Anterograde Crossing of a Bicuspid Aortic Valve Through Transseptal Access to Facilitate Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) for bicuspid aortic valve stenosis can pose several technical challenges including difficult valve crossing. We report the case of a 77-year-old woman undergoing transfemoral TAVI for symptomatic severe bicuspid aortic stenosis. It proved impossible to cross the bicuspid aortic valve retrogradely despite the use of multiple catheters and wires and attempts by two interventional cardiologists. We describe a novel approach to antegrade crossing, through a transseptal access, to permit retrograde implant of prosthesis. Copyright:

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) for the treatment of bicuspid aortic stenosis (AS) is accompanied by technical challenges including difficult valve crossing.[1]

We report a case of an elderly frail woman undergoing TAVI during which we could not cross the bicuspid stenosis valve in a retrograde manner. We hereby describe the novel steps of an anterograde crossing through transseptal access to facilitate TAVI.

CASE PRESENTATION

A 77-year-old frail woman underwent workup for symptomatic severe AS. Echocardiographic parameters showed peak and mean transvalvular gradients of 67 mmHg and 33 mmHg, respectively, a calculated aortic valve area of 0.65 cm2 and normal left ventricular systolic function. Her preprocedural computed tomography demonstrated a bicommissural raphe-type bicuspid aortic valve [Figure 1a] with mild aortic root dilatation (41 mm) and identified the left femoral artery for access. Coronary angiography revealed severe three-vessel coronary artery disease which was managed medically in the absence of angina. After being deemed too high risk for surgery by the heart team, she attended for TAVI.

Figure 1

Bicuspid aortic valve with the right-left fusion (a). Transseptal puncture through right femoral vein access with SL1 sheath (→) and BRK1-XS needle (*) (b). A 0.032” wire (*) was placed in the left upper pulmonary vein (c). En Snare (*) delivered through 7Fr JR4 guide used to snare antegrade wire into the aorta (d). JR4 guide (*) passed into the left ventricle over wire loop and standard wire unsnared and swapped to a Safari wire (→) (e). Deployment of 26 mm S3 (Edwards Lifesciences) (f)

The right radial artery and right femoral vein were accessed for the placement of a pigtail catheter in the aortic root and a temporary pacing wire, respectively. A 14-French eSheath (Edwards Lifesciences) was inserted into the left femoral artery after double ProGlide (Abbott Vascular) preclosure. It proved impossible to cross the bicuspid aortic valve retrogradely despite the use of multiple catheters and wires and attempts by two interventional cardiologists.

After more than 1 h had passed, it was decided that an alternative strategy was required. An SL1 sheath (St. Jude Medical) was inserted using the established right femoral venous access. Transseptal puncture was then performed with a BRK1-XS (St. Jude Medical) needle with fluoroscopic guidance [Figure 1b], and a 0.032” wire was placed in the left upper pulmonary vein [Figure 1c] to maintain access to the left atrium. A JR4 diagnostic catheter was used to direct an exchange length hydrophilic 0.035” guidewire (Glidewire, Terumo) into the left ventricle and then through the aortic valve into the aorta. This wire was snared in the aorta through a 7 Fr JR4 guide (EN Snare, Merit Medical) to form an arteriovenous rail [Figure 1d]. The guide catheter was then passed retrogradely across the aortic valve into the left ventricle over the arteriovenous rail. The rail was disconnected, and a Safari Small wire (Boston Scientific) was placed through the JR4 guide catheter directly into the left ventricular cavity [Figure 1e]. The SL1 sheath was removed from the left atrium and a temporary pacing wire was placed into the right ventricle. A 26 mm S3 TAVI (Edwards Lifesciences) was implanted directly in an optimal position with no resultant aortic regurgitation [Figure 1f]. The patient was discharged home the following day.

DISCUSSION

Landmark TAVI trials have excluded bicuspid aortic valve anatomy due to mainly theoretical risks of increased procedural complications.[2] Bicuspid aortic valve anatomy including bulky asymmetric leaflet calcification and ascending aortic dilatation poses challenges to treatment with TAVI. Nonetheless, there is a small, but not insignificant, proportion of octogenarians and nonagenarians with bicuspid aortic valve disease requiring intervention.[3] Due to the high surgical risk in those patients, TAVI may provide an alternative treatment option. Large registry studies of patients treated with modern generation valves have demonstrated similar outcomes for bicuspid valves when compared to tricuspid valves.[45]

There are several technical challenges when treating bicuspid aortic valve disease including challenging valve crossing. This was evident in our case where we had to perform anterograde crossing of the aortic valve after a prolonged unsuccessful attempt at retrograde crossing. This was enabled by a transseptal puncture allowing passage of a guidewire into the left ventricle, through the aortic valve into the aorta.

Antegrade transseptal approach with antegrade deployment of the prosthesis has been utilized in the early phase of TAVI but is now reserved for cases where there are no other suitable access sites.[6] In our case, we already had large bore femoral access, and we were therefore able to snare the guidewire, pass a guide catheter into the left ventricle retrogradely and exchange to a Safari wire, allowing standard retrograde implantation of the prosthesis.

CONCLUSION

TAVI for bicuspid aortic valve stenosis can be challenging. In this case, we were unable to cross the valve retrogradely. We subsequently demonstrated a safe and effective approach to antegrade crossing, through a transseptal access, to permit retrograde implant of prosthesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his/her consent for images and other clinical information to be reported in the journal. The patient understands that his/her name and initials will not be published and due efforts will be made to conceal his/her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

PW has received speaker and proctor fees from Abbott Vascular.

DM has received speaker and proctor fees from Abbott Vascular and Edwards Lifesciences.

BB and SV have no conflicts of interest to declare.