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