Page 38 - Journal of Structural Heart Disease Volume 3, Issue 1

31 Case Report
Figure 6. Panel A. CoreValve in appropriate position and patent coronary arteries with mild paravalvular leak noted on nal aorto- gram. Panel B. CoreValve in appropriate position with the Palmaz XL deployed xing the upper portion of the CoreValve.
To maintain the position of the valve, a Palmaz XL transhepatic biliary stent (40 mm unexpanded length × 10 mm expansion diameter; Cordis Corp., Rancho Cordova, CA, USA) was placed to achieve adequate ra- dial force against the impingement. This Palmaz stent was then crimped onto a 24-mm balloon in balloon (BIB) catheter (inner: 12 mm diameter × 3 cm length, outer: 24-mm diameter × 4-cm length; NuMED Inc, Hopkinton, NY, USA). The outer balloon was then slightly in ated to prevent the Palmaz stent from slid- ing o the balloon. A 75-cm 12-F Check-Flo introduc- er sheath (Cook Medical, Bloomington, IN, USA) was used to advance the BIB balloon-mounted crimped Palmaz stent into the ascending aorta. The Check-Flo introducer sheath was then withdrawn, leaving the BIB balloon-mounted Palmaz stent in place overlap- ping the proximal stent end of the CoreValve. Rapid pacing at 180 bpm was initiated, and the inner and outer balloons were in ated in succession, securing the stent and valve in place, and the GooseNeck snare was released (Figure 5). The BIB balloon was then fully in ated to position the Palmaz stent, which appeared to x the CoreValve in place. Post-procedure aorto- gram con rmed acceptable location of the valve, pa-
tency of the coronary arteries, and mild paravalvular leak (Figure 6). The patient was extubated immedi- ately and monitored overnight in the intensive care unit. He felt symptomatically improved and was dis- charged home next day.
The patient showed a signi cant reduction in shortness of breath two weeks post-procedure and at 1-month follow-up. Echocardiographic evaluation at 2 and 6 months con rmed accurate positioning of the valve with good valve function (Figure 7A and 7B). However, we also noted moderate perivalvular regurgitation, highlighting di culty in treating NAVR with TAVR. Furthermore, the 6-month follow-up echo- cardiogram revealed a moderate to severe paravalvu- lar leak, and the patient exhibited increased fatigue and failure to thrive. After discussion, we decided to proceed with placing a valve-in-valve transcatheter using an overexpanded Sapien S3.
Discussion
This is the rst description of the use of the radial force of a Palmaz biliary stent to a x the upper por- tion of a CoreValve and mitigate the ventricular mi-
Sunkara, N. et al.
TAVR for NAVR