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00:04:44.617 and we want to see how they're going to be doing under stress. 00:04:44.951 --> 00:04:49.789 So we have seen many patients at Stony Brook with much less noses. 00:04:50.290 --> 00:04:53.393 And the question is, are they going to be able to get pregnant? 00:04:53.960 --> 00:04:56.529 And how well are they going to be doing? 00:04:56.529 --> 00:04:59.532 Do we need to intervene before pregnancy? 00:05:00.199 --> 00:05:03.403 We put those patients on a treadmill and we can see 00:05:03.436 --> 00:05:05.271 what's going to happen to their peer 00:05:05.271 --> 00:05:09.008 pressure is what is going to happen to the gradients close to valve. 00:05:09.375 --> 00:05:13.112 And that gives us an indication in terms of how well they're going 00:05:13.112 --> 00:05:17.717 to be able to tolerate pregnancy or any other, stressful event. 00:05:18.284 --> 00:05:19.052 That's amazing. 00:05:19.052 --> 00:05:22.555 That definitely is a huge change from the way it was. 00:05:22.555 --> 00:05:23.856 And I was training also. 00:05:23.856 --> 00:05:26.859 So a lot has happened in the last 10 to 20 years with echo. 00:05:27.193 --> 00:05:31.597 So with such a, comprehensive examination like that, 00:05:31.597 --> 00:05:36.402 how long would a patient expect to be on the echo table for your team 00:05:36.402 --> 00:05:39.472 to complete such, such a thorough study? 00:05:40.139 --> 00:05:42.108 So our lab is an accredited lab. 00:05:42.108 --> 00:05:45.111 So we really go by national guidelines, 00:05:45.411 --> 00:05:49.182 and we get pretty much between 45 minutes to an hour. 00:05:49.949 --> 00:05:51.517 For going to get all that done. 00:05:51.517 --> 00:05:56.689 And I can tell you that we typically do utilize for, valvular patients. 00:05:56.723 --> 00:06:02.729 We, we do perform all the, quantification and all the calculations. 00:06:02.762 --> 00:06:06.866 Oftentimes, like I said, we do add 3D, measurements as well. 00:06:07.333 --> 00:06:11.738 So it takes about an hour to perform a trans thoracic echo on these patients. 00:06:13.172 --> 00:06:16.743 Trans echo, which is a whole other modality 00:06:16.776 --> 00:06:20.947 still utilizing echo, but, with, 00:06:21.481 --> 00:06:24.484 with the additional, probe. 00:06:25.718 --> 00:06:28.955 That's extremely helpful, especially for assessment of the microbiome. 00:06:29.355 --> 00:06:33.192 So we, performed 3D echo with all of our, 00:06:33.860 --> 00:06:36.429 TS and, 00:06:36.429 --> 00:06:39.799 for the mitral valve, really get the surgical view of the matter valve. 00:06:39.799 --> 00:06:41.134 So we can really look at this. 00:06:41.134 --> 00:06:44.137 The valve the same way that you look at the vowel in the O.R.. 00:06:44.370 --> 00:06:48.040 And, and this way we can really, look at the pictures together, 00:06:48.040 --> 00:06:52.078 and we can have very meaningful conversation about the anatomy, 00:06:52.145 --> 00:06:55.148 the pathology, the hemodynamics, what needs to be done. 00:06:55.648 --> 00:06:59.018 So transfer echo is extremely helpful. 00:06:59.018 --> 00:07:02.155 And, and we use quantification as well. 00:07:02.155 --> 00:07:05.158 When we perform transfer. You know. 00:07:05.191 --> 00:07:09.362 Yeah, I know that, it has been extremely valuable for, 00:07:09.796 --> 00:07:13.499 us as surgeons to sit with you 00:07:13.499 --> 00:07:18.204 as, cardiologists and, and choreographer so that, as you said, 00:07:18.204 --> 00:07:22.175 we're looking at the images together and we're looking at the valve, 00:07:22.508 --> 00:07:24.911 the way that we would see it in the operating room. 00:07:24.911 --> 00:07:28.548 And that way we can really pin down what the pathology is. 00:07:28.548 --> 00:07:33.319 And then in the operating room, we can try to address that pathology specifically. 00:07:33.853 --> 00:07:38.391 And also, in the operating room for some of our procedures, 00:07:38.391 --> 00:07:42.361 having yourself and members 00:07:42.361 --> 00:07:46.599 of your team present during the procedure is also very critical. 00:07:46.599 --> 00:07:49.702 And this is especially so in some of our percutaneous 00:07:49.702 --> 00:07:55.041 therapies, like the, the mitral valve edge to edge repair. 00:07:55.041 --> 00:07:59.879 So talk to us a little bit about what that kind of echo work is like 00:07:59.879 --> 00:08:03.716 in the operating room when we're trying to get a valve percutaneous closed. 00:08:03.950 --> 00:08:07.587 So our doc should take a step back because before we even 00:08:07.587 --> 00:08:10.590 bring the patient to the hybrid O.R., 00:08:10.656 --> 00:08:14.327 we have to make a decision about the timing of intervention. 00:08:14.660 --> 00:08:19.465 So we start by really, assessing is there a valvular disease? 00:08:19.465 --> 00:08:23.369 What it is, the severity of it, how it affects the rest of the heart. 00:08:24.003 --> 00:08:26.506 And, and then make a decision about the timing, 00:08:26.506 --> 00:08:30.810 because we do not want to intervene too early yet 00:08:30.810 --> 00:08:35.548 we do not want to wait too long before there is a damage which is irreversible. 00:08:35.982 --> 00:08:38.618 So that's a big part of what we really do. 00:08:38.618 --> 00:08:43.222 And, and this is when we use all those other tools like strain imaging, 00:08:43.723 --> 00:08:47.193 getting a stress test done 00:08:47.193 --> 00:08:51.631 so we can really look at the patient's hemodynamics, their exercise tolerance. 00:08:51.931 --> 00:08:54.901 We put it all into that, equation 00:08:55.201 --> 00:09:00.106 and, and have a discussion typically among all members of the team 00:09:00.540 --> 00:09:03.175 as well as the patient and their family member. 00:09:03.175 --> 00:09:06.178 So we can all make a decision together about the best timing. 00:09:06.779 --> 00:09:10.650 So, before we actually bring the patient, 00:09:10.650 --> 00:09:13.953 once we decide that the patient would benefit 00:09:13.953 -->

