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Pt admitted with severe PVL in cardiogenic shock. Step-by-step approach below. Please share any other tips and tricks that you may have. #ACCFIT #FOAMed
Generally, close if symptomatic PVL (HF or hemolysis) or chamber enlargement. Trans-septal for MV and retrograde aortic for AV. Thorough overview article by @EleidMack on the topic. https://www.ahajournals.org/doi/full/10.1161/circinterventions.115.001945
Deploy plug (we use AVPII plugs sized with TEE assistance) while keeping 0.018 wire in LV. If need more support, can snare the LV wire into Ao to create a rail (as seen below).
A trans-septal puncture with enough posterior approach is particularly important for medial MV PVL jets.
8.5 Fr steerable Agilis sheath is used and PVL is crossed typically with an angled glide wire. 3D guidance is critical here to point Agilis in correct trajectory.
3D TEE can also help you know which leak was entered.
After crossing with glide wire, can use a Bernstein catheter to exchange for a stiff wire for support (amplatz). Then exchange for an 8 Fr MP guide with railway to cross the leak into LV. Remove railway and 0.035 wire. Place an 0.014 or 0.018 wire to secure access in LV.
Final Cine.
AVP II usually selected as it has 3 sections, and the middle lobe sits in the leak.
First and foremost, a high quality baseline TEE (including 3D analysis) is required for procedural planning. @mariovar55 @almasthela @NadeenFaza @MasriAhmadMD
