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Daniel R. Wong, MD, MPH, Jian Ye, MD, Anson Cheung, MD, John G

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Presentation on theme: "Daniel R. Wong, MD, MPH, Jian Ye, MD, Anson Cheung, MD, John G"— Presentation transcript:

1 Technical considerations to avoid pitfalls during transapical aortic valve implantation 
Daniel R. Wong, MD, MPH, Jian Ye, MD, Anson Cheung, MD, John G. Webb, MD, Ronald G. Carere, MD, Samuel V. Lichtenstein, MD, PhD  The Journal of Thoracic and Cardiovascular Surgery  Volume 140, Issue 1, Pages (July 2010) DOI: /j.jtcvs Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

2 Figure 1 Comparison of high-quality fluoroscopic images of the transcatheter valve obtained from hybrid room image intensifier (A) versus standard C-arm fluoroscopy (B). The ascending aorta is at the top left corner, and the left ventricular apex is beyond the bottom right corner. The Journal of Thoracic and Cardiovascular Surgery  , DOI: ( /j.jtcvs ) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

3 Figure 2 Technique for hemostatic control of the left ventricular apex. A, Two perpendicular, pledget-supported sutures are placed at the apex (X) to avoid epicardial fat and vessels; the suture (highlighted) is passed full-thickness through myocardium and then snared with a tensioning tourniquet. B, A needle is passed through the apex at the central point bounded by the pledget-supported sutures. Temporary ventricular pacing wires are also shown. The Journal of Thoracic and Cardiovascular Surgery  , DOI: ( /j.jtcvs ) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

4 Figure 3 After the stenotic native aortic valve is crossed with a wire (top inset), balloon aortic valvuloplasty is performed during rapid ventricular pacing. Dilute contrast solution permits visualization of the balloon under fluoroscopy (bottom inset). The Journal of Thoracic and Cardiovascular Surgery  , DOI: ( /j.jtcvs ) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

5 Figure 4 The aortic annulus is measured between hinge points to size the transcatheter valve, and transesophageal echocardiography is the most accurate means of measurement. The Journal of Thoracic and Cardiovascular Surgery  , DOI: ( /j.jtcvs ) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

6 Figure 5 The transcatheter valve is positioned with transesophageal echocardiographic (top inset) and fluoroscopic guidance (bottom inset), with fine positioning adjustments informed by hand injections of contrast through a pigtail catheter deep in the aortic root. The valve is positioned so that 40% to 50% of the stent lies below the annulus (arrow) and so that the valve extends just cranial to the native cusp edges. The Journal of Thoracic and Cardiovascular Surgery  , DOI: ( /j.jtcvs ) Copyright © 2010 The American Association for Thoracic Surgery Terms and Conditions

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