Retrograde percutaneous aortic valve implantation for critical aortic stenosis

Abstract

Recently, a prosthetic aortic valve has been implanted percutaneously in several patients using an antegrade transseptal approach. This has been shown to be feasible and associated with dramatic hemodynamic improvement. We report a retrograde implantation of a percutaneous heart valve (PHV) in an 84-year-old man with critical aortic stenosis and refractory congestive heart failure after difficulties encountered with an initial antegrade approach. While attempting antegrade transseptal implantation of a PHV, the anterior leaflet of the mitral valve was tethered by the guidewire resulting in severe mitral regurgitation and pulseless electrical activity. Cardiac resuscitation was successful. Utilizing a retrograde approach, the PHV was successfully implanted in a stable position below the coronary ostia and well above the mitral valve leaflets. The aortic valve area increased from 0.55 to 1.7 cm2 with only mild paravalvular aortic regurgitation. Despite marked improvement in aortic valve function, the patient died secondary to guidewire-induced mitral valve anterior leaflet laceration, severe mitral regurgitation, and cardiogenic shock. Retrograde implantation of a PHV can be successfully performed with substantial increase in aortic valve area and an acceptable degree of aortic regurgitation. Although the retrograde approach may be associated with greater risk of vascular access site complications, it may be considerably safer by avoiding potential guidewire injury to the mitral valve. Further refinements in technique may establish the retrograde approach as the preferred means of PHV implantation in nonsurgical patients with critical aortic stenosis.

Percutaneous Aortic Valve Implantation Retrograde From the Femoral Artery

“…Initial attempts at transarterial implantation with standard balloon valvuloplasty equipment were, however, compromised by difficulties negotiating the aortic arch and reaching and crossing the stenotic native valve, ultimately leading to abandonment of this approach (A. Cribier, MD, unpublished data, 2005). Recently, Hanzel et al 15 reported an antegrade procedure, which, when unsuccessful, was converted to a retrograde approach; however, mitral valve injury as a consequence of the antegrade component of the procedure led to cardiovascular collapse and death. Our experience suggests that with the use of equipment and techniques specifically designed for a transarterial approach, percutaneous aortic valve implantation can be accomplished routinely.…”

“…14 Although a retrograde femoral arterial approach is an intuitive extension of aortic valvuloplasty technique, initial experiences were disappointing. 15 Antegrade femoral access problems relate not only to positioning the prosthesis across the stenotic, calcified aortic valve but also to delivery of the large-profile device and sheath through frequently diseased and tortuous femoral and iliac arteries and the abdominal and thoracic aorta. We describe our experience with the development of this procedure and the techniques and equipment designed to allow percutaneous retrograde transarterial implantation of aortic prosthetic valves.…”

Percutaneous and Minimally Invasive Valve Procedures

“…The technique has proved too complex for widespread dissemination, particularly with the firstgeneration device. Cribier also treated some patients with a retrograde transarterial approach, and Hanzel et al 53 reported the successful deployment of a percutaneous aortic valve through a retrograde approach. Conceptually simpler and more reproducible, reliable retrograde passage of the stent valve is facilitated by the introduction of a flexible, steerable delivery catheter.…”

“…Both the Cribier-Edwards and CoreValve devices have been used in high-risk patients with predicted Euroscores Ͼ30%, with actual 30-day mortality rates Ͻ10%. [52][53][54][55][56] …”

“…Novel complications such as device migration or embolization, mitral valve laceration, and paravalvular aortic insufficiency have already been reported. [52][53][54][55][56] Other developmental issues that still need to be addressed and that are discussed in the "Final Considerations" section include optimization of access routes, further reduction in delivery system and prosthesis profile, and development of balloonexpandable versus self-expanding stent platforms and repositionable and retrievable devices. The extent and nature of the valve and valve annulus pathology are important elements in these considerations.…”