Concurrent antegrade transseptal inoue-balloon mitral and aortic valvuloplasty

Computed tomography analysis of coronary ostia location following valve-in-valve transcatheter aortic valve replacement with the ACURATE neo valve: Implications for coronary access

BACKGROUND

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an emerging alternative to re-do surgery. However, the challenge of coronary access (CA) following ViV-TAVR is a potential limitation as TAVR expands to younger lower-risk populations.

OBJECTIVES

Using post-implantation computed tomography (CT) scans to evaluate the geometrical relationship between coronary ostia and valve frame in patients undergoing ViV-TAVR with the ACURATE neo valve.

METHODS

Post-implant CT scans of 18 out of 20 consecutive patients treated with the ACURATE neo valve were analyzed. Coronary ostia location in relation to the highest plane (HP) (highest point of the ACURATE neo or surgical valve) was determined. Ostia located below the highest plan were further subclassified according to the gap available between the transcatheter heart valve frame and ostium (transcatheter-to-coronary [TTC] distance). The impact implantation depth has on these geometrical relationships was evaluated.

RESULTS

A total of 21 out of 36 coronary ostia (58%) were located below the level of the HP with the left coronary artery (36%) more likely to be affected than the right (22%). Further sub-classification of these ostia revealed a large (>6 mm), moderate (4-6 mm), and small (<4 mm) TTC distance in 57% (12/21), 38% (8/21), and in 6% (1/18) of cases, respectively. At an implantation depth <4 mm compared to >4 mm, all ostia were located below the HP with no difference in post-procedural mean gradients (14.5 mmHg ± 4.7 vs. 12.6 mmHg ± 5.8; p = .5, 95%CI 3.8-7.5).

CONCLUSIONS

CA following ACURATE neo implantation for ViV-TAVR could potentially be challenging in a significant proportion of patients and specific consideration should be given to the implantation depth.

Transvenous Transseptal Concurrent Inoue Balloon Mitral and Aortic Valvuloplasty in an Octogenarian With Severe Aortic and Mitral Stenosis

An octogenarian was admitted because of severe aortic stenosis (AS) and mitral stenosis. He declined surgical double-valve replacement and underwent intracardiac echocardiography–guided transseptal puncture and concurrent Inoue (Toray, Tokyo, Japan) balloon aortic valvuloplasty (BAV) and balloon mitral valvuloplasty (BMV). Nine months later, he had worsening pulmonary edema and received a second session of Inoue BAV and BMV. Our case shows that concurrent transseptal Inoue BAV and BMV can treat severe AS and mitral stenosis with adequate safety and efficacy. However, the durability is limited in elderly persons with calcified AS. The procedure should be reserved for patients who refuse surgery.

Transseptal Techniques for Emerging Structural Heart Interventions

The development of new transseptal transcatheter interventions for patients with structural heart disease is fueling increasing interest in transseptal puncture techniques. The authors review contemporary transseptal puncture indications and techniques and provide a step-by-step approach to challenging transseptal access and procedural complications.

Application of a snare technique in retrograde chronic total occlusion percutaneous coronary intervention - a step by step practical approach and an observational study

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has recently become popular among interventional cardiologists. CTO originating from the ostium has been one of the most difficult CTO lesions to treat with PCI for a number of reasons. Our aim was to illustrate a specific technique during retrograde CTO PCI referred to as the "snare technique."We retrospectively examined the use of "snare technique" among 371 consecutive retrograde CTO PCIs performed at our institution between 2006 and 2015."Snare technique" was used in 10 patients among the 371 retrograde CTO PCIs. The baseline clinical and angiographic characteristics of patients with or without "snare technique" were similar. The "snare technique" group had significantly fewer side branches at occlusion (30.0% vs 71.2%, P = 0.01) and a higher incidence of externalization (90% vs 25.5%, P < 0.001). The contrast volume was significantly lower in the "snare technique" group (285.0 ± 68.5 vs 379.2 ± 144.0, P = 0.04). The incidence of major complications, retrograde success, or final success did not differ between the groups.The "snare technique" is safe and feasible in retrograde CTO PCI, especially in cases of difficult coronary engagement in cases such as ostial occlusion, challenging coronary anatomy, or retrograde guidewire cannot get in antegrade guiding catheter.