” A “too-low” implantation is defined as the distal edge of the valve frame (commonly referred to as the “inflow” aspect) positioned more than 12

mm below the annulus, into the left ventricular outflow tract (LVOT). A “too-high” implantation is defined as the inflow aspect positioned above the annulus level. Low Implantation Except in cases of severe left ventricular hypertrophy, a low implantation is generally associated with moderate (Grade II) to severe (Grade III-IV) degrees of aortic regurgitation (AR) on contrast aortography. Transesophageal echocardiography (TEE) can Inhibitors,research,lifescience,medical confirm the nature of the regurgitation (i.e., paravalvular vs. central). In the case of “too-low” positioning associated with significant AR and hemodynamic instability, the Inhibitors,research,lifescience,medical first objective would be to manually reposition the valve using a “goose-neck” catheter (i.e., the “Lasso” technique). If unsuccessful, the second option would be to implant a second valve inside the first one (i.e., valve-in-valve technique) but positioned slightly higher. Primary option: The “Lasso” Technique The choice of projection on fluoroscopy is crucial and is dictated by the valve frame, which should be aligned as perfectly as possible. This will provide a reliable reference line when repositioning the valve. With this option, the operator advances

Inhibitors,research,lifescience,medical a Inhibitors,research,lifescience,medical regular 20-35 mm “goose-neck” catheter alone

or through a 7-Fr guiding catheter to engage one of the “loops” of the implanted valve. At this stage it is critical to understand that the success of this maneuver depends on applying torsion to the frame (“unscrewing the valve”) rather than applying direct axial force, which frequently results in ejection of the valve into the ascending aorta. It is for this reason that the simultaneous use of two “goose-neck” catheters is strongly discouraged. Upon “loop” engagement, the operator applies gentle and slowly increasing torsion/traction to the “goose-neck” catheter under constant Inhibitors,research,lifescience,medical fluoroscopic guidance. After confirming mobilization of the valve with hemodynamic analysis, angiogram, and Bumetanide TEE, the “goose-neck” catheter is carefully detached and retrieved. Alternative option: The Valve-in-Valve Technique If the previously described technique of repositioning the valve is unsuccessful or is deemed too dangerous, correction of the severe AR can still be obtained using a second CoreValve implanted inside the first one in a slightly higher position. As with the previous technique, the correct projection is crucial and is dictated by the frame of the valve, which should be aligned as perfectly as possible. The operator PXD101 advances the second valve into the previously implanted valve and calculates the position for implantation with regard to the patient’s anatomy.