CoreValve in degenerated CoreValve 1st Re do CoreValve
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1 TAVI summit 2012 Seoul, Sep 7, 2012 CoreValve in degenerated CoreValve 1st Re do CoreValve Eberhard Grube MD FACC, FSCAI Universitätsklinik ität ik Bonn, Medizinische i i Klinik ik und Poliklinik II, Bonn, Germany Stanford University, School of Medicine, Stanford, California
2 Eberhard Grube, MD Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) i listed below. Physician Name Company/Relationship Eberhard Grube, MD Medtronic, CoreValve: C, SB, AB, OF Sadra Medical: E, C, SB, AB Direct Flow: C, SB, AB Mitralign: AB, SB, E Boston Scientific: C, SB, AB Biosensors: E, SB, C, AB Cordis: AB Abbott Vascular: AB Capella: SB, C, AB Devax: SB, AB, Embrella: SB Claret: SB Key G Grant and or Research Support E Equity Interests S Salary, AB Advisory Board C Consulting fees, Honoraria R Royalty Income I Intellectual Property Rights SB Speaker s Bureau O OwnershipOF Other Financial Benefits
3 Medical History Patient A.M.O., female, 91 years Presents with: Dyspnea NYHA III IV Dx: Severe stenosis of a degenerated 26mm CoreValve prosthesis 1st generation (AVA 0.5 cm 2 ) which was implanted via surgical cut down on 08/31/2005.
4 Porcelain aorta Comorbidities Peripheral arterial disease Stadium IIa COPD Moderately reduced LV function (EF 40%) Pulmonary hypertension (PAP sys. 70 mmhg) Insignificant CAD Logistic EuroSCORE 64.97% STS Score 27.0%
5 TEE
6 CoreValve 26mm Prosthesis
7 Transfemoral Access Right AIC: 5mm; AFC: 6mm Left AIC: 6mm; AFC: 6mm
8 Aortogram of stenosed Core Valve Prosthesis 26mm
9 Aortic Arch with Narrowing of Truncus
10 Claret Deployment proximal Filter
11 Claret second Filter deployed (left Carotid)
12 Claret second Filter deployed (left Carotid) Position Control
13 Inflation of Onset Sheath in left Femoral Artery 18 French
14 1 st attempt to cross the Valve with AL1 and Terumo straight (through Struts)
15 Attempt to re cross with Terumo Wire
16 Material used to cross the Valve 1. Terumo straight/curved Guide wire 3. AL1 4. AL 2 5. JR 6. Multipurpose 7. Swan Ganz with Terumo after 45 Minutes
17 Final attempt with 35 Guide wire.but the with hard!
18 3D Echo of stenosed Core Valve
19 Degenerated Core Valve (6 years)
20 Calcific Aortic Stenosis Deformed Eccentric Calcified Nodular Rigid HOSTILE TARGET difficult to displace prone to fragmentation and embolization i
21 Crossing with JR and Guide
22 Super Stiff in LV
23 1 st attempt with Nucleus Balloon
24 Rupture of Nucleus Balloon
25 Second Balloon Rupture
26 2 nd Core Valve does not cross; stalls in the crown of previous Core Valve
27 Superior Crown of the CV
28 Buddy Wire
29 Buddy Wire and Balloon
30 Attempt to cross with Buddy Wire and Balloon
31 Attempt to cross with Buddy Wire and Balloon
32 Attempt to cross with Buddy Wire and Balloon
33 Attempt to cross with Buddy Wire and Balloon
34 Attempt to cross with Buddy Wire and Balloon
35 Positioning of 2 nd CV (slightly higher)
36 Delivery of 2 nd Core Valve
37 Final Results
38 Dissection of left common Femoral Artery
39 Variety of Emboli Captured & Removed Embolic Material
40 Final Results before Discharge
41 Lessons learned: 1. Due to tenting of the restenosed and calcified leaflets, retrograde passage of the Valve is very difficult. 2. Preferred approach is antegrade via transseptal/lv/ao Valve and then snare the wire in the aorta. This wire then serves as a rail for the Balloon. 3. Use aggressive Predilatation to crack calcifications 4. In order to pull the prosthesis around the aortic arch into the previous prosthesis, place a snare around the tip of the Core Valve before introducing into sheath. 5. Position the 2 nd Core Valve slightly higher than the previous valve and use the upper crown as a reference for delivery.
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