Challenges in Valve Crossing and Positioning During Transfemoral Transcatheter Aortic Valve Implantation
Despite improvements in delivery catheter prole, size and steerability compared with the rst generation devices, retrograde aortic valve crossing during transfemoral TAVI may be challenging especially in the presence of a severely calcied native aortic valve or horizontal ascending aorta.
Sheiban et al. rst reported the use of the buddy balloon technique to successfully deliver a transcatheter aortic valve through a severely calcied aortic valve. Despite repeated balloon valvuloplasty, several attempts to deliver a 23 mm Edwards SAPIEN device were unsuccessful, probably due to calcied spiculae and/or recoil. Finally the buddy balloon technique using a 23 x 40 mm NuCLEUS valvuloplasty balloon (NuMed, New York, US) inated at low pressure was successful. The valvuloplasty balloon was used as a shoehorn to enable successful delivery of the Edwards SAPIEN valve.14 Balkin et al. also reported two cases of failure to cross highly calcied aortic valves with the Retroex catheter, used to deliver the Edwards SAPIEN device.15 The buddy balloon technique using an 8 Fr 20 x 40 mm valvuloplasty balloon (OSYPKA AG, Rheinfelden, Germany) allowed successful valve crossing.
At the congress of the European Association of Percutaneous Cardiovascular Interventions (EuroPCR) 2013, we presented a case of retrograde aortic valve crossing with the AccuTrak CoreValve device (Medtronic Inc, Minneapolis, Minnesota, US) requiring the buddy balloon technique to be successful.16 The difference with the previous reports is that we used a 6 Fr compatible 8 x 80 mm Admiral peripheral balloon (Medtronic Inc) instead of a valvuloplasty balloon. The difculty of crossing the native aortic valve in this case was probably due to the horizontal orientation of the ascending aorta. The main advantage of using a 6 Fr compatible balloon is that we do not need to oversize our contralateral access since we routinely insert a 6 Fr introducer in the contralateral femoral side in order to be ready to perform a crossover balloon ination technique in case of major vascular complication when the large sheath is retrieved.
The buddy balloon technique is a simple and easy tip and trick for challenging retrograde valve crossing. Of note, the buddy wire technique was not effective in the report by Sheiban et al.,14 similarly as in our own experience. Finally, the buddy balloon technique may avoid excessive manipulations with the delivery system and wire, and potentially reduce the risk of left ventricle perforation by the wire and embolisation of calcic particles when struggling to cross the valve. Another option in such cases is to convert to transapical approach or even surgical aortic valve replacement. The former is the only TAVI approach using an antegrade crossing of the valve with the device, which is technically easier than the retrograde crossing required with all the other TAVI approaches.