Anchor balloon, buddy wire, and wire and sheath techniques to deploy percutaneous pulmonary valves in tetralogy of fallot patients

Abstract

Advances in surgical techniques in tetralogy of Fallot (TOF) patients have improved survival of these patients into adulthood. The procedure requires right ventricular outflow tract or trans-annular patch with resultant pulmonary stenosis and/or regurgitation. As such, adult patients seen with this condition may have increasing right ventricular hypertrophy and/or right ventricular dilation. Recently, the Sapien XT valve (Edwards Lifesciences, CA) was approved by the FDA for pulmonary implantation. In some cases, advancing the valve in right ventricular outflow tract is difficult. This is a case series of delivering Sapien XT valves in TOF patients with severe pulmonary regurgitation and/or stenosis, using the anchor balloon, buddy wire, and the novel, wire and sheath techniques. © 2017 Wiley Periodicals, Inc.

Modified delivery of SAPIEN 3 valve in the pulmonary position: Evolution of technique or dire need?

“…Unfortunately, even with adequate wire position, the advancement of the valve into the RVOT is not guaranteed. We and others have previously described the use of a “buddy catheter” to pin the distal guide wire in the pulmonary artery, which can facilitate valve positioning by allowing additional tension to be applied to the guide wire, but this technique may not always be successful . Other techniques of using a stiff wire or sheath to help with straightening the RVOT to help with advancing the Commander delivery system have also been described .…”

“…We and others have previously described the use of a “buddy catheter” to pin the distal guide wire in the pulmonary artery, which can facilitate valve positioning by allowing additional tension to be applied to the guide wire, but this technique may not always be successful . Other techniques of using a stiff wire or sheath to help with straightening the RVOT to help with advancing the Commander delivery system have also been described . The stiffness and lack of flexibility of the commercially available delivery system as well as reports of tricuspid valve injury during advancement, has led some implanters to implement alternative methods of valve delivery that utilize commercially available but more flexible balloons, sheaths, and catheters.…”

“…11,13 Other techniques of using a stiff wire or sheath to help with straightening the RVOT to help with advancing the Commander delivery system have also been described. 13 The stiffness and lack of flexibility of the commercially available delivery system as well as This led to us to attempt the sheath-less delivery.…”

“…As such, reports of tricuspid valve injury during placement have been published . This has led to the development of innovative techniques for Sapien valve implantation in the pulmonary position; however, these techniques remain suboptimal. A recent report also describes using a long sheath to cover the valve .…”

The snared wire technique for Sapien valve implantation in the pulmonary position

“…system was designed for aortic valve replacement and has proven to be challenging for TPVR, as detailed in several reports which describe different techniques to overcome these difficulties. [5][6][7][8][9][10][11] Stiff guide wires that provide sufficient support, careful wire shaping and positioning, and most importantly, avoiding the loss of wire position are the mainstays of a successful delivery of any percutaneous valve in the pulmonary position. Excessive traction on the guidewire can lead to the loss of wire position, potentially jeopardizing the procedure.…”