2019 Scientific Sessions

Authors: Shahrukh N. Bakar, MD; Patrick J. Teefy, MD; Pantelis Diamantouros, MD; Rodrigo H. Bagur, MD, PhD Title: Emergent Balloon Aortic Valvuloplasty Using Bi-Radial Approach and Left Ventricular Guidewire as Pacing Wire Introduction: Balloon aortic valvuloplasty is used nowadays for hemodynamic palliation or as a bridge to definitive management of symptomatic severe aortic stenosis. The majority of cases are currently performed using a transfemoral approach. We describe a successful case of balloon aortic valvuloplasty and simultaneous rapid cardiac pacing using a bi-radial approach. Clinical Case: A 74-year old female with critical aortic stenosis (aortic jet velocity 5.5 m/s; mean gradient 67 mmHg, indexed aortic valve area 0.16 cm²/m²) presented with cardiogenic shock to a peripheral hospital and was transferred to our institution for further management. Comorbidities included severe left ventricular dysfunction (LVEF 25-30%), morbid obesity (body mass index 60), recent large upper gastrointestinal bleeding, hypertension, Type 2 diabetes, dyslipidemia, atrial fibrillation, and prior permanent pacemaker implantation. Surgical aortic valve replacement was deemed to confer prohibitive risk by the Heart Team and she was too hemodynamically unstable for transcatheter aortic valve replacement (TAVR). She was therefore referred for balloon aortic valvuloplasty as a bridge to definitive treatment. Conventional femoral access was challenging due to body habitus and therefore bi-radial access was used by placing two 6-French introducer sheaths. The aortic valve was crossed using a straight guidewire through a Judkins Right 4 diagnostic coronary catheter and then exchanged with two Safari-2 (Boston Scientific, Marlborough, MA, USA) pre-shaped guidewires that were well-seated in the left ventricle apex. Thereafter, two 10 mm x 4 cm Mustang balloon dilatation catheters (Boston Scientific, Marlborough, MA, USA) were simultaneously delivered across the aortic valve. Notably, temporary ventricular pacing was performed using one of the Safari-2 guidewires as the intracardiac electrode, and a subcutaneous puncture needle as the skin electrode. Valvuloplasty was performed under rapid (170 bpm) ventricular pacing for 5 seconds with simultaneous balloon inflation. Access site hemostasis was successfully achieved using conventional radial wrist bands. Mean aortic gradient dropped to 30 mmHg (Doppler). Discussion: Bi-radial access is an attractive and safe option for balloon aortic valvuloplasty that avoids femoral access and its associated complications in a patient with morbid obesity. Interestingly, cardiac pacing can also be reliably achieved using an intracardiac left ventricular guidewire; thus eliminating the need for a separate pacemaker access site. Even though this technique is feasible, operators must bear in mind that there is no bailout option if the patient develops severe aortic regurgitation. A balloon/annulus ratio ≤ 0.8 (0.8 in our case) is recommended to avoid the risks of annular rupture or significant aortic regurgitation. Clinical decision-making therefore remains of paramount importance.