Valve-in-Valve TAVR for Degenerated Perceval Valves

Figures

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  Visual Summary. The Perceval Sutureless Valve's Supra-Annular Nitinol Frame and Lack of Radiopaque Markers Predispose to Noncentral Wire Crossing During Retrograde ViV-TAVR, Increasing the Risk of Delivery System Entrapment An alternative anterograde transseptal approach along with IVUS and TEE guidance enables controlled central crossing, facilitating precise valve delivery and successful deployment with favorable outcomes. IVUS = intravascular ultrasound; LV = left ventricle; RA = right atrium; RV = right ventricle; TEE = transesophageal echocardiography; ViV = valve-in-valve; TAVR = valve-in-valve transcatheter aortic valve replacement.

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  Figure 1. Perceval Bioprosthetic Valve (A) The Perceval sutureless aortic bioprosthetic valve. (B and C) Preprocedural computed tomography angiography demonstrating lack of coaptation between the edge of the supra-annular ring of the Perceval valve and the aorta in patient 1 (B) and patient 2 (C). The red arrows point to the distances.

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  Figure 2. Coronary Angiogram Images of Valve Deployment, Entrapment, and Snaring in Patient 1 (A) Coronary angiography demonstrating crossing the valve with the wire. (B) Central crossing of the Perceval valve ring was confirmed using multiple fluoroscopic views. (C) This was followed by deployment of the Edwards Sapien valve. (D) The balloon delivery system was entrapped behind the Perceval frame, and partial inflation attempt to release the balloon was unsuccessful. (E and F) The system was successfully retrieved after snaring.

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  Figure 3. Coronary Angiography of Successful Central Crossing Using Multiple Techniques in Patient 2 (A) Intravascular ultrasound was used to guide central crossing. (B) The anterograde transseptal approach was used to cross the wire from the left ventricle to the aorta using transesophageal echocardiography guidance. (C and D) The wire was snared in the aorta, an arteriovenous loop was created, and a pigtail catheter was advanced in the left ventricle to ensure central crossing. (E) The valve was successfully deployed.