00:09:17.657 from intervention, we need to decide what kind of an intervention. 00:09:17.657 --> 00:09:21.694 And here at Stonybrook, we have all options available. 00:09:21.694 --> 00:09:24.931 And we're going to hear more from the surgeons 00:09:24.931 --> 00:09:27.633 and the interventional cardiologist about the various options. 00:09:27.633 --> 00:09:32.738 But we do have both surgical as well as non-surgical options for the patients. 00:09:33.239 --> 00:09:36.275 And within each one of them, we do have multiple different options. 00:09:36.676 --> 00:09:42.181 So we try to make that decision before we bring the patient for the procedure. 00:09:42.848 --> 00:09:44.917 And we utilize echo. 00:09:44.917 --> 00:09:46.218 We utilize CT. 00:09:46.218 --> 00:09:48.120 It's extremely helpful 00:09:48.120 --> 00:09:51.891 to, reconstruct the heart with, 00:09:51.891 --> 00:09:55.628 the new device or the new valve in place so we can actually see what it's going to 00:09:55.628 --> 00:09:56.762 look like. 00:09:56.762 --> 00:10:00.600 And based on that, we can recommend some additional, 00:10:00.600 --> 00:10:04.604 procedures and additional devices that can be used to really make the, 00:10:05.137 --> 00:10:08.274 procedure more feasible and safer for the patient. 00:10:08.341 --> 00:10:11.944 So then we can present the patient with all that information. 00:10:12.545 --> 00:10:16.649 And, and by the time the patient shows up in the O.R. 00:10:16.649 --> 00:10:19.919 or hybrid O.R., the operator knows exactly 00:10:19.919 --> 00:10:23.155 what is the planned procedure and have everything available 00:10:23.456 --> 00:10:26.459 in their disposal to be able to perform that procedure. 00:10:26.959 --> 00:10:28.961 So now that we are in the hybrid O.R.. 00:10:30.062 --> 00:10:32.365 So. And actually so I. And. 00:10:32.365 --> 00:10:35.067 Yeah, before we actually get into the hybrid, or 00:10:35.067 --> 00:10:36.569 are you going to tell us what that's like? 00:10:36.569 --> 00:10:41.874 I just want to emphasize what you said about the pre procedural planning 00:10:41.874 --> 00:10:44.777 and the exhaustive steps that are taken to make sure 00:10:44.777 --> 00:10:47.780 that the diagnosis is accurate, the extent of disease is accurate, 00:10:48.180 --> 00:10:51.717 and that we are very clear on what pathology needs to be fixed. 00:10:51.717 --> 00:10:55.988 And I think a very important part of what we offer here at Stony 00:10:55.988 --> 00:10:57.223 Brook is the power 00:10:57.223 --> 00:11:01.694 of the multidisciplinary team, because, as you said, you know, we, 00:11:01.761 --> 00:11:06.098 the team which involves yourself and interventional cardiologist 00:11:06.098 --> 00:11:10.169 and surgeons and so on, you know, we meet regularly to review these patients 00:11:10.503 --> 00:11:14.206 and it's very much, 00:11:14.206 --> 00:11:20.179 a matter of measuring 3 or 4 times and then cutting wants to make sure 00:11:20.179 --> 00:11:24.750 that when we actually do our procedure, we do it precisely, and we do it right, 00:11:24.750 --> 00:11:26.919 and we do it. We do it just once. Yes. 00:11:26.919 --> 00:11:32.024 So so I think it is really exciting that we have all these therapeutic options. 00:11:32.024 --> 00:11:34.326 We have the diagnostic options, but we also have 00:11:35.895 --> 00:11:39.298 lots of, therapeutic options for our patients. 00:11:39.632 --> 00:11:45.571 But we do needs to choose the best one, the optimal one for this specific patient. 00:11:45.571 --> 00:11:48.541 And it is really tailored to the individual patient. 00:11:48.541 --> 00:11:52.611 And this is why all these Stem interactions are really, really critical. 00:11:53.179 --> 00:11:56.482 Yep. So now we're in the hybrid or the hybrid O.R.. Yes. 00:11:56.515 --> 00:11:57.917 And or the final procedure. 00:11:57.917 --> 00:12:01.487 And and in the O.R., I were the head of the 00:12:01.487 --> 00:12:06.592 interventional echocardiography, which is a field within cardiology 00:12:06.592 --> 00:12:10.329 that clearly did not exist when I was a fellow. 00:12:10.996 --> 00:12:16.035 But, essentially the way to describe that niche 00:12:16.035 --> 00:12:19.739 is that I'm essentially the eyes and the GP's of the procedure. 00:12:20.372 --> 00:12:20.873 Yeah. 00:12:20.873 --> 00:12:23.876 So I use, sweetie, 00:12:24.777 --> 00:12:29.048 sometimes with additional eyes, intra cardiac echo as well. 00:12:29.548 --> 00:12:33.119 And, in which we utilize those to guide the procedure 00:12:33.519 --> 00:12:37.289 so I can visualize all the wires, the catheters. 00:12:37.723 --> 00:12:41.861 I look at the valve again, assess the pathology 00:12:42.294 --> 00:12:45.131 and guide interventional, 00:12:45.131 --> 00:12:48.134 in terms of where to place the device. 00:12:48.768 --> 00:12:53.139 And, and if it's a valve that is being repaired or replaced, 00:12:53.139 --> 00:12:57.810 then where exactly the, repair needs to take place. 00:12:59.011 --> 00:12:59.945 You mentioned Tavira. 00:12:59.945 --> 00:13:04.416 You mentioned the magical Calypso were clip supposed to be, placed. 00:13:05.417 --> 00:13:08.287 And we have the advantage of actually 00:13:08.287 --> 00:13:12.424 assessing the fact of, let's say, clip before we deployed. 00:13:12.992 --> 00:13:17.096 So that's when I get my images. 00:13:17.096 --> 00:13:21.200 I, do my calculations and measurements and assess 00:13:21.667 --> 00:13:27.072 the amount of residual, like if there is any the, the gradients, 00:13:27.106 --> 00:13:30.576 because the valve is the valve now becoming too tight, 00:13:31.043 --> 00:13:34.713 or do we have the ability to use more than one clip. 00:13:35.214 --> 00:13:38.217 So again, this is not something that we can 00:13:38.484 --> 00:13:41.987 we kind of have an idea before we go in. 00:13:41.987 --> 00:13:46.592 But oftentimes this is the, the fine tuning 00:13:46.592 --> 00:13:50.696 that is being done based on real time imaging in the

