trans catheter aortic valve implantation with core valve revalving system in uncoiled (horizontal)...

Trans Catheter Aortic Valve Implantation with CoreValve Revalving System in Uncoiled (Horizontal) Aorta.

Overcoming Anatomical and Technical Challengesfor Successful Deployment

Kunal Sarkar,1 MD, Gian Paolo Ussia,1,2* MD, and Corrado Tamburino,1,2 MD, PhD

Uncoiling of the aortic root (horizontal aorta) offers a considerable technical challengein successful deployment of core valve prosthesis. The problem is compounded in thepresence of significant calcification of the ascending aorta that limits the capability tocontrol the tension on delivery catheter during device release and may lead to implantfailure. Recognition of adverse anatomical features and use of proximal access sitessuch as subclavian artery are likely to attenuate the degree of technical difficulty inthese cases. Familiarity and facility with retrieval techniques using a snare catheter isdesirable in cases of implant failure. VC 2011 Wiley Periodicals, Inc.

Key words: valvular heart disease; diagnostic cardiac; catheterization; complicationsadult cath/intervention

INTRODUCTION

Trans catheter aortic valve implantation (TAVI) is apromising alternative to surgical aortic valve replace-ment in appropriately selected patients [1,2] based on aclinical consensus between various members of a mul-tispecialty team and use of predictive risk algorithmssuch as Euro SCORE [3] and STS-PROM scores.

Unfavorable anatomical characteristics such asuncoiled (horizontal) aorta (Fig. 1) can create significanttechnical challenges for tracking the prosthesis to theannulus and subsequent deployment of the core valve(CRS) prosthesis. It is not uncommon to find the devicebeing deployed ‘‘too high’’ or’’ too low’’ leading to sig-nificant problems like device embolization, inadequateexpansion, papraprosthetic regurgitation, worsening ofmitral regurgitation and conduction disturbances with re-sultant hemodynamic instability [4,5]. In this article, wehave described important anatomical considerations andtechnical expedients during planning and execution ofthe TAVI procedure in cases of horizontal aorta thatneed to be factored in to avoid complications and ensureoptimal deployment of the CRS prosthesis.

CASE 1

An 81-year-old lady with chronic renal insufficiency(e GFR 38 mL/min), severe chronic obstructive pulmo-nary disease (COPD) with home oxygen therapy, priorPCI with bare metal stent in the first obtuse marginal

branch of the circumflex artery and balloon aortic valvu-loplasty presented with worsening dyspnea over the last6 months and recurrent admissions for exacerbation ofheart failure. The balloon aortic valvuloplasty performeda year ago had reduced the transaortic gradient from 90to 60 mm Hg. coronary angiogram showed patent priorPCI site and a transvalvar gradient of 80 mmHg. Inview of her comorbidities and high Logistic Euro Score,she was offered TAVI for her aortic stenosis. Screeningwith echocardiography and CT angiography recorded thefollowing measurements. Aortic annulus 21 mm; Sinusof valsalva height 16 mm: Sinus of valsalva width 27mm. Iliac artery diameter.6.2 mm. It was decided to treather AS with a 23-mm CRS prosthesis.

1Division of Cardiology, Ferrarotto Hospital, University ofCatania, Italy2Excellence through Newest Advances (ETNA) Foundation

Conflict of interest: Gian Paolo Ussia is a proctor physician for

Medtronic Core Valve.

*Correspondence to: Gian Paolo Ussia, MD, Director of Interven-

tional Structural and Congenital Heart Disease Program, Invasive

Cardiology, Division of Cardiology – Ferrarotto Hospital, University

of Catania, Catania, Italy. E-mail: [email protected]

Received 21 February 2011; Revision accepted 20 March 2011

DOI 10.1002/ccd.23133

Published online 15 November 2011 in Wiley Online Library (wiley

onlinelibrary.com)

VC 2011 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 78:964–969 (2011)

Procedure

Aorto femoral angiography showed an iliofemoralvasculature suitable for access without significant calcifi-cation or atherosclerotic disease. Ascending aortogramshowed significant uncoiling of the aorta (horizontalaorta) with an almost vertical orientation of the aorticannulus. The procedure was performed under conscioussedation and local anesthesia. The left common femoralartery (CFA) was cannulated with a 7Fr introducer anda pigtail catheter was advanced to the aortic root.

