PCR London Valves Best Cases: Dr. Denise Todaro
Combined transcatheter treatment of degenerated aortic bioprosthesis and paravalvular leak: procedural tips & tricks
Explore one of the Best Cases on degenerated aortic bioprosthesis and paravalvular leak to be presented by Dr. D. Todaro at PCR London Valves 2018.
In the presented case, Dr. D. Todaro describes an educative case of a patient with degenerated aortic bioprosthesis and concomitant paravalvular leak undergoing combined transcatheter treatment. The case focuses particularly on delivering some tips and tricks used to overcome the setback experienced during the procedure.
How do you think your Case — which is now officially part of this year’s Programme — will impact the PCR London Valves community?
The higher life expectancy of surgical-treated patients has increased the frequency of degenerated bioprosthesis requiring re-intervention. Paravalvular leaks and degenerated bioprosthetic valves often coexist. When needed, the combined treatment of both conditions could be very challenging, especially when the surgical option is too risky and transcatheter treatment is required. In particular, crossing a degenerated aortic bioprostesis for a valve-in-valve procedure could be very challenging and time-consuming. In these cases the presence of paravalvular leaks could be used as a back-door to gain the left ventricle avoiding the need of other more challenging alternative access (e.g. transeptal or transapical puncture).
What are the fundamental learnings the PCR London Valves community will be able to draw out from your Case presentation?
The most important message provided by this Case is: ‘think out of the box’. A good planning of the procedure could not be enough if unexpected events occur. Good knowledge of tools and techniques typical of structural and vascular interventions is key.
Otherwise, in this particular case of degenerated aortic bioprosthesis and paravalvular leak:
- The paravalvular leak should be closed before the prosthesis implantation
- THV implantation can reduce the degree of the leak by stabilizing the complex THV-degenerated bioprosthesis
- In this context, antegrade crossing (aorta > leak > left ventricle > bioprosthesis > aorta) and the subsequent use of the snaring technique to drag a catheter into the left ventricle going through the aortic bioprosthesis revealed to be an effective strategy
What are some of the reasons that drove you to submit for this year’s Programme? How do you think this achievement will influence your career?
I think that sharing is the best way to improve knowledge. The PCR London Valves meeting is attended by many young interventional cardiologists (as me), and it is designed to be one of the most educational Courses. As a young resident physician, presenting this case to the PCR community and to some of the world’s key opinion leaders in the field is a real privilege and a unique opportunity. I am sure that it will provide visibility at our staff’s work and at the same time it will improve my personal and professional growth.
Tips for a successful PCR Submission by Dr. D. Todaro:
- Be educative. The case could not be the most challenging or innovative one, but it has to bring a message useful for all the community.
- Share the mental process used to overcome the obstacles experienced, particularly focusing on take-home messages that each procedure brings: why does the setback occur? How can I resolve it? Have I explored all the therapeutic options available? Have I chosen the simplest one?
- Use integration of fluoro, CT, echo images and videos to better explain the procedure and results achieved. Underline the trickiest passages with captions, arrows or informative videos and text.