hybrid O.R.. 00:13:50.729 --> 00:13:51.363 Right. 00:13:51.363 --> 00:13:52.631 Which is critically important 00:13:52.631 --> 00:13:55.734 because without the eyes, we can't see what we're doing, 00:13:55.734 --> 00:13:57.503 and the procedure is not getting done properly. 00:13:57.503 --> 00:13:59.071 So it's really important. 00:13:59.071 --> 00:14:03.809 And then once a valve has been successfully repaired or replaced, 00:14:04.109 --> 00:14:08.180 what kind of surveillance is necessary after surgery to make sure that 00:14:08.180 --> 00:14:09.748 patients continue to do well? 00:14:11.016 --> 00:14:14.620 So the goal is always for the patient to, 00:14:15.054 --> 00:14:18.490 outlive the device or the valve, the to put in place. 00:14:18.858 --> 00:14:22.361 So the first thing that we need to do is establish 00:14:22.361 --> 00:14:24.463 a first baseline for the patient. 00:14:24.463 --> 00:14:29.034 So that's the full echo that we do just prior to discharge from the hospital. 00:14:29.034 --> 00:14:32.838 And typically the patients stay here overnight just to monitor them. 00:14:32.838 --> 00:14:35.774 So before they go home they get a full echocardiogram. 00:14:35.774 --> 00:14:39.078 We assess not just a valve that was repaired or replaced, 00:14:39.078 --> 00:14:42.648 but we really look at everything because affecting one 00:14:42.648 --> 00:14:46.218 valve or treating one valve can affect the rest of the heart. 00:14:46.619 --> 00:14:50.723 So we reassess their LV function and the RV function, 00:14:50.723 --> 00:14:54.760 and we measure the pressures and we assess for any 00:14:54.760 --> 00:14:57.763 residual leak, any stenosis. 00:14:57.930 --> 00:15:01.166 And this is now becoming the new baseline for that patient. 00:15:01.700 --> 00:15:04.403 And most of our patients stay within the system. 00:15:04.403 --> 00:15:07.139 So they come back to us for follow up echos. 00:15:07.139 --> 00:15:09.241 And we look for progression. 00:15:09.241 --> 00:15:12.945 We also need to keep in mind that with the percutaneous 00:15:12.945 --> 00:15:17.182 or transcatheter procedures, we typically address one valve at a time. 00:15:17.182 --> 00:15:18.717 We don't really it's not like 00:15:18.717 --> 00:15:22.021 an open heart surgery that we fixed everything that is abnormal. 00:15:22.588 --> 00:15:25.024 We make a decision about 00:15:25.024 --> 00:15:29.895 what is really the most, critical valve that needs to be addressed. 00:15:29.895 --> 00:15:30.829 Forest. 00:15:30.829 --> 00:15:35.100 We addressed that with the hope that may be for going to address one valve. 00:15:35.701 --> 00:15:38.504 The other valves may improve in function. 00:15:38.504 --> 00:15:40.873 So we do need to bring those patients back. 00:15:40.873 --> 00:15:45.844 And we look at the other valves and and look for either 00:15:45.844 --> 00:15:49.415 progression or improvement in the function of those valves. 00:15:49.815 --> 00:15:53.052 And we also look for progression or

deterioration of the new valve 00:15:53.052 --> 00:15:56.588 that we put in place, or the new device that we put in place. 00:15:57.089 --> 00:15:59.591 The follow up is extremely, extremely important. 00:15:59.591 --> 00:16:03.195 Is there anything else that you'd like to add before we wrap up before we finish? 00:16:03.195 --> 00:16:03.929 Yeah. 00:16:03.929 --> 00:16:07.766 So we typically talk about people that have valvular 00:16:07.766 --> 00:16:10.769 heart disease and how we address them and how we diagnosed in. 00:16:10.769 --> 00:16:15.474 But I really want to emphasize that it is also very important 00:16:15.741 --> 00:16:19.378 to at least get an echocardiogram on people 00:16:19.378 --> 00:16:22.448 that are at risk for developing valve heart disease. 00:16:23.082 --> 00:16:26.685 And very important, those would be either people 00:16:26.685 --> 00:16:30.389 who have family members who were diagnosed with level of heart disease. 00:16:30.389 --> 00:16:32.925 The most common one would be bicuspid aortic valve. 00:16:33.892 --> 00:16:35.761 Also, people that 00:16:35.761 --> 00:16:40.733 have none valvular heart disease like cardiomyopathy is ischemia can be 00:16:40.966 --> 00:16:45.637 cardiomyopathy is can have secondary effects on on the valves. 00:16:46.405 --> 00:16:50.609 Also patients who have other systemic systemic disorders like, 00:16:51.677 --> 00:16:54.747 hematological disorders, those patients are at risk 00:16:54.747 --> 00:16:56.115 for developing valvular heart disease. 00:16:56.115 --> 00:16:59.618 So it is really important, especially for primary care physicians, 00:17:00.152 --> 00:17:06.158 to, really think about those people and, and refer them to us 00:17:06.158 --> 00:17:09.161 whenever they're at risk for developing valve. 00:17:09.361 --> 00:17:13.432 What are the triggers in terms of age of patient, 00:17:13.432 --> 00:17:16.435 for example, that such a referral should take place. 00:17:16.869 --> 00:17:22.875 So for, family members, if you have, a patient at any age, 00:17:23.375 --> 00:17:27.646 that's a family member, first degree family member was diagnosed 00:17:27.646 --> 00:17:32.451 with either congenital heart disease or with a known valvular. 00:17:32.451 --> 00:17:35.120 How this is like a make us video tick valve. 00:17:35.120 --> 00:17:38.223 You really want to gather all the first degree 00:17:38.223 --> 00:17:41.527 relatives and send them for one echocardiogram? 00:17:41.627 --> 00:17:46.331 And hopefully that would be sufficient to basically exclude the presence 00:17:46.331 --> 00:17:51.336 of any other congenital anomalies or the presence of a bicuspid valve. 00:17:51.537 --> 00:17:54.239 And that would be the first and last echo for them. 00:17:54.239 --> 00:17:57.910 But if you do find it, you really want to then follow them up. 00:17:57.910 --> 00:17:59.611 Hopefully you would, 00:18:00.746 --> 00:18:01.680 diagnose them 00:18:01.680 --> 00:18:04.683 early enough so they would have no

symptoms. 00:18:04.850 --> 00:18:09.188 And, and maybe we can intervene before there is any deterioration 00:18:09.188 --> 00:18:10.589 or any symptoms development. 00:18:10.589 --> 00:18:13.192 So that's a very valuable, piece of information. 00:18:13.192 --> 00:18:17.429 And I think, something that many people don't consider 00:18:17.729 --> 00:18:22.067 the importance of screening for this where there are elevated risk factors. 00:18:22.067 --> 00:18:24.403 So thank you very much for that. 00:18:24.403 --> 00:18:26.105 Absolutely. 00:18:26.105 --> 00:18:27.806 We'll be right back with doctors price. 00:18:27.806 --> 00:18:30.776 And you mean to continue our conversation. 00:18:38.984 --> 00:18:40.285 Welcome back everyone. 00:18:40.285 --> 00:18:43.255 Now that we understand how valve disease is diagnosed. 00:18:43.255 --> 00:18:45.324 Let's turn to how we fix it. 00:18:45.324 --> 00:18:49.194 And for this we are going to speak with our surgical experts. 00:18:49.595 --> 00:18:52.631 We're fortunate to have with us today Doctor Jonathan Pryce, 00:18:52.631 --> 00:18:55.634 who is the co-director of the center here at Stony Brook. 00:18:55.734 --> 00:18:59.605 And Doctor Monoamine, who is the director of Adult congenital surgery. 00:18:59.905 --> 00:19:01.406 So, Doctor Pryce, let's start with you. 00:19:01.406 --> 00:19:06.145 We heard from Doctor Kort earlier about how we diagnose valve disease. 