Balloon-Assisted Crossing of a Severely Calcified Aortic Valve During Transcatheter Balloon-Expandable Bioprosthesis Implantation

Keywords: aortic stenosis, aortic valve replacement, transcatheter heart valve

A 91-year-old man presented with syncope secondary to severe aortic stenosis. A transthoracic echocardiogram revealed a calcified stenotic trileaflet aortic valve (AV) with a mean gradient of 60 mmHg (Figures 1A and 1B). Cardiac computed tomography demonstrated a heavily calcified trileaflet AV without commissural fusion (Figure 1C). Following heart team discussion, transfemoral transcatheter AV replacement (TAVR) was the preferred option in view of the patient’s age. Due to the severe aortic leaflet calcifications, we planned to perform a balloon-expandable 32-mm Myval transcatheter heart valve (THV; Meril Life Sciences) implantation preceded by balloon predilation.

The AV was crossed with difficulty using an Amplatz left 2 6 Fr catheter and a 0.35˝ regular, straight-tip guidewire, which was then exchanged for a Safari wire (Boston Scientific). To facilitate crossing, we performed a predilation with a 23 x 40 mm Mammoth balloon (Meril Life Sciences) from the right femoral artery. A 32-mm Myval valve was then advanced. Despite balloon predilation, the THV delivery system followed the aortic outer curvature and halted in the right/noncoronary commissure. The AV was extremely stenosed and did not allow the Navigator delivery system to cross despite flex adjustments, considerable forward push on the system, and tension on the Safari wire.

The AV was crossed with a second Safari using contralateral femoral access. An 8 × 20 mm Ultraverse peripheral balloon (Bard Peripheral Vascular) was then advanced across the AV. The balloon inflation in the right/noncoronary commissure facilitated the AV crossing by THV and delivery system (Figures 1D-1F). The balloon was exchanged with a pig catheter which was placed in the noncoronary cusp. The THV was implanted in an uncomplicated fashion with a good final result (mean gradient, 10 mm Hg with no paravalvular leak).

Affiliations and Disclosures

From the Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell'Angelo, Mestre - Venice, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ronco is a member of the speakers’ bureau for Abbott and GE; advisory board for GE. The remaining 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 accepted March 17, 2022.

Address for correspondence: Gianpiero D’Amico, MD, PhD, Interventional Cardiology, Department of Cardio-Thoracic and Vascular Sciences, Ospedale dell'Angelo, Via Paccagnella, 12, 35128 Mestre, Venice, Italy. Email: gianpiero.damico@hotmail.it