary obstruction. And then a little bit more rare, but still, we're putting a lot of osteolefemain stents in. Whether or not there's existing stents in the osteum already and what's going to happen when we put the valve in. So let's go to the first, the age of the patient. And why is that important? Well, is it better for them to get SAVR plus CABG? Because as much as we like to think that PCI, you know, improves mortality, we've still never really been able to improve that. So is SAVR-CABG better? Or is TAVR-PCI better? And we have some trials coming, like, complete to see if this will make a difference. And then the mortality benefit as well as life expectancy. So how long do these patients have to live? And is it better to undergo surgery or is it better to undergo TAVR? So there's a lot of simulations out there now. This is one. This is AI from DOSI simulations that we use every so often to try to predict if there is going to be a coronary obstruction because that will decide whether or not you're going to put a TAVR valve in or surgery. So in this case, this was a balloon expandable 29 with a high risk for left coronary obstruction. So in this patient, we would probably not put a TAVR in. This is again the same patient where we looked at, well, if we do a lower implantation, can we get away with a TAVR valve? And in this case, if you did an 80-20 deployment, then you have a less risk of coronary obstruction. So it makes you have to know what the S3 and EVELUTE measurements are. So you really need to know how high that skirt is or how high the valve is and how it's going to sit on the annulus. And these are things that you really need, especially as we put them into younger patients, you really need to think about so that you prepare for the future of them. So for instance, in a self-expanding valve, you need to know your SOV measurements because your risk of left main coronary obstruction is if it's less than 12 millimeters and if the sinus salvo width is less than 30 millimeters. So what about existing stents? This is someone who put an RCA osteostent in, and as you can see, it's hanging out into the—hanging out, and so if you put a 26 balloon, which is what this patient required, you're going to cause a crimping of that RCA stent. So if this patient is inoperable, then you have to decide how you're going to treat that to protect that coronary stent. The second problem is if you have a TAVR and you have coronary disease, is your coronary access. I know there's a lot of Evolute operators in here, but I personally cannot stand having to go back into an Evolute to do a coronary. It is just not fun. Is it doable? Of course. But it's just not fun, and you have a lot of operators out there that they look at—they do an angiogram on someone who has an Evolute, and they're like freaking out. They take them off the table, and they send it to somebody who's a TAVR operator and let them deal with it. So these are things that you have to think about in the future about, you know, who you want to reengage their access. So with that, these are the factors that impact coronary access for a self-expanding valve or at least the Evolute. You need to know your sinotubular junction dimensions, your sinus heights, your leaflet length, which a lot of people forget about the leaflet length, the sinus to valsalva width, and the coronary height. And for a sapien, you want to look at the commissural tab orientation because they don't really have commissural alignment. The new valve that's coming out that we're waiting for does have commissural alignment. Ceiling skirt height and valve implant depth. So in a sapien, even—we don't really use XTs anymore at all, but the cells of the sapien 3 are 33 percent larger than they were in the XT, so they're a little easier to get back through if you have to get back through, though you usually don't need to go through because it's a lower valve. You have to know your STJ height and diameter. If the valve is implanted too high, it may be challenging or sometimes even impossible to get into the coronary. So the bottom picture shows those red dots are 10, 14, and 18 millimeter coronary heights. The red line is the annular plane. So depending on where you place that valve, if you placed it higher, you could have your coronary that's below and in that skirt. So sometimes you need guides that—I mean, you need coronary wires to help pull your guide in in that situation. So a CT scan prior helps you know where your coronary access is. For a self-expanding valve, the concave portion of the frame ensures that the device is not touching the coronary ostea. However, the implant depth is important, and we are—you know, the cusp overlap, you're being told that we need to place these things much higher, but you need to note about the skirt height, that it's 13 millimeters, and if you're—and your implant should be at least 4 millimeters below the annular plane to ensure that the skirt is not overlaying that coronary artery. But yeah, we're told to go, you know, the implant depth at zero. And a lot of times it doesn't matter, but again, you need to be thinking about these things, especially when you're putting these valves in younger patients. This isn't really a problem that much anymore because they now have the commissural alignment on the valve, but we're going to be seeing, you know, patients from before, before they had this particular valve. Actually, we're now—I don't know about you guys, but we're starting to begin to see our TAV and TAVs coming back, and so we didn't have this before, and we weren't thinking about these things as much before, and now these people are living and coming back. So you need to make sure that the commissural line is not blocking your hostia, and again, you may need coronary wires to help pull your guide in to be able to do interventions on these. So really planning with the CTA is important. Then what about catheters and guides? Kenny wrote a great article that was published to help everybody know what kind of catheter or guide to use. For balloon expandable, your standard catheter and guides are pretty much all that you need, but for your self-expanding valves, a lot of times you have to use a table wire to get into the cell, or you may need a stiff glide to get your catheter in, and you usually have to size down to—if you use JL-4s, you need a JL-35, and size down when you're doing radial. You know, you already may be using a JL-35. You may need a JL-3. You also have to downsize your guides, and again, you may need the coronary wire to pull in your guide extensions. And then the third problem, the valve and valve. The valves are being placed higher and higher, and I worry more and more about putting a second valve in and coronary obstruction in leaflets. There are things like Basilica and then the Unicorn, which is so much easier than Basilica, or at least not as much equipment. You can get sequestration of sinuses and then valve modification issues. So these were courtesy of Steve Yock. These are your VTC distance. This is low risk for coronary obstruction. Your VTC distance here, the LCA osteum was approximately 11.8 millimeters to the leaflet border for a surgical aortic valve, so this was low risk. Here's an intermediate risk where the osteum is 6.7 millimeters to the leaflet border on the left, but the right was 3.6. So this, you begin to worry about having obstruction there when you put a valve in. But then here's the high risk. This was actually a surgical valve that had the leaflets on the outside of the stent, so you need to know that too, whether it's on the inside or the outside. In this left, coronary osteum was 3.7, but the right coronary osteum was 0.5. So this is high risk to having coronary obstruction. So you say, oh, well, we can just do, you know, basilica, but this paper came out and showed that not all people can have basilica. So this is the valve that's in China. It's the venous A valve that looks awful like Evolute, but it's not. And what they found when they looked at bicuspid valves, type 0, type 1 bicuspid valves, both of those, and then tricuspid valves, they found that basilica was not feasible in 60 percent of their cases, because even if they tried to split the leaflet, you would still have coronary obstruction. The percentage was actually lower in type 0 balloon—I mean type 0 bicuspid valve than in type 1 or tricuspid valve, but you can't always do basilica. And then you're stuck with, you know, what do you do? Do you do surgery or do you do it anyway and try to protect the coronary? So in summary, you know, we have to really think about the lifetime management of these AS patients, especially as we're getting lower risk in younger patients. It does matter what valve you pick and where you place it. Not everyone may be able to get a valve-in-valve. You need to try to predict this beforehand, and we can use AI and CT algorithms to help us try to figure this out. Thank you.

first valve importance

coronary access challenges

SAVR or TAVR decision

coronary obstruction prevention

CT scans and AI algorithms