Snare-Assisted Transseptal Antegrade Transcatheter Aortic Valve Replacement

BACKGROUND: Transfemoral access remains the preferred route for transcatheter aortic valve replacement (TAVR); however, severe peripheral artery disease (PAD) and unfavorable anatomy can result in the preclusion of conventional access. Transseptal antegrade TAVR may offer another avenue in such cases. CASE SUMMARY: An 81-year-old man with severe symptomatic aortic stenosis, extensive peripheral artery disease, porcelain aorta, prior coronary artery bypass graft, and prohibitive surgical risk had no feasible conventional access. As such, a transseptal antegrade TAVR approach was pursued. During advancement of a balloon-expandable valve system through the left atrium and mitral valve, navigation toward the aortic annulus was difficult. Retrograde snare capture of the valve nose cone enabled traction, coaxial positioning, and successful deployment of a 29-mm SAPIEN 3 Ultra RESILIA valve with excellent hemodynamics and trace paravalvular regurgitation. DISCUSSION: Retrograde snare assistance facilitated valve delivery when antegrade advancement was insufficient. TAKE-HOME MESSAGE: In carefully selected patients, transseptal antegrade TAVR with retrograde snare-assisted delivery may be an alternative strategy.