An 89-year-old man was admitted to the Nagoya Heart Center because of symptomatic severe aortic stenosis. For treatment, we decided on transfemoral transcatheter aortic valve implantation (TF-TAVI) using the Navitor valve (Abbott, St. Paul, MN, USA). However, the Navitor valve could not cross the aortic arch (Figure A). Computed tomography showed heavy deposition of calcium in the aortic arch (Figure B,C). We tried to pass the entire system by rotating the delivery system and pulling back the extra-stiff guidewire (Figure D), none of which solved the problem. Therefore, we decided to use a snare catheter (OSPIKA, Rheinfelden, Germany) to catch the proximal edge of the device (Figure E). We pulled back the snare carefully, avoiding the joint capsule part of the device, before crossing the aortic arch in the same manner as for the other self-expandable series (Figure F), resulting in successful delivery of the device to the aortic arch (Figure G). The snare could be removed after crossing the device into aortic valve (Figure H). TF-TAVI was performed without any adverse events (Figure I,J). Although the Navitor system is designed for high deliverability via difficult access routes, physicians are aware that even this system may be challenging to deliver across an aortic arch with heavy calcium deposition. The snare technique described here is a possible solution, changing the wire bias to deliver the catheter with, for example, a Navitor valve for TF-TAVI.
Figure.
Transcatheter aortic valve implantation (TAVI) using the Navitor valve. (A) The Navitor valve could not be passed across the aortic arch. (B,C) Preprocedural computed tomography revealed massive calcification (white arrows) in the greater curvature of the aortic arch. (D) Rotating the system (curved arrows) and pulling back the guidewire (dashed arrow) did not solve the problem. (E,F) A snare catheter (white arrowhead; E) was used to change the wire bias (white arrows; F). (G–J) The Navitor delivery system was positioned in the aortic valve (G,H) and successfully implanted without complications (I,J).
Disclosures
M.Y. has received lecture fees from Edwards, Medtronic, Boston, Abbott, and Daiichi-Sankyo. The other authors have no conflicts of interest to disclose.