tavr: it’s a career, not just a procedure!...tavr: it’s a career, not just a procedure! jeffrey...
TRANSCRIPT
![Page 1: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/1.jpg)
TAVR: It’s a Career, Not Just a Procedure!
Jeffrey A Southard, MD
Cardiology May 5, 2012
![Page 2: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/2.jpg)
Transcatheter Aortic Valve Replacement
• T- eam • A- pproach to • V- alve • R- eplacement
UCDMC Team • Administration • Cardiology • CT Surgery • Anesthesia • Nurses • Cath Lab Techs • Perfusionists • Echo staff • Ancillary support
![Page 3: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/3.jpg)
Before You Start
• Do you have a hybrid OR? • Do you have the necessary equipment? • Do you have the necessary staff? • Are you sure you want to do this? • Novelty wears off very fast! • These patients are very old, very needy
and have lots of concerned family!
![Page 4: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/4.jpg)
Aortic Stenosis
• Symptomatic Aortic Stenosis - Surgical Aortic Valve Replacement is the standard of care
• Surgical Aortic Valve Replacement - Mortality Risk
Isolated AVR - 3.3 to 5.7%
AVR with CABG - 6.8 to 7.3%
• Percutaneous Aortic Valve Implantation in high risk aortic stenosis patients - feasible and safe
![Page 5: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/5.jpg)
Aortic Stenosis – Etiology
Calcific degenerative • Degenerative process with proliferative &
inflammatory changes, lipid accumulation, up regulation ACE, infiltration with macrophages & T lymphocytes . Bone formation (vascular calcification)
Congenital - Bicuspid • Turbulent flow - traumatizes leaflet
fibrosis, rigidity, calcification & narrowed orifice Rheumatic
• Adhesion & fusion of commissures & cusps retraction & stiffening cusps borders.
• Calcific nodules both surfaces - small round or triangular opening
![Page 6: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/6.jpg)
Prolonged latent period - morbidity & mortality very low Symptomatic aortic stenosis - Cardinal symptoms
Angina • Syncope • Heart failure Onset of symptoms - Outlook changes dramatically
Average survival 2 - 3 years - High risk of sudden death Management decisions based on these data
Asymptomatic - Conservative treatment Symptomatic - Aortic Valve Replacement
Failure
2 3 5
Angina Syncope
AV. SURVIVAL YEARS
Onset Severe Symptoms Latent Period
(Increasing obstruction Myocardial overload)
100
80
60
40
20
40 50 60 70 80 63
Average age death (males)
PE
RC
EN
T S
UR
VIV
AL
AGE, YEARS
![Page 7: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/7.jpg)
Symptomatic Severe Aortic Stenosis
ASSESSMENT: High Risk AVR Candidate 3105 Total Patients Screened
PARTNER Study Design
High Risk TA
ASSESSMENT: Transfemoral Access
TAVI Trans
femoral
Surgical AVR
High Risk TF
Primary Endpoint: All Cause Mortality (1 yr) (Non-inferiority)
TAVI Trans
femoral
Surgical AVR
1:1 Randomization 1:1 Randomization
VS VS Standard Therapy
(usually BAV)
ASSESSMENT: Transfemoral Access
Not In Study
TAVI Trans
femoral
Primary Endpoint: All Cause Mortality over length of trial (Superiority)
1:1 Randomization
VS
Total = 1058 patients
2 Parallel Trials: Individually Powered
High Risk n= 700 Inoperable n=358
![Page 8: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/8.jpg)
Absolute Reduction in Mortality Continues to Diverge at 2 Years
8
![Page 9: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/9.jpg)
> 30% Absolute Reduction in Cardiovascular Mortality
9
![Page 10: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/10.jpg)
Valve Clinic
• Must have a dedicated valve clinic • Must have a dedicated valve nurse • Must have CT surgeons with you in clinic • Should have multiple screening exams
done before patients are seen in clinic • Janine will go over screening exams • All data must be submitted online to
Edwards for approval
![Page 11: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/11.jpg)
Valve Size Selection
• The SAPIEN valve is intended to be implanted in a native annulus size range comparable to the following TEE measurements:
11
Valve Size to Annulus Diameter
23 mm valve
Annulus diameter by TEE
26 mm valve
18 mm 19 mm 20 mm 21 mm 22 mm 23 mm 24 mm 25 mm
![Page 12: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/12.jpg)
Valve Size Selection
• In annulus diameters 21 mm and 22 mm, either a 23 mm or 26 mm valve may be implanted
12
Valve Size to Annulus Diameter
23 mm valve
Annulus diameter by TEE
26mm valve
18 mm 19 mm 20 mm 21 mm 22 mm 23 mm 24 mm 25 mm
![Page 13: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/13.jpg)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
23 mm valve 26 mm valve
Effe
ctive
Orif
ice A
rea
(cm
2)
23 mm or 26 mm Valve?
