Utility of the long DrySeal sheath in facilitating transcatheter pulmonary valve implantation with the Edwards Sapien 3 valve

Abstract

Objective: To assess the utility of the 65-cm-long Gore DrySeal sheath when compared to the standard 36-cm-long Edwards expandable sheath (e-sheath) for transcatheter pulmonary valve implantation (TPVI) with the Edwards Sapien 3 valve. Methods: All patients who underwent TPVI with the Sapien 3 valve, excluding those performed via hybrid approach, at our center between September 2015 and November 2019 were retrospectively reviewed and compared between two groups. Results: A total of 94 patients were enrolled; 29 patients underwent TPVI with the Sapien valve using the DrySeal sheath and 65 underwent TPVI using the e-sheath. The height and body weight of patients implanted using the DrySeal sheath ranged from 137 to 193 cm and from 33 to 129 kg, respectively. Valve delivery time was significantly shorter in the DrySeal group (median time 4 min 33 s vs. 9 min 6 s, p = .002). There were no complications in the DrySeal group (0/27). Nine procedural complications occurred in the e-sheath group (9/65), five of which were potentially directly related to sheath choice, including tricuspid valve injury in four and embolization of the tip of the e-sheath during retrieval of a ruptured balloon in one patient. Conclusions: TPVI with the Sapien 3 valve using the 65-cm-long DrySeal sheath facilitates faster and safer valve implantation when compared to the e-sheath.

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

“…The stiffness of the delivery system, and the fact that the valve is unprotected can make for very challenging delivery, especially when the RVOT and/or the central pulmonary arteries are stented and in much dilated hearts. 10,11,15 Extensive manipulations of the delivery system and significant traction on the guidewire are frequently necessary to align the tip of the delivery system with the RVOT, which ultimately make it possible to advance the valve into the main pulmonary artery. These maneuvers sometimes result in loss of wire position and also increase the risk of tricuspid valve injury, especially when the system is looped in the right atrium.…”

“…These maneuvers sometimes result in loss of wire position and also increase the risk of tricuspid valve injury, especially when the system is looped in the right atrium. 7,11 Indeed, the tricuspid valve injury is a wellknown complication of TPVR with the Sapien Valve, with a reported incidence up to 6-7.5%. 4,5,7,[11][12][13]16 For all these reasons, new and safer strategies to facilitate the delivery of this system in the pulmonary position have been described.…”

“…Various techniques have been described to assist the delivery of the Sapien valve in the pulmonary position and to reduce the incidence of tricuspid valve injury. 5,[7][8][9][10][11] Currently, the use of an appropriately sized 65 cm long DrySeal sheath seems to be the most widely accepted and adopted technique. 7,10,11 The DrySeal offers the unquestionable advantage of protecting the tricuspid valve and its apparatus from the uncovered Sapien valve and delivery system.…”

“…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.…”

SAPIEN S3 valve deployment in the pulmonary position using the gore DrySeal sheath to protect the tricuspid valve

“…They were also able to deliver the 26 and 29 mm SAPIEN XT valves through a 26 Fr GDS sheath. Most recently, Fukada et al9 described their experience using the GDS for implantation of the S3 in the pulmonary position. In their series, 4/65 patients (6.2%) had tricuspid valve injury using the standard Commander delivery system and short expandable e-sheath compared to 0/29 patients who underwent S3 implantation through a long GDS.…”