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This didactic procedure concerns an 83 years old man with a history of multiple percutaneous coronary interventions with a chronic total occlusion of the left circumflex and a symptomatic severe aortic stenosis that was assigned for TAVI treatment by the Heart Team with an ACURATE Neo2 Valve.

 

Educational objectives

  • Step-by-step implantation of the ACURATE Neo2 Valve
  • Step-by-step use of the SENTINEL™ Cerebral Protection device
  • How valve design impact coronary access and condition future treatment options for the patient after TAVI
  • Tips and tricks to preserve coronary access after TAVI
  • Advantages of the ACURATE Neo2 valve system in horizontal aortic root

 

Step-by-step procedure: Left internal carotid artery stenting

1) Access sites and set-up

  • Femoral access: Ultrasound guided puncture
  • Second Access: Left radial access 6 Fr: Aortic angiogram
  • Third access: Right radial access 6 Fr: Implantation of cerebral protection device: distal and proximal filter after a good screening on pre-TAVI CT for left carotid and brachiocephalic arteries diameter
  • Pre-closing with 2 ProGlide™ systems.
  • Support guidewire through very tortuous iliac arteries: Lunderquist® guidewire.
  • Advancement of the large bore sheath on the Lunderquist® guidewire smoothly under fluoroscopy through tortuous and kinked iliac arteries.

2) Aortic valve crossing

  • AL1 catheter with Terumo® straight tip
  • Exchange with pre-shaped Safari ® guidewire
  • Ensure good position of the wire on LV with the Pigtail catheter
  • Ensure a good position of the pigtail catheter at the bottom of the NC cusp

3) Pre-dilatation valvuloplasty

  • Non-compliant 22mm balloon. (Minimum diameter of the valve 23mm)
  • Pacing over the wire at 180 bpm.

4) Advancement of the ACURATE Neo2 Valve

  • Description of the delivery catheter
  • Aortic arch crossing: avoid interference with the cerebral protection device
  • Pre dilatation of the lesion using a 5.5*20mm Ultra-Soft™ balloon.
  • Positioning the valve through the horizontal aortic root (valve/wire maneuver)

5) Implantation of the ACURATE Neo2 Valve

  • ACURATE Neo2 Valve: implantation marker in the delivery system that indicates the level of implantation: 7mm marker
  • Angiogram check of the position of the valve before delivery
  • Delivery of the valve: turn wheel 1 slowly
  • Check the level and the opening of the upper crown of the valve towards the aortic root
  • Ensure good alignment with the outer aortic root curve
  • The annular part of the valve is the last to be opened
  • Fast opening the wheel 2
  • Retrieve the delivery system in the descending aorta

Tips and tricks for commissure alignment with the ACURATE Neo2 valve: Put the pin at 6 o’clock / alignment of the three stent arches.

6) Final control of valve implantation results

  • Check of the valve opening and the height of the implant, aortic regurgitation
  • Angiogram control
  • Hemodynamic pressure control
  • ECG control
  • Echo control

7) Remove of the SENTINEL™ Cerebral Protection device

8) Vascular closure with 2 ProGlide™ at 2 and 10 O’clock.

 

Bibliography

 
 

4. Coronary Access After Repeated Transcatheter Aortic Valve Implantation. Buzzatti N, Romano V, De Backer O, Soendergaard L, Rosseel L, Maurovich-Horvat P, et al. JACC Cardiovasc Imaging. févr 2020;13(2):508‑15.

5. Coronary Access After Transcatheter Aortic Valve Replacement in Patients With Bicuspid Aortic Valve. Tarantini G, Fabris T, Cardaioli F, Nai Fovino L. JACC Cardiovasc Interv. juin 2019;12(12):1190‑1.

6. Transcatheter Valve Neo-Commissural Overlap With Coronary Orifices After Transcatheter Aortic Valve Replacement: Implication on Coronary Reaccess Tang GHL, Zaid S, Ahmad H, Undemir C, Lansman SL. Circ Cardiovasc Interv [Internet]. oct 2018 [cité 2 sept 2021];11(10).

7. Predicting the Feasibility of Post-TAVR Coronary Access and Redo TAVR. Tang GHL, Kaneko T, Cavalcante JL. JACC Cardiovasc Interv. mars 2020;13(6):736‑8.

8. The SAVI-TF Registry. Kim W-K, Hengstenberg C, Hilker M, Kerber S, Schäfer U, Rudolph T, et al. JACC Cardiovasc Interv. juill 2018;11(14):1368‑74.

9. Transcatheter aortic valve implantation using the ACURATE neo in bicuspid and tricuspid aortic valve stenosis: a propensity-matched analysis of a European experience.Mangieri A, Chieffo A, Kim W-K, Stefanini GG, Rescigno G, Barbanti M, et al. EuroIntervention. déc 2018;14(12):e1269‑75.

10. Unplanned Percutaneous Coronary Revascularization After TAVR. Stefanini GG, Cerrato E, Pivato CA, Joner M, Testa L, Rheude T, et al. JACC Cardiovasc Interv. janv 2021;14(2):198‑207.

Audience

This webinar is for Interventional Cardiologists and Heart Surgeons who implant TAVI devices or have an interest in learning more about Transcatheter Aortic Valve Implantation, as well as non-invasive Cardiologists with an interest in the current developments in the field TAVI therapy for their patients.
 

*Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent (RE-ACCESS); NCT04026204) J Am Coll Cardiol Intv 2020.
Last update : 2021-09-10

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  • dramthirugnanam@aol.com D. position is not perfect

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    • dramthirugnanam@aol.com D. 2 mm can be inside

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