A 76-year-old male patient presented in the cardiology clinic with symptomatic severe AS with fatigue in NYHA functional class III, without dyspnea, angina or syncope. He has a prior medical history of arterial hypertension, chronic obstructive pulmonary disease, peripheral artery disease, paroxysmal atrial flutter and a dual-chamber permanent pacemaker implanted for AV-node disease. He was administered edoxaban, nebivolol, perindopril, furosemide, spironolactone, atorvastatin, gabapentin and formoterol. The transthoracic echocardiogram showed a severely calcified tricuspid AV, with mean gradient of 52 mmHg and aortic valvular area of 0.6 cm², mild left ventricular hypertrophy, left ventricular ejection fraction 60%, mild-to-moderate mitral regurgitation, mild tricuspid regurgitation with an estimated pulmonary artery systolic pressure of 35 mmHg and no pericardial effusion. The ECG showed sinus rhythm with ventricular pacing. Coronary angiogram (Figures 1 A-B) showed a significant stenosis in Ramus Intermedius of 90%. Carotid Doppler ultrasound showed obstructive disease in the left internal carotid artery, with 70% stenosis. After a discussion with the heart team, the patient was selected for a TAVI procedure.

Figure 1 LAD: left descending artery; LCx: left circumflex artery; RI: ramus intermedius; RCA: right coronary artery; RFA: right femoral artery; LFA: left femoral artery.

Pre-procedural cardiac computed tomography angiography (CTA) for TAVI planning (Figures 1 C-G) shows a tricuspid AV with severe calcification, AV calcium score of 3560 units and marked calcification in the commissures next to the non-coronary cusp, mean annular diameter of 25.6 mm and annular angle of 44°. Coronary ostia were high (16 mm for the left main coronary artery and 14 mm for the right coronary artery), with a very low risk for coronary obstruction. Ilio-femoral axis evaluation showed good luminal diameters (7.1x9.5 mm for the right femoral artery, 7.3x8.9 mm for the left femoral artery), moderate non-circumferential calcification, and no significant tortuosity.

Through the right femoral artery, a pre-dilation was made using a 20 mm size balloon (Figure 2A), followed by unsuccess in attempting to cross the valve delivery system of Corevalve Evolut Pro 29 mm (Medtronic) through the native AV. Later on, it was attempted to perform buddy wire and buddy balloon techniques (Figures 2B and C) in order to fill the external commissure (between the non-coronary and right coronary cusps), allowing centralization and better alignment of the valve delivery system, but they were also unsuccessful.

Figure 2

Through the left femoral artery, a snare was placed around the valve delivery system. To perform that, both the stiff wire already in the LV and the valve delivery system had to be pulled back. The crossing straight wire was snared, placed again into the LV and exchanged again by the preshaped stiff wire. By snaring the delivery system and pulling it to a better centralization, the operators were able to cross the native calcified AV. This technique is shown in Figures 2 D-F. The valve was later delivered without complications and post-dilated with a 24 mm size balloon (Figure 3), with a good final result and no paravalvular regurgitation. No complications occurred during the hospitalization. The post-procedural transthoracic echocardiogram showed a well-functioning prosthetic valve without a paravalvular leak, and the patient was discharged on the third day. At six months of follow-up, the patient was clinically improved at NYHA functional class I.

Figure 3