Page 34 - Journal of Structural Heart Disease Volume 4, Issue 1

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Case Report
Video 1. Intracardiac echocardiography showing the entrapped non-coronary lea et. Motion loss and entrapment of the non-coronary lea et are observed. View supplemental video at https://doi.org/10.12945/j.jshd.2018.038.17.vid.01.
cusp, and a 10-F sheath in the right femoral vein with intracardiac echocardiography (ICE; ViewFlex, St. Jude Medical Japan Co., Ltd, Tokyo, Japan). Heparin was administered with a target activated clotting time of 200–300 s. The contrast media was diluted twice with saline.
The aortic valve was crossed with a 5-F AL1.0 di- agnostic catheter (Terumo Medical Corporation, To- kyo, Japan) using a 0.035” Radiforcus straight wire (Terumo Medical Corporation), which was exchanged for a manually shaped Amplatz Super Sti Wire (Bos- ton Scienti c Corporation, Tokyo, Japan). An 18-mm NuMed balloon (Trytech Co., Tokyo, Japan) was in- serted into the aortic valve and in ated with rapid pacing (Figure 2A).
Immediately after ballooning, the patient’s systolic blood pressure dropped to 60 mmHg, and she com- plained of chest discomfort. Aortic root angiography revealed severe AR (Figure 2B). ICE and TTE con rmed movement loss and entrapment of the non-coronary lea et. AR color jet was mainly observed in this area (Figure 2C and 2D and Video 1). The pigtail catheter was inserted into the left ventricle without any resis- tance; this is referred to as the “free oating pig tail sign”. The aortic-left ventricle pressure gradient was almost equivalent after BAV due to entrapment of the non-coronary lea et. TTE and ICE revealed no pericar- dial e usion.
We were able to control the patient’s blood pres- sure with catecholamine, and thus she did not require mechanical support. However, because her SpO2 lev-
Video 2. Cineangiography showing in ation of the Fogarty catheter. View supplemental video at https://doi.org/10.12945/j. jshd.2018.038.17.vid.02.
el dropped and central venous pressure increased, we added noninvasive positive pressure ventilation (NPPV ).
Our patient was considered unsuitable for emer- gency TAVR or surgical conversion for several reasons. First, TAVR was not clearly indicated, as we had not yet determined whether AS would be e ective for im- proving the patient’s symptoms. Second, as our insti- tution had limited experience with TAVR at that time, we thought that the emergent preparation of TAVR would have the potential to cause further problems. Finally, the patient had a high STS score and lung dis- ease, and surgical intervention was considered to be too risky. Thus, we decided bailout was required with- out conversion to TAVR or open surgery.
We rst attempted mechanical push back using the pigtail catheter. We ensured insertion of the catheter between the entrapped non-coronary lea et and the wall of the sinus of Valsalva by ICE and then rotated it repeatedly. However, we encountered huge resis- tance, with no movement of the non-coronary lea et. We then tried to use a sti wire in the pigtail to sti - en the catheter itself; however, this was not e ective (Figure 2E and 2F).
We needed another option to push the non-cor- onary lea et back from its entrapped position. We
Komatsu I. et al.
Non-TAVR Bailout for Severe AR After BAV