Transradial access for balloon aortic valvuloplasty - Zoltan Ruzsa

1. Transradial aortic valve valvuloplasty
Ruzsa Z., Bárczi Gy., Édes I. F., Molnár L., Becker D., Merkely B.
AimRadial 2017

2. Financial disclosures
I have no conflict of interest to declare

3. Vascular complications increase the mortality
after TAVI
Predictors of mortality
N=419 pts TF TAVI after TAVI in PARTNER
1A és 1B után (22/24 F)
64 pts has major vascular complications after TAVI by VARC definitions
Généreux et al. JACC 2012;60:1043-52

4. How to decrease the complications during TAVI-
IMAGING (US, Fluoro and CT)

5. Background
• BAV indications
• Bridge to TAVI
• Bridge to death
Patients with symptomatic AS and any of the following:
- Bridge to surgical AVR in hemodynamically unstable patients
- Increased perioperative risk, STS risk score >15%
- Anticipated survival of <3 y
- Age in the late 80s or 90s and prefer BAV over open thoracotomy
Severe comorbidities such as porcelain aorta, severe lung disease, and others for
which the CV surgeon prefers not to operate
Severe and/or disabling neuromuscular or arthritic conditions that would limit the
ability to undergo postoperative rehabilitation

6. Is it a forgotten therapy (BAV in UK and Hu) ???

7. BAV complications (NHLBI Balloon Valvuloplasty Registry.)
Circulation. 1991;84:2383-2397
Haematoma 7%
Vascular Surgery Required 5%
Embolism 2%
Transfusion 20%

8. Limitations of BAV
• Balloon “slip”
• Use of rapid pacing
• Obstruction of LV output
• Balloon rupture
• Annular injury
• Acute result
• Long term durability
• Long term mortality

9. Transradial access for balloon aortic valvuloplasty
Levente Molnár, Zoltán Ruzsa, Roland Papp, Béla Merkely
Heart and Vascular Center of Semmelweis University, Budapest, Hungary
Introduction:
Balloon aortic valvuloplasty
(BAV) may be considered as to
bridge to surgical or TAVI
procedure (IIb/C). Bridge to
TAVI is common indication in
Hungary.
Aims and methods:
Some of our patients had the need
for non-transfemoral BAV. Our goal
was to prove feasibility and safety
with this access. 9 patient recieved
transradial BAV between June
2016 and april 2017. Cut off limit
was radial artery diamater > 2.0
mm confirmed by echo (2,0-3,2
mm). Radial echo controll was
performed on day 5. 30 day follow-
up controll included cardiac echo
parameters.
Results:
• Age: 81 ± 5 years
• Log. EuroSCORE: 24,5% ± 8%
• Male/female: 6/3
• Bridge to TAVI:7
• Palliative therapy: 2
• Radial and ulnar artery echo
• Balloon sizeing compared to
annulus parameters on CT or
Echo.
• 7-9 Fr radialis/Destination sheath
• 4 cases with Tyshak 18-20x40
mm (NuMEd-8 Fr ; RBP: 2 atm)
• 5 cases XXL Vascular 16-18x40
mm (BSC-7 Fr; RBP: 5 atm)
Conclusion:
Transradial BAV is feasible and
safe in selected cases. Patient
selection with echo for radial
access is necessary. Further
investigation is needed.
procedural 30 day
Aortic Peak Gradient 92±22,5 Hgmm 71± 18Hgmm
Aortic Mean Gradient 50±19 Hgmm 39±16 Hgmm
AVA 0,72±0,21 cm2 0,98±0,23 cm2
NYHA st. III-IV I-III
Aortic regurge 0-I 0-II

10. Methods
• Prospective pilot study inclusing 17 patients
• Inclusion criteria
• Pts with BAV indication
• Exclusion criteria
• Contraindications of the RA access
• Less than ½ year life expectancy
• End points
• Primary
• Procedural success
• MAEs
• Secondary
• Procedural complications including vascular complications, MACCE
• Procedural reletaed factors

11. Preparing the patient in the hybrid lab

12. Ultrasound guided puncture

13. RIGHT RADIAL 6F-8F and LEFT RADIAL 5-6F

15. BAV procedure
• 1. Vascular US of both radial and ulnar arteries
• 2. Puncture of the bigger and non-calcified artery
• 5F Left radial
• 6F Right radial
• 3. Temporary pacemaker from jugular vein (US puncture)
• 4. Coronary angiography if necessary
• 5. Pig tail from the left radial access and aortography
• 6. AL1 or AL2 from right radial approach and passing the Terumo GW in the LW
• 7. Changing for Starter GW and Ventriculography and measuring the Peak to peak
gradient
• 7. Changing for Amplatz Super Stiff
• 8. Upsizing the sheath for 7-8F Terumo (femoral) sheath
• 7. BAV
• 8. Controll aortography and Pressure measurements
• 9. Sheath and PM removal
• 10. Early mobilisation

20. Results
Demographic and clinical data n (%)
Demographic data Age (years)
Male
Hypertension
Current smokers
Diabetes mellitus
- IDDM
- NIDDM
Weight (kg)
Height (cm)
Chronic obstuctive pulmonary disease
Renal insuffitiency
70,13± 9
9 (50)
11 (61)
6 (35.2)
10 (55)
1 (5)
9 (50)
80,9 ± 22
167,4 ± 12
2 (11)
6 (33)
Cardiac and vascular history CAD
PAD
Previous PCI or coronary bypass
Previous valve surgery
Symptoms
- Angina
- Dyspnoea
- Collapse
(6) 33
(2) 11
(6) 33
(1) 5
(13) 72
(18) 100
(3) 16

21. Indications
Preferences
- Physician preference
- Patient /Family preference
- Surgical preference
- „Bridge” procedure
6
1
0
11

22. Results
Pre-interventional Postinterventional
Vascular ultrasound
- Radial artery (mm)
- Ulnar artery (mm)
2,03±0,48
1,92±0,57
2,05±0,5
1,94±0,5
Cardiac ultrasound
- LVEF
- 50-70%
- 30-50%
- 30%
- Aortic gradient (peak)
- Aortic gradient (Mean)
- AVA (mm2)
- Aortic regurgitation
- No or mild
- Moderate to severe
- Mitral regurgitation
- No or mild
- Moderate to severe
8
9
1
85±32
52±21
0,59±0,14
18
0
14
4
9
8
2
70±18
43±11
0,62±0,19
18
0
14
4
Haemodinamic data
- Peak to peak gradient 85±30 58±12

23. The first patient.....
Presented atTCT 2016

25. Final angiography and coronary angiography

26. What has been changed during the study
• Long sheath 6-7F 60-70 cm
• Dual injection and 2 short sheath (5F and 7F)
• Routine
• Left radial - Snuff Box
• Radial radial – BAV with 7 or 8F
• Side depends on US result
• (7F only when the RAO is bigger than 1.5 mm and it is not severely
calcifiedí)

27. Limitations (dedicated vs non-dedicated balloons)
Non dedicated LARGE
balloons
Dedicated BAV balloons
XXL balloon from Boston Sci
XL Balloon from Cordis
Intervalve (12 F)
Tyshak Nucleus
Z med II
Cristal

28. Conclusion
• Transradial BAV is safe end effective for treating high risk patients
with aortic stenosis as a bridge therapy

29. Thank you very much