Snare Technique for Transcatheter Aortic Valve Implantation in a Difficult Anatomy With Calcified Aortic Valve

J INVASIVE CARDIOL 2019;31(8):E258.

Key words: aortic disease, calcification, elderly patients, transcatheter valve implantation

A 92-year-old male Caucasian patient was deemed suitable for TAVI at our hospital based on severe symptomatic aortic stenosis. He had a history of coronary artery disease, type 2 diabetes mellitus, and hypercholesterolemia. Echocardiography showed a severely calcified aortic valve with aortic valve area of 0.8 cm², mean gradient of 52 mm Hg, and ejection fraction of 50%. Multislice computed tomography had shown an extremely calcified aortic valve and a horizontal aorta. Based on the diameters of the aortic valve annulus and left ventricular outflow tract, we decided to use a 29 mm self-expanding Portico valve (St. Jude Medical).

The patient was brought to the cath lab; under mild sedation, the left common femoral artery was punctured after surgical cutdown. An 18 Fr sheath was then inserted and the aortic valve was crossed using an Amplatz Left 1 catheter and a straight wire (Teflon 0.035˝). Consequently, a Safari 0.035˝ wire was advanced over a pigtail and into the left ventricle.

After performing two aggressive predilations with a 22 mm balloon (Balton), we were unable to cross the aortic annulus with the prosthetic valve. We attempted to overcome the challenge utilizing the push-pull technique, the buddy-wire technique, and the buddy-balloon technique, but these methods were ineffectual.

Our final solution was to use a snare catheter to pull the nose cone of the Portico valve and centralize the entire system with the aortic orifice. First, we removed the Portico valve from the sheath and re-inserted it along with a snare catheter that was placed at the junction of the proximal part of the radiopaque tip and the retainer receptacle. Next, we advanced the prosthetic valve; after crossing the aortic arch, we pulled the nose cone of the Portico valve using the snare catheter, allowing easy passage across the native valve (Figure 1). Finally, a 29 mm Portico prosthesis was implanted with a good angiographic and clinical result.

From the ¹Interventional Cardiology Department, Henry Dunant Hospital Center, Athens, Greece; ²Cardiology Department, “Evaggelismos” General Hospital of Athens, Athens, Greece; and ³Cardiology Department, “Hippokration” Hospital, University of Athens, Athens, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 18, 2018.

Address for correspondence: Athanasios Kolyviras, MD, PhD, Department of Interventional Cardiology, Henry Dunant Hospital Center, P.O. Box 11526, 107 Leoforos Mesogion Str, Athens, Greece. Email: kolyvirasthanos@hotmail.com