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This didactic procedure concerns a 81 y.o gentelman, with history of Surgical Aortic valve bioprosthesis replacement with Mitroflow 21; presenting  heart failure due to  severe  aortic prosthesis dysfunction (severe Aortic regurgitation); after Heart Team discussion, he was considered for Valve-in-Valve TAVI With Auto-expandable Evolut-R  valve.

 

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Educational objectives

• Optimal Echo-guided Femoral access for TAVI Procedures.
• Managing  degenerative aortic bioprosthesis with Valve -in-Valve implantation in High risk patients.
• Optimal choice and sizing  of the Valve-in-Valve device.
• Dealing with Valve positioning and deployment in case of severe Aortic regurgitation.
• Protection of  coronary arteries  from occlusion in High risk patients during  TAVI procedures. 

Step-by-Step Procedure

• Echo-guided Right Femoral artery access, Left femoral access & right radial artery access.
• Right Femoral artery  access 14F, Left femoral artery access 7F, Right radial artery access 5F.
• Protection of the Right coronary artery with 7F JR4 guiding catheter & workhorse coronary guidewire (Sion blue) (Over left femoral access).
• Placing a 5Fr Pigtail catheter in the ascending aorta through Right Radial access.
• Preclosing the right Femoral access  with two Proglide devices (Abbott).
• First evaluation aortography.
• Crossing the degenerated valve with AL1 5F Catheter and regular wire.
• Loading the 14 F introducer.
• Pre-implantation Pressure parameters recording.
• Exchange the regular guidewire with Safari guidewire.
• Evolut-R Valve loading, Fluoroscopic chek of the valve.
• Evolut-R valve optimal positioning, recapture and second positioning  for best compromise between coronary occlusion risk and transvalvular residual gradient.
• Partial release of the Evolut-R valve and angiographic control.
• Pulling back the Pigtail 5F Catheter & the  JR4 7F protection guiding catheter.
• Final release of the valve.
• Post-implantation pressure parmeters recording.
• Angiographic control of the Coronary arteries patency.
• Final angiographic result.
• Femoral access closure with Proglide devices.

Biobliography

• 2017 ESC/EACTS Guidelines for the management of valvular heart diseasek  - Guidelines Article
  Authors: Helmut Baumgartner* (ESC Chairperson).
  Publication: doi.org/10.1093/eurheartj/ehx391
   
• Meta-Analysis of Transcatheter Valve-in-Valve Implantation Versus Redo Aortic Valve Surgery for Bioprosthetic Aortic Valve Dysfunction. -Meta-analysis
  Authors: Neupane S, Singh H, Lämmer J, Othman , Yamasaki H, Rosman , Bossone E5, Mehta R, Eggebrecht 
  Publication: Am J Cardiol. 2018 Jun 15;121(12):1593-1600. doi: 10.1016/j.amjcard.2018.02.054. Epub 2018 Apr 19.
   
• Valve in valve implantation of the CoreValve Evolut R in degenerated surgical aortic valves. - Article
  Authors: Schwerg M, Stangl K, Laule M, Stangl V, Dreger H.
  Publication: Cardiol J. 2018;25(3):301-307. doi: 10.5603/CJ.a2018.0004. Epub 2018 Mar 23.