“Commissural Drop” Wiring Technique Facilitates Catheter Crossing of Severely Stenotic Aortic Valve

“Commissural Drop” Wiring Technique Facilitates Catheter Crossing of Severely Stenotic Aortic Valve

The “commissural drop” wiring technique represents a significant advancement in the field of transcatheter aortic valve replacement (TAVR), particularly in cases involving severely stenotic aortic valves. This innovative approach addresses a common challenge encountered during TAVR procedures: the difficulty in crossing a highly stenotic, calcified aortic valve with a catheter. The technique’s efficacy is demonstrated in a case involving an 82-year-old male patient with symptomatic severe calcific aortic valve stenosis.

The patient presented with severe aortic stenosis, evidenced by a peak velocity of 5.19 m/s, a mean gradient of 78.0 mmHg, and an aortic valve area of 0.48 cm². These parameters indicate a critical narrowing of the aortic valve, necessitating intervention. The chosen treatment was transfemoral TAVR, a minimally invasive procedure that involves replacing the aortic valve via a catheter inserted through the femoral artery.

During the procedure, the medical team encountered a significant obstacle. A 0.035-inch straight-tip glide wire, supported by a 6 Fr Judkins Right 4 (JR4) coronary catheter, was used in an attempt to cross the severely stenotic aortic valve. However, the JR4 catheter was unable to pass through the valve. This difficulty arose because the wire initially crossed the aortic valve in the left/right coronary commissure, creating an unfavorable angle and limiting the catheter’s pushability.

Instead of resorting to a differently shaped catheter, such as an Amplatz left 1 catheter, the team employed the “commissural drop” technique. This involved advancing the glide wire further through the aortic valve, thereby utilizing the more supportive portion of the wire. As a result, both the wire and the JR4 catheter dropped into the non/left coronary commissure. This repositioning allowed the JR4 catheter to cross the valve easily, overcoming the initial impediment.

The success of the “commissural drop” technique is visually documented in Figure 1A–E. The figure illustrates the procedural steps: the initial unfavorable trajectory of the JR4 catheter (Figure 1A), the advancement of the glide wire providing more body (Figure 1B), the wire curving towards the left ventricular apex (Figure 1C), and the eventual drop of the catheter and wire into the non/left coronary commissure, facilitating easy crossing of the aortic valve (Figure 1D). Additionally, a pre-procedural computer tomography diagram (Figure 1E) shows the previous wire location crossing the aortic valve and the latter wire location after the “commissural drop.”

Following the successful crossing of the aortic valve, a 34 mm self-expanding Evolut R valve was implanted. The patient was discharged without complications, marking a successful outcome for the procedure.

The “commissural drop” wiring technique is a valuable addition to the arsenal of strategies used in TAVR, particularly for highly stenotic calcified aortic valves. While technical issues during wire crossing of stenotic aortic valves are well recognized, reports focusing on wiring techniques that facilitate easier catheter crossing are scarce. This technique addresses a critical need in the field, offering a practical solution to a common procedural challenge.

The technique’s effectiveness lies in its simplicity and the utilization of existing equipment. By advancing the glide wire further through the aortic valve, the procedure leverages the wire’s supportive portion to reposition the catheter into a more favorable commissure. This approach eliminates the need for catheter exchange, streamlining the procedure and potentially reducing procedural time and complexity.

In conclusion, the “commissural drop” wiring technique is a significant development in the management of severely stenotic aortic valves during TAVR. Its successful application in a challenging case underscores its potential as a reliable method for facilitating catheter crossing in similar scenarios. As TAVR continues to evolve, techniques like the “commissural drop” will play a crucial role in enhancing procedural success and patient outcomes.

doi.org/10.1097/CM9.0000000000001142

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