The right CFA was prepared for closure with theProstar XL 10F closure device (Abbott Vascular Devi-ces, Redwood City, California). Pre implantation bal-loon aortic valvuloplasty was performed with an 18-mm Z Med balloon (B. Braun, Melsungen, Germany).The delivery catheter system (DCS) was advancedthrough the Iliofemoral vasculature and the descendingaorta without much resistance. However, the DCScould not be advanced through the aortic arch to theaortic annulus. Even after multiple attempts with alter-ing the trajectory and tension on the DCS, the distaltip kept tracking into the ascending aortic wall cepha-lad to the aortic root. The increased curvature of theaorta due to uncoiling made it impossible to advance thedevice beyond the angulation. To facilitate advancementof the DCS, the superstiff wire in the left ventricle waspulled back a few millimeters to release some tension

simultaneously as the catheter was advanced. Using thismaneuver, the DCS was advanced distally to the level ofthe annulus but could not be advanced across it as it pref-erentially tracked into the noncoronary cusp of the aorticroot. It was clear that, an extraneous flexion force wasneeded to alter the trajectory of the DCS across the archand ascending aorta. To accomplish the same, a 30-mmgooseneck snare (ev3Inc) was loaded on to the DCS overthe protective sheath of the CRS and the two were intro-duced together through the 18Fr introducer. As the DCSapproached the arch of the aorta, the first operator appliedcontinuous traction to flex the DCS thus facilitating itsdelivery across the aortic annulus (Fig. 2). Once the cor-rect position was assumed, the snare was withdrawn, andthe CRS was released in the standard fashion.

CASE 2

A frail 79-year-old lady with prior history of breastcancer and radiation to the chest, chronic renal insuffi-ciency (LES ¼ 18%) underwent TAVI with a 26-mmCRS device with the transfemoral approach. There wasuncoiling of the aorta and the annular plane was almostvertical. A 30-mm Snare catheter was loaded on to theDCS to facilitate tracking the device through the aorticarch and the annulus. The radio opaque marker waspositioned below the level of pigtail catheter in the

Fig. 1. Aortograms representing normal aortic root and aortic annulus angulation (A) anduncoiled (horizontal aorta) (B). The angulation of the aortic root and vertical orientation of theannulus make successful tracking and delivery of the CRS device extremely challenging.

Trans Catheter Aortic Valve Implantation 965

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

noncoronary cusp, and CRS release was initiated. Thedevice moved toward the left ventricle despite continu-ous tension on the DCS and monitoring the releaseunder fluoroscopic control. The device was wellexpanded, however the final position was >10-mm to-ward the ventricle. This was accompanied with an ele-vated LVEDP (21 mmHg) and low aortic diastolicpressure (38 mm Hg). Moderately severe regurgitation(þ3) was documented on aortogram. The 30-mm snarecatheter was used to grab on to the device hooks andgradually pull it upward. Traction was applied for 15–20 sec at a time with close attention to the diastolicpressure and rhythm. The process was terminated assoon as the diastolic blood pressure increased to 50mm Hg. Repeat aortogram showed significant improve-ment in regurgitation to grade þ1 (Fig. 3).

CASE 3

An 80-year-old lady with past medical history ofCOPD, liver cirrhosis and chronic renal insufficiency (LES28%) presented with severe dyspnea at minimal exertion(NYHA III-IV). Echocardiography demonstrated severeaortic stenosis with a mean transvalvar gradient of 64 mmHg. A BAV procedure for proximal symptomatic reliefwas planned to serve as bridge to TAVI 6–8 weeks later.

