CPLVK

A 65-year-old gentleman, a diagnosed case of Primary Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease (CKD)presented with progressive breathlessness on exertion. Clinically vitals were stable. Cardiovascular system examination revealed heaving apical impulseand reverse splitting of second heart sound. He had late peaking mid systolic murmur in right second intercostal space radiating to right carotid.Other systems were unremarkable.

ECG showed sinus rhythm with ST depression and T inversion in leads I, AVL, V5, V6.Chest X Ray showed features of COPDEchocardiography showed global left ventricular hypokinesia with Left Ventricular ejection Fraction (LVEF) 25%. Aortic Valve was calcified with maximumgradient 48 and mean gradient 22 mmHg. There was no Aortic Regurgitation. There was concentric LVH and bi atrial enlargement. PA pressure was 60 mmHg. Diagnosis - Severe Calcific Aortic stenosis with low flow low gradient

Aortic root angiography showed calcified Aortic Valve, No aortic regurgitation.In view of severe LV dysfunction, Aortic Valve Balloon dilatation (AVBD) was done with 16 x 40 mm balloon in stage I.Result was good.Patient symptomatically improved but still was in NYHA class III.LVEF improved from 25 % to 55% after AVBD. Now the mean gradient across aortic valve was 45 mmHg.
1 Aortogram (Converted).mov
2 AVBD pre implant (Converted).mov

Based on the perimeter and area, it was decided to implant a 26 mm Evolute R device (Medtronic, Minneapolis, MN). Pre-dilatation was performed with an 18 mm balloon and then the 26 mm Evolut R valve was deployed under angiographic guidance.  Shortly upon release, the valve embolized into the ascending aorta. Using a loop snare the valve was pulled back into the ascending aorta. An attempt was made to deploy a second larger valve 29mm Evolute R but was not successful as it moved the previously implanted valve down into the aortic annulus.  Deployment in this position would have resulted in the obstruction of coronary arteries. Since the snare used was not able to hold the embolized valve in ascending aorta an additional loop snare was introduced from a separate arterial puncture through the left femoral artery. However, the valve could not be held with this additional snare and as a desperate measure, one more arterial puncture was taken in the left radial artery. Through the left radial artery, a Judkins right (JR) guiding catheter was introduced passing it across the cell of the embolized valve. An exchange length Terumo wire was introduced through the JR guide and was looped back and was snared out of the left femoral artery. Now using the loop snare and the snare made out of the Terumo wire the embolized valve was pulled back into the ascending aorta and stabilized. The second larger 29 mm Evolute R was deployed without complication after removing both the snares.
7 Valve deployed (Converted).mov
8 Valve embolization (Converted).mov
9 Snaring of Valve (Converted).mov

Transcatheter Aortic Valve Replacement has been established as a viable alternative and unexpected complications and challenges are bound to emerge as more and more procedures are done. Meticulous assessment of aortic valve anatomy is the most important step in the success of the procedure. All the hardware listed for the procedure should be available on the shelf. Innovations in the cath lab are welcome but nothing should be done at the cost of patient safety.Overall experience and expertise in handling catheters and complications go a long way in bailing out of tricky situations.