Counterintuitively Crossing a Critically Stenosed Aortic Valve is a Diastolic Phenomenon

Abstract: Crossing of a critically stenosed aortic valve is a pivotal step during diagnostic cardiac catheterization to measure the transvalvular gradient, especially in patients with discordant clinical and echocardiographic findings and also during transcatheter aortic valve replacement procedures. However, there are no data in the literature indicating whether aortic valve crossing typically occurs during systole or diastole. We hypothesize that aortic valve crossing is a diastolic phenomenon and describe our technique for crossing critically stenosed aortic valves.

J INVASIVE CARDIOL 2019;31(4):E67-E68.

Key words: aortic stenosis, aortic valve crossing, diastole

Background and Hypothesis

We hypothesize that aortic valve (AV) crossing is a diastolic phenomenon because the leaflets of critically stenosed AVs (CSAVs) are essentially immobile,^1,2 producing not only a high-velocity systolic jet leading to a systolic supravalvular vortex (SSV) but also resulting in high-velocity diastolic jet rapidly receding into the left ventricular cavity (LVC) during diastole (Figures 1A and 1B). Thus, the more critical the stenosis, the greater the velocity of either jet,¹ leading essentially to: (1) a systolic impediment to the wire crossing the AV; and (2) a strong diastolic suction drawing the wire into the LVC and potentially facilitating valve crossing.

Methods

Intraventricular conduction abnormalities are common in patients with CSAVs,^3,4 making the QRS complex (electrical systole) of a superimposed monitor electrocardiogram an unreliable marker of mechanical systole. Therefore, we used fluoroscopic systolic wire bobbing (FSWB) as a real-time marker of the cardiac cycle. Instead of forceful haphazard pecking while crossing a CSAV, a strategically placed wire within the perimeter of the SSV has a better chance to atraumatically follow the diastolic suction into the LVC, thus facilitating atraumatic wire passage across the CSAV. The following is our technique for crossing a CSAV:

1. First, a diagnostic catheter (Amplatz Left 1 or Judkins Right 4) is advanced to the ascending aorta over a standard 0.035˝ J wire. Then, we observe the bobbing of this wire in both right anterior oblique (RAO) and left anterior oblique (LAO) views (Figures 1C and 1D) and select the view for AV crossing that best demonstrates FSWB.
2. The J wire is then removed. This step is followed by a hand-injection aortic root angiogram to ascertain the approximate location of the AV opening (Figure 1E).
3. A 0.035˝ standard, straight-tip, fixed-core Emerald guidewire (Cordis) or 0.035˝ stiff, straight-tip, GlideWire (Terumo) is advanced several centimeters out of the delivery catheter and positioned above the valve and within the SSV (as evidenced by FSWB). Gentle rotation of the catheter may be needed to point the tip of the wire toward the already determined approximate AV opening (Figure 1F).
4. The wire is slowly and incrementally advanced into the LVC during the diastolic phase only, thus following the receding high-velocity diastolic jet (Figures 1F and 1G). Once the wire crosses the valve, we use the RAO view to advance the catheter into the LV over the wire now already in the LVC.
5. It is helpful to establish the cadence of forward-wire movement to occur only during diastole by murmuring under one’s breath the word “diastole” with every forward bob of the wire and by only advancing the wire in small increments each time.

Results

We retrospectively reviewed the cardiac catheterization films of 10 consecutive patients with CSAV in whom the above technique was used. Six patients (60%) were males, mean age was 83 years, mean AV gradient was 41.7 mm Hg, mean peak AV gradient was 70.3 mm Hg, and mean AV area was 0.81 cm². Following the above technique, crossing of the CSAV occurred during diastole in all patients.  

Discussion

The high success rate of our technique lends credence to the logical concept that crossing of the CSAV is a diastolic phenomenon that can be facilitated by the initial positioning of the wire tip in the SSV and subsequent effortless wire glide into the LVC following the diastolic suction.

Interestingly, the more severe the aortic stenosis, the greater the velocity of the supravalvular receding diastolic jet, resulting in more diastolic suction. Therefore — at least theoretically — the greater the severity aortic stenosis, the greater the ease with which a carefully placed and timed wire advancement should cross the CSAV during diastole, as has been our experience.

It remains to be seen if adopting this technique will be associated with a shorter crossing time, less trauma to the CSAV, and possibly fewer neuroembolic events. Therefore, larger studies (possibly incorporating transcranial Doppler) are needed to corroborate our findings and to determine any clinical benefit from the timed diastolic crossing of CSAVs.

There may be a place within the interventional cardiologist’s armamentarium for a flow-detecting Doppler wire that can identify diastole (when positioned above the CSAV) and then be advanced across the CSAV only during diastole.

References

1. Otto CM. Valvular aortic stenosis: disease severity and timing of intervention. J Am Coll Cardiol. 2006;47:2141-2151.
2. Chin CWL, Pawade TA, Newby DE, et al. Risk stratification in patients with aortic stenosis using novel imaging approaches. Circ Cardiovasc Imag. 2015;8:e003421.
3. Marchandise B, Piette F, Chalant CH, Kremer R. [Conduction disorders in aortic valve diseases]. Acta Cardiol. 1975;30:111-128.
4. Kalusche D, Betz P, Roskamm H. [Disorders of intraventricular conduction in patients with calcified aortic valve diseases: pre- and postoperative incidence and effect on prognosis following aortic valve replacement]. Z Kardiol. 1986;75:147-150.

From the Department of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript submitted November 3, 2018 and accepted November 22, 2018.

Address for correspondence: Najam Wasty MD, Department of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ 07112. Email: Najam.wasty@RWJBH.org