Angiography revealed calcification of the aortic rootand ascending aorta (Porcelain aorta), significantuncoiling of the ascending aorta as well as a horizontallie of the left ventricle. The BAV was accomplishedwith a 22 mm Nucleus balloon (NuMed) with moder-ate difficulty in delivering the BAV balloon across theannulus. It was anticipated that device tracking andprecise delivery of the CRS would be almost impossi-ble with the femoral approach. Six weeks later, theTAVI with a 26-mm CRS prosthesis was accomplishedwith the left subclavian approach. The left subclavianartery was exposed surgically and after access a 7Frintroducer was placed there in. The stenotic valve wascrossed with a straight tip steerable wire and an AL-1catheter and exchanged for a superstiff wire. The 18Frintroducer was advanced through the subclavian arteryinto the ascending aorta with gentle rotator motion andunder continuous fluoroscopic guidance till the radio-paque tip was inside the aortic arch just beyond thesubclavian artery ostium. The CRS was tracked acrossthe annulus and released into position. The positioningof the device was ‘‘low’’ accompanied with 3þ aorticregurgitation. A 30-mm gooseneck snare was advancedthrough the 18Fr introducer to grip the hooks and repo-sition the CRS with the ‘‘pull and stop’’ technique. Thedevice was successfully repositioned with a residual1þ regurgitation (Fig. 4).

DISCUSSION

Uncoiling of the aorta (Horizontal aorta) poses a sig-nificant anatomic and technical challenge to successfultracking and optimal deployment of the CRS prosthe-sis. The procedure becomes even more complex in thepresence of significant calcification in the iliofemoralvasculature, descending aorta or the ascending aorta(porcelain aorta). If a horizontal lie of the ventriclecoexists in the same case, precise positioning of theCRS prosthesis becomes a daunting task. The operatorhas to keep these challenges in mind during the plan-ning of the procedure. Once the diagnosis of uncoilingof aorta has been established with angiography and/orCT, emphasis should be directed to three issues.

1. Angulation of the aortic arch and orientation of theannulus: Close attention should be given to the angula-tion of the arch and left ventricle and orientation of theannulus during preprocedure angiography and/ or CTangiography. The tracking of the DCS and accuratepositioning of the CRS frame are likely to be challeng-ing in this scenario. The operator may try to track thedelivery catheter alone without loading the valve toassess the degree of resistance and trackability of thedevice through the angulation of the aorta. We find it

Fig. 2. Successful tracking of a CRS device across the aorticannulus (solid line) using a 30-mm gooseneck snare (dottedline). The snare catheter is introduced together with the DCSthrough the 18Fr introducer. The second operator appliescontinuous traction to keep the device aligned toward theaortic orifice and prevent the DCS from going into the noncoronary sinus.

966 Sarkar et al.


particularly useful to mount a snare catheter onto theDCS and advance both together. The shaft of the deliv-ery catheter is 12 F, the technique consists in pre-mounting the snare on the stiff wire and the deliverycatheter, advancing the 18 Fr distal part in the intro-ducer over the stiff wire first and then advancingsimultaneously the 12 F shaft and the 5 F snare cathe-ter in parallel in the introducer. This technique allowsthe snare catheter to be placed anywhere along theDCS for applying traction As the DCS navigatesthrough the aortic arch and the aortic root, the operatorapplies a constant flexion force on the DCS throughthe proximal end of the snare catheter thereby aligningit toward the center of the annulus. The CRS isdeployed in the usual manner. The snare catheter iswithdrawn along with the DCS after deployment.

2. Implant failure and retreival: Beyond difficulty intracking the device through the aorta and across theaortic annulus, the excessive angulation of the aorticarch and almost vertical orientation of the aortic annu-

lus increase the likelihood of implant failure due to asuboptimal deployment. The unfavorable anatomy ofthe ascending aorta makes it extremely difficult to al-ter the tension on the delivery catheter and control therelease of the prosthesis. In case of a horizontal lie ofthe ventricle, the effective tension exerted on the sys-tem by the operator is negated by the extreme ana-tomic angulation resulting in an imprecise and uncon-trolled release of the prosthesis using the transfemoralapproach. The left subclavian is a better access strat-egy in these cases as it allows for better control dur-ing prosthesis release and further on in repositioningthis device with a snare catheter in cases of low im-plantation. In cases of low deployment of CRS pros-thesis with a transfemoral approach, left subclavianaccess may offer a better trajectory for the snare cath-eter for pulling and repositioning the device.

