Background: Prior studies have neither described methods for crossing a severely stenotic aortic valve (AV) in light of modern imaging modalities (echocardiography, computed tomography, fluoroscopy) nor characterized a successful crossing. This study aimed to fill that gap.
Methods: Time to cross the valve (TTCV) was measured prospectively in 35 consecutive patients undergoing transcatheter AV replacement and used to define two groups (≤60 seconds or >60 seconds). TTCV was analyzed as a function of 20 imaging variables. The AV was crossed systematically with a pigtail catheter parked in the non-coronary cusp, AL-1 catheter above the AV, and a straight wire for crossing, in 20° left anterior oblique view, as the operator adjusted catheter-to-catheter (CTC; AL-1 to pigtail) and catheter-to-wire (CTW; pigtail to wire) with each failed pass.
Results: Mean TTCV was 39.5 ± 59 seconds. Of all the imaging variables, only lower AV peak velocity (3.9 ± 0.69 m/s vs 4.28 ± 0.35 m/s; P<.05) and larger aortic annulus perimeter (77 ± 5.7 mm vs 65 ± 23 mm; P<.05) were significantly different in the <60 group (n = 29; TTCV, 21 ± 12 seconds) vs the >60 group (n = 6; TTCV, 157 ± 52 seconds). The successful pass was characterized by a CTC of 1.67 ± 0.78 cm and CTW of 0.2 ± 0.36 cm. These distances increased in horizontal hearts (CTC and CTW were 0.76 cm) to higher in normally oriented hearts (CTC, 1.63 cm; CTW, 0.5 cm) to even higher in vertical hearts (CTC, 2.9 cm; CTW, 0.56 cm).
Conclusion: Although lower peak jet velocity was associated with rapid AV crossing, the major insight from these data is characterization of a successful pass, which can facilitate clinical practice.
Keywords: TAVR; contemporary era; crossing time; physician technique; severely stenotic aortic valve.