Left bundle branch block during antegrade balloon aortic valvuloplasty caused by stiff-wire loop stress
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IMAGES IN CARDIOVASCULAR INTERVENTION
Left bundle branch block during antegrade balloon aortic valvuloplasty caused by stiff‑wire loop stress Hiroki Shibutani1 · Yuzo Akita1 · Yumie Matsui1 · Masahiro Yoshinaga1 · Masahiro Karakawa1 · Ichiro Shiojima2 Received: 20 December 2017 / Accepted: 2 July 2018 © Japanese Association of Cardiovascular Intervention and Therapeutics 2018
Images in cardiovascular intervention An 88-year-old female with recurrent heart failure due to severe aortic stenosis underwent antegrade balloon aortic valvuloplasty (ant-BAV) using Inoue balloon catheter (Toray, Tokyo, Japan). Preprocedural coronary angiogram revealed no significant stenosis. The stiff wire was across from left atrium, via mitral valve and left ventricle to the descending aorta and captured by the snare catheter (Fig. 1a). The Inoue balloon was advanced over the intraventricular wire loop to a position across aortic valve. During this manipulation, holding the stiff wire made the snare fixing point and the wire to be pulled down near to aortic valve, indicating strong wire tension (Fig. 1b). Incidentally, there was a new-onset left bundle branch block (LBBB) (Fig. 1c). Her hemodynamic state was stable and
then, dilatation was performed using stepwise technique (Fig. 1d). Even though the LBBB was continued during the procedure, it was improved after 6 h without advancement to atrioventricular block (Fig. 1e, f). The successful reduction in transaortic valve gradient and increase in AV area resulted in improvement of her clinical condition. Cardiac conduction disturbances while retrograde BAV (retro-BAV) and transcatheter aortic valve implantation are previously reported and associated with balloon oversizing [1]. In this case, the mechanical stress by stiff-wire intraventricular loop during advancement of the Inoue balloon caused the new-onset LBBB regardless of balloon inflation. Although the maximum characteristic of ant-BAV the stiffwire loop with snare fixing offers several advantages over retro-BAV, this procedure gives stronger wire-loop stress for intra-ventricular conduction systems. In positioning of the
* Hiroki Shibutani [email protected] 1
Division of Cardiology, Osaka Saiseikai Izuo Hospital, 3‑4‑5 Kitamura, Taisho‑ku, Osaka 551‑0032, Japan
Department of Medicine II, Kansai Medical University, Osaka, Japan
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Fig. 1 a The stiff wire was placed in the intra-ventricular loop and captured by the snare catheter in the ascending aorta. b Holding the stiff wire during advancement of Inoue balloon catheter (yellow arrow) made the snare fixing point and the wire to be pulled down near to aortic valve (red arrow), indicating significant wire tension. c Incidentally, new left bundle branch block (LBBB) appeared before
inflation. d Multiple times of inflations with stepwise increased balloon diameters were performed, resulting in remarkable improvements in clinical conditions. e A standard 12-lead electrocardiogram after the procedure revealed complete LBBB.
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