A safe and simple technique for crossing stenotic aortic valves.

OBJECTIVES: To describe and to validate a new technique for crossing stenotic aortic valves (AV). BACKGROUND: Current techniques for crossing the AV may be time-consuming and hazardous. METHODS: One hundred consecutive patients with severe aortic stenosis treated by transfemoral TAVI were prospectively selected to have an initial attempt of 5 min to cross the AV with a novel pigtail/J-wire technique before switching to the conventional Amplatz®/straight wire approach. For the pigtail/J-wire technique, the catheter is placed 3-4 cm above the AV and turned anteriorly in the 30° RAO view. A J-wire pushed out of the pigtail-catheter will reach the anterior wall of the ascending aorta, forming a u-shaped curve above the AV. The height of the pigtail catheter determines the width of the curve, rotation will help to find an orientation, where the vertex of the curved J-wire easily passes the AV. We analyzed the primary success rate within 5 min and the mean crossing time required. RESULTS: Patients were 83.5 ± 5.5 years of age and predominantly male (62%). Primary success rate was 86%, AV crossing took 48.2 ± 34.6 s without complications. Fourteen failed cases were successfully managed with AL1- (6) and both, AL1- and AL2-catheters (8), respectively CONCLUSIONS: The pigtail/J-wire technique for AV crossing is safe, simple and fast. Primary placement of a pigtail catheter into the left ventricle at a success rate of 86% facilitates TAVI procedures.

Matched comparison of next- and early-generation balloon-expandable transcatheter heart valve implantations in failed surgical aortic bioprostheses.

AIMS: Transcatheter valve-in-valve implantation (VinV) is established for the treatment of degenerated surgical bioprostheses in patients at high operative risk. Our aim was to report on the first large assessment of VinV with next-generation balloon-expandable transcatheter heart valves. METHODS AND RESULTS: After SAPIEN XT or SAPIEN 3 VinV, 514 patients were analysed using an inverse probability of treatment weighting. Standardised clinical and haemodynamic outcomes were compared, and core laboratory evaluation of implantation depth was performed. Thirty-day all-cause mortality was 0.6% and 3.5% for SAPIEN 3 and SAPIEN XT (p=0.077). Residual transprosthetic gradient ≥20 mmHg was observed in 38.3% (SAPIEN 3) and 35.7% (SAPIEN XT) of patients (p=0.627) with increased rates in small bioprostheses (≤21 mm true ID). In SAPIEN 3 VinV, low implantation depth >20% THV stent frame length was associated with a higher rate of elevated transaortic gradients (p=0.048). Similarly, an implantation depth >5 mm was linked to more pacemaker implantations (p=0.01). Overall, a trend towards higher pacemaker implantation rates was observed after SAPIEN 3 VinV (6% vs. 2.5% in SAPIEN XT, p=0.071). CONCLUSIONS: Transcatheter aortic VinV with the balloon-expandable SAPIEN XT or SAPIEN 3 was similarly safe and effective. However, residual stenosis remains a concern, particularly in smaller bioprostheses and with increasing implantation depth.

Transfemoral implantation of Edwards SAPIEN-XT® transcatheter heart valve in a degenerated tricuspid bioprosthesis.

We report on a percutaneous transcatheter valve-in-valve implantation (Edwards-SAPIEN-XT®) (Edwards Lifesciences Corp., One Edwards Way Irvine, CA 92614) in a 50-year-old i.v. drug user with a history of biological tricuspid valve replacement (Perimount 31 mm) (Edwards Lifesciences Corp., One Edwards Way Irvine, CA 92614) due to tricuspid valve endocarditis five years earlier. Re-operation was considered unfavorable due to general and specific risk factors. The case was discussed by the heart team. Obviously, some type of valve replacement was required. Given the high risk of tricuspid valve re-operation in general and the specific risk factors of the patient (New York Heart Association functional class III, reduced right ventricular function, continued drug abuse, active hepatitis C and human immunodeficiency virus infection, suspected non-compliance, unfavorable social background) the consensus was to attempt percutaneous transcatheter valve-in-valve implantation. Implantation of an Edwards-SAPIEN-XT® valve (Edwards Lifesciences Corp., One Edwards Way Irvine, CA 92614) in tricuspid position was successfully performed and the patient was transferred to the ward on day 2, completely free of symptoms. Pre-discharge echocadiographic control on day 6 again confirmed adequate position and regular function of the Edwards-SAPIEN-XT® valve (Edwards Lifesciences Corp., One Edwards Way Irvine, CA 92614) without any signs of regurgitation or stenosis. .