A Novel Approach to Extraction of a Large Thrombus on the Intraventricular Guide-Wire During Transcatheter Aortic Valve Replacement

For appropriate patients with severe symptomatic aortic stenosis with a prohibitively high surgical risk, trans-catheter aortic valve replacement (TAVR) is now established as a viable option. Thrombosis on the intra-ventricular guide-wire during TAVR is a recognized complication (Wiper et al., Cardiovasc Revasc Med 2014). There is an obvious potential for embolization with particular concern for stroke in this situation. We describe a case in which a >1cm thrombus was noted on the intra-ventricular guidewire by trans-esophageal echocardiogram (TEE) during a TAVR procedure. Balloon aortic valvuloplasty was still performed and an Edwards Sapien valve was deployed. After valve deployment a multi-purpose guiding catheter was advanced with continuous suction. The guide-wire and thrombus were withdrawn inside the guiding catheter. The guide-wire and catheter were removed as a single unit, allowing the thrombus to be safely retrieved. We believe that this is a novel technique of aspiration thrombectomy in this potentially hazardous clinical circumstance. As our experience with TAVR increases, so does our experience with the complications. In the PARTNER trial there was a higher rate of neurological events in TAVR patients than those who had open aortic valve replacement (Smith et al. N Engl J Med 2011; 364: 2187-2198.). This may be related to peri-procedural formation of thrombus and subsequent embolization. We report a case where a large guide-wire thrombus identified during TAVR was successfully removed using a novel approach, preventing a potentially major stroke in this high-risk patient. (C) 2015 Wiley Periodicals, Inc.