Page 40 - Journal of Structural Heart Disease Volume 3, Issue 1

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Case Report
the origin of the innominate artery, to avoid jailing of this artery.
When choosing a balloon, diameter and length are important considerations. Shorter balloons o er the advantage of in ating the inner part of the stent rst, thus avoiding the potential complication of aring of the ends of the stents, resulting in balloon rupture or vessel wall perforation; however, this can result in stent sliding or embolization. Longer balloons allow more precise placement and repositioning if neces- sary before their full in ation. The BIB balloon has two balloons, one shorter (inner) and one longer (outer) than the stent, which o ers potential advantages. In our situation, to prevent the crimped Palmaz stent from sliding o the balloon during its introduction into the sheath, we in ated the inner balloon to a low 2 atm. Once the sheath is withdrawn and the stent is adequately positioned, the inner balloon is in ated rst. After the position of the inner balloon is ensured to be satisfactory, the outer balloon is in ated. In choosing the diameter of the balloon, we took into consideration the measurements of the ascending aorta based on pre-procedure CT and aortogram per- formed during the procedure. The balloon was sized 1:1 with the intent to expand the Palmaz stent and adequately x the CoreValve in place.
Potential risks of this approach that should be kept in mind are vessel wall perforation while deploying the Palmaz stent, balloon rupture and aortic dissec- tion, inadequate expansion of the Palmaz stent with ventricular migration of the stent and valve, and pos- sible jailing of the major branches of aorta. Careful measurements of the ascending aorta and balloon and stent sizing, taking foreshortening into account, should minimize such complications.
There are a variety of other valves in various stages of development that are designed for the treatment
of NAVR. These typically utilize a transapical approach and include the Acurate TA valve, Medtronic engag- er valve, and Jena valve [5-8]. The Helio transcatheter dock (Edwards Lifesciences, Irvine, CA, USA) has been described as an ancillary device intended to confer greater annular stability to the Edwards SAPIEN XT valve. The dock consists of a self-expandable nitinol stent with a polyethylene skirt designed to be po- sitioned inside the aortic root, which is intended to secure the balloon-expandable SAPIEN XT by incor- porating and entrapping the native cusps [9].
TAVR is not an approved treatment for NAVR, al- though it is being used o -label in high-risk surgical candidates. Experience in using the transcatheter ap- proach to treat NAVR is limited but growing. Patients with mixed aortic valve disease with severe steno- sis and at least moderate regurgitation have been successfully treated with both commercially avail- able TAVR devices, but NAVR without stenosis is still considered a relative contraindication in published guidelines.
Newer-generation valve designs that use lea et pinning or stabilization mechanisms are showing promise, but experience with these devices is still lim- ited. Therefore, additional experience and evidence from larger registries, longer follow-up periods, and randomized clinical trials is necessary for the expand- ed use of TAVR for NAVR.
Con ict of Interest
Dr. Welt has reported as being on the advisory board for Medtronic.
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References
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2. Testa L, Latib A, Rossi ML, De Marco F, De Carlo M, Fiorina C, et al. CoreValve im- plantation for severe aortic regurgitation: a multicentre registry. EuroInterven-
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scatheter aortic-valve replacement with a self-expanding prosthesis. N Engl J Med. 2014;371:1790-1798. DOI: 10.1056/NE- JMc1408396
Sei ert M, Diemert P, Koschyk D, Schirmer J, Conradi L, Schnabel R, et al. Transapical implantation of a second-generation tran- scatheter heart valve in patients with non- calci ed aortic regurgitation. JACC Cardio- vasc Interv. 2013;6:590-597. DOI: 10.1016/j.
Sunkara, N. et al.
TAVR for NAVR