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Clinical Images

Snare Technique to Facilitate ‘Tall-in-Short’ Redo-TAVR

August 2024
1557-2501
J INVASIVE CARDIOL 2024;36(8). doi:10.25270/jic/24.00058. Epub March 14, 2024.

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.


An 82-year-old man with a prior history of transcatheter aortic valve replacement (TAVR) with a 23-mm balloon-expandable transcatheter heart valve (THV) presented with bioprosthetic stenosis. Preoperative computed tomography revealed an underexpanded THV (Figure, A) with large sinuses with no risk for coronary obstruction (Figure, B). Hence, we decided to use a 26-mm self-expandable THV (Evolut FX 26 mm, Medtronic) to optimize hemodynamics for redo-TAVR.

The THV was crossed and a pre-shaped stiff wire (Confida, Medtronic) was inserted into the left ventricle apex. We were unable to advance the self-expandable prosthesis past the frame of the initial THV despite multiple attempts due to bias towards the greater curvature (Figure, C; Video 1). Next, we advanced a 25-mm Amplatz Goose Neck snare catheter (Medtronic) around the self-expandable THV and facilitated entry through the THV by pulling towards the lesser curvature. This snare technique centralized entry of the THV, and we were then able to perform successful redo-TAVR (Figure, E & F; Video 2)

To the best of our knowledge, this is the first reported use of a snare technique to facilitate ‘tall-in-short’ redo-TAVR. This snare technique should be considered in advance of the procedure, as it may be difficult to advance across the frame during redo-TAVR when using a tall THV platform without the ability to flex.

 

Figure. (A) Preoperative computed tomography
Figure. (A) Preoperative computed tomography demonstrated an under-expanded transcatheter heart valve with pannus. (B) Large sinuses with no risk for coronary obstruction with redo-TAVR. (C) A self-expandable THV is biased towards the outer curvature and unable to cross past the frame of previously implanted THV (white arrow points to nose-cone unable to advance past the THV frame). (D) Snare is used to pull THV towards inner curvature (white arrow points to snare) to cross implanted TAVR valve. (E) Aortic angiography demonstrates successful redo-TAVR without PVL. (F) Transthoracic echocardiography shows no PVL. PVL = paravalvular leak; TAVR = transcatheter aortic valve replacement; THV = transcatheter heart valve.

 

Affiliations and Disclosures

From the Department of Cardiology and Cardiothoracic Surgery, Hackensack University Medical Center, Hackensack, New Jersey, USA.

Disclosures: Dr Kaple is a speaker for Edwards Lifesciences and Abbott. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Craig Basman, MD, FACC, FSCAI, Division of Cardiology, Hackensack University Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601, USA. Email: craigbasman@gmail.com; craig.basman@hmhn.org; X: @craigbasman

 


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