• The primary goal of aortic valve implantation is to maximize the effective orifice area and reduce the mean and peak pressure gradients – When possible a 26 mm valve should be implanted in annulus diameters
21 mm and 22 mm
13
Effective Orifice Area*
![Page 14: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/14.jpg)
Transfemoral Room Setup
14
OR/CCL Staff
A
E
IP* PA CTS
DPL
Fixed C-arm
OR/CCL Staff
OR/CCL Staff
OR/CCL Staff
P
RAPID PACER
Ideal room size is >800ft2
Edwards Product Preparation Table (≥150cm)
Members of the Heart Team present in the TAVR procedure: • IP: Implanting physician (Room-setup shown for transfemoral procedure) • PA: Physician’s Assistant • CTS: Cardiothoracic Surgeon • A: Anesthesiologist
• E: Echocardiographer • P: Perfusionist • DPL: Device Prep Lead • OR/CCL Staff: Operating Room/Cardiac Cath Lab Staff
![Page 15: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/15.jpg)
Prepare the Patient
• RIJ large sheath and PA catheter • Radial arterial line • General Anesthesia • Oral Gastric Tube • Foley catheter • Full surgical prep • TEE probe in place • Defibrillator pads in place • IABP leads on the patient
![Page 16: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/16.jpg)
![Page 17: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/17.jpg)
Puncture Site
17
![Page 18: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/18.jpg)
![Page 19: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/19.jpg)
![Page 20: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/20.jpg)
96402 (25 mL) Two Atrion QL2530 Inflation Devices
9120BC20 (20 mm x 3 cm) RetroFlex
Balloon Catheter
9000TFX Edwards SAPIEN Transcatheter
Heart Valve
9120S23 (22F) RetroFlex
Introducer Sheath Set
RetroFlex 3 Transfemoral System
20
23 mm RetroFlex 3 Transfemoral System
9120FS23 RetroFlex 3 Transfemoral
Delivery System
9100DKS7 RetroFlex Dilator Kit
9100CR23 Crimper
![Page 21: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/21.jpg)
96402 (25 mL) Two Atrion QL2530 Inflation Devices
RetroFlex 3 Transfemoral System
21
9100DKS7 RetroFlex Dilator Kit
9000TFX Edwards SAPIEN Transcatheter
Heart Valve
9100CR26 Crimper
9120BC23 (23 mm x 3 cm) RetroFlex
Balloon Catheter
9120FS26 RetroFlex 3 Transfemoral
Delivery System
26 mm RetroFlex 3 Transfemoral System
9120S26 (24F) RetroFlex
Introducer Sheath Set
![Page 22: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/22.jpg)
Edwards SAPIEN Valve Model 9000TFX
22
*No clinical data are available which evaluate the long-term impact of the Edwards Lifesciences tissue treatment in patients.
Edwards SAPIEN Valve • 23 mm and 26 mm valve sizes
• Stainless steel frame
• Bovine pericardial tissue
• Carpentier-Edwards ThermaFix process*
![Page 23: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/23.jpg)
Edwards Crimper Models 9100CR23 and 9100CR26
Uniquely designed to crimp transcatheter heart valves
23
9100CR23 9100CR26
![Page 24: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/24.jpg)
RetroFlex 3 Delivery System
Tapered Distal End
Articulating Delivery System
24
Flex Catheter
![Page 25: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/25.jpg)
Valve Crossing and Wire Exchange
25
• Cross native valve with straight wire (suggestion: AL1 or AL2) • Can measure pressure gradients prior to wire exchange • Exchange 0.035” Amplatz extra-stiff wire with pre-shaped distal end in left ventricle
– Ensure guidecath is advanced upon wire exchange to ensure exchange wire does not get caught in the mitral chordae.
