A Buddy When You Need One: Buddy Balloon-Assisted Bailout for Failed Valve Crossing During Transfemoral Transcatheter Aortic Valve Implantation

Figures

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  Figure 1. Preprocedural echocardiographic assessment of critical calcific aortic stenosis. (A) Transthoracic echocardiography demonstrating a severely calcified native aortic valve with markedly restricted leaflet mobility and virtually absent leaflet separation (arrow). (B) Continuous-wave Doppler interrogation across the aortic valve showing severe transvalvular obstruction, with a peak velocity of approximately 5.9 m/s and a mean gradient of 90 mmHg (arrow), consistent with critical aortic stenosis.

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  Figure 2. Preprocedural computed tomography demonstrating extensive aortic valve calcification. Multiplanar reconstruction images of the aortic root and aortic valve complex show massive leaflet and annular calcification (arrows). The extensive and asymmetric calcium burden resulted in a critically stenotic valve orifice and represented the principal anatomical challenge for transcatheter valve delivery.

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  Figure 3. Buddy-balloon-assisted facilitation of valve crossing during transfemoral TAVI. Stepwise application of the buddy-balloon technique: (A) Initial aortography demonstrating severe aortic stenosis. (B) Failure of the Edwards SAPIEN 3 Ultra delivery system to cross the heavily calcified native valve despite predilatation and optimal guidewire support. (C) Re-crossing of the valve through secondary arterial access and positioning of a second stiff guidewire in the left ventricle. (D) Inflation of a 22-mm buddy balloon across the native valve during rapid ventricular pacing. (E) Successful advancement of the transcatheter heart valve across the aortic annulus, facilitated by temporary modification of valve geometry. (F) Final deployment of the balloon-expandable prosthesis in the optimal annular position. TAVI: Transcatheter aortic valve implantation.

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  Figure 4. Schematic illustration of the buddy-balloon technique. Repeat balloon valvuloplasty temporarily increases valve compliance and modifies the geometry of the severely calcified native valve. During balloon deflation, the balloon may additionally act as a mechanical “shoehorn,” facilitating advancement of the transcatheter heart valve delivery system across the stenotic valve. Note: Original hand-drawn illustration created by Leivaditis V (first author); no digital or generative AI tools or external sources were used.