We will next go to Dr. Kenneth Chang, who will show us EUS cardiac liver biopsy. Yeah, thanks. I think we have a few minutes. I just wanted to show you the liver biopsy technique and how to salvage with blood patch. And then I want to show you the liver specimen that we were able to get with our patient today. Can you guys hear me okay? So this is another case that we did where we needed to salvage. So I just wanted to show you how we do the liver biopsy and what happens if you've got flow. So this is the liver biopsy right lobe. And essentially I'm using a 19 gauge Franci needle. And it's fully primed. It's fully primed. And just as I'm about to make the actuation, I actually take the syringe and stopcock off. This is really important. So your front end is free and your back end is free, but your needle is primed with heparin. And then I take my first actuation all the way through. I don't stop at the beginning. I just push it all the way through and go as fast as possible for my first actuation. For my second actuation, because there's stuff in the liver already, I will put the stopcock and syringe on. I will turn on the stopcock just before the actuation for number two and number three. So this is now actuation number two. I bring it back and then actuation number three. So in today's patient, I did a total of four actuations because I knew the patient was cirrhotic. So I really wanted to make sure I could get his specimen. And it's okay to do, you know, two, three, four, five actuations because you've only violated the liver capsule once. And what you're most concerned about is this last two centimeters to make sure there's no flow coming through that. All the other actuation tracks will converge to this point here. So on this video, which I prepared for you, it's a case where the Doppler was showing really rigorous flow for beyond five minutes. So here I've done my three actuations and I am turning on the eFLOW. And you can see there's lots of flow. And we waited, this is during a live course, we waited, we waited three minutes, four minutes, five minutes, and it would just not, not stop. So after waiting the three minutes and it's not stopping, we decided then to employ the U.S. guided blood patch delivery technique. So I'm going to go to that right now and I'm going to go live so you can hear what's going on. Let me see what happens. I'm going to change my needle angle. I'm going to come up a little bit and see what happens here. Okay. So I tried to change my needle angle. It's, it's not, it's not stopping. The flow is continuous. Even when I try to back the needle out to see if it's really following me, it really is following me. You can see it's going right to my needle. So at this point, I don't dare take the needle out. If I take the needle out, there's enough pressure for that blood to come right out of the liver capsule. And once it's out of the liver capsule, it'll continue to flow. It'll continue to bleed. So technically this is not a bleed yet, but we don't want it to be a bleed. So here I'm going to now ask my assistant to hand me the stylet back or to push the stylet back in. So here she's going to grab the stylet and I'm going to have her start. She's starting to put the stylet in and she's starting to push the stylet now. So the stylet is going back. Half a second. She's putting, how much are you in there? 40, 50% of the stylet is now back in the needle. Okay. So you see, I've created distance by, by clearing half of the needle. I put some stuff back in and I think I created a roadblock. So then I'm just going to slowly back up very slowly to see if indeed I stopped the flow from the needle track to my needle tip. You guys see that? I'm seeing a distance here. And then I pull back, pull back. Hopefully I didn't give it all the liver back. Hopefully I gave some of the liver back, but hopefully I'll have enough specimen. So at this point I feel confident I can take the needle out. And so I'm going to pull the needle out now since there's no flow beyond the blood patch. And then here I'm processing the specimen just like I did when I finished the case today. I decant and I pull out the specimen. And here I've got about 12 centimeters of liver still, even despite the fact that I gave half the needle back to the patient. And this is a very, very fibrotic liver. So today's, this is today's case. I did a single pass in the right lobe. I made four actuation and we all knew that this is a cirrhotic liver. This, this single piece is about eight and a half centimeters. These are five centimeters each. These are four centimeters each. And this is one pass, 27 centimeters of liver in a very nice quality core. So because of the quality and quantity, I didn't feel it was necessary. I confirmed with our transplant hepatologist, do you really want me to sample the left lobe or not? And he goes, no, with DILI, it doesn't matter. This is more than sufficient. So this is off the pathology. So I just wanted to share with you, A, the technique of the liver biopsy, B, how to manage the specimen and C, how to deal with bleeding in the needle track with the blood patch technique. Thank you so much.

EUS cardiac liver biopsy technique

blood patch

19-gauge Franci needle

U.S. guided blood patch delivery technique

liver specimen management