Page 35 - Journal of Structural Heart Disease Volume 4, Issue 1

Case Report
26
attempted to use a Fogarty catheter (Edwards Life- sciences Corporation, Tokyo, Japan) because we thought that a sphere-shaped balloon would t in the shape of the sinus of Valsalva and the coronary cusp and that it could be advanced into the narrowed space between the entrapped coronary lea et and the wall of the sinus of Valsalva using an over-the- wire lumen.
A 4-F compatible, 9.0-mm balloon expansion size Fogarty catheter was selected. The 0.035” wire was switched to a 0.025” wire as the balloon was com- patible with a 0.025” wire. Tracking with the wire, the Fogarty catheter was successfully advanced and in- serted into the slit of the non-coronary lea et and the wall of the sinus of Valsalva, which was con rmed by ICE and uoroscopy. The balloon was gently in ated three times for ~10 s each time (Video 2). After the in- ation, TTE and ICE showed that non-coronary lea et movement had been restored and that the degree of AR was reduced to mild. Findings of aortic root an- giography were also compatible with AR reduction. The patient was transferred to the intensive care unit without NPPV or catecholamine support.
On postoperative day 1, the patient’s respiratory condition worsened, and she required NPPV again; however, right and left heart diagnostic catheteriza- tion on postoperative day 2 revealed no increases in pulmonary capillary wedge pressure or left ventric- ular end-diastolic pressure, which ruled out heart failure with AR. This was therefore diagnosed as an acute worsening of lung disease. The patient gradu- ally recovered and was discharged on postoperative day 15 without further complications. Follow-up TTE showed mild AR; moderate AS with 0.8 cm2 (planim- etry); peak velocity, 3.3 m/s; mean pressure gradient, 26.2 mmHg; and max pressure gradient, 43.9 mmHg.
Discussion
To our knowledge, this is the rst case report de- scribing the successful bailout of acute AR after BAV using a Fogarty catheter. Postmortem images of acute AR due to lea et entrapment after BAV were previously shown by Treasure et al. [7], who report- ed that malalignment of the irregular surfaces of the fractured calci c nodule entrapped the non-coro- nary lea et in an open position and mechanically
hindered the ability of the lea et to close. Hara et al. reported that BAV created intralea et fractures within the aortic valve calci ed deposit [8], and Mizuno et al. reported a case in which cracks made by BAV were observed in the chunky calci cation at the coronary lea et on postmortem images 6 months after BAV [9]. Based on these reports, we hypothesize that the en- trapment in our case might have been caused by the inside-bending of cracked calci ed nodular deposits, which locked the lea et into an open position. ICE in this case clearly showed bending of the non-coronary lea et.
The Fogarty catheter was suitable for our require- ments in the present case for two reasons. First, as a sphere-shaped balloon was required to t the shape of the wall of the sinus of Valsalva and the coronary cusp, a coronary or endovascular over-the-wire type balloon would not have been appropriate due to their rectangular shape. Second, it was considered di - cult to advance the balloon into position accurately; however, this was a necessary aspect of the bailout procedure. An over-the-wire type balloon met these requirements, as this type of balloon can be tracked by the wire and manipulated and inserted into the slit of the entrapped lea et and the wall of the sinus of Valsalva using a MultiPurpose or Judkins Right cath- eter, with echocardiography performed as a backup.
We believe that our method can decrease the need for emergency TAVR or surgical conversion, which may decrease further complications of acute AR after BAV. It might be possible to use this Fogarty catheter bailout technique to stabilize a patient’s he- modynamics during preparation for TAVR or surgical conversion.
In conclusion, the Fogarty catheter can be safely used for bailout of acute AR caused by an entrapped coronary lea et after BAV. We believe that using this technique as a bailout procedure can reduce the need for emergency TAVR conversion or surgery.
Acknowledgments
We thank Drs. Osamu Okada and Kohei Abe, who were involved in the treatment of the patient.
Journal of Structural Heart Disease, February 2018
Volume 4, Issue 1:21-27