Abstract
The direct measurement of left ventricular pressure in the presence of a mechanical aortic valve is a technical challenge for the interventional cardiologist. Direct recording, which is rarely performed, becomes necessary when other imaging methods have failed to evaluate prosthetic valve stenosis or restrictive physiology. Left ventricular pressure has typically been measured after transseptal or direct left ventricular apical puncture.
In recent years, investigators have used the 0.014-in coronary Radi PressureWire™ (St. Jude Medical, Inc.; St. Paul, Minn) to cross the St. Jude bileaflet prosthetic aortic valve without the need for puncture. Although another bileaflet aortic valve, the ATS Open Pivot® (ATS Medical, Inc.; Minneapolis, Minn), has an overall design similar to that of the St. Jude valve, the ATS valve has an open-pivot hinge, which has the potential for wire entrapment.
Herein, we describe how we successfully measured left ventricular pressure by crossing an ATS Open Pivot prosthetic valve with a Radi PressureWire, in a 60-year-old man in whom pericardial constriction was suspected. The straightforward, uncomplicated procedure enabled confirmation of the diagnosis. We believe that further investigation of this technique is warranted.
Key words: Angioplasty/instrumentation/methods; equipment design; heart catheterization/instrumentation/methods; heart valve prosthesis/adverse effects; heart ventricles/physiopathology; ventricular dysfunction, left/diagnosis; ventricular pressure
In the presence of a mechanical aortic valve, directly recording left ventricular (LV) pressure with conventional catheters is technically challenging, because of the risk of wire entrapment when crossing the valve. Pressure measurements have typically been obtained through transseptal or direct LV puncture.1,2 Herein, we describe our technique for crossing an ATS Open Pivot® bileaflet prosthetic aortic valve (ATS Medical, Inc.; Minneapolis, Minn) with a Radi PressureWire™ (St. Jude Medical, Inc.; St. Paul, Minn) to directly measure LV pressure in a patient in whom pericardial constriction was suspected.
Case Summary
A 60-year-old man presented with possible pericardial constriction 18 months after he had received an ATS Open Pivot® bileaflet prosthetic aortic valve. The pericardial thickness on computed tomography was 4 mm. Echocardiography revealed no valvular dysfunction but did not clearly show restrictive physiology. Therefore, a direct evaluation of LV pressure was needed. We decided to cross the ATS valve with a 0.014-in coronary Radi PressureWire.
Technique
First, right ventricular access and standard right-sided pressure recordings were obtained with the use of a Swan-Ganz catheter. A 6F JR4 guide catheter was then placed in the aortic root, 2 to 3 cm above the prosthetic aortic valve leaflets (Fig. 1A).
Fig. 1 A ) A 6F JR4 guide catheter (G) is placed in the aortic root just above the ATS Open Pivot® bileaflet prosthetic aortic valve (V). A 0.014-in coronary Radi PressureWire® (W) has been advanced through the valve, and a Swan-Ganz catheter (S) is seen in the right ventricle. B ) Valve function appears to be uncompromised, evidenced by the open leaflets. C ) Simultaneous measurements of left ventricular pressure (red, recorded by the Radi PressureWire) and right ventricular pressure (blue, recorded by the Swan-Ganz catheter) show high and equal end-diastolic pressures and respiratory discordance, consistent with restrictive physiology and constrictive pericarditis.
The Radi PressureWire was prepared and calibrated in standard fashion. It was advanced retrograde across the ATS valve in the right anterior oblique projection and into the LV cavity, with minimal manipulation. Valve leaflet function did not appear to be compromised (Fig. 1B). Simultaneous LV and right ventricular recordings were consistent with restrictive physiology (Fig. 1C). The Radi wire was withdrawn into the guide catheter without difficulty or pressure drift. The study was completed in an otherwise standard manner. The patient was subsequently accepted for surgery, during which the diagnosis of constrictive pericarditis was confirmed.
Discussion
During the last few years, investigators have shown the feasibility and efficacy of using the Radi PressureWire to cross the St. Jude prosthetic aortic valve.3–5 The ATS and St. Jude prosthetic valves have similar bileaflet designs; however, the ATS valve has an open-pivot hinge—a potential source of wire entrapment.
In our patient, the procedure was straightforward, uncomplicated, and very helpful in confirming the suspected diagnosis of constrictive pericarditis. Further examination of this method is warranted.
References
- 1.Baxley WA, Soto B. Hemodynamic evaluation of patients with combined mitral and aortic prostheses. Am J Cardiol 1980; 45(1):42–7. [DOI] [PubMed]
- 2.Walters DL, Sanchez PL, Rodriguez-Alemparte M, Colon-Hernandez PJ, Hourigan LA, Palacios IF. Transthoracic left ventricular puncture for the assessment of patients with aortic and mitral valve prostheses: the Massachusetts General Hospital experience, 1989–2000. Catheter Cardiovasc Interv 2003;58(4):539–44. [DOI] [PubMed]
- 3.Doorey AJ, Gakhal M, Pasquale MJ. Utilization of a pressure sensor guidewire to measure bileaflet mechanical valve gradients: hemodynamic and echocardiographic sequelae. Catheter Cardiovasc Interv 2006;67(4):535–40. [DOI] [PubMed]
- 4.Parham W, El Shafei A, Rajjoub H, Ziaee A, Kern MJ. Retrograde left ventricular hemodynamic assessment across bileaflet prosthetic aortic valves: the use of a high-fidelity pressure sensor angioplasty guidewire. Catheter Cardiovasc Interv 2003;59(4):509–13. [DOI] [PubMed]
- 5.Cavendish JJ, Carter LI, Tsimikas S. Recent advances in hemodynamics: noncoronary applications of a pressure sensor angioplasty guidewire. Catheter Cardiovasc Interv 2008;71 (6):748–58. [DOI] [PubMed]