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Complex Valve-in-Valve (VIV) TAVI for Aortic bioprosthesis dysfunction

Case of the Month: July 2018

This didactic procedure concerns a 81 y.o gentelman, with history of Surgical Aortic valve bioprosthesis replacement with Mitroflow 21; presenting  heart failure due to  severe  aortic prosthesis dysfunction (severe Aortic regurgitation); after Heart Team discussion, he was considered for Valve-in-Valve TAVI With Auto-expandable Evolut-R  valve.
 

Educational objectives

  • Optimal Echo-guided Femoral access for TAVI Procedures.
  • Managing  degenerative aortic bioprosthesis with Valve -in-Valve implantation in High risk patients.
  • Optimal choice and sizing  of the Valve-in-Valve device.
  • Dealing with Valve positioning and deployment in case of severe Aortic regurgitation.
  • Protection of  coronary arteries  from occlusion in High risk patients during  TAVI procedures. 

Step-by-Step Procedure

  • Echo-guided Right Femoral artery access, Left femoral access & right radial artery access.
  • Right Femoral artery  access 14F, Left femoral artery access 7F, Right radial artery access 5F.
  • Protection of the Right coronary artery with 7F JR4 guiding catheter & workhorse coronary guidewire (Sion blue) (Over left femoral access).
  • Placing a 5Fr Pigtail catheter in the ascending aorta through Right Radial access.
  • Preclosing the right Femoral access  with two Proglide devices (Abbott).
  • First evaluation aortography.
  • Crossing the degenerated valve with AL1 5F Catheter and regular wire.
  • Loading the 14 F introducer.
  • Pre-implantation Pressure parameters recording.
  • Exchange the regular guidewire with Safari guidewire.
  • Evolut-R Valve loading, Fluoroscopic chek of the valve.
  • Evolut-R valve optimal positioning, recapture and second positioning  for best compromise between coronary occlusion risk and transvalvular residual gradient.
  • Partial release of the Evolut-R valve and angiographic control.
  • Pulling back the Pigtail 5F Catheter & the  JR4 7F protection guiding catheter.
  • Final release of the valve.
  • Post-implantation pressure parmeters recording.
  • Angiographic control of the Coronary arteries patency.
  • Final angiographic result.
  • Femoral access closure with Proglide devices.

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