00:19:06.311 --> 00:19:08.914 Can you speak a little bit about how we fix it? 00:19:08.914 --> 00:19:10.048 Sure. Surgically. 00:19:10.048 --> 00:19:14.286 So I think once you have a valve problem diagnosed by your doctor, 00:19:14.286 --> 00:19:17.689 it's important to know that there are two broadways to address it. 00:19:17.890 --> 00:19:19.491 One is to repair the valve. 00:19:19.491 --> 00:19:20.926 One is to replace the valve. 00:19:20.926 --> 00:19:22.361 I think the most important thing to remember 00:19:22.361 --> 00:19:24.563 for the patient is that at the end of the day, 00:19:24.563 --> 00:19:28.500 whatever you have to have, it's to make your valve work 00:19:28.667 --> 00:19:31.036 and to make your heart pump better and more efficiently. 00:19:31.036 --> 00:19:34.540 So both modalities are options, but it's based on a discussion with you 00:19:34.540 --> 00:19:37.109 and your doctor about which one is best for you. 00:19:37.109 --> 00:19:38.110 Okay, that's fair enough. 00:19:38.110 --> 00:19:45.551 So, doctor, you mean tell us why would somebody prefer or or, 00:19:45.784 --> 00:19:48.754 would a doctor prefer to recommend 00:19:48.754 --> 00:19:52.824 valve repair surgery rather than valve replacement? 00:19:52.824 --> 00:19:55.194 Are the two treatment options equivalent, 00:19:55.194 --> 00:19:58.197 or are there advantages one over the other? 00:19:58.463 --> 00:20:02.201 So for for certain specific patients, there is an advantage 00:20:02.201 --> 00:20:06.939 of repairing the valve or what we call preserving the native valve 00:20:07.806 --> 00:20:12.511 compared to replacing it with a, either a biologic prosthesis, 00:20:12.844 --> 00:20:17.649 or a animal prosthesis, or a mechanical properties or metallic. 00:20:18.417 --> 00:20:21.119 If patients receive a metallic prosthesis, 00:20:21.119 --> 00:20:24.189 they have to be on blood thinners the rest of their life. 00:20:24.656 --> 00:20:28.493 For those who have a biologic prosthesis, will have, a certain 00:20:28.493 --> 00:20:32.364 lifespan of that prosthesis and might need re intervention down the line. 00:20:32.764 --> 00:20:36.301 For certain patients with certain problems, 00:20:36.301 --> 00:20:38.904 we can preserve their native valve. 00:20:38.904 --> 00:20:44.042 And by preserving it, they that valve could last much longer than animal valve. 00:20:44.309 --> 00:20:48.146 And it doesn't need blood thinners like a metallic or mechanical valve would. 00:20:48.146 --> 00:20:51.149 So that's where the bigger advantage of 00:20:51.817 --> 00:20:55.621 preserving the native valve or repairing it comes compared to replacement. 00:20:55.954 --> 00:20:57.456 Okay. So that's very helpful. 00:20:57.456 --> 00:21:01.994 So then Doctor Price, tell us what are some of the diagnoses that would 00:21:01.994 --> 00:21:05.030 require valve replacement 00:21:05.030 --> 00:21:08.634 rather than even consideration for valve repair? 00:21:09.001 --> 00:21:12.804 So again in general terms the valve cannot 00:21:12.804 --> 00:21:15.774 be repaired once the tissue of the valve has been destroyed. 00:21:16.475 --> 00:21:20.279 And in general, for the optic valve, that would be aortic stenosis. 00:21:20.279 --> 00:21:21.413 When the valve has a very, 00:21:21.413 --> 00:21:25.150 it's heavily calcified and deposited with sclerotic tissue. 00:21:25.284 --> 00:21:29.087 And the valve is no longer opens properly in those cases, repairing 00:21:29.087 --> 00:21:30.722 the valve is not possible. 00:21:30.722 --> 00:21:35.093 Similar for the mitral valve when you have mitral valve, stenosis, 00:21:35.227 --> 00:21:38.363 not every case, but in most cases of mitral valve stenosis, 00:21:38.363 --> 00:21:41.633 when the leaflets are, heavily calcified and restricted 00:21:41.633 --> 00:21:45.771 and not moving properly, those leaflets are not repairable anymore. 00:21:46.772 --> 00:21:47.773 Doctor, you 00:21:47.773 --> 00:21:51.410 mentioned, mechanical prostheses 00:21:51.743 --> 00:21:54.746 and, biological prostheses. 00:21:55.013 --> 00:22:00.752 So can you, make a recommendation on which one might be better for a patient? 00:22:00.752 --> 00:22:06.658 Like how how does a surgeon decide which prosthesis to offer a patient? 00:22:06.658 --> 00:22:10.362 And how should a patient think about it and decide which one to accept? 00:22:10.529 --> 00:22:11.697 That's an excellent question. 00:22:11.697 --> 00:22:14.700 And it's really one for the ages, because I think that is one of the most 00:22:14.700 --> 00:22:18.937 heavily debated,

topics when physicians speak to each other 00:22:19.137 --> 00:22:22.974 and when physicians speak to patients and when patients speak to patients. 00:22:23.375 --> 00:22:25.944 And the reason is because everyone will have an opinion, 00:22:25.944 --> 00:22:29.548 and there is some good data to guide our recommendations, 00:22:29.548 --> 00:22:32.751 but at the same time, a valve replacement 00:22:33.018 --> 00:22:36.154 and the type of value use really is dependent on the patient, 00:22:36.521 --> 00:22:41.193 their lifestyle, comorbidities and, and a lot of other factors. 00:22:41.193 --> 00:22:44.963 So for instance, as doctor, you mean, I mentioned earlier 00:22:44.963 --> 00:22:49.000 that a metallic valve, or a mechanical prosthesis 00:22:49.267 --> 00:22:52.237 may not be something someone is, is interested in 00:22:52.237 --> 00:22:54.806 because they have to be on blood thinners for the rest of their life. 00:22:54.806 --> 00:23:00.145 However, a mechanical valve has a, longevity and a likelihood of staying 00:23:00.145 --> 00:23:05.150 patent and lasting and working much longer than any other type of prosthesis. 00:23:05.150 --> 00:23:06.385 Like how much longer? 00:23:06.385 --> 00:23:08.453 Well, decades. 00:23:08.453 --> 00:23:09.888 Longer, potentially. 00:23:09.888 --> 00:23:13.925 So the the question then becomes, you know, for a very young patient 00:23:14.126 --> 00:23:17.829 who might need a valve replacement, is a mechanical valve a viable option? 00:23:18.397 --> 00:23:19.231 And the answer is yes. 00:23:19.231 --> 00:23:20.565 It's a it is a viable option 00:23:20.565 --> 00:23:24.069 because it's still a very good operation that gives very good results. 00:23:24.302 --> 00:23:28.540 Now, the counter side to that is that you do have to be on blood thinners 00:23:28.540 --> 00:23:29.708 and not just any blood. 00:23:29.708 --> 00:23:32.611 And as of right now, the only button that's FDA approved 00:23:32.611 --> 00:23:35.447 to be used with a mechanical valve is warfarin. 