Novel apical-to-femoral rail technique for horizontal aorta in transcatheter aortic valve replacement

Novel apical-to-femoral rail technique for horizontal aorta in transcatheter aortic valve replacement 经导管主动脉瓣置换术中应用心尖-股动脉轨道技术治疗极度横位心主动脉瓣狭窄一例 1 2 equal first-author https://orcid.org/0000-0003-1556-9198 2 equal 1 1 1 2 corresp Jian’an WANG, wangjianan111@zju.edu.cn Jian’an WANG, wangjianan111@zju.edu.cn wangjianan111@zju.edu.cn https://orcid.org/0000-0002-4583-3204 Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China Department of Cardiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China 浙江大学附属第二医院心血管内科，中国杭州市，310009 浙江大学附属第二医院心血管内科，中国杭州市，310009 Internal Medicine, Zhejiang University School of Medicine, Hangzhou 310058, China Internal Medicine, Zhejiang University School of Medicine, Hangzhou 310058, China 浙江大学医学院内科学，中国杭州市，310058 浙江大学医学院内科学，中国杭州市，310058 目的： 2 为经导管主动脉瓣置换术中治疗极度横位心的主动脉瓣狭窄患者制定手术策略提供借鉴。 创新点： 2 本研究的患者为老年女性，她被诊断为重度主动脉瓣狭窄，拟接受经导管主动脉瓣置换术。术前电子计算机断层扫描（CT）结果显示患者为主动脉瓣呈type 0型二叶式主动脉瓣，主动脉成角为84°，为极度横位心。术中我们通过建立心尖-股动脉轨道实现瓣膜同轴置入，术后病人无并发症发生。 方法： 2 在左胸前外侧第五肋间切一小口，打开心包，经心尖引入圈套器，捕捉经右侧股动脉引入的超滑导丝并将其拉出体外，建立心尖-股动脉轨道。通过同时牵拉轨道的两端增加张力，调整输送系统的成角，实现球囊扩张及瓣膜同轴置入。 结论： 2 使用经导管主动脉瓣置换术治疗主动脉瓣狭窄患者时，心尖-股动脉轨道技术是应对极度横位心的有效治疗策略。 经导管主动脉瓣置换术 主动脉瓣狭窄 极度横位心 心尖-股动脉轨道技术 Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment option for patients with severe aortic stenosis regardless of its surgical risk stratification ( Otto et al., 2021 Otto et al., 2021 ). Aortic angulation is usually measured as the angle between the horizontal and the aortic annulus planes based on preproced‍ural multidetector computed tomography (MDCT) ( Al-Lamee et al., 2011 Al-Lamee et al., 2011 ). Extremely horizontal aorta, defined as an aortic angulation greater than 70°, is an unfavorable anatomic structure that poses particular technical challenges for TAVR. Abramowitz et al. (2016) Abramowitz et al. (2016) have proved that an extremely horizontal aorta increased the risk of procedural complications, such as lower device success rates, more moderate or even severe perivalvular leakage (PVL), and the need for second valve implantation. Because of the long stent frame, inflexibility, and non-steerability, it is challenging to pass the delivery system of self-expanding valves (SEVs) through an extremely horizontal aorta. As a result, patients with an extremely horizontal aorta have always been excluded from the clinical trials of TAVR, and transfemoral (TF)-TAVR with SEV is considered as an "off-label" use of TAVR ( Adams et al., 2014 Adams et al., 2014 ; Kaneko et al., 2020 Kaneko et al., 2020 ). Herein, we present a technically difficult case, in which a patient with an extremely horizontal aorta underwent TF-TAVR with SEV by applying a unique apical-to-femoral rail strategy. An 84-year-old woman was presented with progressive exertional dyspnea for two months, classified as New York Heart Association (NYHA) class III. She had a history of refractory hypertension and diabetes mellitus, which were managed with medication. The transthoracic echocardiography revealed severe aortic stenosis with left ventricular ejection fraction of 69.2%. The patient's Society of Thoracic Surgeons Score was 5.534%, classifying her as an intermediate-risk patient for the surgical procedure. The preprocedural MDCT assessment revealed an extremely aortic angulation of around 84°‍‍. A small left ventricular type 0 bicuspid aortic valve and a short and dilated ascending aorta were also found in MDCT ( Fig. 1 Fig. 1 ). Considering the advanced age of the patient, she and her family members pushed for minimally invasive surgery. After a careful review of her anatomy and repeated discussion by the multidiscip‍linary heart team, TF-TAVR was performed with a 21-mm VitaFlow (Microport, Shanghai, China) due to the lack of available commercial balloon-expanding valves (BEVs). The TAVR procedure was performed in our hybrid catheter lab as previously reported ( Fan et al., 2021 Fan et al., 2021 ). Because of the aorta's extreme angulation, the tips of the straight guidewire and super-stiff wire were difficult to align with the valve orifice, resulting in a situation that these guidewires could not be introduced smoothly into left ventricle. A loop snare cath‍eter was pushed into the ascending