Catheter techniques 4: LV catheterization - Elias Hanna, Univ Iowa

-Left ventriculography, techniques and diagnostic value, including for MR
-Aortography, including for AI
-How to access the LV in AS
-How to access the LV
***Additional tips regarding crossing severe AS:
-When crossing any severe AS, it is often useful to perform small aortic root angiographic (5-10 ml), usually in LAO, to delineate the aortic valve hole and know where to aim your catheter/wire.
-Regarding bicuspid severe AS: it is often more difficult to cross bicuspid AS than tricuspid AS, as the hole is eccentric. 80% of bicuspid valves have fusion of the right and left cusps, and ~20% have fusion of the right and noncoronary cusps. In the first scenario: LAO view, which normally spreads apart the right and left cusps, is not likely to help, as the hole is rather in an antero-posterior plane, not right-left plane. Thus, RAO view is instead helpful and separates the anterior cusp (fused R+L) and the posterior cusp (NC). Do root angiography in RAO to delineate the hole, and may consider further angulations, eg RAO caudal.
If you do aortic angiography in LAO, you will often see one domed cusp rather a separation between 2 cusps.
-In relation to the above, during standard left coronary engagement in pts with bicuspid valve of the 1st type, you will not see nor seek my beloved “jump” from right to left cusp (the one I describe at 12:50). Rather, you will see a subtle catheter movement across the valve from right to left, not a typical jump.
-Regarding bioprosthetic AS: the anatomy is variable and the hole may be better seen in a right-left plane in some, vs. ant-post plane in others. Do root angiography in LAO and RAO and may even consider a bit of cranial and caudal angles if difficulty persists.
-For mechanical valves, crossing is not safe and not recommended: risk of catheter entrapment + it frequently induces significant AI which falsifies measurements. I have unintentionally crossed many mechanical valves (eg, while engaging RCA) with no issue, but it should not be done intentionally. Transseptal puncture is required for invasive LV assessment, if absolutely needed. There are several case reports of using FFR wire across the aortic mechanical valve; this may be safe but data is limited.

[@rat_water1638]

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[@aasaad007]

Excellent 7