“Commissural drop” wiring technique facilitates catheter crossing of severely stenotic aortic valve

To the Editor: An 82-year-old man with symptomatic severe calcific aortic valve stenosis (peak velocity: 5.19 m/s; mean gradient: 78.0 mmHg; aortic valve area: 0.48 cm²) underwent transfemoral transcatheter aortic valve replacement. During the procedure, a 0.035-inch straight-tip glide wire (Terumo, Somerset, NJ, USA) supported by a 6 Fr Judkins Right 4 (JR4) coronary catheter (Medtronic, Minneapolis, MN, USA) were used to cross the severely stenotic aortic valve. However, the JR4 catheter could not pass the aortic valve because the wire crossed the aortic valve in the left/right coronary commissure creating an unfavorable angle and limited pushability for the catheter. Instead of switching to a differently shaped catheter (eg, an Amplatz left 1 catheter), we advanced the glide wire and therefore the more supportive portion of the wire further through the aortic valve. Subsequently, both wire and JR4 catheter dropped into the non/left coronary commissure, allowing the JR4 catheter to cross the valve easily. Eventually, a 34 mm self-expanding Evolut R valve (Medtronic) was implanted, and the patient was discharged uneventfully (Figure 1A–E and Supplementary Video 1, [“Commissural drop” wiring technique.]).

Figure 1.

“Commissural drop” technique. (A) With the 0.035 glide wire in the RC/LC commissure (Left anterior oblique 1, Cranial 5), the Judkins Right 4 catheter's trajectory (white arrow) is unfavorable, and is unable to pass through stenotic aortic valve (dotted line); (B) The glide wire is carefully pushed forward providing more body (red arrow) while keeping the catheter stable; (C) Glide wire curving towards to left ventricular apex (red arrow); (D) The catheter and wire dropped down into NC/LC commissure (white arrow) and the former is able to cross the aortic valve easily; (E) pre-procedural computer tomography diagram shows previous wire location crossing aortic valve (red asterisk), and latter wire location after “commissural drop” (yellow asterisk). LC: Left coronary cusp; NC: Non coronary cusp; RC: Right coronary cusp.

Although technical issues during wire crossing of the stenotic aortic valves are well recognized,^[1] reports focusing on wiring techniques of highly stenotic valves that allow the catheter to cross more easily over the wire are scarce. In this context, we show the “commissural drop” wiring technique facilitating catheter crossing of highly stenotic calcified aortic valves.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s)/patient's guardians has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the article. The patients/patient's guardians understand that their names and initials will not be published and due efforts will be made to conceal the identity of the patient, although anonymity cannot be guaranteed.

Conflicts of interest

Dr. Gössl serves as a speaker for Abbott Vascular; consultant for LivaNova; has received research support from Edwards Lifesciences. Dr. Sorajja is a consultant and speaker for Abbott Vascular, Medtronic, Boston Scientific, Edwards Lifesciences, Admedus, Gore; has received research support from Abbott Vascular, Medtronic, Boston Scientific, Edwards Lifesciences.