Snare-Assisted Transcatheter Aortic Valve Replacement in a Bicuspid Aortic Valve
Presenter
Priyanka Ghosh, DO, Guthrie Robert Packer Hospital, Sayre, PA
Priyanka Ghosh, DO and Edo Kaluski, M.D., FSCAI, Guthrie Robert Packer Hospital, Sayre, PA
Title:
Snare-Assisted Transcatheter Aortic Valve Replacement in a Bicuspid Aortic Valve
Introduction:
Tortuosity of the aorta and angle of the aortic root can affect the advancement of the valve delivery system. Pre-procedure CT imaging can provide insight and forewarning of these issues however tips and tricks must be kept in mind should unanticipated issues arise intra-procedure.
Clinical Case:
70-year-old female with bicuspid aortic valve and severe symptomatic aortic valve stenosis, heterozygous factor 5 Leiden mutation was evaluated for worsening exertional shortness of breath with stairs and walking quickly. Physical exam was significant for a 3/6 harsh systolic murmur. Transthoracic echocardiogram demonstrated ejection fraction 65-70%, grade 1 diastolic dysfunction, bicuspid aortic valve with fusion of the right and non-coronary cusps, severe aortic stenosis with a valve area by continuity equation 0.6 cm2, mean gradient 46 mmHg, peak gradient 71 mmHg, dimensionless index 0.2 with trivial aortic valve regurgitation. Based on CT angiography of chest, abdomen, pelvis patient was deemed appropriate for a Medtronic #26 Evolute R Pro Plus valve via right common femoral percutaneous approach with pre-deployment balloon valvuloplasty with #18 True Balloon and post-deployment balloon valvuloplasty with #20 True Flow Balloon. Coronary angiogram demonstrated minimal luminal irregularities in the left anterior descending artery but otherwise angiographically normal-appearing remainder of the coronary tree. Right heart catheterization demonstrated normal filling pressures with preserved cardiac output and index. During the TAVR procedure, after pre-deployment valvuloplasty, the Medtronic valve would not cross the aortic valve due to the angle of the aorta.
Discussion:
The initial extra stiff wire was exchanged for a Lunderquist wire but the valve would still not cross the native aortic valve. Unsuccessful attempts were made using a Safari wire with a buddy wire and with a balloon in the ascending aorta to help centralize the delivery system. Innovatively, a 35 millimeter gooseneck snare was advanced through a 6 French JR4 guiding catheter via the left femoral artery to snare the distal end of the valve delivery system and change the angle of entry to successfully allow for valve advancement and deployment. A 0.018 inch wire was used to demarcate the level of the aortic cusps. Moderate paravalvular leak was corrected to trivial using balloon dilation. Successful valve advancement and deployment was achieved with the use of a snare.