TECHNIQUE
Ultrasound and fluoroscopic guidance were used to gain access to the bilateral common femoral arteries using a micropuncture needle technique. A 6 Fr long sheath was placed in the left femoral vein. In the right common femoral artery, 2 Perclose ProGlide closure device was deployed in a pre-close fashion. A 5 Fr balloon tipped temporary transvenous pacemaker was placed in the right ventricular apex and a 6 Fr pigtail catheter was placed at the base of the aortic valve. Aortography was performed to obtain an optimal angle for valve deployment. The aortic valve was crossed via the right common femoral arterial approach and a long Confida wire was placed in the left ventricular apex.
In both cases, an initial Medtronic Evolut valve was advanced over a Confida wire and utilized for the TAVR-procedure. The valve was deployed with the assistance of small dye injections through the pigtail catheter, so as to carefully choose the location for deployment. After the valve was deployed, we noticed the valve had migrated into the Left Ventricular Outflow Tract (LVOT), generating significant perivalvular leakage. At that point, a Balloon-expandable Edwards SAPIEN valve was chosen and placed within the initial Medtronic-Evolut valve, decreasing the degree of aortic insufficiency to trace amounts.