00:23:35.447 --> 00:23:39.317 And as most people know, warfarin is labor intensive and time 00:23:39.317 --> 00:23:41.186 consuming and energy consuming. 00:23:41.186 --> 00:23:44.523 It takes a lot of effort on the part of the patient and the physician 00:23:44.523 --> 00:23:48.260 to make sure that it's being used properly and being measured, make sure that it's, 00:23:49.294 --> 00:23:52.330 it's it's being, effectively use of the patient's blood 00:23:52.330 --> 00:23:55.333 thinner levels are appropriate for the type of valve. 00:23:55.734 --> 00:23:58.236 That's one thing that you cannot skimp on. 00:23:58.236 --> 00:24:02.274 If you have a mechanical valve, you need to be on your warfarin 00:24:02.274 --> 00:24:03.642 and you can't take it lightly. 00:24:03.642 --> 00:24:05.610 You have to be checking regularly. 00:24:05.610 --> 00:24:06.878 So does you mean. 00:24:06.878 --> 00:24:10.248 You know, Doctor Price just said that for a young patient, 00:24:10.482 --> 00:24:16.054 a mechanical valve might be a good option because it might last for many, many, 00:24:16.054 --> 00:24:19.391 many decades and therefore not necessarily need to be replaced. 00:24:19.825 --> 00:24:23.128 So for a young patient 00:24:23.662 --> 00:24:27.766 who has a valve abnormality and is going to need surgery. 00:24:28.133 --> 00:24:31.970 Can you speak a little bit about the valve repair options 00:24:31.970 --> 00:24:33.572 that might be possible 00:24:33.572 --> 00:24:36.508 that might obviate the need for a mechanical valve, 00:24:36.508 --> 00:24:40.312 and therefore the need for lifelong anticoagulation for this young patient 00:24:40.312 --> 00:24:42.781 for many, many, many years. Absolutely. 00:24:42.781 --> 00:24:46.585 I think before going into valve repair, it's very important to point that, 00:24:46.885 --> 00:24:52.657 as Doctor Price mentioned, every patient would benefit from different surgeries. 00:24:52.691 --> 00:24:54.726 Some patients have more than one option. 00:24:54.726 --> 00:24:56.695 And we should discuss all options. 00:24:56.695 --> 00:24:59.931 Some of and then depending on each patient, 00:24:59.931 --> 00:25:02.234 their best option might be different. 00:25:02.234 --> 00:25:05.337 Some patients where if the valve is repairable, we can offer repair. 00:25:05.337 --> 00:25:09.007 Some patients, especially young ones who need the replacement. 00:25:09.007 --> 00:25:11.276 Mechanical prostheses are a great option. 00:25:11.276 --> 00:25:13.311 Their logic prostheses have their limitations. 00:25:14.646 --> 00:25:16.314 If a patient is 00:25:16.314 --> 00:25:19.885 found to be a candidate for valve preservation or valve repair, 00:25:20.151 --> 00:25:25.156 then it is possible for both aortic valve and mitral valve disease. 00:25:25.156 --> 00:25:29.995 It's more commonly done for mitral valve because it's a more common problem 00:25:29.995 --> 00:25:30.629 that we see, 00:25:30.629 --> 00:25:35.066 and it's been there for much longer time compared to the aortic valve repair. 00:25:35.333 --> 00:25:38.436 But aortic valve repair is also known, and it's studied 00:25:38.436 --> 00:25:41.673 and has good, long term outcomes. 00:25:41.773 --> 00:25:44.743 We have up to ten years follow up for the valve repair. 00:25:44.743 --> 00:25:47.746 And usually younger patients would 00:25:47.779 --> 00:25:51.316 with aortic regurgitation would benefit from it. 00:25:51.683 --> 00:25:55.620 But there are certain strict criteria for repair, 00:25:55.620 --> 00:25:59.124 which makes some patients, unfortunately not candidates for it. 00:25:59.124 --> 00:26:02.928 And then we'd have to look into types, other types of replacements. 00:26:04.162 --> 00:26:06.431 I say okay fair enough. 00:26:06.431 --> 00:26:10.068 Now what about we've heard a little bit, 00:26:10.535 --> 00:26:14.472 about, valve replacement. 00:26:14.639 --> 00:26:18.577 What about the surgical techniques that one would use

00:26:18.577 --> 00:26:21.880 to achieve either replacement or repair? 00:26:22.213 --> 00:26:23.748 You know what? 00:26:23.748 --> 00:26:28.853 What would, a referring doctor, be thinking about 00:26:28.853 --> 00:26:33.825 when they're sending their patients, to us to be, treated. 00:26:34.392 --> 00:26:37.762 So I think, again, it depends on, the patient. 00:26:37.762 --> 00:26:39.564 It depends on what comorbidities they have, 00:26:39.564 --> 00:26:41.967 and it depends on what we're trying to achieve. 00:26:41.967 --> 00:26:45.503 With the, with the valve replacement, or repair. 00:26:45.770 --> 00:26:47.606 You know, we have many options. 00:26:47.606 --> 00:26:49.574 Open heart surgery is an option. 00:26:49.574 --> 00:26:55.180 Open heart surgery can be done, with a, not I mean, a full incision. 00:26:55.180 --> 00:26:58.617 It can be done with a mini anatomy or a, basically a mini incision. 00:26:58.917 --> 00:27:01.586 It can be done through a thoracotomy, through the ribs. 00:27:01.586 --> 00:27:05.757 So there are different ways to access, the heart and to get a valve implanted. 00:27:05.757 --> 00:27:08.526 It doesn't always have to be the traditional way that people most, 00:27:08.526 --> 00:27:10.829 think about when they think of open heart surgery. 00:27:10.829 --> 00:27:14.966 And again, depending on what the patient needs, 00:27:14.966 --> 00:27:18.937 many patients would be in, I would say a candidate for different access points. 00:27:21.406 --> 00:27:22.641 Which is good because as you 00:27:22.641 --> 00:27:26.511 know, the world is moving towards minimally invasive interventions. 00:27:26.511 --> 00:27:32.017 And, obviously, if we can minimize, the invasiveness 00:27:32.017 --> 00:27:35.020 of what we're doing to our patients, we can hopefully accelerate recovery. 00:27:35.120 --> 00:27:36.921 So, doctor, you mean, can you speak a little bit 00:27:36.921 --> 00:27:41.226 about some of the very, very minimally invasive options that are available, 00:27:41.493 --> 00:27:46.131 including things like trans femoral 00:27:46.131 --> 00:27:53.238 percutaneous options for for, the aortic valve, 00:27:53.238 --> 00:27:56.808 the mitral valve and actually, no, the tricuspid valve. 