TAVR - Complex TAVR
Sang Yong Jo1
Asan Medical Center, Korea (Republic of)1
Relevant Clinical History and Physical Exam
An 80-year-old male patient was referred for treatment for aortic stenosis due to chest pain occured 6 months ago. He was an ESRD patient on dialysis and had a history of PCI in LAD and RCA 9 years ago.
Relevant Test Results Prior to Catheterization
Because he has heart failure with reduced ejection fraction, we use dobutamine echo to evaluate valve function. Peak and mean pressure gradient was 83 and 48 indivisually and Vmax was 4.5m/s. Meaningful stenosis on mid RCA and Lt. Main observed on coronary angiogram. We treat Lt. Main before the TAVR and plan staged PCI for RCA when TAVR.
Relevant Catheterization Findings
Because the aorta and peripheral artery had severe tortuosity, we think wire and catheter advance will be challenging.
After the left femoral puncture, we attempted to insert a pigtail catheter into the aortic annulus, but it was challenging due to the tortuosity of the aorta. Even with the use of an extra-stiff wire (Lunderquist Ring Torque 145S), the curvature became smoother, but we still couldn't advance it successfully. Therefore, we decided to use the right radial artery for pigtail catheter insertion into the aorta. However, we still needed the extra-stiff wire for additional support.Following the insertion of the temporary pacemaker via the left femoral vein, we located the 0.035'' Safari extra small 275 at the LV. In this case, due to the difficulty in advancing, we also used an extra-stiff wire.The problem persisted when we attempted to deliver the valve. After several attempts, we retracted the balloon to the valve and applied supporting force during delivery. Finally, we successfully deployed the valve, overcoming the tortuosity.
This case involves a successful transcatheter aortic valve replacement (TAVR) procedure in an elderly patient who had extremely tortuous aorta. Our experience suggested that even in patients with a tortuous aorta, it is possible to deliver the device and extra-stiff wire and some tips can be helpful to overcome the curvature.