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Mastering Redo Surgery after TAVR: An Introduction and LVOT Enlargement

Thursday, January 4, 2024

In this series of videos, to published over the next month, Dr. Vincent Gaudiani shares his experience in the new field of surgery after previous TAVR and provides his tips for safely performing redo surgery for a variety of indications including TAVR early and late failure, endocarditis, and when further valve surgery is required. 

In this introductory video, Vincent Gaudiani sets the scene for his outstanding series of videos on preoperative surgery after previous TAVR. 

Dr. Gaudiani has forty years of experience in cardiothoracic surgery. He earned his BA in English from Harvard University and his MD from the Case Western Reserve University School of Medicine. He completed an internship and a residency in general surgery at the UH Cleveland Medical Center and another residency in cardiovascular surgery at Stanford Healthcare. 

Today, this expert is board-certified in thoracic and cardiac surgery. Formerly, Dr. Gaudiani served as the Director of Cardiothoracic Surgery at the California Pacific Medical Center and as the Director of Cardiac Surgery at the Community Hospital of the Monterey Peninsula. He currently serves as a senior surgeon at the El Camino Hospital and at the Pacific Coast Cardiac and Vascular Surgeons. He is also a surgeon at the Palo Alto Medical Foundation and the Community Hospital of the Monterey Peninsula.

This video demonstrates the removal of a four-year-old Evolute TAVR followed by a Manougian LVOT patch enlargement and placement of a 23 mm surgical aortic valve. 

The patient had an Evolute TAVR in 2019. After an initially good post-procedural course, the valve started to become stenotic, and after four years had a 70 mm gradient and required surgical aortic valve replacement.  

Dr Gaudiani demonstrates his strategy for removal of the TAVR using the handlebar mustache technique. This technique requires grasping of the cut sides of the valve and peeling it in towards itself to reduce the diameter of the valve, which facilitates removal. After excision of the valve and assessment of the annulus, surgeons found that the radius was too small for a direct valve placement, as this would cause patient prosthesis mismatch. Therefore, a Manougian left ventricular outflow tract enlargement was performed.


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Bovine pericardium is fine but it is harder for me to shape. A large Dacron graft is a conic section so it has the necessary shape built into it. The principles are the same so it’s dealers choice. Thx.
Great case. I have done this with bovine pericardium which is a great material because the needle holes dont bleed. Due to the rise of TAVR every surgeon will need to do this case within the next few years.

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