SHA24/088004

Aortic Arch Mobile Thrombus in TAVR: the Direct Aortic Solution Basel Ramlawi,MD, MMSc, FACS, FACC, FRCSC Co-Director, Methodist Aortic Network Cardiothoracic Surgery & Transplantation Methodist DeBakey Heart Center The Methodist Hospital Houston, TX

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Left Carotid Angiogaphy

M2 Cutoff

Flow Restored Basel Ramlawi, MD Bramlawi@TMHS.ORG

Angiogram Pre and Post Rescue

PRE

POST

Basel Ramlawi, MD Bramlawi@TMHS.ORG

MRI AT 24 Hours

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Clot Retrieved from M2 After Hemiparesis Noted • Minor residual deficits • Walking in ICU next day…

• … Prevention better option!

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Case • • • •

82M with severe AS. Very poor lung function FEV1 <30% predicted Renal failure with HD EF 25%, previous stents, mild MR

•  Accepted for TAVR. • Preoperative TEE in OR showed…

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Technical Considerations: Determine aortic access site is â&#x2030;Ľ6 cm from the annulus Assess location of the ascending aorta (midline/ant chest wall) Select access site to achieve a delivery trajectory that optimizes coaxial alignment with native aortic valve Assess calcification Identify critical vessels (esp location and course of patent LIMA or RIMA grafts) Basel Ramlawi, MD Bramlawi@TMHS.ORG

11

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Mini sternotomy vs Anterior mini thoracotomy

Basel Ramlawi, MD Bramlawi@TMHS.ORG

13

Basel Ramlawi, MD Bramlawi@TMHS.ORG

Aortic Arch Mobile Thrombus in TAVR: the Direct Aortic Solution Basel Ramlawi,MD, MMSc, FACS, FACC, FRCSC Co-Director, Methodist Aortic Network Cardiothoracic Surgery & Transplantation Methodist DeBakey Heart Center The Methodist Hospital Houston, TX

Basel Ramlawi, MD Bramlawi@TMHS.ORG