Frisoli, Tiberio M

Kang, Guson

O\u27Neill, Brian P

O\u27Neill, William W

So, Chak-Yu

Villablanca, Pedro A

Wang, Dee Dee

English

Henry Ford Health System Scholarly Commons

Henry Ford Health System Henry Ford Health System Scholarly Commons Cardiology Articles Cardiology/Cardiovascular Research 11-9-2020 Balloon-Assisted Valve Tracking: Atraumatic Retrieval of a Ventricularized Transcatheter Aortic Valve Prosthesis Guson Kang Henry Ford Health System, gkang1@hfhs.org Chak-Yu So Henry Ford Health System, cso2@hfhs.org Pedro A. Villablanca Henry Ford Health System, PVillab1@hfhs.org Tiberio M. Frisoli Henry Ford Health System, TFRISOL1@hfhs.org Dee Dee Wang Henry Ford Health System, dwang2@hfhs.org See next page for additional authors Follow this and additional works at: https://scholarlycommons.henryford.com/cardiology_articles Recommended Citation Kang G, So CY, Villablanca PA, Frisoli TM, Wang DD, O'Neill BP, and O'Neill WW. Balloon-Assisted Valve Tracking: Atraumatic Retrieval of a Ventricularized Transcatheter Aortic Valve Prosthesis. JACC Cardiovasc Interv 2020; 13(21):2576-2578. This Article is brought to you for free and open access by the Cardiology/Cardiovascular Research at Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Cardiology Articles by an authorized administrator of Henry Ford Health System Scholarly Commons. Authors Guson Kang, Chak-Yu So, Pedro A. Villablanca, Tiberio M. Frisoli, Dee Dee Wang, Brian P. O'Neill, and William W. O'Neill This article is available at Henry Ford Health System Scholarly Commons: https://scholarlycommons.henryford.com/cardiology_articles/662 Balloon-Assisted Valve TrackingAtraumatic Retrieval of a Ventricularized Transcatheter AorticValve ProsthesisGuson Kang, MD,* Chak-yu So, MD,* Pedro A. Villablanca, MD, MS, Tiberio M. Frisoli, MD, Dee Dee Wang, MD,Brian P. O’Neill, MD, William W. O’Neill, MDW e report a novel percutaneous approachfor the retrieval of a migrated balloon-expandable transcatheter aortic valve(TAVR) that: 1) minimizes interaction with the unsta-ble valve; 2) stabilizes it on an arteriovenous rail; and3) minimizes vascular trauma.A 90-year-old gentleman underwent successfulTAVR with a 23-mm SAPIEN 3 Ultra valve, with noresidual gradient or paravalvular regurgitation(Video 1).The following day, the patient developed hemoly-sis and acute renal injury, and was found to havesevere paravalvular regurgitation on echocardiogram(Video 2). Aortography showed the valve had slippedinto the left ventricular outflow tract, with the top ofthe frame pinning the native leaflet open (Video 3).We considered valve-in-valve TAVR, but felt thevalve was too unstable to cross retrograde or pass anew valve through it. To prevent it from embolizingand inverting inside the ventricle, we stabilized thevalve by wiring it antegrade (Figure 1). Transseptalaccess was obtained under transesophageal echocar-diographic (TEE) guidance, and the mitral valve wascrossed with a balloon-tipped catheter. The valve wascrossed with a Versacore wire (Abbott Vascular, SantaClara, California), which was exchanged for a 400-cmNitrex flexible shaft guidewire (Medtronic, Dublin,Ireland), which was snared and externalized throughthe femoral artery.A 25-mm NuCLEUS-X balloon (Braun, Kronberg,Germany) was advanced retrograde, and its taperedwaist was centered inside the prosthesis. The balloonwas inflated while rapidly pacing, securing the pros-thesis between the balloon shoulders, and pulled enbloc from the ventricle to the proximal descendingaorta (Figure 2, Video 4).Aortography confirmed no dissection or perfora-tion of the aorta (Video 5). The valve was then stabi-lized with a 30-mm Z-stent (Cook Medical,Bloomington, Indiana) (Video 6).We elected to defer repeat TAVR (Figure 3).Transesophageal echocardiographic demonstratedmobile native leaflets and only mild regurgitation,suggesting either leaflet compliance improved or thestenosis had been overestimated. The patient recov-ered and was discharged the following day.Valve migration into the left ventricular outflowtract is a rare, but potentially devastating, complica-tion that often requires sternotomy. Obtaining centralwire access across the valve is critical to eliminate thepotential for it to invert and obstruct ventricularoutflow. The antegrade transseptal approach achievesISSN 1936-8798/$36.00 https://doi.org/10.1016/j.jcin.2020.06.052From the Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan. *Drs. Kang and So contributed equallyto this work.The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,visit the JACC: Cardiovascular Interventions author instructions page.Manuscript received June 15, 2020; accepted June 23, 2020.J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S VO L . 1 3 , N O . 2 1 , 2 0 2 0ª 2 0 2 0 B Y T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y F O U N D A T I O NP U B L I S H E D B Y E L S E V I E RDownloaded for Anonymous User (n/a) at Henry Ford Hospital / Henry Ford Health System (CS North America) from ClinicalKey.com by Elsevier on December 15, 2020.For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.FIGURE 1 Antegrade Wiring, Externalization, and Balloon Positioning(A) Antegrade wiring, (B) externalization, and (C) balloon positioning.FIGURE 2 Balloon-Assisted Valve Retrieval and Schematic(A) Balloon-assisted valve retrieval and (B) schematic. Balloon shoulders protrude beyond the leading edge of the frame (arrowheads)minimizing vascular trauma.J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 3 , N O . 2 1 , 2 0 2 0 Kang et al.N O V E M B E R 9 , 2 0 2 0 : 2 5 7 6 – 8 Balloon-Assisted Valve Tracking2577Downloaded for Anonymous User (n/a) at Henry Ford Hospital / Henry Ford Health System (CS North America) from ClinicalKey.com by Elsevier on December 15, 2020.For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.this without disturbing the valve. Utilizing a “dogbone”-shaped balloon such as the NuCLEUS allowsfor the valve to be repositioned without furtherexpanding it, and the oversized shoulders protect theaorta from the frame.AUTHOR RELATIONSHIP WITH INDUSTRYThe authors have reported that they have no relationships relevant tothe contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr. Guson Kang,3801 Miranda Avenue, Palo Alto, California 94304.E-mail: guson.kang@gmail.com. Twitter: @GusonKang,@BillONeillMD.KEY WORDS balloon-assisted tracking, complication, embolization,migration, TAVR, transcatheter aortic valve replacementAPPENDIX For supplemental videos, please see the online versionof this paper.FIGURE 3 Final Valve PositionKang et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 1 3 , N O . 2 1 , 2 0 2 0Balloon-Assisted Valve Tracking N O V E M B E R 9 , 2 0 2 0 : 2 5 7 6 – 82578Downloaded for Anonymous User (n/a) at Henry Ford Hospital / Henry Ford Health System (CS North America) from ClinicalKey.com by Elsevier on December 15, 2020.For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Balloon-Assisted Valve Tracking: Atraumatic Retrieval of a Ventricularized Transcatheter Aortic Valve Prosthesis

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Balloon-Assisted Valve Tracking: Atraumatic Retrieval of a Ventricularized Transcatheter Aortic Valve Prosthesis

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