aorta from an ipsilateral femoral approach to assist the straight guidewire, and a Lunderquist super-stiff guidewire was barely inserted into the left ventricle (Video S1). The super-stiff guidewire could be hardly located in the left ventricle stably when attempting to convey the pre-dilatation balloon. This step took several hours, and all attempts were unsuccessful. After much deliberation, our heart team decided to pursue a novel therapeutic strategy of making a micro-thoracotomy at the apex to connect it with the femoral artery pathway, and establish the apical-to-femoral rail. A 2.6-inch super-slip guidewire was threaded through the ipsilateral femoral artery and looped by a snare inserted from the apex with a 6-Fr (6-French, 1 Fr=1/3 mm) sheath (Video S2). The angle between the delivery system and the aortic annulus was precisely controlled by concurrently pulling or loosening the wire ends. The technique improved the maneuverability of the delivery system by increasing the tension of the wire. The delivery system was progressed slowly across the aortic arch in order to avoid contact with the aortic lumen. Coordinated manipulation resulted in successful balloon dilatation and coaxial valve implantation under rapid ventricular pacing (Video S3). Nevertheless, during deployment, the valve migrated downward slightly more than intended. Intraprocedural digital subtraction angiography (DSA) confirmed the prosthesis's coaxial but relatively deep valve position, resulting in moderate-to-severe PVL (Video S4). Subsequently, a second 21-mm VitaFlow prosthesis was implanted at a relatively higher position to reduce PVL. The final intraoperative DSA confirmed that the valve was in an appropriate position with trace PVL, and a maximum aortic gradient was 4 mmHg (1 mmHg=0.133 kPa) (Video S5). At the end of the procedure, aortography was performed to confirm aortic injury or dissection. The patient was transferred to the intensive care unit after the procedure, where her symptoms relieved soon and then she was moved to the general ward within one day. Cardiac computed tomography (CT) revealed that the prosthetic valve was in an appropriate position with good coaxiality. Transthoracic echocardiography showed normal valve function and a mean aortic gradient of 7 mmHg. The patient was discharged without any periprocedural complications, she remained asymptomatic afterwards, and her cardiac function was graded II. Following 30 d of follow-up, the mean aortic gradient was 4 mmHg without PVL. This is the first reported case of the novel apical-to-femoral rail technique applied successfully in SE-TAVR for a frail elderly patient with a pronounced angulated aorta. After reviewing this case, the following technical difficulties were identified: (1) Extreme aortic angulation would significantly weaken the tension of the guidewire, making it difficult for the system to pass smoothly through the aortic arch; (2) The guidewire tip lacked enough cushioning to adjust the direction due to the short dilated ascending aorta, which increased the difficulty in aligning the guidewire tip with the aortic orifice; (3) Because of the small left ventricular cavity, the guidewire was difficult to be anchored in place and was prone to shifting into the aortic sinus. The following benefits of the apical-to-femoral rail were highlighted: (1) This technique can enhance the rigid guidewire's maneuverability, assist the delivery system with passing through the aortic arch and coaxial valve implantation, and minimize the risk of aortic dissection and cerebral infarction. (2) A pronounced angulated aorta is one of the risk factors for left ventricular perforation, especially if combined with aortic-left ventricle misalignment and small hypertrophic left ventricle ( Ancona et al., 2018 Ancona et al., 2018 ). This technique prevents the guidewire tip from being exposed to the ventricular cavity and lowers the risk of left ventricular perforation. (3) Compared to the incision required by the transapical approach, the apical-to-femoral rail technique requires a tiny incision, which can minimize the procedural trauma and is conducive to rapid rehabilitation. The horizontal aorta has been excluded from well-designed prospective clinical trials due to its