Multi-Pigtail Technique Is Associated with Decreased Contrast Use, Radiation Dose, and Fluoroscopic Adjustment in Determining Perpendicular Angle of Deployment for Transcatheter Aortic Valve Replacement

Eng, Maia

Multi-Pigtail Technique Is Associated with Decreased Contrast Use, Radiation Dose, and Fluoroscopic Adjustment in Determining Perpendicular Angle of Deployment for Transcatheter Aortic Valve Replacement

Tuesday, May 21, 2019

Belmont Ballroom 2-3 (The Cosmopolitan of Las Vegas)

Maia Eng, M.D. , UC Davis Medical Center, Sacramento, CA

Sarah A Chen, M.A. , University of California, Davis Medical Center, Sacramento, CA

Jeffrey Allen Southard, M.D., FSCAI , University of California, Davis Medical Center, West Sacramento, CA

Thomas Smith, M.D. , University of California, Davis Medical Center, Sacramento, CA

Garima Agrawal, M.D. , University of California, Davis Medical Center, Sacramento, CA

Walter D Boyd, M.D. , University of California, Davis Medical Center, Sacramento, CA

Reginald Low, M.D., FSCAI , University of California, Davis Medical Center, Sacramento, CA

Gagan Singh, M.D., FSCAI , UC Davis Medical Center, Sacramento, CA

Garrett B. Wong, M.D. , University of California, Davis Medical Center, Sacramento, CA

Background
Successful transcatheter aortic valve replacement (TAVR) is partly determined by deploying the valve in the fluoroscopic perpendicular angle of deployment (PAOD). This places the valve in a 90-degree plane to the aortic annulus, minimizing paravalular leak. Pre-procedurally, a predicted PAOD is determined with multi-detector computed tomography (MDCT). Intra-procedurally, one or more pigtail catheters are placed in the aortic annulus and an aortogram is used to corroborate the predicted PAOD. However, the aortogram often shows a non-PAOD, necessitating fluoroscopic adjustments with multiple aortograms.

Methods
283 patients undergoing TAVR were retrospectively analyzed from 2015-2017. 42% (n = 118) of the patients underwent a OP technique and 58% (n = 165) used MP technique. We reviewed MDCT and fluoroscopic LAO-RAO (L-R) and Cranial-Caudal (Cr-Ca) projections, time to valve deployment, radiation dose, contrast use, and in-hospital major adverse cardiovascular events (MACE).

Results
Patients in the MP group had decreased fluoroscopy time, contrast dose, radiation dose, and time to valve deployment (17.8 ± 8.7 vs 23.5 ± 13.6 min, p = 0.0000; 74.8 ± 39.8 vs 117.3 ± 59 cc, p=0.0000; 249 ± 167.6 vs 144 ± 131.8 Gycm², p = 0.0000; and 22.6 ± 9.4 vs 27.1 ± 13.1 min, p=0.0011, respectively). MP technique had greater deviation from the MDCT PAOD in the L-R (7.4 ± 8.7 vs 4.5 ± 6.4 degrees, p=0.0032) but not the Cr-Ca projection prior to deployment. After deployment, the MP technique had less adjustment in the L-R (2.9 ± 6.5 vs 5.4 ± 10 degrees, p=0.012) and Cr-Ca (2.3 ± 5.3 vs 5.3 ± 8.1 degrees, p=0.0002) projections to achieve a non-paralaxed view of the valve. There was no difference in in-hospital MACE.

Conclusions
In this single center retrospective study, we found that use of a MP technique resulted in significantly decreased time to deployment, fluoroscopy time, radiation dose, and contrast utilization in patients undergoing TAVR without increased risk of in-hospital MACE. The MP technique has the potential to increase TAVR procedural efficiency and may also have important implications for patients who are at risk for developing acute kidney injury, although larger prospective studies are needed.