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Percutaneous Closure of Aortic Valve for Persistent Aortic Insufficiency With Left Ventricular Assist Device
Percutaneous Closure of Aortic Valve for Persistent Aortic Insufficiency With Left Ventricular Assist Device Joseph M. Venturini, MD, and Atman P. Shah, MD
A 69-year-old man with history of ischemic cardiomyopathy requiring left ventricular assist device (LVAD) support was referred for percutaneous transcatheter closure of the aortic valve. Transesophageal echocardiography (TEE) demonstrated central aortic insufficiency (arrowheads) in (A) long-axis and (B) short-axis view. The dimensions for the left ventricular outflow tract and sinuses of Valsalva measured to be 24 mm and 30 mm, respectively, on TEE. C, Aortography confirmed the significant aortic insufficiency in the setting of the LVAD inflow cannula noted on fluoroscopy (asterisk). D, The aortic valve was crossed with a 6-Fr AL1 catheter stiff, followed by placement of an Amplatzer 0.035″ × 260 cm guidewire (St. Jude Medical, St. Paul, MN), which was advanced and looped in the apex of the left ventricle. An 8-Fr Amplatzer TorqVue delivery sheath (St. Jude Medical, St. Paul, MN) (arrow) was advanced retrograde over the guidewire into the left ventricle (asterisks) under echocardiographic guidance. E, A 30-mm Amplatzer Cribriform Occluder (St. Jude Medical, St. Paul, MN) was advanced through the sheath and partially deployed on the ventricular side of the aortic valve. Under echocardiographic guidance, the device was retracted against the ventricular side of the aortic valve (arrowhead). F and G, The proximal disc was then exposed on the aortic side of the aortic valve
134 AORTIC VALVE DISEASE
(arrowheads) under echocardiographic (F) and fluoroscopic (G) guidance. After confirming adequate seating of the device and no significant valvular regurgitation, the device was deployed. H, Postprocedural TEE in long-axis demonstrated no residual regurgitation. Ao, Ascending aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
KEY POINTS • Following retrograde placement of the Cribiform device, the occluder is fully deployed across the valve but not released immediately. Prolonged hemodynamic monitoring (>10 min) with the device in place may be necessary to fully assess the hemodynamic effects of aortic valve closure. The device is fully retrievable until it is released. • Measurement of the aortic valve annulus area with TEE can be used to facilitate appropriate sizing of the occluder device.
A
B
C
D
E
F
G
H
AORTIC VALVE DISEASE 135
A 69-year-old man with history of ischemic cardiomyopathy requiring left ventricular assist device (LVAD) support was referred for percutaneous transcatheter closure of the aortic valve. Transesophageal echocardiography (TEE) demonstrated central aortic insufficiency (arrowheads) in (A) long-axis and (B) short-axis view. The dimensions for the left ventricular outflow tract and sinuses of Valsalva measured to be 24 mm and 30 mm, respectively, on TEE. C, Aortography confirmed the significant aortic insufficiency in the setting of the LVAD inflow cannula noted on fluoroscopy (asterisk). D, The aortic valve was crossed with a 6-Fr AL1 catheter stiff, followed by placement of an Amplatzer 0.035″ × 260 cm guidewire (St. Jude Medical, St. Paul, MN), which was advanced and looped in the apex of the left ventricle. An 8-Fr Amplatzer TorqVue delivery sheath (St. Jude Medical, St. Paul, MN) (arrow) was advanced retrograde over the guidewire into the left ventricle (asterisks) under echocardiographic guidance. E, A 30-mm Amplatzer Cribriform Occluder (St. Jude Medical, St. Paul, MN) was advanced through the sheath and partially deployed on the ventricular side of the aortic valve. Under echocardiographic guidance, the device was retracted against the ventricular side of the aortic valve (arrowhead). F and G, The proximal disc was then exposed on the aortic side of the aortic valve
134 AORTIC VALVE DISEASE
(arrowheads) under echocardiographic (F) and fluoroscopic (G) guidance. After confirming adequate seating of the device and no significant valvular regurgitation, the device was deployed. H, Postprocedural TEE in long-axis demonstrated no residual regurgitation. Ao, Ascending aorta; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
KEY POINTS • Following retrograde placement of the Cribiform device, the occluder is fully deployed across the valve but not released immediately. Prolonged hemodynamic monitoring (>10 min) with the device in place may be necessary to fully assess the hemodynamic effects of aortic valve closure. The device is fully retrievable until it is released. • Measurement of the aortic valve annulus area with TEE can be used to facilitate appropriate sizing of the occluder device.
A
B
C
D
E
F
G
H
AORTIC VALVE DISEASE 135