Abstract
During percutaneous pulmonary valve implantation, it is challenging to advance the delivery system loaded with a stent-valve through the right ventricular outflow tract. An extra-stiff wire can provide enough supporting and stable positioning to prevent the displacement of the guide wire in stent-valve delivery. In the 2 cases reported here, we used a snare to trap the extra-stiff wire and a large sheath to support the snare; thus, the extra-stiff wire was pulled to the distal end and provided strong support for the advancement of the delivery system. After 8 months of follow-up, the patients were in good condition with excellent valve function. We named this novel, efficient technique the “parallel anchor sheath snare” technique. This report highlights a novel delivery strategy for patients with tortuous right ventricular outflow tracts in percutaneous pulmonary valve implantation.
Keywords: Percutaneous pulmonary valve implantation, pulmonary regurgitation, delivery system, advancing technique
Percutaneous pulmonary valve implantation (PPVI) is currently an accepted treatment option for patients with pulmonary regurgitation after right ventricular outflow tract (RVOT) surgical repair.1 Advancing the delivery system loaded with a stent-valve through the RVOT may be challenging in some cases, especially if the delivery system is thick or the anatomic structure is extremely abnormal, which is the most common cause of PPVI procedure failure.2–4 We report the successful advancement of a bulky delivery system using a novel technique during PPVI in 2 technically challenging cases.
Case Reports
Patient 1
In September 2020, a 50-year-old man with decreased exercise tolerance was admitted to our center. He had tetralogy of Fallot and underwent surgical repair with a transvalvular patch for correcting RVOT obstruction 40 years ago. Echocardiography showed severe pulmonary regurgitation, moderate tricuspid regurgitation, and an enlarged right ventricle. Computed tomography angiography revealed the narrowest diameter of the RVOT to be 30.2 mm, derived from the perimeter. The patient was to undergo PPVI with a 34-mm (diameter) × 25-mm (cylinder length) self-expanding Venus P-valve in a 24F delivery system (Venus MedTech). The Venus P-valve is composed of a nitinol support frame and a trileaflet porcine pericardial tissue valve. The proximal and distal ends are flared to secure anchoring at the pulmonary artery bifurcation end and the RVOT.5
The right femoral vein was punctured as the access route, and a 24F introducer sheath was inserted. A Lunderquist extra-stiff wire (Cook Medical) was difficult to get to the left pulmonary artery, so it was placed into the right pulmonary artery to support the delivery system loading a Venus P-valve. A 32-mm compliant balloon was placed in the RVOT and inflated, whereas aortic root angiography was performed to exclude the risk of coronary artery compression.
First, along the stiff wire, the delivery system could not be advanced through RVOT because of an enlarged right atrium, a sharp angle between the RVOT and right ventricular inflow tract, and calcification and local stenosis of the RVOT. Then, another Lunderquist extra-stiff wire through the left femoral vein was placed into the right pulmonary artery to straighten the transport path (the “buddy wire technique”). However, this approach failed (Fig. 1A). More advanced techniques were then tried. A 14F delivery sheath for atrial septal defect occlusion through the left femoral vein was used to straighten the transport path. This technique also failed.
Fig. 1.
Patient 1. Cineangiograms show A) the difficulty in advancing the delivery system with the buddy wire technique, B) the delivery system successfully advanced by using a snare (arrowhead) in a 14F sheath to trap and anchor the Lunderquist extra-stiff wire (arrow), and C) the deployed valve.
Supplemental motion images are available for Fig. 1A, Fig. 1B, and Fig. 1C.
Finally, a snare loaded in a 6F multipurpose angiography (MPA) catheter was placed into the 14F sheath to trap and anchor the Lunderquist extra-stiff wire and enhance the support to the delivery system. As a result, the delivery system was easily advanced into the pulmonary artery branch (Fig. 1B). Then, the snare and 14F sheath were retrieved. The valve was deployed with a good outcome, as demonstrated by angiography (Fig. 1C). The patient's clinical course after discharge from the hospital was favorable and uneventful. At the 8-month follow-up visit, his heart function was improved significantly from New York Heart Association class III to I. Echocardiogram showed good pulmonary valve function with no regurgitation and a left ventricular ejection fraction (LVEF) of 65%.
Patient 2
In September 2020, a 37-year-old woman presented with palpitations of 3 years' duration; she had undergone surgical transvalvular patch repair 32 years ago for tetralogy of Fallot. Echocardiography demonstrated severe pulmonary regurgitation, an enlarged right atrium and ventricle, and left pulmonary atresia. The diameter of the RVOT was calculated as 28.5 mm derived from the perimeter, and left pulmonary atresia was noted on computed tomography angiography (Fig. 2A). A 30-mm (diameter) × 30-mm (cylinder length) Venus P-valve with a 24F delivery system was selected.
