Distal Balloon Inflation Technique　― A Bailout Method of Difficulty in Crossing Balloon-Expandable Valve Delivery System Due to Unfavorable Guidewire Position During Transcatheter Aortic Valve Replacement ―

An 81-year-old man with severe aortic stenosis (mean pressure gradient 52.0 mmHg; valve area 0.84 cm²) underwent transcatheter aortic valve replacement (TAVR) via the femoral artery. A 29-mm SAPIEN-3 valve (Edwards Lifesciences Inc.) was selected (annulus area 664 mm²; aortic angulation 47°) due to a saccular aneurysm on the greater curvature of the distal aortic arch, and balloon aortic valvuloplasty (BAV) was not performed to reduce the risk of vascular complications. The SAPIEN delivery system on a SAFARI^2TM Guidewire failed to cross the aortic valve due to unfavorable guidewire location attached to severe calcification (Figure A). The coaxiality of the valve was adjusted by flexing the system and adding counter-traction tension to the guidewire, which was ineffective. BAV with a 16-mm balloon using the buddy wire technique via the right radial artery pushed the guidewire even deeper into the aortic root, and the device became immovable near the calcified commissure between the right and non-coronary cusps (Figure B,C). Finally, we inflated the delivery system with 1 mL contrast medium as a distal balloon inflation technique, which formed a tapered, cone-shaped buffer, successfully guiding the tip to shift away from the greater curvature and freeing the device from the commissure (Figure D,E; Supplementary Movie).¹ The entire delivery system was pushed to the implantation depth, resulting in successful valve implantation.

Figure.

(A) Initial wire crossing point. LCC, left coronary cusp; NCC, non-coronary cusp; RCC, right coronary cusp. (B) The guidewire position after balloon valvuloplasty, biased further towards the greater curvature. (C) Computed tomography showing the calcified aortic valve. (D,E) Distal balloon inflation (dotted lines) shifted the guidewire (from red dot to blue dot) and allowed passage. (F,G) Comparison of a 29-mm valve delivery system before (F) and after (G) inflation with 1 mL contrast medium (dots indicate the outer margin).

Difficulty in crossing the valve delivery system is challenging in the TAVR procedure. This case demonstrated that the distal balloon inflation technique (Figure F,G) could be useful as a bailout method to shift the guidewire away from the calcified commissure and change the unfavorable guidewire position, which had been aggravated by additional BAV.

Disclosures

None.

Supplementary Files

Supplementary Movie. Transcatheter aortic valve implantation with the distal balloon inflation technique.

Please find supplementary file(s);

https://doi.org/10.1253/circrep.CR-23-0013

Reference

• 1.   Yearoo I, Joshi NV, Turner M, Mahadevan K, Dorman SH. Novel techniques to crossing a severely stenotic aortic valve. JACC Case Rep 2019; 1: 848–852.