negative anatomic features. To date, the influence of aortic angulation on SE-TAVR remains debatable. Compared to balloon-expanding TAVR, patients with an aortic angulation of ≥48° had lower device success rates but similar mortality in SE-TAVR ( Abramowitz et al., 2016 Abramowitz et al., 2016 ). The causes of device failure include valve embolization, increased demand for a second valve, and mild or more severe PVL. Nevertheless, Kaneko et al. (2020) Kaneko et al. (2020) expatiated that TF-TAVR with Medtronic Evolut R and Evolut PRO (Medtronic, Minneapolis, Minnesota, USA) SEV in an extremely horizontal aorta was feasible and effective with a high device success rate. It seems that the performance of SEV degrades in patients with unfavorable anatomic features because of inflexibility and long stent frame. Compared to SEV, the shorter valve stent frame and adjustable delivery system of BEV contribute to more accurate and satisfactory coaxial valve alignment in patients with an extremely horizontal aorta ( Abramowitz et al., 2016 Abramowitz et al., 2016 ). In addition, the super-stiff wire can be used to provide more support. "The buddy-balloon technique" and "the buddy-wire technique" assist the operator in dealing with these unfavorable anatomical features by adjusting the direction of the delivery catheter and facilitating its retrograde aortic valve crossing ( Noble and Roffi, 2014 Noble and Roffi, 2014 ). Espinoza Rueda et al. (2021) Espinoza Rueda et al. (2021) described the successful use of a snare catheter in five patients with horizontal aorta via the contralateral femoral artery or the radial artery. In general, operators should weigh all factors carefully when developing procedural strategies for patients with an extremely horizontal aorta. The TF approach is the first-line choice of vascular access route for TAVR, accounting for 75% of TAVR, which is associated with favorable clinical outcomes ( Leon et al., 2010 Leon et al., 2010 ). Although transapical and transaortic access can avoid the undesirable effect of aortic angulation in SE-TAVR, and these are considered as alternative access routes for patients not suitable for TF-TAVR, their mortality rate is statistically higher than that of TF access ( Arai et al., 2016 Arai et al., 2016 ). Being an experienced center, our multidisciplinary heart valve team deemed the TF approach as the least invasive access for this case to reduce the incidence of procedural complications. However, underlying complications such as failing to pass through the aortic arch, aortic dissection, and ventricular perforation are not uncommon during TF-TAVR with a horizontal aorta. Our successful case enlightened us that when encountering a situation of inability to pass through the aortic arch during the TAVR procedure, establishing the apical-to-femoral rail might be an effective emergency strategy to avoid converting to open surgery. Our case study described the successful use of the apical-to-femoral rail technique during TF-TAVR in a patient with bicuspid aortic stenosis and an extremely horizontal aorta. This case prompts us to devise dependable and effective procedural strategies for patients based on their distinct anatomical characteristics. References Abramowitz Y , Maeno Y , Chakravarty T , et al. , 2016 . Aortic angulation attenuates procedural success following self-expandable but not balloon-expandable TAVR . JACC Cardiovasc Imaging , 9 ( 8 ): 964 - 972 . https://doi.org/10.1016/j.jcmg.2016.02.030 https://doi.org/10.1016/j.jcmg.2016.02.030 Aortic angulation attenuates procedural success following self-expandable but not balloon-expandable TAVR Adams DH , Popma JJ , Reardon MJ , et al. , 2014 . Transcatheter aortic-valve replacement with a self-expanding prosthesis . N Engl J Med , 370 ( 19 ): 1790 - 1798 . https://doi.org/10.1056/NEJMoa1400590 https://doi.org/10.1056/NEJMoa1400590 Transcatheter aortic-valve replacement with a self-expanding prosthesis Al-Lamee R , Godino C , Colombo A , 2011 . Transcatheter aortic valve implantation: current principles of patient and technique selection and future perspectives . Circ Cardiovasc Interv , 4 ( 4 ): 387 - 395 . https://doi.org/10.1161/CIRCINTERVENTIONS.‍111.961128 https://doi.org/10.1161/CIRCINTERVENTIONS.