Preserving Coronary Access After TAVI

Educational objectives

• Step-by-step implantation of the ACURATE Neo2 Valve
• Step-by-step use of the SENTINEL™ Cerebral Protection device
• How valve design impact coronary access and condition future treatment options for the patient after TAVI
• Tips and tricks to preserve coronary access after TAVI
• Advantages of the ACURATE Neo2 valve system in horizontal aortic root

Step-by-step procedure: Left internal carotid artery stenting

1) Access sites and set-up

• Femoral access: Ultrasound guided puncture
• Second Access: Left radial access 6 Fr: Aortic angiogram
• Third access: Right radial access 6 Fr: Implantation of cerebral protection device: distal and proximal filter after a good screening on pre-TAVI CT for left carotid and brachiocephalic arteries diameter
• Pre-closing with 2 ProGlide™ systems.
• Support guidewire through very tortuous iliac arteries: Lunderquist® guidewire.
• Advancement of the large bore sheath on the Lunderquist® guidewire smoothly under fluoroscopy through tortuous and kinked iliac arteries.

2) Aortic valve crossing

• AL1 catheter with Terumo® straight tip
• Exchange with pre-shaped Safari ® guidewire
• Ensure good position of the wire on LV with the Pigtail catheter
• Ensure a good position of the pigtail catheter at the bottom of the NC cusp

3) Pre-dilatation valvuloplasty

• Non-compliant 22mm balloon. (Minimum diameter of the valve 23mm)
• Pacing over the wire at 180 bpm.

4) Advancement of the ACURATE Neo2 Valve

• Description of the delivery catheter
• Aortic arch crossing: avoid interference with the cerebral protection device
• Pre dilatation of the lesion using a 5.5*20mm Ultra-Soft™ balloon.
• Positioning the valve through the horizontal aortic root (valve/wire maneuver)

5) Implantation of the ACURATE Neo2 Valve

• ACURATE Neo2 Valve: implantation marker in the delivery system that indicates the level of implantation: 7mm marker
Angiogram check of the position of the valve before delivery
• Delivery of the valve: turn wheel 1 slowly
• Check the level and the opening of the upper crown of the valve towards the aortic root
• Ensure good alignment with the outer aortic root curve
• The annular part of the valve is the last to be opened
• Fast opening the wheel 2
• Retrieve the delivery system in the descending aorta

Tips and tricks for commissure alignment with the ACURATE Neo2 valve: Put the pin at 6 o’clock / alignment of the three stent arches.

6) Final control of valve implantation results

• Check of the valve opening and the height of the implant, aortic regurgitation
• Angiogram control
• Hemodynamic pressure control
• ECG control
• Echo control

7) Remove of the SENTINEL™ Cerebral Protection device

8) Vascular closure with 2 ProGlide™ at 2 and 10 O’clock.

Bibliography

4. Coronary Access After Repeated Transcatheter Aortic Valve Implantation. Buzzatti N, Romano V, De Backer O, Soendergaard L, Rosseel L, Maurovich-Horvat P, et al. JACC Cardiovasc Imaging. févr 2020;13(2):508‑15.

5. Coronary Access After Transcatheter Aortic Valve Replacement in Patients With Bicuspid Aortic Valve. Tarantini G, Fabris T, Cardaioli F, Nai Fovino L. JACC Cardiovasc Interv. juin 2019;12(12):1190‑1.

6. Transcatheter Valve Neo-Commissural Overlap With Coronary Orifices After Transcatheter Aortic Valve Replacement: Implication on Coronary Reaccess Tang GHL, Zaid S, Ahmad H, Undemir C, Lansman SL. Circ Cardiovasc Interv [Internet]. oct 2018 [cité 2 sept 2021];11(10).

7. Predicting the Feasibility of Post-TAVR Coronary Access and Redo TAVR. Tang GHL, Kaneko T, Cavalcante JL. JACC Cardiovasc Interv. mars 2020;13(6):736‑8.

8. The SAVI-TF Registry. Kim W-K, Hengstenberg C, Hilker M, Kerber S, Schäfer U, Rudolph T, et al. JACC Cardiovasc Interv. juill 2018;11(14):1368‑74.

9. Transcatheter aortic valve implantation using the ACURATE neo in bicuspid and tricuspid aortic valve stenosis: a propensity-matched analysis of a European experience.Mangieri A, Chieffo A, Kim W-K, Stefanini GG, Rescigno G, Barbanti M, et al. EuroIntervention. déc 2018;14(12):e1269‑75.

10. Unplanned Percutaneous Coronary Revascularization After TAVR. Stefanini GG, Cerrato E, Pivato CA, Joner M, Testa L, Rheude T, et al. JACC Cardiovasc Interv. janv 2021;14(2):198‑207.

Audience

This webinar is for Interventional Cardiologists and Heart Surgeons who implant TAVI devices or have an interest in learning more about Transcatheter Aortic Valve Implantation, as well as non-invasive Cardiologists with an interest in the current developments in the field TAVI therapy for their patients.