Transradial balloon aortic valvuloplasty

Consult this Twitter Case concerning an 85-year-old man with previous CABG, severe aortic stenosis, worsening minimal effort dyspnea (NYHA III) and recurrent syncope

This case was originally published on Twitter by @saia_francesco via #CardioTwitterCase

Clinical presentation

An 85-year-old man with previous CABG, severe aortic stenosis, worsening minimal effort dyspnea (NYHA III) and recurrent syncope was referred to our centre to be evaluated for TAVI. Extra-cardiac comorbidity included moderate-to-severe chronic obstructive pulmonary disease and a recent (2 months) melanoma excision.
Echocardiography confirmed severe aortic stenosis, aortic valve area 0.8 cm2, max/mean gradients 97/49 mmHg, mild inferior hypokinesia, preserved global left ventricular ejection fraction (61%). Coronary angiography was performed with left radial access and showed left main and right coronary artery disease, patent mammary artery bypass on the left anterior descending coronary, patent venous bypasses on the first diagonal branch and the right coronary artery. Having excluded coronary artery disease as the cause of rapidly worsening symptoms, during the same session BAV was performed as a bridge-to-TAVI through the same radial access, since this approach is being investigated and increasingly used at our institution for BAV.

Case management

Radial BAV procedure

I.V. heparin 2500 IUs were administered before coronary angiography and no additional heparin was given. A contralateral radial artery was cannulated with a 20 Gauge cannula for pressure monitoring during the procedure (figure 1).

Before aortic valve crossing, we simultaneously measure peripheral and central aortic pressure to check if there is a relevant difference (>15 mmHg). If so, a double lumen pig-tail can be used for precise assessment of transvalvular gradients.

Figure 1

Figure 2

After aortic valve crossing, a manually shaped Super-stiff wire 260 cm was placed at the left ventricle apex and only at that point the 6F sheath exchanged with an 8 F sheath. If resistance is encountered, the sheath can be inserted only for 3-4 cm, which is sufficient for a safe balloon retrieval (figure 2).

A Cristal Balloon 20x45 mm (Balt, Montmorency, France) was used during rapid pacing at 180/min (figure 3). This semi-compliant balloon has been recently innovated to fit into 8F sheath, whereas the 23 mm still requires a 10F sheath. Pacing was performed through the wire (positive electrode at the groin, figure 1, negative on the wire). Invasive trans-aortic gradient was reduced from 46 to 26 mmHg (figure 3). The patient’s case was discussed within the heart team and accepted for TAVI.

Figure 3

Figure 3

This case demonstrated the feasibility and illustrates our technique for BAV performed through radial artery access. Many other patients have recently received trans-radial BAV, some even with the 10F sheath. This technique is hypothesized to be safer than transfemoral access, although this should be tested prospectively.

Author

Francesco Saia

@saia_francesco

Interventional cardiologist / Cardiologist

Bologna, Italy

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