1. Tips and Tricks for Safe Deployment of the Balloon Expandable Valve
E Murat Tuzcu, MD
Cleveland Clinic
Disclosure: None

2. Edwards Transcatheter Valve Evolution
Untreated
Equine Tissue
Untreated
Equine Tissue
Treated
Bovine Tissue
TFX Treated
Bovine /CC
Andersen
Pig implant, May ’89
Cribier-Edwards™
FIM, April 2002
Edwards SAPIEN™
August, 2007
Sapien XT™
January, 2010 2 2 2

4. Access Inguinal ligament Inferior epigastric
Profunda
femoris
Superficial
femoral
Inguinal
ligament
Determine access side by CT
Landmarks for puncture from
- Prior angiogram
- CT
- Calcification
Puncture at optimal site
Visualize before larger sheath
Contra-lateral artery for pigtail
Femoral vein for PM
Pre-close when possible
10F Prostar or
Two 6F Perclose
Figure 5

5. Crossing the Stenotic Aortic Valve with Wire
Left Amplatz catheter ( 5F AL1)
0.35” straight wire
Locate the aortic valve orifice
Calcified leaflet movement
Aortography
Control movement
Catheter clockwise and cc
Wire protrusion
Catheter height
Avoid coronaries and SVG
Cross and advance wire into LV
Advance catheter over the stiff part of the wire
May be difficult if very tight & Ca

6. Balloon Aortic Valvuloplasty
Use 4- 6 cm balloon to avoid repeat inflations
Dilate with rapid pacing
Confirm uninterrupted capture
If there is suspicion, check if LMCA ostium is obstructed
Observe recovery after pacing
Assess post-balloon status
Ao diastolic pressure
TEE
Motion of calcified leaflets

8. Advancing THV from insertion to Aortic Valve
Confirm proper position of THV
Be careful exiting the sheath
Avoid scraping the aorta
Flex the catheter progressively while negotiating the arch
Don’t push against resistance
Don’t let the wire pulled !!!!
Pause before crossing
Check wire position
Briefly assess the hemodynamics

9. Crossing the Aortic Valve with THV
Ensure optimum wire position
Gentle push
If it doesn’t cross, it won’t cross with sheer force
Problem may be
Commisural location of the valve
LV – Ao angle
Inadequate valvuloplasty
Severely tortuous unfolded aorta
Readjust your approach
Reduce flexion
Readjust wire
Try to change approach angle
Extreme measures may be needed

10. Positioning of the Valve
Don’t rush. You have time
Pull flexcath back
Confirm x-ray angles are correct
Use calcified landmarks
Small injections via pigtail
THV mid-portion at annulus (50%/50%)
Confirm in predetermined views
If needed, dry run w/ pacing
TEE may help as adjunctive imaging
Keep an eye on hemodynamics

11. Aortic Valve Plane by CT Scan
RCC
LCC
NCC
Aortic Valve Plane
LAO Cranial
LCC
RCC
NCC
Aortic Valve Plane
RAO Caudal

12. Starting overlay of visualized 3D structures onto fluoroscopic images.
To overlay the rendered 3D visualization live onto fluoroscopic images, we use a
software available with the angiographic C-arm system (syngo iPilot, Siemens, Erlangen,
Germany). The 3D volume is inherently registered to the fluoroscopic images
because both images are acquired on the same system. The overlay dynamically
adapts to C-arm rotations and table movements (see Figure 4, left). This mode can be
used to adjust or fine-tune the C-arm angulation needed for implantation. The overlay
does not compensate for patient and heart motions, but can be corrected manually in
these cases.

13. Implantation Make sure nothing moved Call for rapid pacing
Confirm uninterrupted capture
Wait until BP drops
Fully inflate for 3-5 seconds
Stop pacing after complete deflation
Take a moment to assess
Recovery
Stability of THV
THV location, leaflet movement by TEE
Remove the balloon from the LV

14. Assessment Immediately After TAVI
BP waveform, diastolic pressure
HR, PAP
ECG, ST-T, conduction
THV location & movement
Use TEE for
Leaflet motion
Para-valvular AR
Valvular AR (after removing stiff wire)
LV wall motion
Be prepared to deal with complications swiftly
Coronary occlusion
Severe AR
Embolization of THV
Baseline: LV-Ao: 48 CO: 3.9L AVA: 0.55
Post-TAVI LV-Ao: 8 CO: 4.8 L AVA: 1.7

15. Repair of Access site Surgical repair of cut-down
Perclose if sutures were pre-placed
Keep in mind vascular trauma
Un-masking of an insertion trauma
Perforation during sheath removal
Be prepared
Introducer available
Occlusion balloon available
Remove the large sheath
Tighten the pre-placed sutures
Pre-removal options
Angiography
Proximal balloon occlusion
Post-repair angiography

16. Transcatheter Aortic Valve Implantation
Properly functioning THV No surgical incision