Anterograde percutaneous transseptal valvuloplasty in a case of severe calcific aortic stenosis

The retrograde catheterization and percutaneous dilatation of calcific stenotic aortic valves is not always possible in elderly patients. We report the case of a 76-year old woman admitted with severe aortic stenosis in whom it was impossible to reach the left ventricle retrogradely. This led us to attempt percutaneous aortic valvuloplasty using a transseptal anterograde approach. The Mullins transseptal sheath catheter was advanced into the left ventricle and a 7 F catheter containing a long guide wire (400 cm) passed through the sheath. The flexible end of the guide wire was advanced through the aortic valve anterogradely and an angled wireloop retriever used to catch the flexible end of the guide wire and to draw it out of the body through the left femoral artery. A 7 F balloon catheter was introduced percutaneously over the long guide wire and allowed dilatation of the interatrial septum and femoral vein. A 8 F Schneider-Grüntzig catheter (80 mm) length, 19 mm diameter when inflated) was inserted anterogradely through the aortic valve over the guide wire without difficulty and the balloon catheter was inflated to a pressure of 6 atmospheres with a 30 seconds inflation-deflation cycle. Before the procedure the mean aortic valvular gradient was 114 mmHg and the aortic valve area was 0.30 cm2. After the procedure the mean aortic gradient had fallen to 60 mm Hg and the valve area had risen to 0.90 cm2. These results are comparable to those expected using the more usual retrograde balloon dilatation of the aortic valve.