3. Presence and extent of calcium in the aorta: Thetechnical complexity of TAVI in a horizontal aortais increased further in the presence of significant

Fig. 3. Deployment of a CRS device in a case of horizontal aorta. (A)-Aortogram demonstrat-ing horizontal aorta and almost vertical annulus aortic valvuloplasty. (C-D) Release of CRSprosthesis. E Low deployment of CRS prosthesis resulting in significant regurgitation F-Repositioning of the CRS with the help of a 30-mm gooseneck snare.



calcification in the aorta. Significant calcificationmay lead to dislodgement with embolization result-ing in stroke/transient ischemic events or peripheralembolization. Calcification increases the resistanceto advancing the DCS and limits the capability tocontrol the torque and tension on the delivery cathe-ter during deployment with an increased probabilityof suboptimal (often low) deployment. Further, post-deployment successful repositioning of low deploy-ment with a snare catheter may be hindered byreducing the operators’ ability to apply a sustained

and adequate traction force that can move the devicecephalad symmetrically into an optimal position. Thehorizontal orientation of the device may cause the pullforce applied to the frame to be transmitted asymmet-rically with resultant loss of optimal orientation of theCRS frame or worse embolization out of the annulus.

CONCLUSIONS

Successful deployment of a CRS prosthesis can be achallenging endeavor in cases of horizontal aorta. The

Fig. 4. (A) Low deployment of CRS with 13 Aortic regurgitation postdeployment. (B,C) Thesubclavian access is used to position a 30-mm Gooseneck snare catheter to reposition thedevice. (D) Final result with 11 regurgitation.

968 Sarkar et al.


technical difficulty is multiplied manifold in presenceof horizontal ventricle and porcelain aorta. At present,implantation of CRS in cases of significant aortic archangulation and more than 30–45� of aortic root angula-tion is considered an off label procedure. Once a com-bination of horizontal aorta and calcification is detectedprior to the procedure, strong consideration must begiven to using an alternate, more proximal access tothe aortic annulus such as left subclavian access. If thesubclavian artery is adequate in caliber (>6 mm) andfree of significant disease it facilitates a more con-trolled release process. In addition, cases of lowdeployment, repositioning of the device with a snarecatheter can be better managed through the subclavianaccess with decreased likelihood of device mal orienta-tion or embolization. Communication and sharing ofoperator experiences are likely to be of help in devel-oping optimal deployment strategies in these cases.

REFERENCES

1. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, et al. Trans-

catheter aortic-valve implantation for aortic stenosis in patients

who cannot undergo surgery. N Engl J Med 2010;363: 1597–1607.

2. Thomas M, Schymik G, Walther T, Himbert D, Lefevre T, et al.

Thirty-day results of the SAPIEN aortic bioprosthesis european

outcome (SOURCE) registry: A European registry of transcathe-

ter aortic valve implantation using the Edwards SAPIEN valve.

Circulation 2010;122:62–69.

3. Andrade IN, Moraes Neto FR, Oliveira JP, Silva IT, Andrade

TG, Moraes CR. Assesment of the EuroSCORE as a predictor

for mortality in valve cardiac surgery at the Heart Institute of

Pernambuco. Rev Bras Cir Cardiovasc 2010;25:11–18.

4. Leon MB, Piazza N, Nikolsky E, Blackstone EH, Cutlip DE, et al.

Standardized endpoint definitions for transcatheter aortic valve im-

plantation clinical trials: A consensus report from the valve aca-

demic research consortium. Eur Heart J 2011;32:205–217.

5. Ussia GP, Barbanti M, Imme S, Scarabelli M, Mule M, Cammalleri V,

Aruta P, Pistritto AM, Capodanno D, Deste W, Di Pasqua MC, Tam-

burino C. Management of implant failure during transcatheter aortic

valve implantation. Catheter Cardiovasc Interv 2010;76:440–449.



trans catheter aortic valve implantation with core valve revalving system in uncoiled (horizontal)...

Documents