Snare-Assisted Valve Delivery to Overcome a Severely Calcified Aortic Arch during Transcatheter Aortic Valve Replacement

Snaring Self-Expanding Devices to Facilitate Transcatheter Aortic Valve Replacement in Patients with Complex Aortic Anatomies

The snare-assisted technique has been described to facilitate transcatheter aortic valve replacement (TAVR) delivery system advancement in complex aortic anatomies. However, the evidence is limited to case reports. To evaluate the safety profile of the snare-facilitated approach and its impact on self-expanding (SE) TAVR outcomes, we collected consecutive patients who underwent transfemoral SE-TAVR for aortic stenosis, using propensity score matching (PSM) separately in tricuspid and type-0 and type-1 bicuspid aortic valve morphology between the snare and non-snare groups. In 766 patients, despite the snare group having significantly larger annulus angulation and maximal ascending aortic diameter, both groups achieved comparable 30-day device success rates, regardless of first-generation or new-generation valve use. After PSM, the snare group had a significantly lower new permanent pacemaker implantation rate among 193 type-0 patients (3.3% vs. 18.3%, p = 0.01). The ipsilateral group used new-generation valves less frequently (23.0% vs. 75.4%, p < 0.001), but there were no significant inter-group differences in procedure-related events, except for a lower incidence of PVL ≥ mild in the ipsilateral group (14.9% vs. 32.3%, p = 0.01). In conclusion, the snare-assisted technique appears useful in SE-TAVR with angulated aortic root anatomy, and the benefits were comparable between ipsilateral and contralateral snare techniques.

Snare and track (SNACK) technique: a novel approach for successful placement of an intracardiac echocardiogram catheter in the left atrium: a case report

Background

Placing an intracardiac echocardiogram (ICE) catheter in the left atrium allows for excellent visualization of the left atrial appendage to guide left atrial (LA) appendage occlusion (LAAO). Nonetheless, it requires a separate septal puncture or a unique set of skills to navigate the ICE through a previously prepared septal puncture, which can be challenging.

Case summary

This report describes a novel method to insert an ICE in the left atrium through a single septal puncture utilizing a snare technique. A 76-year-old male underwent LAAO by ICE guidance. After obtaining a standard atrial septal puncture, we were unable to advance the ICE into the left atrium. Therefore, we used a loop snare to grasp the ICE catheter-tip in the right atrium and direct it into the left atrium via the prepared septal puncture by tracking a pigtail wire that we routinely place as part of the procedure. Afterward, the left atrial appendage was successfully occluded with a Watchman device (Boston Scientific, Galway, Ireland), and the patient was discharged home without complications.

Discussion

The described technique could be a helpful tool for ICE placement to the left atrium in a controlled fashion, especially when challenging anatomy is encountered.