Fluoroscopic calcification‐guided optimal deployment projection during transcatheter aortic valve replacement—“The eye of the pigtail.”(Follow the right cusp rule—Part II)

Transfemoral transcatheter aortic valve replacement (TAVR) has evolved significantly over the last decade. Various imaging modalities play a critical role in the assessment and management of the TAVR patients. Aortic root angiograms, multiple detector computed tomography (MDCT), and C-arm rotational angiography using DynaCT (Siemens AG, Munich, Germany) are the most common imaging modalities used to obtain the optimal deployment projection (ODP) [1–3]. We describe how to predictably and successfully obtain the ODP under fluroscopy using the aortic valve (AV) calcification as guidance. To obtain the ODP, first identify the calcification outlining the aortic cusps and the opening movements of leftand non-coronary cusp which is usually visible under fluroscopy in a posterior–anterior projection. Place a curved pigtail catheter in the right coronary cusp and bring the opening movement in the “eye” of the Pigtail catheter by using the Right Cusp Rule as described previously [4] (Fig. 1A and B). From January 2013 until February 2014, we evaluated the procedural and clinical outcomes of a 129 consecutive patients with severe aortic stenosis (AS) who underwent transfemoral TAVR with an Edwards Sapien valve (Edwards Lifesiences, Irvine, CA). The ODP for all cases were derived using our described fluoroscopic technique. The primary endpoint was the amount of contrast used to obtain the ODP. The secondary endpoints were device success, acute kidney injury (AKI), and in-hospital mortality. The ODP was obtained successully in all patients with a mean contrast volume of 25.5 13.6 mL (Fig. 2). Device success was achieved in 99% of our patients. AKI was noted in four patients (3.1%) of which only one (0.8%) had stage 3 kidney disease. One patient (0.8%) died during the primary hospitalization from an aortic annulus rupture. Kasel et al. [4] described how to use fluoroscopy to define the perpendicular annulus plane and to obtain the alignment of the right cusp in one line between leftand non-coronary cusps. We took this “Follow the Right Cusp” rule a step further by describing how to use the calcification outlining the aortic cusps, as seen under fluoroscopy, to guide us in obtaining the ODP before taking the first bulbous angiogram; this minimizes the amount of contrast and number of angiograms performed to obtain the ODP. Knowing how to obtain the ODP with fluoroscopic assessment plays a vital role in situations where MDCT derived data is not available, or is innacurate. The amount of contrast generally used with MDCT examination is 80–120 mL [1,2], and 3D reconstruction with DynaCT requires from 20 mL to 32 mL of contrast media [1]. The need for rapid pacing and breath hold before the contrast injection with DynaCT [1] make it a less desirable option for obtaining the ODP. The majority of patients undergoing TAVR are elderly with multiple comorbidities, poor left ventricular function, and more prone to kidney injury; therefore, it is important to reduce the contrast load during the procedure and avoid deleterious steps such as rapid pacing. Our technique of using valve calcification, when present, to set up the ODP under fluroscopy, and then adjusting the angulation using the “Follow the Right Cusp” rule provides a means to successfully obtain the ODP without the need for rapid pacing and with minimal contrast amount. Our high device success rate, low rates of in-hospital mortality, and AKI shows that our technique is feasible and safe.