1. CRT 2010
Washington DC, January 21, 2010
Medtronic CoreValve Trans-Femoral TAVI System. Dealing with Complications!
Eberhard Grube, MD, FACC, FSCAI
St.Elisabeth Hospital, Essen, Germany
Heart Center Rhein-Ruhr
Instituto Cardiologico Dante Pazzanese, São Paulo, Brazil

2. Eberhard Grube, MD DISCLOSURES Consulting Fees Honoraria
Abbott Vascular, Boston Scientific Corporation, Cordis, a Johnson & Johnson Company, Medtronic CardioVascular, Inc.
Honoraria
Biosensors International , Boston Scientific Corporation, Medtronic CardioVascular, Inc
Ownership Interest (Stocks, Stock Options or Other Ownership Interest)
Biosensors International , Medtronic CardioVascular, Inc.
I intend to reference unlabeled/ unapproved uses of drugs or devices in my presentation.
I intend to reference off-label use of stents and valve prosthesis.

3. Medtronic CoreValve implantation Tips and Tricks
Avoid complications (femoral access route)
Balloon valvuloplasty
Prosthesis positioning
Options to correct mal-positioned prosthesis
Treatment options for access site complications

4. Wiring the aortic valve
Technique
with AL1/2 and straight Terumo (alternativelly straight 0,035‘‘) Wire
LAO 15
 CAVEAT: do not engage the Coronaries
Exchange for a 5 F Pigtail using a 260 Wire
Simultaneous Pressure Recording

5. Wiring the aortic valve

6. Placing the stiff wire Amplatz Superstiff ST1 (short floppy tip 1 cm)
Alternative stiff wires
Longer floppy tips
aimmanually bending the stiff part into a pigtail shape
18 French sheath always over the stiff wire

7. Balloon Valvuloplasty
Balloon catheters:
Nucleus 12 F (Inoue like behavior)
Stabilize position
Z-med X 12 F
Tyshak II (9 F to 25mm) rated burst Atm
or other Valvuloplasty Balloons possible
Rapid RV stimulation ~ BPM
(systolic pressure <60 mmHg)

8. Balloon valvuloplasty with Nucleus (Balloon Rupture !)

9. Balloon Valvuloplasty using a 25 mm ZMed Balloon and simultaneous Dye Injection in a 28 mm Anulus (measured by CT)

10. Aortic regurgitation III / IV after valvuloplasty (2-5%)

11. Always have the Prosthesis loaded for immediate implantation

12. Angiographic Result after 26mm CV

13. Aortic Regurgitation IV after Valvuloplasty
Acute Aortic Regurgitation IV
resulting in
Acute LV overload
Acute LV failure / asystole or VF due to Volume-loading of the LV

14. ...also during CPR (ongoing V-Fib)

15. ...also during CPR (ongoing V-Fib)

16. Spontaneous Return to Sinus Rythm after implant

17. Aortic Dissection after Valvuloplasty

18. Aortic Dissection after Valvuloplasty treated by CV Implantation

19. Aortic Dissection after Valvuloplasty treated with Prosthesis

20. Push the wire to stabilize CoreValve position during delivery („ostial stenting“)

21. Aortic Regurgitation after Delivery of the Prosthesis

22. Aortic regurgitation after delivery of the prosthesis

23. Prosthesis with insufficient radial force (due to calcification ) AR III

24. Post-dilatation with bigger balloon

25. Final result

26. AR due to too deep prosthesis (paravalvular leakage)

27. Re-positioning using a Goose Neck ‚snare‘ (15/20 mm) from femoral 6F

28. Controlled during continuous pulling by monitoring of the diastolic blood pressure

29. Example of a malpositioned prosthesis ( too deep ) >> repositioning mandatory

30. Example of a ‘too deep’ prosthesis, re-positioned with a snare
From femoral unsuccessful

31. Example of a ‘too deep’ prosthesis, re-positioned with a snare
From brachial successful

32. Example of a ‘too deep’ prosthesis, re-positioned with a snare
Final
result