00:27:57.475 --> 00:28:02.213 So the percutaneous options, for different valves 00:28:02.213 --> 00:28:08.319 have gone through different, generations and advancements and the latest form. 00:28:08.319 --> 00:28:12.657 Now, we know that the treatment for aortic valve disease, 00:28:12.724 --> 00:28:16.494 that is the, tavor, which is a cutaneous 00:28:16.695 --> 00:28:20.765 that has come a long way and it's become one of the most common procedures we do, 00:28:21.266 --> 00:28:24.302 along with our, colleagues from Intervention Cardiology. 00:28:24.836 --> 00:28:27.639 That one is used very commonly for 00:28:27.639 --> 00:28:31.209 to treat aortic valve stenosis where valve is not repairable. 00:28:31.643 --> 00:28:36.114 And it's a, so it's a procedure performed through the groin 00:28:36.347 --> 00:28:40.652 with catheters and where the aortic valve is replaced for the mitral valve. 00:28:40.885 --> 00:28:45.790 There is a mitraclip, which is another procedure we perform. 00:28:45.790 --> 00:28:50.562 And tricuspid valve, tricuspid clip where both valves are not replaced, 00:28:50.562 --> 00:28:54.933 but rather, repaired or preserved, 00:28:54.999 --> 00:28:58.570 just in a way to lower the amount 00:28:58.570 --> 00:29:02.741 of regurgitation or backwards leak that those valve are causing 00:29:02.907 --> 00:29:06.878 to help the patient feel better and, recover from their disease. 00:29:07.946 --> 00:29:10.148 So, you know, if if I was a patient, 00:29:10.148 --> 00:29:14.452 I would want the most minimally invasive option. 00:29:14.786 --> 00:29:18.389 So, Doctor Price, tell me, why not offer 00:29:18.690 --> 00:29:22.460 all patients percutaneous options like the tava 00:29:22.460 --> 00:29:27.565 or the percutaneous, yeah, valve, mitral valve. 00:29:27.565 --> 00:29:29.367 And tricuspid valve repair is a duct. 00:29:29.367 --> 00:29:34.806 You mean, just describe like, what might be exclusion criteria 00:29:34.806 --> 00:29:38.843 for not having this minimally invasive option, because if you can avoid 00:29:38.843 --> 00:29:41.946 an incision in open heart surgery, then why not go for it? 00:29:42.614 --> 00:29:43.815 Again, an excellent question. 00:29:43.815 --> 00:29:46.918 Because, you know, that is the thing that people ask us the most. 00:29:47.018 --> 00:29:51.055 Why would I ever want surgery if I could just have a puncture hole in my groin? 00:29:51.356 --> 00:29:52.157 And the fact of the matter 00:29:52.157 --> 00:29:55.760 is that not every minimally invasive option is good for every patient. 00:29:56.094 --> 00:29:58.897 Now, us specifically of what kind of criteria do we look for? 00:29:58.897 --> 00:30:01.699 And it depends on the valves. So let's start with the aortic valve. 00:30:01.699 --> 00:30:04.135 When you're talking about a Nordic valve replacement, 00:30:04.135 --> 00:30:07.272 let's say open surgery versus a tava, which is basically 00:30:07.272 --> 00:30:10.275 a stent with a valve implanted in it that is inserted through the groin. 00:30:10.575 --> 00:30:14.245 They're both options to replace, astronautics out 00:30:14.279 --> 00:30:16.080 for the pathology of aortic stenosis. 00:30:16.080 --> 00:30:20.218 However, there are certain pathologies or, you know, extents of aortic stenosis 00:30:20.218 --> 00:30:21.486 and calcification 00:30:21.486 --> 00:30:25.790 and valve morphology that makes the tava, less likely to function properly. 00:30:25.790 --> 00:30:29.661 So, for instance, a very heavily calcified aortic valve, or when the, 00:30:29.661 --> 00:30:33.298 calcium extends off the valve but down into the left ventricle. 00:30:33.498 --> 00:30:38.469 Those are things that make the the risk of injury to the heart and or 00:30:38.469 -->

00:30:42.574 a, an improper seal of the valve such that there is para valvular regurgitation. 00:30:42.574 --> 00:30:43.908 Much more likely. 00:30:43.908 --> 00:30:45.877 And if you're talking about a young patient 00:30:45.877 --> 00:30:49.047 who is coming to you for a perfect outcome, 00:30:49.447 --> 00:30:53.918 to trade one pathology for another, and a young patient seems to be, 00:30:54.219 --> 00:30:58.289 not imperfect and defined young 00:30:58.590 --> 00:31:02.093 because, you know, like 60 is the new 50, if you will. 00:31:02.093 --> 00:31:03.595 So what's young these days? 00:31:03.595 --> 00:31:08.766 Well, so again, it's it's interesting because we do open heart surgery 00:31:09.033 --> 00:31:10.301 on people in their 80s. 00:31:10.301 --> 00:31:13.204 We also do taggers on people in their 50s. 00:31:13.204 --> 00:31:17.675 And it really depends on the patient and their risk profile for surgery 00:31:17.876 --> 00:31:20.845 and whether or not we think that they will benefit from the surgery. 00:31:20.845 --> 00:31:25.383 Now, in planning for this, you know, we have a lot more long 00:31:25.383 --> 00:31:28.386 term data with surgical valves than we do with the tava valves. 00:31:28.653 --> 00:31:31.990 So, you know, the Tava procedure has only been around for about 20 years now. 00:31:32.223 --> 00:31:35.526 And, you know, being performed here at this institution in the northeast 00:31:35.526 --> 00:31:38.863 and most of the hospitals in the area for, you know, a little over a decade. 00:31:39.163 --> 00:31:43.234 So the fact of the matter is, the long term data really isn't there to support, 00:31:43.434 --> 00:31:46.671 you know, do you have 10 or 20 years of longevity out of these valves? 00:31:47.605 --> 00:31:50.642 Now, we do know, the surgically placed valves, 00:31:50.642 --> 00:31:53.311 especially the bio prosthetic valves, do not last forever. 00:31:53.311 --> 00:31:55.947 They also have a shelf life, but we do at least have the data 00:31:55.947 --> 00:31:58.316 to report that with the towers, we really don't. 00:31:58.316 --> 00:32:01.953 So for a young patient who were looking for a certain outcome, 00:32:02.253 --> 00:32:05.623 we would likely offer them surgery over a tava 00:32:05.623 --> 00:32:08.826 because the longevity is not, not quite clear. 00:32:09.260 --> 00:32:12.263 That being said, certain other types of valve pathologies, 00:32:12.263 --> 00:32:15.767 like people who have bicuspid valves, a bicuspid valve causes 00:32:15.767 --> 00:32:18.770 an abnormal geometric shape of the optic root. 00:32:18.803 --> 00:32:22.373 And when you place a perfectly rounded aortic valve stent 00:32:22.373 --> 00:32:25.076 in an abnormally shaped root or an oblong root, 00:32:25.076 --> 00:32:27.478 there is a higher chance that you will have a parallel leak, 00:32:27.478 --> 00:32:30.815 which again, may not be, ideal for certain patient. 00:32:31.549 --> 00:32:33.952 So those are things we all take into consideration.

