Associazione Nazionale Medici Cardiologi Ospedalieri



Case Report of Snaring-assisted TAVR under cerebral embolic protection: the “Chaperone” with “Top Hat” Technique

Casilli Francesco Milano(Milano) – IRCCS Osp Galeazzi S Ambrogio – MI – GSD | Medda Massimo Milano(Milano) – IRCCS Osp Galeazzi S Ambrogio – MI – GSD | Montonati Carolina Milano(Milano) – IRCCS Osp Galeazzi S Ambrogio – MI – GSD

A 84-year-old woman was admitted for effort dyspnea (NYHA class II-III) in severe aortic stenosis (peak/mean gradient 107/61 mm Hg, aortic valve area 0.5 cm2) with high surgical risk (STS PROM 8%). Pre-operative computed tomography angiography showed the aortic valve and the sinotubular junction severely calcified, multiple protruding calcific nodules of ascending aorta, ‘gothic’ aortic arch (AA) and multiple calcific stenosis of both iliac-femoral vessels, severely tortuous. We planned a transfemoral implantation of a 29-mm self-expandable Evolut R valve (Medtronic) under complete cerebral protection (CP) with TriGuard™ system and delivery advancement ‘snaring-assisted’. The placement of a CP system has been planned because the patient had a history of previous stroke, due to the presence of severe calcifications of the ascending aorta, of the sino-tubular junction and of the aortic valve (in addition of suspected calcific bridge between the left coronary cusp and the right coronary cusp). The snaring procedure of self-expanding transcatheter heart valve (THV) has been planned to anticipate traumatic contact with the aortic wall calcifications and to easier navigate with THV in the ‘gotic’ and calcific AA. The procedure required the management of 5 vascular accesses: 1 radial access + 2 femoral accesses + 2 ancillary femoral accesses. In order to guide the advancement of the THV through the AA we preventively inserted a 20-mm AndraSnare catheter from the contra-lateral femoral artery. The THV was advanced on the snared guidewire, and the tip of the THV was ensnared and then pulled in order to be detached from the calcified wall of the ascending aorta, allowing the valve to be steered (“Chaperoned”) through them moreover without any interference with the CP system (“Top Hat”). At the macroscopic analysis of CP device there were also present small debris of calcium. Finally no complications related to the vascular accesses occurred.

On the basis of our experience the risk-benefit balance of implementing CP with device (and specifically with TriGuard™ system) needs to be deeply evaluated because it requires a great care:

a) to avoid uncontrolled movement of the device once opened,

b) to avoid aggressive contacts with the aortic wall during complex maneuvers,

c) the CP system requires a dedicated vascular femoral access (8F).

To our knowledge, this is the first case of snaring-assisted TAVR under complete cerebral embolic protection with TriGuard™ system.