4-Dimensional Intracardiac Echocardiography-Guided Antegrade TAVR Using a Novel CABLE-TAVR Technique.

Figures

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  Visual Summary. Case Overview for the Novel CABLE-TAVR Technique

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  Figure 1. Preoperative Vascular Imaging Preoperative computed tomography angiography with 3-dimensional reconstruction of the (A) common carotid artery, (B) iliofemoral artery, and (C) subclavian artery exhibiting narrow internal diameters. Heavy continuous calcification of the descending aorta is shown on coronal (D) and axial (E) preoperative computed tomography angiography imaging. The lateral view of the descending aorta on 3-dimensional reconstruction shows lack of an adequate calcium-free window for transcaval access (F).

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  Figure 2. Trans-septal Puncture Intracardiac echocardiography showing the trans-septal puncture (A) followed by atrial septostomy (B).

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  Figure 3. Mitral Valve Intracardiac Echocardiography Four-dimensional intracardiac echocardiographic view of the mitral valve from the left atrium (A) before and (B) after wire placement.

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  Figure 4. Aortovenous Loop Creation Fluoroscopic image with the Agilis introducer (∗) positioned toward the mitral valve with a balloon-tipped catheter (Δ), creating a loop within the left ventricle and out of the aortic outflow tract.

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  Figure 5. CABLE-TAVR Technique Fluoroscopic images of the CABLE-TAVR technique in sequence (A to D) showing an unloaded Edwards Commander delivery system bending the overlying DRYSEAL sheath toward the mitral valve.

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  Figure 6. DRYSEAL Sheath Across the Mitral Valve Intracardiac echocardiography showing the DRYSEAL sheath traversing through the mitral valve with its distal tip in the midcavity of the left ventricle.

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  Figure 7. Prosthetic Aortic Valve Delivery Fluoroscopic images of the Edwards Commander delivery system loaded with the prosthetic valve within the DRYSEAL sheath (A), at the distal end of the sheath (B), within the aortic valve apparatus (C), and at deployment (D). Intracardiac echocardiographic images show the DRYSEAL sheath in the left ventricular midcavity (∗) with the prosthetic valve (♦) at the apex curving superiorly toward the aortic outflow tract (E).

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  Figure 8. Postoperative Echocardiography Postoperative transthoracic echocardiography showing normal function of the prosthetic aortic valve (A), mild mitral regurgitation (B), and a small atrial septal defect with left to right shunting (C).