00:32:33.952 --> 00:32:36.354 When we discuss with the patient what would be better for them 00:32:36.354 --> 00:32:38.156 because obviously no one wants surgery. 00:32:38.156 --> 00:32:39.724 But at the end of the day, that actually be the 00:32:39.724 --> 00:32:42.727 maybe the thing that saves their life and is really the best thing for them. 00:32:43.194 --> 00:32:47.598 And you know, doctor, you mean so as, as we all know, 00:32:47.865 --> 00:32:50.768 in the early days of the percutaneous valve therapy, 00:32:50.768 --> 00:32:54.238 especially TAVR, there was a lot of enthusiasm. 00:32:54.238 --> 00:32:59.677 There were, low risk trials and a lot of low risk younger patients had tavaris. 00:33:00.044 --> 00:33:03.614 And as as you gentlemen know, we have seen, 00:33:03.681 --> 00:33:06.884 a spike in patients 00:33:06.884 --> 00:33:11.155 with complications of their tavaris coming now for open heart surgery. 00:33:11.155 --> 00:33:14.659 Can you speak a little bit about some of the complexity of trying to 00:33:15.026 --> 00:33:18.196 to deal with a patient with a problematic 00:33:18.463 --> 00:33:21.632 TAVR valve who now needs surgery? 00:33:22.667 --> 00:33:25.103 So, yeah, I 00:33:25.103 --> 00:33:28.573 having a previous any manipulation to the valve, 00:33:28.740 --> 00:33:32.510 especially with having a new replaced valve in 00:33:32.944 --> 00:33:35.580 would make the surgery 00:33:35.580 --> 00:33:38.583 for replacement or re replacement more complicated. 00:33:39.017 --> 00:33:40.184 It's always the case. 00:33:40.184 --> 00:33:42.954 Second time operation is always more complicated. 00:33:42.954 --> 00:33:46.190 Now we have a lot more experience in 00:33:46.657 --> 00:33:49.627 doing second line operations 00:33:49.627 --> 00:33:52.563 following a previous surgical replacement. 00:33:52.563 --> 00:33:57.235 But as we're gaining more exposure and experience with the transcatheter, 00:33:57.568 --> 00:34:01.439 we're realizing that it does cause little more, 00:34:01.873 --> 00:34:06.010 maybe damage to the aorta around it, to the aortic root. 00:34:06.010 --> 00:34:10.915 And sometimes we find ourselves having to repair the aorta around the tava, 00:34:11.282 --> 00:34:15.853 valve before we implant the new aortic valve prosthesis surgically. 00:34:16.120 --> 00:34:19.157 So there's no doubt that makes it more complicated. 00:34:19.157 --> 00:34:21.225 But it's something that we've gained experience 00:34:21.225 --> 00:34:25.563 in, and we're very comfortable offering to our patients if the procedure they need. 00:34:27.465 --> 00:34:28.299 All right. 00:34:28.299 --> 00:34:30.535 So we're going to be winding up soon. 00:34:30.535 --> 00:34:36.841 So, do you have any final thoughts or, comments that you'd like to make 00:34:36.841 --> 00:34:42.380 about the spectrum of valve care that we can offer here at Stony Brook? 00:34:42.380 --> 00:34:43.915 And we've heard a little bit about, 00:34:43.915 --> 00:34:48.152 surgery and incisions and percutaneous options. 00:34:48.586 --> 00:34:53.391 I will just say that what we also have is an excellent multidisciplinary team 00:34:53.391 --> 00:34:56.594 that we can sit with to discuss complex patients. 00:34:57.395 --> 00:35:00.865 Anything else that you'd like to highlight about the services that we offer you? 00:35:00.932 --> 00:35:01.466 Absolutely. 00:35:01.466 --> 00:35:04.635 So I think that's a great point to bring up the multidisciplinary team, 00:35:04.635 --> 00:35:05.803 because at the end of the day, 00:35:05.803 --> 00:35:09.073 I think the overarching theme of this entire talk is that 00:35:09.273 --> 00:35:12.210 there are a lot of different options for valve intervention, 00:35:12.210 --> 00:35:15.746 whether it be a repair or replacement, and every patient 00:35:15.746 --> 00:35:19.283 deserves an in-depth conversation to see what is right for them. 00:35:19.584 --> 00:35:22.386 And it's important to know that that decision is not made 00:35:22.386 --> 00:35:25.389 unilaterally by the surgeon or a cardiologist. 00:35:25.456 --> 00:35:27.592 Or a referring doctor. 00:35:27.592 --> 00:35:30.995 This is really a conversation that happens with many, many physicians 00:35:30.995 --> 00:35:34.165 who are each giving their unique expertise and insight 00:35:34.298 --> 00:35:36.868 to make sure that no stone is left unturned 00:35:36.868 --> 00:35:39.937 and the patient is really being evaluated for every single option. 00:35:40.171 --> 00:35:43.107 And at the end of the day, when there are multiple options and the patient has 00:35:43.107 --> 00:35:46.110 all of the data and all of the information available to them, 00:35:46.277 --> 00:35:48.279 they can choose what they think is best for them. 00:35:49.614 --> 00:35:50.114 Right. 00:35:50.114 --> 00:35:54.185 And I think being able to offer patients choice is important. 00:35:54.385 --> 00:35:56.154 Sometimes too much choice gets confusing. 00:35:56.154 --> 00:35:59.524 So I think we do need to be able to at least give them some structure 00:35:59.524 --> 00:36:02.527 within which to make decisions. 00:36:02.693 --> 00:36:05.263 So, on the heels of, of, 00:36:05.263 --> 00:36:08.499 of talking about multidisciplinary decision 00:36:08.499 --> 00:36:12.904 making and selection, perhaps, doctor, you mean we could end with you 00:36:12.937 --> 00:36:18.442 just describing a little bit about one of, the more complex decision 00:36:18.442 --> 00:36:22.180 making options for patients, which is the introduction of something 00:36:22.180 --> 00:36:23.381 called the RA procedure. 00:36:23.381 --> 00:36:24.882 Tell us a little bit about it 00:36:24.882 --> 00:36:29.020 and why a patient might be a candidate for this kind of valve surgery. 00:36:29.554 --> 00:36:35.193 So the Ross procedure, is a procedure that was initially performed 00:36:35.193 --> 00:36:39.263 and invented for congenital aortic valve disease 00:36:39.263 --> 00:36:43.201 or it happened in neonates or