![Page 26: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/26.jpg)
![Page 27: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/27.jpg)
Rapid Ventricular Pacing: Test Run
• Set output to high setting to ensure proper capture • Note that there can be a delay between pacing onset and effective
reduction of cardiac output
Effective Pulse Pressure and Blood Pressure Reduction
27
![Page 28: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/28.jpg)
Tracking Over Aortic Arch
28
• Rotate flex wheel to track over aortic arch
• Use LAO 30 to 40 to provide view of aortic arch
• Catheter flexes away from the flush port
• Five rotations of the flex wheel for full flex
![Page 29: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/29.jpg)
Crossing Native Valve
• Flex catheter should be fully flexed to pull wire out of commissure
• Always keep delivery system and SAPIEN valve directly adjacent to support crossing the native valve
• DO NOT FORCE THE VALVE • Use short movements to prevent
“jumping” of the valve into the ventricle • Use RAO or AP projection for crossing
to visualize the wire in the ventricle
29
Tip extends 4.5 cm past crimped valve
4.5 cm
![Page 30: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/30.jpg)
Final Positioning
• Fluoroscopy should be the primary method of visualization for positioning and deployment
• Use of TEE will assist with positioning
• Position the Edwards SAPIEN valve: – 50% to 60% ventricular – Valve positioning should be
coaxial
30
50% - 60%
![Page 31: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/31.jpg)
![Page 32: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/32.jpg)
Valve Foreshortening
Edwards SAPIEN Valve Crimped Height Expanded Height
23 mm 16 mm 14 mm
26 mm 18 mm 16 mm
The Edwards SAPIEN valve foreshortens approximately 2 mm for both size 23 mm and 26 mm
16 mm
23 mm SAPIEN Valve
14 mm
23 mm SAPIEN Valve
16 mm
23 mm SAPIEN Valve
14 mm
23 mm SAPIEN Valve
32
![Page 33: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/33.jpg)
![Page 34: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/34.jpg)
Assessing Aortic Regurgitation: TEE
• 2D TEE provides better visualization than TTE • 3D TEE
– Biplane Imaging allows real-time evaluation of both short and long axis
34
![Page 35: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/35.jpg)
•Reinsert introducer into sheath over guidewire
•Carefully withdraw sheath into common femoral artery
•Contrast can be injected contralateral or through the sheath to detect vascular damage
•Withdraw sheath
•Leave guidewire and contralateral pigtail in place
Sheath Removal
![Page 36: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/36.jpg)
Post Procedure Care
• Monitor patients in ICU or CCU for 24 hours
• Monitor closely for potential post-op complications Bleeding Late AV block (ECG monitoring) CHF Renal dysfunction CVA
![Page 37: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/37.jpg)
CCU/CTICU
• Systolic blood pressure control Manage between 110 and 130 mmHg for
the first 24 hours • Antiplatelet therapy
81-325 mg aspirin PO QD Optional: Clopidogrel 75 mg PO QD for
six months (or 250 mg ticlodipine PO BID for patients who are allergic to aspirin or clopidogrel)
![Page 38: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/38.jpg)
Reimbursement?
• CMS released a statement on May 1st: They will pay for TAVR in properly selected patients and appropriately selected sites.
• Patients with severe symptomatic AS in whom 2 CT surgeons have deemed the patient not to be a candidate for standard surgery
• Certain number of PCIs, AVRs experience etc.
![Page 39: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/39.jpg)
Registry
• Mandatory reporting of every case and follow up for at least one year.
• Database is not cheap • Follow for complications and redo
procedures as well as quality of life assessment.
![Page 40: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/40.jpg)
Position & Fill Lumens
Aortic Ring
Ventricular Ring
Guidewire Lumen
A B
C
![Page 41: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/41.jpg)
Boston Scientific - LotusTM Valve • Braided nitinol stent structure
Radial expansion as it shortens • Bovine pericardial valve • Valve leaflets function during
deployment • Repositionable • Retrievable at any point prior to
release • Adaptive Seal • 23 mm, 27 mm - 18 French
First in Man 18 French
CE Mark
European Trial
European Trial
2007 2008 2009 2010 2011 2012
First in Man 21 French
European Trial
![Page 42: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/42.jpg)
Final Thoughts
• The greatest new technology since stents- without question
• Don’t rush into this, it is a career choice not a hobby
• The patients aren’t going anywhere fast • Don’t do patients just to do patients! • They better be able to recover or the
procedure is not worth doing.
![Page 43: TAVR: It’s a Career, Not Just a Procedure!...TAVR: It’s a Career, Not Just a Procedure! Jeffrey A Southard, MD . Cardiology . May 5, 2012](https://reader033.vdocuments.us/reader033/viewer/2022051822/5febefa4ecac5951281b2096/html5/thumbnails/43.jpg)
Thanks