Hemodynamic evaluation of patients with combined mitral and aortic prostheses

Assessment of trans-aortic pressure gradient using a coronary pressure wire in patients with mechanical aortic and mitral valve prostheses

Accurate evaluation of trans-aortic valvular pressure gradients is challenging in cases where dual mechanical aortic and mitral valve prostheses are present. Non-invasive Doppler echocardiographic imaging has its limitations due to multiple geometric assumptions. Invasive measurement of trans-valvular gradients with cardiac catheterization can provide further information in patients with two mechanical valves, where simultaneous pressure measurements in the left ventricle and ascending aorta must be obtained. Obtaining access to the left ventricle via the mitral valve after a trans-septal puncture is not feasible in the case of a concomitant mechanical mitral valve, whereas left ventricular apical puncture technique is associated with high procedural risks. Retrograde crossing of a bileaflet mechanical aortic prosthesis with standard catheters is associated with the risk of catheter entrapment and acute valvular regurgitation. In these cases, the assessment of trans-valvular gradients using a 0.014˝ diameter coronary pressure wire technique has been described in a few case reports. We present the case of a 76-year-old female with rheumatic valvular heart disease who underwent mechanical aortic and mitral valve replacement in the past. She presented with decompensated heart failure and echocardiographic findings suggestive of elevated pressure gradient across the mechanical aortic valve prosthesis. The use of a high-fidelity 0.014˝ diameter coronary pressure guidewire resulted in the detection of a normal trans-valvular pressure gradient across the mechanical aortic valve. This avoided a high-risk third redo valve surgery in our patient. © 2017 Wiley Periodicals, Inc.

Direct right ventricular puncture for hemodynamic evaluation of a mechanical tricuspid valve prosthesis: a new indication for an old procedure

The advent of transvenous right heart catheterization has relegated direct transthoracic right ventricular puncture largely to the role of "interesting historical footnote." However, in the case of a right ventricle that is "protected" by a mechanical tricuspid valve prosthesis, direct right ventricular puncture represents a reasonable alternative for obtaining accurate hemodynamic information.

Transseptal catheterization in adults: enhanced efficacy and safety by low-volume operators using a "non-standard" technique

Transseptal catheterization is often not performed because of concerns about morbidity and mortality. The authors present several refinements of this technique that have allowed a series of cases to be done with minimal morbidity or mortality. This was possible despite limited previous experience in this technique and a relatively low-volume of cases.

Aortic catheterisation via percutaneous left ventricular puncture

When retrograde catheterisation and angiography of the ascending aorta from the brachial or femoral approach is not possible, this can be accomplished by direct percutaneous left ventricular puncture. The haemodynamic and angiographic information obtained was essential to surgical correction of aortic arch anomalies as illustrated in two patients.