kids with aortic valve disease 00:36:43.201 --> 00:36:46.437 where they cannot fit in a prosthesis 00:36:46.437 --> 00:36:49.540 that is, either the metallic or the, the biologic. 00:36:49.774 --> 00:36:55.346 So, it's a more complicated procedure where the pulmonary valve or the, 00:36:56.847 --> 00:36:58.482 one of the other valves in the heart 00:36:58.482 --> 00:37:03.120 is moved to the aortic position to replace the aortic valve. 00:37:03.120 --> 00:37:07.525 And in kids it was shown to work, exactly like an aortic valve. 00:37:07.525 --> 00:37:10.528 And it grew with these patients, to adulthood. 00:37:10.795 --> 00:37:13.764 So that had been, 00:37:14.765 --> 00:37:16.767 applied to adults with aortic 00:37:16.767 --> 00:37:20.104 valve disease, especially those in the younger age group. 00:37:20.104 --> 00:37:24.508 So in fact, it's actually considered in the American College of Cardiology 00:37:24.508 --> 00:37:28.446 and the American Heart Association as the procedure as a possible option 00:37:28.446 --> 00:37:31.782 for patients who are younger than 50 to 55 years of age. 00:37:32.450 --> 00:37:35.386 It has the benefits of, 00:37:35.386 --> 00:37:39.357 not having a metallic prostheses or mechanical. 00:37:39.357 --> 00:37:41.225 So no anticoagulation. 00:37:41.225 --> 00:37:45.229 It certainly last much longer than a aortic valve. 00:37:45.296 --> 00:37:49.433 That is, bioprocess or biologic or animal based prostheses. 00:37:49.834 --> 00:37:53.671 The, the only thing is that it's a more complicated procedure, 00:37:53.671 --> 00:37:57.708 so it cannot be offered, in all institutions, only 00:37:58.676 --> 00:38:01.679 institutions with good experience, with it. 00:38:01.946 --> 00:38:06.951 So we're, you know, very proud to be able to offer this here at Stony Brook. 00:38:07.218 --> 00:38:12.790 And, it's definitely more complicated to decide on doing this procedure 00:38:12.790 --> 00:38:16.160 and the technicality of the procedure is more complex 00:38:16.160 --> 00:38:20.364 than in a other, aortic valve replacement, but it's it's 00:38:20.364 --> 00:38:23.501 very well described, and it's been there for more than 30 years now. 00:38:25.236 --> 00:38:29.006 But yet it adds to the complexity and especially as, as Doctor 00:38:29.006 --> 00:38:32.943 Price was saying earlier that the age group plays a major role in deciding which 00:38:33.411 --> 00:38:36.414 which prostheses or which choice to to make. 00:38:36.781 --> 00:38:39.817 The guidelines do help us by saying that if you're 00:38:39.817 --> 00:38:42.853 less than 65, you should have 00:38:42.853 --> 00:38:45.990 the surgery considered, even though travel might still be an option. 00:38:45.990 --> 00:38:50.394 But as you move further younger than 65, 00:38:50.394 --> 00:38:54.465 as you get closer to the 50s or even the younger than 50, that's when, 00:38:55.099 --> 00:38:57.668 Ross versus mechanical, 00:38:57.668 --> 00:39:01.439 possibly biologic becomes more of a conversation to have. 00:39:01.906 --> 00:39:04.175 Okay. All right. That's very helpful. 00:39:04.175 --> 00:39:06.844 And that's all the time we have today. 00:39:06.844 --> 00:39:09.613 Thank you very much to all our panelists. 00:39:09.613 --> 00:39:12.616 And thank you to all our listeners and viewers. 00:39:13.050 --> 00:39:16.354 As we've heard, Stony Brook Medicine's Heart Institute offers 00:39:16.354 --> 00:39:19.357 the full range of treatment options for heart valve disease, 00:39:19.590 --> 00:39:23.127 and we prioritize repairing native valves where possible 00:39:23.361 --> 00:39:26.464 to confer the greatest long term benefit to our patients. 00:39:27.064 --> 00:39:30.968 Our outstanding multidisciplinary team will care for you or your loved one 00:39:30.968 --> 00:39:35.339 with valve disease from diagnosis to discharge, and provide state of the art 00:39:35.339 --> 00:39:38.442 treatment to get you back on your feet in a timely fashion. 00:39:39.276 --> 00:39:41.779 For evaluation by one of our team, please 00:39:41.779 --> 00:39:46.016 call (631) 444-1820. 00:39:46.617 --> 00:39:49.920 And if you found this information helpful or informative, 00:39:50.221 --> 00:39:53.090 please like and subscribe for more content. 00:39:53.090 --> 00:39:54.058 Just like this. 00:39:57.595 --> 00:39:58.729 Stony Brook Medicine 00:39:58.729 --> 00:40:01.732 is Long Island's premier academic medical center. 00:40:01.866 --> 00:40:06.404 We transform lives through scientific discovery, education and care, 00:40:06.404 --> 00:40:10.975 and we bring together innovative research, advanced education and extraordinary 00:40:10.975 --> 00:40:15.613 health care expertise to set the standard for how healthy communities thrive. 00:40:15.913 --> 00:40:18.949 For more information, visit Stony Brook Medicine Dot 00:40:18.949 --> 00:40:21.952 Edu or follow us on social media. 00:40:22.186 --> 00:40:25.122 Stony Brook Medicine on Instagram Threads. 00:40:25.122 --> 00:40:29.527 Facebook, YouTube and LinkedIn and Stony Brook Med Onex.