‍111.961128 Transcatheter aortic valve implantation: current principles of patient and technique selection and future perspectives Ancona MB , Hachinohe D , Giannini F , et al. , 2018 . Hypertrophic left ventricle with small cavity and severe aortic angulation: a dangerous association in case of transcatheter aortic valve replacement . JACC Cardiovasc Interv , 11 ( 4 ): e29 - e30 . https://doi.org/10.1016/j.jcin.2017.10.034 https://doi.org/10.1016/j.jcin.2017.10.034 Hypertrophic left ventricle with small cavity and severe aortic angulation: a dangerous association in case of transcatheter aortic valve replacement Arai T , Romano M , Lefèvre T , et al. , 2016 . Direct comparison of feasibility and safety of transfemoral versus transaortic versus transapical transcatheter aortic valve replacement . JACC Cardiovasc Interv , 9 ( 22 ): 2320 - 2325 . https://doi.org/10.1016/j.jcin.2016.08.009 https://doi.org/10.1016/j.jcin.2016.08.009 Direct comparison of feasibility and safety of transfemoral versus transaortic versus transapical transcatheter aortic valve replacement Espinoza Rueda MA , Muratalla González R , García García JF , et al. , 2021 . Description of the step-by-step technique with snare catheter for TAVR in horizontal aorta . JACC Case Rep , 3 ( 17 ): 1811 - 1815 . https://doi.org/10.1016/j.jaccas.2021.09.006 https://doi.org/10.1016/j.jaccas.2021.09.006 Description of the step-by-step technique with snare catheter for TAVR in horizontal aorta Fan J , Yu C , Ren K , et al. , 2021 . Kidney function change after transcatheter aortic valve replacement in patients with diabetes and/or hypertension . J Zhejiang Univ-Sci B (Biomed & Biotechnol) , 22 ( 3 ): 241 - 247 . https://doi.org/10.1631/jzus.B2000431 https://doi.org/10.1631/jzus.B2000431 Kidney function change after transcatheter aortic valve replacement in patients with diabetes and/or hypertension Kaneko U , Hachinohe D , Kobayashi K , et al. , 2020 . Evolut self-expanding transcatheter aortic valve replacement in patients with extremely horizontal aorta (aortic root angle≥70°) . Int Heart J , 61 ( 5 ): 1059 - 1069 . https://doi.org/10.1536/ihj.20-120 https://doi.org/10.1536/ihj.20-120 Evolut self-expanding transcatheter aortic valve replacement in patients with extremely horizontal aorta (aortic root angle≥70°) Leon MB , Smith CR , Mack M , et al. , 2010 . Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery . N Engl J Med , 363 ( 17 ):‍ 1597 - 1607 . https://doi.org/10.1056/NEJMoa1008232 https://doi.org/10.1056/NEJMoa1008232 Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery Noble S , Roffi M , 2014 . Retrograde aortic valve crossing of the corevalve prosthesis using the buddy balloon technique . Catheter Cardiovasc Interv , 84 ( 6 ): 897 - 899 . https://doi.org/10.1002/ccd.25215 https://doi.org/10.1002/ccd.25215 Retrograde aortic valve crossing of the corevalve prosthesis using the buddy balloon technique Otto CM , Nishimura RA , Bonow RO , et al. , 2021 . 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines . Circulation , 143 ( 5 ): e35 - e71 . https://doi.org/10.1161/CIR.0000000000000932 https://doi.org/10.1161/CIR.0000000000000932 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines Xianbao LIU and Hanyi DAI checked the literature and wrote the first draft of the paper. Lihan WANG and Jiaqi FAN collected data of the case. Jian'an WANG revised and checked the final manuscript. All authors have read and approved the final manuscript, and therefore, have full access to all the data in the study and take responsibility for the integrity and secur-ity of the data. Xianbao LIU, Hanyi DAI, Lihan WANG, Jiaqi FAN, and Jian'an WANG declare that they have no conflict of interest. 10.1631/jzus.B2100860 1673-1581（2022）07-0613-04 This work was supported by the Zhejiang Province Science and Technology Department Key R&D Program (Nos. 2021C03097 and 2018C03084), China. 2021-10-08 2022-01-06 2022-07-15 2022-12-27 2022-06-10 Copyright © Zhejiang University and Springer-Verlag GmbH Germany, part of Springer Nature 2022 2022 浙江大学出版社 This procedure followed was in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from the patient for being included in the report. Compliance with ethics guidelines Supplementary information 1 Videos S1‒S5 浙江大学学报（英文版）（B辑：生物医学和生物技术） 7 23