snare technique for tavi in a difficult anatomy of a calcified … · 2018-05-18 · local...
TRANSCRIPT
Snare technique for TAVI in a difficult anatomy of a calcified
aortic valve
Speaker's name: V. Tzifos
q I do not have any potential conflict of interest
Medical history
92-year-old male presented to our hospital with progressive dyspnoea (NYHA III)
Risk factors: CAD, aortic valve stenosis, diabetes mellitus type 2, hypercholesterolemia, anemia
Life style: Active
Psychological status: No abnormalities
Primary diagnosis: dyspnoea probably related to the progression of aortic valve stenosis
• Echocardiography: AVA:0.8cm², mean Gradient:57mmHg, EF:50%
• Coronarography: 1-vessel coronary artery disease with PCI in LCx
• Logistic Euroscore I: 41.60%• Society of thoracic surgeons (STS) risk score: 7.52%
Risk evaluation
Aortic valve annulusPerimeter mean diameter: 25.9mmArea mean diameter: 25.6mmArea: 514.6mm²
Left ventricular outflow tractPerimeter mean diameter: 26.3mmArea mean diameter: 25.5mmArea: 510.0mm²
Multislice Computed Tomography
Multislice Computed Tomography
Heart Team decision: TAVI
Local anesthesia, conscious sedation
Right femoral access, surgical cutdown
Portico™ 29mm valve:a. Repositionable and completely retrievableb. Self-expanding valve
Procedural strategy
Extremely calcified aortic valve and horizontal aorta
Procedure
Unable to advance the valve after 2 aggressive pre-dilatations
Procedure
- Two wires in the LV in order to perform buddy-wire, buddy-balloon technique.- Unable to cross the valve
Procedure
2 Safari wires in the LV for better support.A snare catheter is used to pull the nose cone of the Portico valve in order to have co-axiality with the aortic orifice and to successfully cross the aortic valve.
Procedure – Snare technique
2 Safari wires in the LV for better support.A snare catheter is used to pull the nose cone of the Portico valve in order to have co-axiality with the aortic orifice and to successfully cross the aortic valve.
Procedure – Snare technique
Procedure
Snare release and post dilatation
Snare technique can provide a safe
solution to these cases
Other solutions:
Pre-dilatations (aggressive)
Buddy - balloon technique
Push pull technique
Backup Meier wire instead of Safari wire
Change access (ex. trans-aortic approach)
Final result – successful implantation of 29mm Portico Valve with dood angiographic and hemodynamic result
Final Result and Take Home Messages
77 -year-old male,
Risk factors: 2VD CAD, aortic valve stenosis, hypercholesterolemia, smoker
Life style: Active
Psychological status: No abnormalities
Primary diagnosis: dyspnoea probably related to the progression of aortic valve stenosis
Echocardiography: AVA:0.8cm², mean Gradient:60mmHg, EF:50%
Logistic Euroscore = 13.66%
Medical History
Aortic valve annulusPerimeter derived: 27.6mmArea derived: 27.2mmArea: 581.1mm²
Left ventricular outflow tractMin Diam. 24.4mmMax Diam. 32.8 mmAvg Diam. 28.5mm
34mm Evolut R Valve
LV-Ao PG=22mmHg
Valve Release
Post Dilatation
25mm – 28mm balloon
LV-Ao PG=10mmHg, AR=1+-2+/4+
Final Result