Fig. 2.
Patient 2. A) A computed tomography angiogram shows left pulmonary atresia. B) A cineangiogram shows the delivery system advanced by using a snare (arrowhead) in a 14F sheath to trap and anchor the Lunderquist extra-stiff wire (arrow). C) Angiogram after valve deployment.
Supplemental motion image is available for Fig. 2B.
Similar to the scenario in case 1, the delivery system could not be maneuvered through the RVOT. Another extra-stiff wire was placed into the right pulmonary artery (using the buddy wire technique). However, the delivery system could not be advanced. Then, a 14F delivery sheath was used to straighten the transport path. It also failed. Then, a snare loaded in a 6F MPA catheter was placed into the 14F sheath to trap and anchor the extra-stiff wire and enhance the support to the delivery system. The delivery system was advanced into the right pulmonary artery (Fig. 2B). Finally, the outcome was satisfactory (Fig. 2C). At the 8-month follow-up visit, echocardiography showed good pulmonary valve function with mild regurgitation and an LVEF of 62%.
Discussion
Inability to maneuver the valve-stent assembly into the RVOT is not common (<2%) during PPVI, but it is the main reason for technique failure in PPVI.2–4 In addition, if a large delivery system (ie, 22F–24F for Venus P-valve) is used, the technique failure rate should be much higher, according to our experience. It is a pillar for successful delivery of a stent-valve that the extra-stiff wire can provide enough support and stable positioning to prevent the displacement of the guide wire.
In these 2 cases, after surgical repair for RVOT, we failed to advance the stent-valve through the RVOT because of the tortuosity of the RVOT and the large size of the delivery system. Recently, a snared wire technique was reported in the SAPIEN delivery system (Edwards Lifesciences), in which a snare was advanced inside a Mullins long introducer sheath, and the tip of the Lunderquist wire was snared to establish a loop/rail.6 However, the Venus P-delivery system is 24F, much larger than the SAPIEN delivery system (16F), so it is more difficult to pass through the RVOT. After trying several methods, we improved this snared wire technique with a larger supporting sheath (14F) to supply a stronger supporting force. This also shows that a larger sheath is available. We used a snare to trap the extra-stiff wire and a large sheath to support the snare; thus, the extra-stiff wire was pulled to the distal end, and it provided strong support for the advancement of the bulky delivery system loaded with a stent-valve. We named this new, efficient technique for advancing the delivery system through the RVOT the “parallel anchor sheath snare” (PASS) technique. Besides PPVI, it might be used in other catheter-based procedures, such as transcatheter aortic valve implantation.
Supplementary Material
Funding Statement
Funding/Support: The study received grant support from the National Key Research and Development (R&D) Plan (2017YFC1104202).
Footnotes
Author Contributions: Wenzhi Pan and Shiqiang Hou contributed equally to this work.
Conflict of Interest Disclosure: None.
References
- 1.Driesen BW, Warmerdam EG, Sieswerda GJ et al. Percutaneous pulmonary valve implantation: current status and future perspectives. Curr Cardiol Rev . 2019;15(4):262–273. doi: 10.2174/1573403X15666181224113855. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Haas NA, Vcasna R, Laser KT et al. The standing of percutaneous pulmonary valve implantation compared to surgery in a non-preselected cohort with dysfunctional right ventricular outflow tract - reasons for failure and contraindications. J Cardiol . 2019;74(3):217–222. doi: 10.1016/j.jjcc.2019.03.021. [DOI] [PubMed] [Google Scholar]
- 3.Esmaeili A, Bollmann S, Khalil M et al. Percutaneous pulmonary valve implantation for reconstruction of a patch-repaired right ventricular outflow tract. J Interv Cardiol . 2018;31(1):106–111. doi: 10.1111/joic.12443. [DOI] [PubMed] [Google Scholar]
- 4.Khambadkone S, Coats L, Taylor A et al. Percutaneous pulmonary valve implantation in humans: results in 59 consecutive patients. Circulation . 2005;112(8):1189–1197. doi: 10.1161/CIRCULATIONAHA.104.523266. [DOI] [PubMed] [Google Scholar]
- 5.Zhou D, Pan W, Jilaihawi H et al. A self-expanding percutaneous valve for patients with pulmonary regurgitation and an enlarged native right ventricular outflow tract: one-year results. EuroIntervention . 2019;14(13):1371–1377. doi: 10.4244/EIJ-D-18-00715. [DOI] [PubMed] [Google Scholar]
- 6.Maschietto N, Sperotto F, Esch JE, Porras D, Callahan R. The snared wire technique for Sapien valve implantation in the pulmonary position. Catheter Cardiovasc Interv . 2020;96(4):898–903. doi: 10.1002/ccd.28970. [DOI] [PubMed] [Google Scholar]
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