Valve-in-valve TAVR: Uncrossable prosthetic valve negotiated by an ingenious approach.
Figure 1. Steps of anterograde crossing
Figure 2. The combined anterograde-retrograde approach for valve-in-valve TAVI
Transcatheter aortic valve replacement (TAVR) is now an established treatment modality for native aortic valve stenosis. Its implications in previous surgically or percutaneously implanted valves is also gaining acceptance. However, such valve-in valve procedures have their own unique challenges; the technique to handle one such case was published by Wong et al in the current issue of JACC.
A 73-year-old woman with a history of surgical aortic valve replacement with a bioprosthetic was referred for a valve-in-valve (VIV) procedure with a transcatheter aortic valve prosthesis in view of symptomatic, severe structural valve deterioration. VIV with a 23-mm Evolut R valve (Medtronic) under local anesthesia was planned.
But the challenge was to cross the severely stenotic surgical bioprosthetic aortic valve. Multiple catheters and guidewires were used but none could cross the valve through the aortic approach. Therefore, the strategy was changed to an antegrade approach to cross the aortic valve, considering that the procedure was performed under local anesthesia. First, a standard atrial transseptal puncture was performed under intracardiac echo- guidance. Next, an 8.5-F Agilis NxT steerable introducer (Abbott Vascular, Santa Clara, California) was introduced into the left atrium over a stiff guidewire that was placed in the left upper pulmonary vein. Through this steerable introducer, a 6-F pigtail catheter was placed into the left ventricle (LV). (Figure 1)
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