GUIDEWIRE SHAPE MODIFICATION: A SIMPLE TECHNIQUE TO PREVENT CONDUCTION SYSTEM INJURIES DURING TRANSCATHETER VALVE IMPLANTATION

Abstract

Abstract Background Atrioventricular (AV) conduction abnormalities remain one of the important unsolved issues with transcatheter aortic valve implantation (TAVI). To minimize trauma on the conduction fibers, we introduced a simple technique involving the bending of the stiff guidewire wire at the level of the arch to prevent and minimize contact with the interventricular septum. Aim To report the technique for shape manipulation of the stiff guidewire during TAVI and to evaluate its safety and effectiveness in reducing the need for permanent pace–make implantation after TAVI. Methods and Results Before insertion into the left ventricle the TAVI stiff wire was bended by hand to obtain a ³180° degree curve 15–20cm from its tip. Distance between stiff wire and septum was assessed in cranial–lao cusp overlap projection. Among 26 consecutive patients who underwent TAVI with a bended stiff wire, 13(50%) presented preoperative factors of increased risk for need of PM implantation after TAVI due to LVOT calcification (10, 38.5%), bicuspid aortic valve with raphe opposite to the septum (2, 7.7%) and baseline RBBB (2, 7.7%). Wire was observed to be distant from the septum >5mm in 22/26 (85%) cases. Median distance from septum was 9.0 [6.0, 12.0] mm. Pre–dilatation was required in 20 patients (77%). Balloon was observed to inflate distant from septum in 18 (90%) of them. Self–expandable valves were most frequently employed (n = 21, 81%).No patient required new PM implantation after TAVI. The two patients with baseline RBBB developed transient complete AVB, which recovered before discharge.No major complication (vascular, ventricular perforation, annular rupture, device embolization) was observed. Conclusions In this early preliminary experience stiff wire bending was able not only to keep far from the septum the wire in the majority of patients, without any complication, but also to provide wire stability and prevented inadvertent pressure of the wire over the left ventricular apex. No patient required PM implantation after TAVI. While wire bending seems promising in minimizing trauma on the conduction system, this study is to be considered hypothesis generating and more data are needed to confirm its findings.